1. The Medicaid waiver program
Jetta Whittaker
Senior and Disabilities Services

2. What is the MEDICAID WAIVER program?
Authorized by sec. 1915(c) of Social Security Act
Administered by the Centers for Medicare and Medicaid (CMS)
Funded in partnership with Feds according to a factor known as the FMAP – 50/50
Allows states to “waive” certain Medicaid rules to target certain populations

3. What is the MEDICAID WAIVER program?
Vehicle for funding home and community-based services (HCBS)
Alternative to institutional care
One of an expanding number of options for providing HCBS
1915(i) – State Plan HCBS
1915(j) – “Cash and Counseling”
1915(k) – “Community Choice Option,” comes with 6% FMAP incentive

4. Who is served by the MEDICAID WAIVER program in alaska?
People with intellectual and developmental disabilities (IDD Waiver)
Adults age 65+ and those with physical disabilities (ALI Waiver)
Children with complex medical needs (CCMC Waiver)
People with intellectual and developmental disabilities (APDD)

5. Eligibility for the MEDICAID WAIVER program
Financial eligibility for Medicaid
Functional assessment – standardized tool, criteria
Decision by the state that your functional capacity is such that you need the “level of care” available in an institution, e.g., nursing home, ICF/IDD

6. What services are available on the medicaid waiver program?
Full array of long-term services and supports
Care coordination
Personal care/chore
Residential care
Habilitation/Intensive active treatment
Primary provider respite
Supported employment
Transportation
Meals
Environmental modifications

7. Who provides the HCBS?
Private, for- and non-profit, community-based agencies
Assisted living homes
All sizes, experience
Over 400 different agencies statewide
Can provide care coordination and services

8. Who oversees?
SDS provides assurances to CMS that these services will be “quality” services and that recipients who receive them will be safe in their homes and communities
Promulgation of regulations
SDS “certification” of each services they provide
Adherence to Conditions of Participation
Oversight and monitoring, corrective action
Decertification

9. Overview - Changes to federal 1915(c) waiver regulations
Emphasis not just on quality services, but on quality of life for recipients of waiver services;
CMS-defined “home and community-based settings in which services may be provided;”
“Conflict-free” care coordination
Added protections for recipients in provider-controlled or operated residential settings

10. Two major areas of Change
Person-Centered Planning
Separation of service planning and service provision;
New requirements for documentation of options offered to the recipient;
Real choice for recipient free from pressure and undue influence

11. Two major areas of Change
Home and Community-Based Settings
Requires the state to verify that all recipients of Medicaid home and community-based waiver services receive those services
in integrated community settings,
selected by the recipient from among setting options, including non-disability specific settings,
appropriate to their needs, and
that those settings provide “full access” to the benefits of community living.

12. Home and Community-Based Settings
The federal Center for Medicare and Medicaid (CMS) has clarified that “full access to the benefits of community living” means:
 “the same degree of access as individuals not receiving home and community-based services, including opportunities to:
seek employment and work in competitive, integrated settings;
engage in community life;
control personal resources;
receive services in the community”

13. Home and Community-Based Settings
CMS-defined qualities of a “home and community-based setting:
Physically accessible;
Choice of roommates;
Freedom to furnish and decorate;
Freedom and support to control schedules and activities;
Access to food (snacks) at any time;
Visitors at any time

14. Home and Community-Based Settings
CMS-defined qualities of a “home and community-based setting:
In a provider-owned or controlled residential setting the following additional conditions must be met:
Must be rented or occupied under a “legally enforceable” agreement such as a lease or rental agreement;
Have the same responsibilities and protections from eviction that tenants have under the landlord/tenant law of the state;
Privacy in sleeping or living unit;
Entrance doors lockable by the individual with
only appropriate staff having keys to doors.

15. Home and Community-Based Settings
Settings that can never be home and community-based:
Nursing facility;
Institution for mental disease;
ICF/IDD;
Hospital;
Any setting co-located with, on the grounds of, or immediately adjacent to a public inpatient institution
Any other location that has the effect of isolating
individuals from the broader community.

16. Person-Centered Planning
“Providers of HCBS for the individual, or those who have an interest in or are employed by a provider of HCBS for the individual, must not provide case management or develop the person-centered service plan, except when the State demonstrates that the only willing and qualified entity to provide case management and/or develop person-centered service plans in a geographic area also provides HCBS.”
42 CFR (c)(1)(vi)

17. Person-Centered Planning
“Conflict-free” case management that provides complete separation of service planning activities and service provision.
Prohibition on any agency providing both case management and home and community-based services;
CMS clarification: there is no acceptable degree or percentage of financial or organizational affiliation between agencies that will allow provision of care coordination and service provision.”
Only exception: when only one qualified and certified agency in a geographic area is available and willing to provide both

18. Person-Centered Planning
Regulations are forcing significant changes in Alaska’s HCBS system
SDS engaged in planning process with providers
Conflict free at the individual or agency level?
The practical issues around separating service planning from service provision
Regulations must be in place by July 1, 2016

19. MEDICAID WAIVER PROGRAM/ CMS REGS
QUESTIONS?
Jetta Whittaker, Manager, Policy and Program Planning