1. Department of Health and Human Services Stakeholder Engagement
Community Alternatives Program 1915(c) HCBS Waiver August 22, 2016
Department of Health and Human Services Stakeholder Engagement

2. 1915(c) waiver requirements
To access the waiver, the individual must:
Require institutional level of care such as a nursing facility
Meet the target group (population)
Meet Medicaid eligibility requirements
Require one or more waiver services
Choose waiver services in lieu of institutional services
Waiver limitations:
Are supplements to state plan services (Medicaid services).
May not duplicate state plan services
Medically necessary services approved under Early and Periodic Screening, Diagnostic and Treatment may not be included
Specifically targeted to children may not provide coverage of any service that can be offered through state plan
CAP/C 1915(c) HCBS Waiver Stakeholder Engagement

3. 1915(c) waiver requirements
Services that are diversional or recreational in nature fall outside the scope of 1915(c)
Waiver funds may not be used to pay for room and board
Services may not duplicate the Individuals with Disabilities Education Act or the Rehabilitation Act
Waiver Entrance Criteria
Do the needs clearly meet the purpose and the scope of the waiver program?
Are planned services appropriate to the nature and type of need to assure health and welfare?
Are selected service providers qualified to provide the service?
CAP/C 1915(c) HCBS Waiver Stakeholder Engagement

4. Home and Community-Based Services
The cost of home and community-based services (waiver services and non-waiver services) are less than the cost of institutional services.
The average per participant expenditures for waiver and non- waiver Medicaid services must not cost more than the average per person costs of furnishing institutional care.
Waiver Services +
Non-Waiver Services
<
Institutional Services
Case management, respite, modifications, caregiver training, community transition, assistive technology, pediatric nurse aide, specialized medical equipment and supplies
All other professional claims such as private duty nursing, home health, HIT, Hospice, durable medical equipment, and therapies (PT, OT, ST)
Home and community-based services are less than or equal to institutional services
Inpatient hospitalizations
Nursing facility placement, both short and long term; and
All professional claims while institutionalized
CAP/C 1915(c) HCBS Waiver Stakeholder Engagement

5. No Change CAP/C Eligibility Current Proposed Draft
Target Population: 0-20
Eligibility: Medicaid Eligible children determine to be medically fragile who require…
Income limit for the individual requesting waiver participation limit
Assessment of Federal Poverty Limit is based on the individual’s income, not household total income
Target Population: 0-20
Eligibility: Medicaid Eligible children determine to be medically fragile who require…
Income limit for the individual requesting waiver participation limit
Assessment of Federal Poverty Limit is based on the individual’s income, not household total income
No Change
CAP/C 1915(c) HCBS Waiver Stakeholder Engagement

6. CAP/C Benefit Package: Family Supports
Current
Proposed Draft
Case Management: 288 units/yr (required)
Respite: up to 720 hrs/yr or 30 consecutive days institution respite based on the number of personal care hours per beneficiary
Commuter Time: up to 4 hrs/day
Sleep Time: 56 hrs/wk
Personal Time: 20 hrs/wk
Training and Education: up to $500/yr
Case Management: 288 units/yr (required)
Respite: 720 hrs/yr or 30 consecutive days institution respite per beneficiary (includes personal time)
Commuter Time: approvable up to max. # of hour to commute to work
Sleep Time: approvable up to max. # hour to support employment & inclusion
Training and Education: up to $500/yr
CAP/C 1915(c) HCBS Waiver Stakeholder Engagement

7. CAP/C Benefit Package: Modifications
Current
Proposed Draft
Home Modifications: up to $10,000 over the life of the waiver, prorated
Vehicle Modifications: up to $15,000 over the life of the waiver, prorated
Community Transition: up to $2,500 over the life of the waiver for use within initial 90-days post discharge
Modification budget combined over the life of the waiver (5years) for home and vehicle modifications addition of assistive technology; no proration or annual limits
Community Transition: up to $2,500 over the life of the waiver for use within initial 90-days post discharge
CAP/C 1915(c) HCBS Waiver Stakeholder Engagement

8. CAP/C Benefit Package: Beneficiary Care
Current
Proposed Draft
Pediatric Nurse Aide Services: up to $75,000/yr
Waiver Services: incontinence supplies, adaptive tri-cycles
CAP Nursing
In- Home Aide
Palliative and Bereavement Counseling Care
Pediatric Nurse Aide Services: based on person-centered care needs
Waiver Services: reusable incontinence supplies, adaptive tri-cycles and vehicle vest
Nursing available through Private Duty Nursing (state plan )*
In-Home Aide available through Personal Care Services (state plan) *
Palliative Care and Bereavement Counseling available through Home Health and Hospice, Behavioral Health (state plan) * and Caregiver training and education services (waiver service)
* May require revision of existing state plan service definitions
CAP/C 1915(c) HCBS Waiver Stakeholder Engagement

9. Case Studies Under the Current Waiver Under the Proposed Draft
Profile: 2 year old with congenital myopathy; vent and trach dependent; total ADLs needs; 3-4 hour suctioning; continuous pump feed at night; flaccid muscles
2 parent household; mother stays at home and father works full-time
Under the Current Waiver
Under the Proposed Draft
Service plan
Waiver services:
Case management units
Respite units
Nursing units
Non-waiver services:
PT units
OT units
ST units
Service plan
Waiver services:
Case management units
Respite units
Non-waiver services
Nursing units
PT units
OT units
PT units
CAP/C 1915(c) HCBS Waiver Stakeholder Engagement

10. Case Studies Under the Current Waiver Under the Proposed Draft
Profile: Three siblings under age 7; Child #1- fetal alcohol syndrome, seizures, developmental delays and limited to extensive assistance with ADLs; Child #2 and #3 are twins- child #2 mitochondrial metabolism disorder; child #3 mitochondrial metabolism disorder, G-Tube and grand-mal seizures; both requires 2-4 hours of supervision and intervention
Father has custody and works full-time
Under the Current Waiver
Under the Proposed Draft
Child #1
Wavier services:
In-home Aide units
CM 288 units
Respite 240 units
Child #2 &3
Waiver services:
CAP nursing units
CM 288 units
Respite 240 units
Child #1
Waiver services:
CM units
Respite units (shared)
Non-waiver
In-home aide units
Child #2 & 3
Waiver services:
CM 288 units
Respite units (shared) Non-waiver
Nursing units
CAP/C 1915(c) HCBS Waiver Stakeholder Engagement

11. Case Studies Under the Current Waiver Under the Proposed Draft
Profile: 10 year old; Cerebral Palsy; Asthma; total dependence on all ADLs; PRN medication to include O2
Custody granted to grandparents; grandmother stays at home; grandfather works full-time
Under the Current Waiver
Under the Proposed Draft
Service plan
Waiver services:
Pediatric nurse aide units
Respite units
Case management units
Home modification $10,000
Service plan
Waiver services:
Pediatric nurse aide units
Respite units
Case management units
Home modification $10,000
CAP/C 1915(c) HCBS Waiver Stakeholder Engagement

12. Case Studies Under the Current Waiver Under the Proposed Draft
Profile: 5 year old; premature at birth; delayed motor skills; left-side weakness; low weight; G-J tube feedings; extensive assistances with ADLs
Two parent household; both parents work full-time
Under the Current Waiver
Under the Proposed Draft
Service plan
Waiver services:
Case management units
Respite units
PNA units
Non-waiver services:
PT units
ST units
Service plan
Waiver services:
Case management units
Respite units
PNA units
Non-waiver services:
PT units
ST units
CAP/C 1915(c) HCBS Waiver Stakeholder Engagement

13. Case Studies Under the Current Waiver Under the Proposed Draft
Profile: 13-year-old with spina bifida, hydrocephalus, limited to extensive needs for ADLs,
2 parent household; Mom works part-time, Dad full time
Under the Current Waiver
Under the Proposed Draft
Service plan
Waiver services:
Case management units
Respite units
In-home aide ,104 units
Service plan
Waiver services:
Case management units
Respite units
Non-waiver services:
In-home aide ,104 units
CAP/C 1915(c) HCBS Waiver Stakeholder Engagement