1. PALLIATIVE CARE WAIVER STAKEHOLDER MEETING California Department of Health Services Medi-Cal Policy Division 11/29/06

2. OVERVIEW Roles/Responsibilities Home & Community-Based Services Waivers Features and Requirements Cost Neutrality Application Process

3. ROLES/RESPONSIBLITIES Centers for Medicare and Medicaid Services (federal CMS) CA Department of Health Services (CDHS) Medi-Cal Policy Division Waiver Analysis Section Children’s Medical Services (State CMS)

4. California Department of Health Services (CDHS) Single State Medicaid Agency Responsible for Oversight of Medi-Cal Waivers

5. Medi-Cal Policy Division Waiver Analysis Section Liaison between the State and the federal CMS Manage waiver application/renewal processes Ensure compliance with federal requirements Manage Interagency Agreement with other Depts

6. Waiver Analysis Section Role as Liaison Advocate for the State with federal CMS Provide technical assistance to Programs (i.e., State CMS) State CMS will operate and monitor the Palliative Care Waiver

7. MEDICAID WAIVERS

8. What is a Medicaid Waiver? Allows federal government to waive specified provisions of Medicaid law. Allows States flexibility in administering its Medicaid program to meet healthcare needs of its populations.

9. Types of Medicaid Waivers Section of Social Security Act 1115 – Demonstration Waivers 1915(b) – Freedom of Choice Waivers 1915(c) – Home and Community Based Services Waivers (HCBS)

10. HCBS Waivers Designed to offer safe and appropriate home care to individuals in lieu of care in an institution (e.g., nursing facility, hospital, etc.) Allows State to design waiver program to address needs of target population

11. HCBS Waivers Allows CMS to waive following requirements: Statewideness - allows geographic limit Comparability - allows focus on specific population Income and Resource Standards - allows exclusion of parental income

12. Requirements of HCBS Waivers Level of Care (e.g., nursing facility or hospital, etc.) Enrollment limit or cap Assurances (e.g., health and safety Fiscal Accountability

13. HCBS WAIVER REQUIREMENTS Services must be different from State Plan services (in scope amount or duration) Individual cannot be enrolled in two HCBS waivers at the same time Cost neutrality

14. COST NEUTRALITY Cost to Federal Government With the waiver must be less than or equal to cost without the waiver

15. COST NEUTRALITY FORMULA Waiver Beneficiaries Non-Waiver Beneficiaries Waiver + State Plan < Institutional + Ancillary Costs Costs

16. HCBS WAIVER DEVELOPMENT AND APPLICATION PROCESS

17. HCBS Waiver Development Process Takes 1 year to 18 months Consultation with federal CMS throughout process Stakeholder input during development and comments on draft application

18. Waiver Development Define population, services, provider types, operational methodology Research/resolve state/federal policy issues Obtain data and develop cost neutrality

19. Waiver Application Process Prepare draft application Obtain stakeholder input Obtain State approvals Submit final application to federal CMS

20. HCBS Waiver Application Process 90-day Clock Federal CMS has 90 days to review/approve or ask questions Federal CMS Sends Questions to State - Clock stops State responds to questions Resolve more policy issues Lots of discussions with federal CMS and program New 90-day Clock starts Federal CMS has 90 days to approve or disapprove application Waiver Approved

21. WAIVER APPROVAL Initially approved for 3 years/renewed for 5 years Conditions of Approval – May require Independent Assessment Additional Reporting Requirements Waiver Implementation – Submit required reports

22. Waiver Renewal Process – starts about 1 year before waiver approved

23. RELATED LINKS Federal CMS Websites General - http://www.cms.hhs.gov/home/medicaid.asp http://www.cms.hhs.gov/home/medicaid.asp HCBS Waiver Application - http://www.cms.hhs.gov/MedicaidStWaivProgD emoPGI/05_HCBSWaivers-Section1915(c).asp Medi-Cal Policy Institute – Medicaid Waivers: California’s Use of a Federal Option (check website for link)