concolidated waiver renewal - Pennsylvania Department of...

PA.0147.R06.00 Renewal

CMS Informal Comments

05/16/2017

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CMS INFORMAL REQUEST FOR ADDITIONAL INFORMATION Major Changes in the Renewal

1. Please note all proposed future effective dates throughout the waiver application will need to be deleted/revised with next amendment(s) to the waiver as appropriate.

ODP Response: Future amendments will delete effective dates that are no longer applicable. CMS – no additional comments

2. For CMS’ understanding, please explain why changes identified in the waiver will not go into effect until 1/1/18, e.g. rates, etc. ODP Response: On January 1, 2018, ODP will change the reimbursement methodology for Residential Habilitation and Life Sharing from a cost-based reimbursement to a fee schedule reimbursement. This date was selected to allow providers who must adjust to a new fee schedule for non-residential services on July 1, 2017 adequate time to plan their transition to the fee schedule for residential services. In addition, the January 1, 2018 date aligns with the promulgation of new Chapter 6100 regulations that will govern ODP’s home and community-based services.

CMS – no additional comments

Attachment #1 Transition 3. Please describe the similarities and differences between the services covered in

the approved waiver and the proposed limitations (Education Support, In-Home and Community Support, Companion, Community Participation Support).

ODP Response: In the current approved waivers the service definition for Education Support is very general and includes general adult educational services, classes, tutoring to receive a General Education Development (GED) degree and support to participate in an apprenticeship program. There are no limits on the current Education Support service. In the renewal, ODP modified the service definition to remove apprenticeship programs and GED programs because analysis of Education Support authorizations indicated no participants use this service for these

CONSOLIDATED WAIVER RENEWAL – CHANGES MADE SINCE APRIL 2017



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purposes. The service definition was revised to clearly enumerate expectations for college classes (including integration standards with the general student population). The following were added to the service definition: payment of general fees, on campus peer support, classes to teach deaf participants how to communicate and adult education or tutoring programs for reading or math instruction. Limits were added based on public comment received. ODP based the limits on current authorizations, publicly posted tuition fees for Comprehensive Transition Programs in the Commonwealth, and discussions with colleges. There are very few changes in the service definition for the current Home and Community Habilitation services and the proposed In-Home and Community Support services in the renewal. There is currently no limit on the amount of service an individual could receive. The proposed service definition, implements a limit effective January 1, 2018. The proposed service definition also decreases the allowable staff to individual ratio from 1:6 to 1:3. There are very few changes in the service definition for the current Companion services and the proposed Companion services in the renewal. There is currently no limit on the amount of service an individual could receive. The proposed service definition, implements a limit effective January 1, 2018. The proposed service definition also decreases the allowable staff to individual ratio from 1:6 to 1:3. Community Participation Support replaces the current approved Licensed Day Habilitation and Prevocational services. The primary distinction in the service definition is broadening the type of support available to provide opportunities for these activities to occur in non-facility settings and establishing a target for the frequency that activities are provided in non-facility settings. Licensed Day Habilitation, Prevocational services and employment services in the approved waiver has a limit of 40 hours per week for any combination of services. To incentivize employment, in the waiver application, for people who use a Supported or Advanced Supported Employment service, the limit is 50 hours per week. CMS – no additional comments

4. Please provide additional specific details of a transition plan for individuals impacted by the reduction of hours per day for In-Home and Community Support, Companion, and Community Participants Supports. The state has identified the need for transition, but is missing details of the plan. CMS recommends including the details that individuals have from 7/01/17 to 1/01/18 to meet,



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discuss, and identify other services and/or support that will meet the needs of the participants. The state should include appeal rights as applicable.

ODP Response: This section of the waiver will be revised to state, “Participants impacted by new limitations on In-Home and Community Support, Companion and/or Community Participation Support will have from 7/01/17 through 12/31/17 to meet with the Individual Support Plan team, discuss and identify other services and/or support that will meet the needs of the participants. From 7/1/17 through 12/31/2017, for participants who have complex behavioral or medical needs, the ISP team may complete and submit a variance request to allow for an exception to the 14 hour limitation on In-home and Community Support, Companion and Community Participation Supports.” ODP bulletin 00-08-05 entitled Due Process and Fair Hearing Procedures for Individuals with Mental Retardation states, “The Department’s fair hearing and appeals process does not apply to the following actions: Changes solely established by a Waiver amendment approved by the Centers for Medicare and Medicaid Services.” In accordance with this policy, participants will not be informed of the opportunity to request a fair hearing for any changes made solely because of a change in the Waiver approved by CMS. Appendix F describes in detail appealable actions and how participants are informed of the opportunity to request a fair hearing for these appealable actions. CMS – no additional comments

5. The State’s transition plan regarding behavior therapy (IDT to meet up to six months after 7/01/17) is not a person-centered approach and doesn’t enable an individual to access needed services timely. By 7/01/17, behavior therapy is no longer an option as a waiver service so alternatives should be in place prior to its elimination.

ODP Response: This section of the waiver will be revised to say, “Behavior Therapy is the only service being removed from the waiver. Behavior Therapy was an option under the Therapy service. One participant in the Consolidated waiver is currently authorized to use Behavior Therapy. This participant is working with his or her service plan team to meet, discuss and identify other services and/or supports that will meet his or her needs by June 30, 2017.” CMS – Please make the revisions noted. No additional comments. ODP Response: Revisions have been made.



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6. Please explain if behavior therapy is provided under the state’s Medicaid State Plan and/or other options. Please explain if individuals utilizing this service have other options or replacements for this service.

ODP Response: Two of the three participants who were authorized for this service have already transitioned from Behavior Therapy to either the Behavioral Support service in the waiver or to therapy through insurance. CMS – no additional comments

7. According to 42 CFR 441.301(a), the State must include a plan on how

participants are informed of the opportunity to request a fair hearing. With the

elimination of Behavior therapy as a waiver service, please identify and include

language to describe how participants are informed of the opportunity to request

a fair hearing and/or appeals based upon these changes that are effective for

July 1, 2017. If applicable, please add language that explains why participants

are not entitled to an opportunity to a fair hearing based upon the proposed

changes.

ODP Response: ODP bulletin 00-08-05 entitled Due Process and Fair

Hearing Procedures for Individuals with Mental Retardation states, “The

Department’s fair hearing and appeals process does not apply to the

following actions: Changes solely established by a Waiver amendment

approved by the Centers for Medicare and Medicaid Services.” In

accordance with this policy, participants will not be informed of the

opportunity to request a fair hearing for any changes made solely because

of a change in the Waiver approved by CMS. Appendix F describes in

detail appealable actions and how participants are informed of the

opportunity to request a fair hearing for these appealable actions.

CMS – no additional comments

Main – Attachment #2 Home and Community-Based Settings Waiver Transition Plan

8. The State must include the following language under this section: The State assures that the settings transition plan included with this waiver renewal will be subject to any provisions or requirements included in the State's approved Statewide Transition Plan. The State will implement any required changes upon approval of the Statewide Transition Plan and will make conforming changes to its waiver when it submits the next amendment or renewal.

ODP Response: This language will be added to the waiver. CMS – Please make the revisions noted. No additional comments. ODP Response: Revisions have been made.



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9. CMS recommends the State to include details that the Statewide Transition Plan received initial approval on 8/30/2016.

ODP Response: This information will be added to the waiver. CMS – Please make the revisions noted. No additional comments. ODP Response: Revisions have been made.

Appendix A Waiver Administration and Operation 10. For Appendix A, one of the functions of the Administrative Entities (AEs) is

participant waiver enrollment – receive/review applications, ensure initial and annual completion of PUNS or its successor and refer applicants for eligibility decisions. Back in December 18, 2015, CMS recommended disapproval of the proposed claiming plan for enrollment fees for the Aging Waiver and move the responsibility from the Area Agency on Aging (AAAs) to Independent Enrollment Broker (IEBs) because we believed them to be duplicative of what the enrollment broker was performing and being paid to do. ODP Response: This waiver does not use IEBs for enrollment of participants or for any other function.

- How would the responsibility of AEs in the Consolidated waiver defer from the responsibilities of IEBs? ODP Response: This would not be applicable to this waiver. The AEs would be the only entity responsible for enrolling participants in this waiver.

- Is this the same concept?

ODP Response: The concept of the Aging Waiver using the IEBs is not the same for this waiver.

- What is the rate to do this? ODP Response: There is no rate since ODP does not use IEBs.

- Will the AEs have the sole responsibility of enrolling individuals or will they share in the responsibility with the enrollment broker?

ODP Response: The AEs are the only entity responsible for participant waiver enrollment for this waiver. This waiver does not utilize IEBs.

CMS – No additional comments. Appendix A-3 Contracted Entity



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11. The State has marked that contracted entities do not perform waiver operational

and administrative functions on behalf of the Medicaid agency and/or the operating agency (if applicable). Please verify if Administrative Entities (AE) and Independent Enrollment Brokers (IEB) perform administrative function on behalf of the Medicaid Agency.

ODP Response: The AEs are the sole entities performing waiver operations and administrative functions on behalf of the Medicaid agency and the operating agency. This waiver does not use IEBs. CMS – No additional comments.

Appendix A-6 Assessment Methods and Frequency: 12. Please indicate if the conduct of ODP assessments are subject to review by the

Medicaid agency to ensure that the operating agency is exercising its

responsibilities and that there are procedures that provide for the reporting of

assessment results to the Medicaid agency.

ODP Response: The Office of Medical Assistance Programs reviews ODP

actions taken to remedy AE noncompliance with the agreement and OMAP

reviews the evidence reports submitted to CMS. Further, upon annual

finalization of the statewide assessment report, a copy will be provided to

the Deputy Secretary of Office of Medical Assistance Programs.

CMS – No additional comments.

13. ODP monitors AEs on a three year cycle. During that period, ODP gathers AE

performance data annually on one-third of AEs. During the cycle the AE must

complete a self-assessment in accordance with the ODP Oversight Process. The

AE self-assessment is reviewed and validated by ODP. Please explain how

ODP is making sure the self-assessments are accurate. Please explain when

during the three-year cycle the self-assessment is required to be completed,

reviewed, and validated by ODP, i.e. the beginning of the cycle, mid-point, end,

etc.

ODP Response: Following the onsite review, ODP’s Quality Assurance and Improvement (QA&I) team will compile a written QA&I Comprehensive Report for each AE within 30 calendar days of the onsite review completion. The report will compile findings from desk review and onsite review, face-to-face interviews, and self-assessments, as applicable. For each AE, the QA&I Comprehensive Report will:

Highlight those areas where the AE is doing well related to person-centered services delivery and best practices;

Analyze performance in ODP’s quality focus areas for the current QA&I cycle;



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Compare results of the desk and onsite reviews with the entity’s self-assessment;

Summarize those instances of non-compliance that were remediated during the onsite review;

Outline issues of non-compliance expected to be remediated within 30 calendar days of report receipt;

Recommend plans of improvement where compliance is below established thresholds of 86%; and

Recommend improvement activities to be addressed during the remainder of the QA&I cycle, including systemic quality improvement projects to incorporate into Quality Management Plans.

AEs will have 30 calendar days to review and respond to the QA&I Comprehensive Report. The response will include the entity’s plans and timelines to address instances of non-compliance requiring remediation within 30 days, and Plans to Prevent Recurrence. The response also may address points of disagreement with the report findings including appropriate evidence justifying the disagreement. Entities are responsible for submitting evidence of remediation along with the submission of the QA&I Comprehensive Report response to the ODP QA&I Coordinator. The ODP QA&I Coordinator will review and approve all remediation and Plans to Prevent Recurrence (PPR) activities in order to close the QA&I Comprehensive Report. Additionally, entities will submit evidence to demonstrate that the PPR activities are successfully completed as they occur. Each year in the self-assessment process, entities are expected to address the impact of PPR activities completed within the past year. If necessary, follow-up site visits may also be conducted to adequately assure that all remediation and PPR actions have been completed as documented in the QA&I Comprehensive Report and for ODP or the AE, as appropriate, to provide technical assistance. All documentation used to complete the self-assessment must be maintained and made available to ODP upon request. AEs that do not submit a self-assessment to ODP by the due date will be considered in non-compliance with the QA&I process requirements and will be scheduled for an onsite review regardless of the distribution assigned by ODP. Annually, at the completion of the self-assessment process for all entities, ODP will issue an aggregate report of self-assessment results and analysis statewide. This report will be used to inform the QA&I process throughout the year and technical assistance targeted to AEs, SCOs and providers.



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Appendix A – Quality Improvement Systems: 14. Performance Measure AA2 - Number and percent of eligible applicants having an

emergency need or who have been identified as being in reserved capacity

status who receive preference in waiver enrollment. Percent = number of eligible

applicants having an emergency need or who have been identified as being in

reserved capacity status who receive preference in waiver enrollment/number of

eligible applicants. Please clearly identify what the numerator and denominator

are for this PM.

ODP Response: Performance Measure AA2 will be revised to state the

following, “Number and percent of eligible applicants having an emergency

need or who have been identified as being in reserved capacity status who

receive preference in waiver enrollment. Numerator = number of eligible

applicants having an emergency need or who have been identified as being

in reserved capacity status who receive preference in waiver enrollment.

Denominator = number of eligible applicants.

CMS – Please make the revisions noted. No additional comments. ODP Response: Revisions have been made.

15. Performance Measure AA3 - Number and percent of participants issued fair

hearing and appeal rights in accordance with policies and procedures. Numerator

= number of participants issued fair hearing and appeal rights in accordance with

policies and procedures. Denominator = number of participants reviewed.

Please move the representative sample data collection from “other” to

representative sample box.

ODP Response: Performance Measure AA3 will be revised to move the

representative sample data collection from “other” to the “representative

sample” box. The other box will no longer be checked.


16. Performance Measure AA5 states a gathering of 100% review data annually but

under Appendix A-6 the “narrative” there indicates a 3 year cycle review. Please

explain.

ODP Response: Each year of the 3-year cycle, one-third of Administrative

Entities, distributed geographically to represent the state, are selected for

review. 100% of the data collected each year is aggregated for review and

analysis annually.



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Appendix B-3-c Reserved Waiver Capacity 17. Please define in the waiver application unanticipated emergencies and the

criteria.

ODP Response: The following information will be added to this section of the waiver, “ODP defines an unanticipated emergency as an occurrence when an individual or participant has an imminent risk of: institutionalization within twenty-four (24) hours, substantial self-harm or substantial harm to others; if the individual does not immediately receive services that are eligible through ODP and this imminent risk is precipitated by at least one of the following situations:

The illness or death of a caretaker;

The sudden loss of the individual’s home (for example, due to fire or natural disaster); or

The loss of the care of a relative or caregiver, without advance warning or planning.”


Appendix B-3-f Selection of Entrants to the Waiver 18. Please provide more details of the selection of entrants to the waiver after

reserved capacity has been met. CMS is unclear how selection is made for individuals who do not meet reserved capacity criteria, e.g. who is next in line and why (application date).

ODP Response: ODP works closely with AEs to manage waiver capacity. This includes tracking both the number of individuals utilizing each type of reserved capacity and the unduplicated number of individuals enrolled in the waiver throughout each year. When there is available capacity the AE enrolls an individual who will not be utilizing reserved capacity, they must enroll a person who meets emergency need status in the Prioritization of Urgency of Need for Services (PUNS). The PUNS was developed to gather information in order to categorize the needs of people with an intellectual disability, developmental disability or autism who have requested services from the County MH/ID Program or Administrative Entity. CMS – Is there any possibility of two people next in line? What would be the tie breaker or deciding factor of who gets the slot? ODP Response: When capacity becomes available, the AE would review the PUNS and other available information to determine which individual



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has the most emergent needs. This information allows the AEs to manage who would be in most need of services in order to allocate capacity. The available capacity would be offered to the person who was identified as having the most emergent need, this eliminates the need for any tie breaker.

Appendix C-1-a Participant Services Based on a review of the service descriptions in the waivers, CMS has the following questions and comments: General: CMS has updated its policy for how services from 1915(c) waivers are

reviewed for inclusion in the Medicaid state plan. This updated policy affords more

flexibility to States, and asks States to share with CMS why services should remain in

the 1915(c) waiver and do not meet the requirements for coverage set forth in 1905(a)

of the Social Security Act. In order to better assist the state, CMS has provided the

recent Autism and Early and Periodic Screening, Diagnostic and Treatment (EPSDT)

CMS Informational Bulletins to help aid the state in determining why services do not

comport with 1905(a) authorities:

i. The EPSDT Informational Bulletin issued 1/5/2017 -

https://www.medicaid.gov/federal-policy-

guidance/downloads/cib010517.pdf

ii. The ASD treatment services Informational Bulletin issued 7/14/2014 -

http://www.medicaid.gov/Federal-Policy-Guidance/Downloads/CIB-07-07-

14.pdf

iii. The ASD FAQs issued on 9/24/2014 - http://www.medicaid.gov/Federal-

Policy-Guidance/downloads/FAQ-09-24-2014.pdf

General: CMS also wanted to remind the State of their EPSDT obligations since many

of the 1915(c) waiver services are targeted to children. EPSDT entitles enrolled infants,

children and adolescents under 21 years of age to any medically necessary treatment

or procedure that fits within any of the categories of Medicaid-covered services listed in

Section 1905(a) of the Social Security Act if that treatment or service is necessary to

“correct or ameliorate” defects and physical and mental illnesses or conditions. The

EPSDT benefit prohibits the targeting of services based on the age of a child or by a

specific diagnosis. States have an affirmative obligation to make sure that Medicaid-

eligible children and their families are aware of EPSDT and have access to required

screenings and necessary treatment services. States must arrange (directly or through

delegations or contracts) for children to receive the physical, mental, vision, hearing,

and dental services they need to treat health problems and conditions. If the state keeps

the services in the 1915(c) waivers the EPSDT state obligations will still be in effect and

https://www.medicaid.gov/federal-policy-guidance/downloads/cib010517.pdf

https://www.medicaid.gov/federal-policy-guidance/downloads/cib010517.pdf

http://www.medicaid.gov/Federal-Policy-Guidance/Downloads/CIB-07-07-14.pdf

http://www.medicaid.gov/Federal-Policy-Guidance/Downloads/CIB-07-07-14.pdf

http://www.medicaid.gov/Federal-Policy-Guidance/downloads/FAQ-09-24-2014.pdf

http://www.medicaid.gov/Federal-Policy-Guidance/downloads/FAQ-09-24-2014.pdf



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the CMS expectation will be that the state is meeting all the EPSDT requirements set

forth in 1905(r) of the Social Security Act.

Behavioral Support Services

19. Please review the CMS policy guidance provided regarding EPSDT. Please

describe why services should remain in the 1915(c) waiver for individuals 21 and

under and do not meet the requirements for coverage set forth in 1905(a) of the

Social Security Act.

ODP Response: The Behavioral Support service definition will be revised

to state, “Behavioral Support services can only be provided to adult

participants. All necessary Behavioral Support services for children under

age 21 are covered in the state plan pursuant to the EPSDT benefit.”

CMS: Please make the revisions as noted above. Also, please add the following

statement under the limits section of the service definition OR right after the

statement regarding individuals under 21. “To the extent that any listed services

are covered under the state plan, the services under the waiver would be limited

to additional services not otherwise covered under the state plan, but consistent

with waiver objectives of avoiding institutionalization”.

ODP Response: Revisions have been made.

Consultative Nutritional Services

20. Please review the CMS policy guidance provided regarding EPSDT. Please

describe why services should remain in the 1915(c) waiver for individuals 21 and

under and do not meet the requirements for coverage set forth in 1905(a) of the

Social Security Act.

ODP Response: The Consultative Nutritional Services definition currently

has language that states this service is only available to individuals age 21

and older. The service definition will be revised as follows to make this

point clearer, “Consultative Nutritional Services can only be provided to

adult participants. All medically necessary Consultative Nutritional

Services for children under age 21 are covered in the state plan pursuant to

the EPSDT benefit. Consultative Nutritional Services may only be funded

for adult participants through the Waiver if documentation is secured by

the Supports Coordinator that shows the service is medically necessary

and either not covered by the participant’s insurance or insurance limits

have been reached. A participant’s insurance includes Medical Assistance

(MA), Medicare and/or private insurance.”

CMS: Please make the revisions as noted above. Also, please add the following

statement under the limits section of the service definition OR right after the

statement regarding individuals under 21. “To the extent that any listed services



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are covered under the state plan, the services under the waiver would be limited

to additional services not otherwise covered under the state plan, but consistent

with waiver objectives of avoiding institutionalization”.


Community Participation Support 21. Please revise the service definition to eliminate language “included, but not

limited to”. The State must be specific in the activities allowed but can provide a broad scope for activities included.

ODP Response: The Community Participation Support service definition will be revised as follows to remove the language, “This service is expected to result in the participant developing and sustaining a range of valued social roles and relationships; building natural supports; increasing independence; increasing potential for employment; and experiencing meaningful community participation and inclusion. Activities include the following supports for:” CMS: Please make the revisions as noted above. No additional comments.


22. Please explain the information described regarding Older Adult Living Centers

(individuals 60+ years, individuals w/dementia, and individuals under 60 years) may receive services at these types of facilities. Please explain who is not allowed to receive services at these types of settings and why.

ODP Response: In Pennsylvania, Adult Training Facilities (subject to licensure under 55 Pa. Code Chapter 2380) and Older Adult Daily Living Centers (subject to licensure under 6 Pa. Code Chapter 11) have distinct eligibility criteria for admissions. The distinctions in eligible populations for these two types of facilities are based on age and presence of dementia or dementia-related diagnosis.

In Adult Training Facilities (subject to licensure under 55 Pa. Code Chapter 2380) services are provided to four or more individuals, who are 59 years of age or younger and who do not have a dementia-related disease as a primary diagnosis. Older Adult Daily Living Centers (subject to licensure under 6 Pa. Code Chapter 11) serve individuals with functional impairment who are 60 years of age or older, or who are 18 years of age or older and have post-stroke dementia, Parkinsonism or a dementia-related disease such as Alzheimer’s.



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Community Participation Supports services may be provided in both types of facilities but, given the needs of the populations served, the expectations for activities provided outside of the facility differ.

CMS: Please make the revisions as noted above. No additional comments.

ODP Response: This information was already included in the waivers

submitted to CMS.

23. Please note the 9/01/18 effective date of change for the phasing for Adult training

facilities or Vocational facilities should be included under the settings transition plan along with the details of the transition in attachment #2.

ODP Response: We would like to take this opportunity to extend the effective date for this provision to July 1, 2019 in accordance with the CMCS Informational Bulletin regarding Extension of Transition Period for Compliance with Home and Community-Based Settings Criteria. This will give providers two years to ensure that each participant is provided with opportunities for community integration consistent with his or her preferences, choices and interests.

Attachment #2: Home and Community-Based Settings Waiver Transition Plan will be revised with the following information, “Description: Provider Service Alignment with Waiver. Time for providers to analyze services rendered and make changes to comply with waiver. This includes compliance with the Community Participation Support requirement that beginning July 1, 2019, participants may not receive services in a licensed facility for more than 75% of his or her support time, on average, per month. This also includes compliance with the requirement in Community Participation Support that starting January 1, 2022, services may not be provided in any facility required to hold a 2380 or 2390 license that serves more than 150 individuals at any one time. Start Date: March 2017 Target End Date: March 2020. Deliverable: No Deliverable For This Item Description: Revise Provider Monitoring Tool. Revise provider monitoring tool to capture new requirements in waiver renewals and regulations. This includes compliance with the Community Participation Support requirement that beginning July 1, 2019, participants may not receive services in a licensed facility for more than 75% of his or her support time, on average, per month. This also includes compliance with the requirement in Community Participation Support that starting January 1, 2022, services may not be provided in any facility required to



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hold a 2380 or 2390 license that serves more than 150 individuals at any one time. Start Date: March 2017 Target End Date: July 2022 Deliverable: Provider Monitoring Tool Description: Provider Self-Assessment All waiver providers will complete a self-assessment of their compliance with current applicable waivers, regulations and policies. This includes compliance with the Community Participation Support requirement that beginning July 1, 2019, participants may not receive services in a licensed facility for more than 75% of his or her support time, on average, per month. This also includes compliance with the requirement in Community Participation Support that starting January 1, 2022, services may not be provided in any facility required to hold a 2380 or 2390 license that serves more than 150 individuals at any one time. Start Date: September 2017 Target End Date: November 2022 Deliverable: Provider Tracking Tool” CMS: Please make the revisions as noted above. No additional comments.


24. Please note the 3/17/19 effective date of prohibiting Adult Training and

Vocational facilities as allowable settings for CPS should be included under the settings transition plan along with details of the transition in attachment #2.

ODP Response: The waiver renewals do not prohibit Adult Training Facilities and Vocational Facilities as allowable settings for Community Participation Support. We would like to take this opportunity to extend the effective date for this provision to January 1, 2022 in accordance with the CMCS Informational Bulletin regarding Extension of Transition Period for Compliance with Home and Community-Based Settings Criteria. The Attachment #2: Home and Community-Based Settings Waiver Transition Plan will be revised as written in the question above to reflect that starting January 1, 2022, services may not be provided in any facility required to hold a 2380 or 2390 license that serves more than 150 individuals at any one time. CMS: Please make the revisions as noted above. No additional comments.




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25. Please provide additional details regarding the reduced maximum 24 hour per day to 14 hours for In-Home Support, Community Support, Companion, and Community Participation Support under the attachment #1 section of the renewal.

ODP Response: Attachment #1 in the Main Module of the waiver will be revised to state, “Participants impacted by new limitations on Education Support, In-Home and Community Support, Companion and/or Community Participation Support will have from 7/01/17 through 12/31/17 to meet with the Individual Support Plan team, discuss and identify other services and/or support that will meet the needs of the participants.” CMS: Please make the revisions as noted above. No additional comments.


Education 26. The State has established limits on who can receive sign language instruction.

Please explain and/or add more details to explain why the limit is established. Can individuals who don’t receive sign language as a waiver service receive it elsewhere?

ODP Response: The lifetime limit of $35,000 for Education Support services was established based on the estimated cost of college certificate programs in Pennsylvania. Adult participants may also receive sign language instruction through In-Home and Community Support and/or through Speech and Language Therapy. CMS: No additional comments.

In-Home and Community Support 27. Specific employment-related activities should not be included under residential

habilitation service and should be provided/reimbursed under prevocational, supported employment, advanced supported employment, or small group employment. Please explain and identify how these activities are general or specific and do not duplicate other services under the waiver. The service definition may need revision.

ODP Response: The In-Home and Community Support service definition will be revised to remove number 17 (which includes employment activities) from the list of assistance, support and guidance that can be provided to participants as part of this service. CMS: Please make the revisions as noted above. No additional comments.




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28. Please note the change implementing multiple staffing levels will need to be reflected fully in appendix I-2-a and appendix J tables.

ODP Response: The tables in appendix J will be revised to reflect this information. The CMS Technical Guide does not require this level of detail be captured in section I-2-a and ODP has already exceeded the character limit for this section of the waiver. ODP requests that it be sufficient for this level of detail to be included in the service definitions and Appendix J tables. CMS: Please make the revisions as noted above. No additional comments. For

future reference, the state may use the Optional Attachment to add information

from other sections of the waiver application that exceed the character count.


29. Please provide additional details for transition regarding the reduced maximum 24 hour per day to 14 hours for In-Home Support, Community Support, Companion, and Community Participation Support under the attachment #1 section of the renewal.

ODP Response: Attachment #1 in the Main Module of the waiver will be revised to state, “Participants impacted by new limitations on Education Support, In-Home and Community Support, Companion and/or Community Participation Support will have from 7/01/17 through 12/31/17 to meet with the Individual Support Plan team, discuss and identify other services and/or support that will meet the needs of the participants.”



Music Therapy, Art Therapy and Equine Assisted Therapy 30. The State has categorized this service as Day Treatment. Within the service

definition the State has indicated individuals with/without mental illness may be eligible to receive this service. Since the category day treatment is defined as services necessary for the diagnosis or treatment of person’ mental illness provided in a fixed site facility (generally day services), CMS recommends the State categorize the service under “Other” (other health and therapeutic services).

ODP Response: The service definition will be revised to reflect the “other” categorization.



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31. Please explain why equine therapy is not provided to individuals under 21 years

through the waiver service.

ODP Response: The service definition submitted to CMS allows participants under 21 years of age to receive Equine Assistance Therapy as it is not covered by Medical Assistance. CMS: No additional comments.

32. Please explain why individuals who receive residential habilitation, life sharing or

supported living may not receive these services.

ODP Response: The services (therapies, nursing and behavioral supports)

that are mutually excluded from residential habilitation, life sharing or

supported living are those services that are intrinsic to and must be

integrated fully into the residential service. These excluded services are

factored into the fee schedule for residential services based on the acuity

level of the participant beginning January 1, 2018.

CMS: No additional comments.

33. The service description provided in the waiver may comport with the Therapy

benefit requirements at 42 CFR 440.110. Please review the guidance provided

and share if the state will be relocating this service to the Medicaid state plan. If

relocating the service under the Medicaid state plan, please specify under which

1905(a) benefit.

ODP Response: Music Therapy, Art Therapy and Equine Assisted Therapy

are not covered therapies for adults under Pennsylvania’s Medicaid state

plan and Pennsylvania has no plans to relocate this service to the Medicaid

state plan.

34. In the waiver description please add the following attestation language in the

Limits box: “To the extent that any listed services are covered under the state

plan, the services under the waiver would be limited to additional services not

otherwise covered under the state plan, but consistent with waiver objectives of

avoiding institutionalization.”

ODP Response: The service definition submitted to CMS contains similar

language, “Music Therapy and Art Therapy may only be funded for adult



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participants through the Waiver if documentation is secured by the

Supports Coordinator that shows the service is medically necessary and

either not covered by the participant's insurance, insurance limitations

have been reached, or the service is not covered by Medical Assistance or

Medicare or limitations for Medical Assistance or Medicare have been

reached… Equine Assisted Therapy can be provided to participants of any

age as it is not covered by Medical Assistance. For school age participants,

Supports Coordinators must document that Equine Assisted therapy is not

covered through the participant’s individualized education plan (IEP) or

through the participant's insurance.” This information can be moved to the

limits box if CMS prefers.



35. The State has opted to include and bundle three service components under this service (music, art, equine). Please note since the service is bundled, each service component will need to be broken out under the appendix J tables. ODP Response: The tables in appendix J will be revised to reflect this information. CMS: Please make the revisions as noted above. No additional comments.


Respite 36. Please identify which type of settings would be considered “non-waiver funded

licensed residential settings” in addition to hotels. The State needs to be as specific as possible identifying the approved settings for this service.

ODP Response: Settings considered non-waiver funded licensed residential settings would include residential settings located on a campus or that are contiguous to other ODP-funded residential settings (settings that share one common party wall are not considered contiguous). This will also include settings enrolled on or after the effective date of the Chapter 6100 regulations that are located in any development or building where more than 25% of the apartments, condominiums or townhouses have waiver funded Residential Habilitation, Life Sharing or Supported Living being provided. CMS: Please add these details to this section. No additional comments.




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Supported Employment

37. Career Assessment – Expanded day habilitation services, Supported employment services may not be provided in residential settings. Please revise the service and definition.

ODP Response: ODP requests a citation of where it is stated that Supported Employment services may not be provided in residential settings. The Waiver Technical Guide states the following for Supported Employment, “Supported employment individual employment supports may also include support to establish or maintain self-employment, including home-based self-employment.” Does your assertion mean that Supported Employment may only be used for support to establish or maintain home-based self-employment when the individual’s home is somewhere other than a residential setting? Does your assertion mean that the Supported Employment provider cannot go to the residential setting to conduct informational interviews with staff who work at the residential setting as part of the career assessment? CMS: After additional consideration, CMS supports individuals’ needs to complete career assessments within their residential settings; however, the state must include additional language for clarification and assurances of non-duplication. The supported employment service definition identifies this service may be provided in a variety of settings and specifically identifies career assessment may be provided in a residential settings. Please revise the service definition to indicate this service component (career assessment) may be provided within a variety of settings such as the residential setting when identified as a need and must be time limited. CMS recommends adding language specifying the end result would be a completed assessment and/or identified as no longer a need. Language that defines “time limited”. ODP Response: Revisions have been made.

38. Job finding or development activities may not be provided in residential habilitation settings. Please revise the service and definition.

ODP Response: ODP requests a citation of where it is stated that Supported Employment services may not be provided in residential settings. Does this mean that the Supported Employment provider cannot go to the residential setting to review available job opportunities, practice interview skills, and fill out job applications with the participant when the participant is most comfortable in his or her home environment?



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CMS: After additional consideration, CMS individuals’ needs to complete job finding or development within their residential setting; however, the state must provide include additional language for clarification and assurances of non-duplication. The supported employment service definition identifies this service may be provided in a variety of settings and specifically identifies job finding or job development may be provided in a residential settings. Please revise the service definition to indicate this service component may be provided within a variety of settings such as residential settings when identified as a need. Please include the restriction/prohibition that any component of supported employment may not be provided/billed at the same time as any residential habilitation service aside from companion services which identifies the component of personal assistance. ODP Response: Revisions were made to indicate that the service can be provided within a variety of settings. Residential Habilitation services are billed as a day unit which means that supported employment would be billed at the same time as the residential habilitation service. Further, companion services are encompassed in the residential habilitation service rate.

39. Supported Employment and components of this service furnished under the waiver may not include services available under a program funded under section 110 of the Rehabilitation Act of 1973 or section 602(16) and (17) of the Individuals with Disabilities Education Act (20 U.S.C. 1401(16 and 17). Please revise the service definition to include this statement. ODP Response: The Supported Employment service definition submitted to CMS states, “Supported Employment services may not be rendered under the Waiver until it has been verified that:

The services are not available in the student’s (if applicable) complete and approved Individualized Education Program (IEP) developed pursuant to IDEA;

OVR has closed the participant’s case or has stopped providing services to the participant;

The participant is determined ineligible for OVR services; or

It has been determined that OVR services are not available. If OVR has not made an eligibility determination within 120 days of the referral being sent, then OVR services are considered to not be available to the participant.”


Supports Broker



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40. Please describe within the service definition what protections are in place for legally responsible, relatives, and legal guardians serving as support brokers for waiver participants.

ODP Response: The CMS Waiver Technical Guide reads that additional protections must be in place when legally-responsible individuals are permitted to provide personal care or similar services (such as home health aide, homemaker, chore and companion services). The Supports Broker service has no personal care or similar component, and involves a degree of programmatic knowledge and expertise exceeding that of legally responsible individuals, relatives, and legal guardians who are not Supports Brokers. There is no prohibition against legally responsible individuals, relatives, and legal guardians serving as their support broker. However, Managing Employers and Common-Law Employers, including surrogates, are prohibited from enrolling as Support Service Professionals and rendering Supports Broker services, and Supports Brokers may not perform duties for which Managing Employers and Common-Law Employers are responsible. Legally responsible individuals, relatives, and legal guardians may not serve in both capacities. All Supports Brokers must successfully complete a Supports Broker Certification Program, one element of which includes establishing role boundaries between natural supports, Managing Employers and Common-Law Employers, Supports Coordinators, and Supports Brokers. The standard protection for all services provided by legally responsible individuals, relatives, and legal guardians is monitoring to assure that services provided are in compliance with the individual plan.

CMS: CMS’s intent was not to insinuate legally responsible, relatives, or legal

guardians for individuals could not be support brokers. It is a paid position that

can create potential conflicts for individuals. CMS made the inquiry to learn if the

state had implemented additional protections to ensure the individual’s best

interests are preserved.

Advanced Supported Employment 41. The State has proposed paying for outcomes specifically successful retention of

a job as evidenced by a participant working a minimum of 5 hours per week for at least four months. Please explain the state’s rationale of how this criteria is evidence of a successful competitive employment.

ODP Response: Advanced Supported Employment is only available to participants who have little or no job skills training or development or any work related experience including volunteering. Participants must have either been found ineligible or OVR services in the past or have not had a successful outcome there. Participants would not be able to complete a traditional vocational assessment, which is why we chose to use Discovery and Customized Employment provided by a nationally certified consultant.



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ODP believes that given the participant’s lack of employment history and the significance of their disability, if they qualify for this services, five hours per week of successful employment and job retention are indications of success for the person. This determination was made in consultation with providers of supported employment and Discovery and Customized Employment services. CMS: No additional comments.

42. Advanced Supported Employment services furnished under the waiver may not

include services available under a program funded under section 110 of the Rehabilitation Act of 1973 or section 602(16) and (17) of the Individuals with Disabilities Education Act (20 U.S.C. 1401(16 and 17). Please revise the service definition to include this statement.

ODP Response: The service definition submitted to CMS states, Eligibility for Advanced Supported Employment is limited to participants whose preferences, skills, and employment potential cannot be best determined through traditional, standardized means due to the impact of their disability. Specifically, the participant: 1. Has been found ineligible for or has a closed case with Office of Vocational Rehabilitation (OVR) services and chooses not to be re-referred or it has been determined that OVR services are not available. If OVR has not made an eligibility determination within 120 days of the referral being sent, then OVR services are considered to not be available to the participant;” The service definition will be revised to state, “Advanced Supported Employment services furnished under the waiver may not include services available under section 602(16) and (17) of the Individuals with Disabilities Education Act (20 U.S.C. 1401 (16 and 17).” CMS: Please make the revisions as noted above as well as the additional

information requested under supported employment.


Assistive Technology 43. In February 2016, Medicaid published the home health face-to-face final rule

which went into effect July 1, 2016. The regulation provides a federal framework

for defining medical equipment and appliances. Based on this definition, there

will be items currently coverable under 1915(c) waivers that must now be

covered under the mandatory home health benefit.

As indicated in the final rule, CMS is allowing a delay in compliance based on legislative timeframes. If the state needs to seek legislative approval to implement the new definitions, the state has up to one year to come into



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compliance, if their legislature has met in that year (i.e., July 2017) or 2 years to come into compliance (i.e., July 2018). At that time items and services that meet the criteria for coverage under the home health benefit must be covered according to home health coverage parameters. To ensure full coverage for medical equipment and appliances, to the extent that there is overlap in coverage with another benefit, states must nevertheless provide for the coverage of these items under the mandatory home health benefit. Please advise CMS of the state’s timeframe for implementation of the home health final rule as outlined above and revise the waiver to include the following assurance: “To the extent that any listed services are covered under the state plan, the services under the waiver would be limited to additional services not otherwise covered under the state plan, but consistent with waiver objectives of avoiding institutionalization.” ODP Response: Pennsylvania’s currently approved MA state plan complies with the home health final rule. The Assistive Technology service definition submitted to CMS states, “Items reimbursed with Waiver funds shall be in addition to any equipment or supplies provided under the MA State Plan… When Assistive Technology is utilized to meet a medical need, documentation must be obtained stating that the service is medically necessary and not covered through the MA State Plan which includes EPSDT, Medicare and/or private insurance. When Assistive Technology is covered by the MA State Plan, Medicare and/or private insurance, documentation must be obtained by the SC showing that limitations have been reached before the Assistive Technology can be covered through the Waiver.

CMS: No additional comments. 44. Please revise the service definition to eliminate language “included, but not


ODP Response: The Assistive Technology service definition will be revised to remove this language. “Examples of electronic devices include: tablets, computers and electronic communication aids… Examples of equipment and services covered as independent living technology include: medication dispensers, door sensors, window sensors, stove sensors, water sensors, pressure pads, GPS Tracking Watches, panic pendants and the remote monitoring equipment necessary to operate the independent living technology.” CMS: No additional comments.




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45. Please note any modification of the additional conditions under 442.301(c)(4)(vi)(A) through (D), which would include devices identified under independent living technology, must follow the requirements outlined under this section of the regulation.

ODP Response: ODP will add the following to the Assistive Technology service definition “Assistive Technology provided to individuals living in provider owned, leased or operated settings must comply with 442.301(c)(4)(vi)(A) through (D) related to privacy, control of schedule and activities and access to visitors.” ODP will add to the residential habilitation service, life sharing and supported living service definitions: “Any use of Independent Living Technology must comply with 442.301(c)(4)(vi)(A) through (D) related to privacy, control of schedule and activities and access to visitors. ” CMS: Please make the revisions as noted above. No additional comments.


46. The State has identified “items reimbursed with waiver funds shall be in addition to any equipment or supplies provided under the MA State Plan” along with limitations language regarding the State plan. With this statement, this service appears to be an extended state plan waiver service. Please categorize the service as an Extended State Plan since items under this service may be reimbursed under the Medicaid State plan.

ODP Response: The Assistive Technology service definition covers items that are not available through Pennsylvania’s MA State Plan such as generators and tablets such as iPads. Further, the Independent Living Technology provider qualifications are different from provider qualifications in the MA State Plan. It is our understanding from the guidance provided in the CMS Waiver Technical Guide that this meets the criteria for categorization as “other”. CMS: No additional comments.

47. Please describe what protections are in place for individuals who chose to have

legally responsible, relatives, and legal guardians serving as their support broker.

ODP Response: The CMS Waiver Technical Guide reads that additional protections must be in place when legally-responsible individuals are permitted to provide personal care or similar services (such as home health aide, homemaker, chore and companion services). The Supports Broker service has no personal care or similar component, and involves a



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degree of programmatic knowledge and expertise exceeding that of legally responsible individuals, relatives, and legal guardians who are not Supports Brokers. There is no prohibition against legally responsible individuals, relatives, and legal guardians serving as their support broker. However, Managing Employers and Common-Law Employers, including surrogates, are prohibited from enrolling as Support Service Professionals and rendering Supports Broker services, and Supports Brokers may not perform duties for which Managing Employers and Common-Law Employers are responsible. Legally responsible individuals, relatives, and legal guardians may not serve in both capacities. All Supports Brokers must successfully complete a Supports Broker Certification Program, one element of which includes establishing role boundaries between natural supports, Managing Employers and Common-Law Employers, Supports Coordinators, and Supports Brokers. The standard protection for all services provided by legally responsible individuals, relatives, and legal guardians is monitoring to assure that services provided are in compliance with the individual plan. CMS: No additional comments.

Behavior Support 48. The State has structured this service to deliver two levels of service which would

indicate two levels or rate reimbursement. Please breakout the two levels of support under the appendix J table.

ODP Response: The tables in appendix J will be revised to reflect this information. The CMS Technical Guide does not require this level of detail be captured in section I-2-a and ODP has already exceeded the character limit for this section of the waiver. ODP requests that it be sufficient for this level of detail to be included in the service definitions and Appendix J tables. CMS: Please make the revisions as noted above. No additional comments.


Companion Services 49. Please revise the service definition to eliminate language “included, but not


ODP Response: The Companion service definition will be revised to remove this language. “Companions may supervise, assist or even perform activities for a participant that include: grooming, household care, meal preparation and planning, ambulating, medication administration in accordance with regulatory guidance and socialization.”



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50. Please note the change implementing multiple staffing levels will need to be reflected fully in appendix I-2-a and appendix J tables.

ODP Response: The tables in appendix J will be revised to reflect this information. The CMS Technical Guide does not require this level of detail be captured in section I-2-a and ODP has already exceeded the character limit for this section of the waiver. ODP requests that it be sufficient for this level of detail to be included in the service definitions and Appendix J tables. CMS: Please make the revisions as noted above. No additional comments.


51. Please provide additional details regarding the reduced maximum 24 hour per day to 14 hours for In-Home Support, Community Support, Companion, and Community Participation Support under the attachment #1 section of the renewal.

ODP Response: Attachment #1 in the Main Module of the waiver will be revised to state, “Participants impacted by new limitations on Education Support, In-Home and Community Support, Companion and/or Community Participation Support will have from 7/01/17 through 12/31/17 to meet with the Individual Support Plan team, discuss and identify other services and/or support that will meet the needs of the participants.” CMS: Please make the revisions as noted above. No additional comments.


Housing Transition & Tenancy Sustaining Services 52. Assistance with establishing a relationship with a housemate is beyond a

coverable, reimbursable service. Please revise the service definition.

ODP Response: The CMS Waiver Technical Guide states, “A state may propose to cover services beyond those that are included here. When coverage of another service is proposed, CMS will review the proposed coverage to ensure that the service is necessary in order to avoid institutionalization and addresses participant needs that stem from their



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disability or condition.” The Housing Transition and Tenancy Sustaining Services is ODP’s proposal to cover a service beyond what is included in the CMS Waiver Technical Guide. As such, ODP requests a citation that states this assistance is beyond a coverable, reimbursable service. The Department of Human Services (DHS) has assembled a Permanent Supportive Housing Analysis Workgroup composed of policy and operations staff from each DHS Program Office representing children and families, physical disabilities, intellectual and developmental disabilities, autism, and serious mental illness as well as staff from the Technical Assistance Collaborative (TAC). This group is developing a Permanent Supportive Housing Needs Analysis which identifies the services necessary for individuals to access PSH units and function successfully as a tenant. The Housing Transition and Tenancy Sustaining Services definition was developed as a result of this workgroup and needs analysis. For participants served through the ODP, sharing costs with a roommate may be the only way that renting a home/apartment is affordable. Further, ODP encourages the sharing of supports in private homes and has purposely written service definitions to allow for this (for example, In-Home and Community Support and Supported Living). The service addresses a gap in our current service array will enable more people who can no longer live with their family to live independently in their own home (with the assistance of the new supported living service) and as such will reduce overall costs to the waiver program through reduced reliance on and utilization of 24 hour staffed residential services. CMS: No additional comments.

53. Please explain if assistance with obtaining financial education is an activity with the individual with budgeting for house/living expenses. Please revise to include more details to describe the activities included.

ODP Response: The service definition will be revised to state, “Assistance with obtaining and identifying resources to assist the participant with financial education. Activities include assistance with budgeting for house and living expenses. Assistance with completing applications for subsidies or other entitlements such as energy assistance, or public assistance. Assistance with identifying resources to assist with financial planning for the individual and family including special needs trusts and ABLE accounts.” CMS: Please make the revisions as noted above. No additional comments. ODP Response: Revisions have been made.



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54. Individuals who need assistance with financial planning should be referred to a financial planner and this would not be covered and reimbursable under housing services. Please revise.

ODP Response: The service definition will be revised to state, “Assistance with obtaining and identifying resources to assist the participant with financial education and planning for housing. Activities include assistance with budgeting for house and living expenses. Assistance with completing applications for subsidies or other entitlements such as energy assistance, or public assistance. Assistance with identifying financial resources to assist with housing for the participant including special needs trusts and ABLE accounts.” CMS: Please make the revisions as noted above and the requested language provided in the CMS email 6/13/207. No additional comments. ODP Response: Revisions have been made.

55. At this time, assistance with community housing is offered only to individuals who are moving from an institutional setting to a community-based setting. Please revise.

ODP Response: The CMS Waiver Technical Guide states, “A state may propose to cover services beyond those that are included here. When coverage of another service is proposed, CMS will review the proposed coverage to ensure that the service is necessary in order to avoid institutionalization and addresses participant needs that stem from their disability or condition.” The Housing Transition and Tenancy Sustaining Services is ODP’s proposal to cover a service beyond what is included in the CMS Waiver Technical Guide. The Department of Human Services (DHS) assembled a Permanent Supportive Housing Analysis Workgroup composed of policy and operations staff from each DHS Program Office representing children and families, physical disabilities, intellectual and developmental disabilities, autism, and serious mental illness as well as staff from the Technical Assistance Collaborative (TAC). This group is developing a Permanent Supportive Housing Needs Analysis which identifies the services necessary for individuals to access PSH units and function successfully as a tenant. The Housing Transition and Tenancy Sustaining Services definition was developed as a result of this workgroup and needs analysis. The service addresses a gap in our current service array will enable more people who can no longer live with their family to live independently in their own home (with the assistance of the new supported living service)



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and as such will reduce overall costs to the waiver program through reduced reliance on and utilization of 24 hour staffed residential services. This service will provide crucial assistance to participants who want to transition from residential settings and homes of relatives to homes that the participant owns, rents or leases. ODP will not limit this service to individuals who are moving from an institutional setting to a community-based setting and will remove the service from the waivers if CMS stipulates that this is the only population who can receive Housing Transition and Tenancy Sustaining services. CMS: Please add the requested language provided in the CMS email dated 6/13/2017. ODP Response: Revisions have been made.

56. Please provide additional details to identify if activities to provide assistance with utility assistance is for deposits for utilities.

ODP Response: The service definition will be revised to state, “Assistance with identifying resources to secure household furnishings and utility assistance. Activities will include identifying and coordinating resources that may assist with obtaining a security deposit, first month rent, or any other costs associated with the transition.” CMS: Please make the revisions as noted above. No additional comments. ODP Response: Revisions have been made.

57. Please provide additional details describing the activities included with assistance in resolving disputes with landlords…CMS will approve supports to assist the individual in communicating with the landlord and/or property manager and assistance to support the individual in understanding and meeting the obligations of tenancy.

ODP Response: The CMCS Informational Bulletin regarding Coverage of Housing- Related Activities and Services for Individuals with Disabilities lists “assistance in resolving disputes with landlords and/or neighbors to reduce risk of eviction or other adverse action” as a tenancy support service. The service definition will be revised to state, “Assistance with activities such as supporting the participant in communicating with the landlord and/or property manager; developing or restoring interpersonal skills in order to develop relationships with landlords, neighbors and others to



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avoid eviction or other adverse lease actions; and supporting the participant in understanding the terms of a lease or mortgage agreement.” CMS: Please make the revisions as noted above. No additional comments.


58. Please provide more details describing advocacy with community resources to

prevent eviction. This activity appears to be duplicated under other services and goes beyond the types of activities covered under this service.

ODP Response: The service provider would access services and resources which are specific to housing resources to ensure stability in the individual's home. CMS: No additional comments.

Life Sharing 59. Please explain how the life sharing specialist does not duplicate activities

performed by the service coordinator.

ODP Response: Supports Coordinators are responsible for developing the individual plan and for locating, coordinating, and monitoring all of the needed medical, social, educational, and other community supports identified in a participant’s Individual Plan (ISP) including Life Sharing services. Life Sharing is an agency model - the Life sharer does not enroll directly as a provider but is under a contract with the enrolled qualified provider agency. Once Life Sharing has been identified in the plan and the participant choses the qualified provider, the Life Sharing Specialist, working for the enrolled qualified provider, is responsible for supporting the life sharing arrangement which involves matching the person with the appropriate life sharing home, providing guidance to the life sharer, developing supports for the life sharer such as respite time, and arranging for an alternative life sharer if the person wishes to change. Life Sharing Specialists may take part in the ISP process, but are not responsible for overseeing or operationalizing services unrelated to Life Sharing. Supports Coordinators may evaluate the effectiveness of the Life Sharing service, but do not specify how Life Sharing services will or must be provided. The roles are related but are separate and distinct from one another with the Life Sharing Specialist having much more frequent contact with the participant and the Life Sharer. CMS: No additional comments.

60. The enhanced staffing is not detailed and broken out in appendix J. Please note the change implementing multiple staffing levels will need to be reflected fully in appendix I-2-a and appendix J tables.



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ODP Response: The tables in appendix J will be revised to reflect this information. The CMS Waiver Technical Guide does not require this level of detail be captured in section I-2-a and ODP has already exceeded the character limit for this section of the waiver. ODP requests that it be sufficient for this level of detail to be included in the service definitions and Appendix J tables. CMS: Please make the revisions as noted above. No additional comments.


61. Please describe in detail Supplemental Habilitation and its reimbursement

structure. These details need to be under the service definition and appendix I-2-a and J.

ODP Response: As stated in the Life Sharing service definition submitted to CMS, Supplemental Habilitation is an add-on to the Life Sharing service at a 1:1 or 2:1 staff to participant ratio in licensed Life Sharing settings. Supplemental Habilitation staffing should only be authorized for temporary medical or behavioral needs that cannot be met as part of the usual staffing pattern. Supplemental Habilitation is a discrete fee schedule service that is billed in addition to the Life Sharing service. Supplemental Habilitation is already listed as a fee schedule service in section I-2-a. Appendix J tables will be revised to list Supplemental Habilitation as a separate service. CMS: Please make the revisions as noted above. No additional comments.


62. Please explain whether Supplemental Habilitation is included in the rate and does not need to be broken out for reimbursement or coding.

ODP Response: Supplemental Habilitation is not included in the Life Sharing rate. Supplemental Habilitation is a discrete fee schedule service with a unique procedure code that is billed in addition to the Life Sharing service. Supplemental Habilitation is listed as a fee schedule service in section I-2-a. Appendix J tables will be revise to list Supplemental Habilitation as a separate service.


ODP Response: Revisions have been made in Appendix I-2-a.

Small Group Employment



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63. Guidance provided in the HCBS Technical Guide identifies small group supported employment does not include services provided in facility based work settings or other similar types of vocational services furnished in specialize facilities that are not part of general community workplaces. Please provide additional details to indicate how Work Station in Industry aligns with this guidance.

ODP Response: A “work station in industry" is an employment station arranged and supported by a provider within a community business or industry site, not within a licensed facility site. An example would be three seats on an assembly line within a computer chip assembly factory. The provider has a contract with the business to ensure that those three seats are filled by adults with disabilities that they support. As per the proposed service definition, small group employment must occur in a location other than a facility subject to 55 Pa. Code Chapter 2380 or Chapter 2390 regulations. CMS: Please add these details from the response above. This information is very helpful and useful to describe these activities and settings under this service. No additional comments. ODP Response: Revisions have been made.

64. Please include the following language: Documentation is maintained in the file of each individual receiving this service that the service is not available under a program funded under section 110 of the Rehabilitation Act of 1973 or the IDEA (20 U.S.C. 1401 et seq.). Federal financial participation is not claimed for incentive payments, subsidies, or unrelated vocational training expenses such as the following: 1. Incentive payments made to an employer to encourage or subsidize the employer's participation in supported employment services; or 2. Payments that are passed through to users of supported employment services.

ODP Response: The service definition submitted to CMS states, “Small Group Employment services may not be rendered under the Waiver until it has been verified that the service is not available in the student’s (if applicable) complete and approved Individualized Education Program (IEP) developed pursuant to IDEA. Documentation must be maintained in the file of each participant receiving Small Group Employment services to satisfy this state assurance. Small Group Employment services may be provided without referring a participant to OVR unless the participant is under the age of 25. When a participant is under the age of 25, Small Group Employment services may only be authorized as a new service in the service plan when documentation has been obtained that OVR has closed the participant's



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case or that the participant has been determined ineligible for OVR services.” The service definition will be revised to add the following information, “Federal financial participation is not claimed for incentive payments, subsidies, or unrelated vocational training expenses such as the following: 1. Incentive payments made to an employer to encourage or subsidize the employer's participation in supported employment services; or 2. Payments that are passed through to users of supported employment services.” CMS: Please make the revisions as noted above. No additional comments.


Supported Living 65. The State has identified this service includes reimbursement for periods of

indirect support. Please provide explanation of what is included and reimbursed as indirect support. ODP Response: Indirect support in the Supported Living service is defined as support provided to the individual through remote monitoring and/or on-call staff support. Time during which a provider of Advanced Supported Employment, Supported Employment, Small Group Employment or Community Participation Support services is supporting the individual may not be counted as indirect support time in establishing whether the billing standard for a day unit has been met. CMS: No additional comments.

66. Please explain how the supported living specialist does not duplicate activities performed by the service coordinator.

ODP Response: Supports Coordinators are responsible for developing the individual plan and for locating, coordinating, and monitoring all of the needed medical, social, educational, and other community supports identified in a participant’s Individual Plan including Supported Living services. Supported Living is an agency model. Once Supported Living has been identified in the plan and the participant chooses the qualified provider, the Supported Living Specialist, working for the enrolled qualified provider, is responsible for supporting the living arrangement which involves hiring and supervising direct support professionals to provide daily support, assuring direct supports are scheduled when they are needed, assessing and arranging for support technology, managing a 24 hour call service, communicating with families of individuals in Supported Living.



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Supported Living Specialists may take part in the ISP process, but are not responsible for overseeing or operationalizing services unrelated to Supported Living. Supports Coordinators may evaluate the effectiveness of the Supported Living service, but do not specify how Supported Living services will or must be provided. The roles are related but are separate and distinct from one another with the Supported Living Specialist having much more frequent contact with the participant.


67. Please describe in detail Supplemental Habilitation and its reimbursement structure in appendix I-2-a if applicable.

ODP Response: As stated in the waiver submitted to CMS, Supplemental Habilitation may only be used in emergency situations or to meet a participant’s temporary medical or behavioral needs. Participants may be authorized to receive Supplemental Habilitation for no more than 90 calendar days unless a variance is granted by the AE. Supplemental Habilitation is a discrete fee schedule service that is billed in addition to the Supported Living service. Supplemental Habilitation is already listed as a fee schedule service in section I-2-a. Appendix J tables will be revised to list Supplemental Habilitation as a separate service. CMS: Please make the revisions as noted above. No additional comments.


68. Please explain whether Supplemental Habilitation is included in the rate and

does not need to be broken out for reimbursement or coding.

ODP Response: Supplemental Habilitation is not included in the Supported Living rate. Supplemental Habilitation is a discrete fee schedule service with a unique procedure code that is billed in addition to the Supported Living service. Supplemental Habilitation is listed as a fee schedule service in section I-2-a. Appendix J tables will be revise to list Supplemental Habilitation as a separate service. CMS: Please make the revisions as noted above. No additional comments.


Therapy Services 69. The State has opted to include and bundle three service components under this

service (OT, PT, speech). Please note since the service is bundled, each service component will need to be broken out under the appendix J tables.



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ODP Response: The tables in appendix J will be revised to reflect this information. CMS: Please make the revisions as noted above. No additional comments.


70. Please change “Therapy Services” from “Other Services” to “Extended State

Plan Services.”

ODP Response: Therapy services will be revised from Other Services to

Extended State Plan Services.



Appendix C-QIS 71. Please add a new performance measure, or modify the existing performance

measure that specifies continuous monitoring of the process of the

licensing/certification of the providers.

ODP Response: The following modifications (in red italicized font) will be made: Performance Measure, “Number and percent of providers that initially and continually meet required licensure and/or certification standards and adhere to other state standards. Numerator = number of providers that initially and continually meet required licensure and/or certification standards and adhere to other state standards. Denominator = all providers that require licensure and/or certification.” Discovery (Textbox a.ii.): QP1. The Department conducts licensing activities initially and continually for licensed residential settings, licensed adult training facilities and licensed vocational facilities. b. Methods for Remediation/Fixing Individual Problems i. Performance Measure QP1. Number and percent of providers that initially and continually meet required licensure and/or certification standards and adhere to other state standards. CMS: Please make the revisions as noted above. No additional comments.




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Appendix C-5 HCB Settings 72. At this time, CMS requests all information pertaining to the waiver settings be

contained in Attachment #2 until the transition period has ended for the STP. The State can have under this section the STP received initial approval.

ODP Response: The information in Appendix C-5 will be relocated to Attachment #2 of the waiver. CMS: Please make the revisions as noted above. No additional comments.


Appendix G-1-b State Critical Event or Incident Reporting Requirements

73. Please add details to define the state’s definition of abuse, neglect, and exploitation.

ODP Response:

o Abuse is defined as an allegation or actual occurrence of the infliction of injury, unreasonable confinement, intimidation, punishment, mental anguish, sexual abuse or exploitation. Abuse is reported on from the victim’s perspective, not on the person committing the abuse.

Physical abuse. An intentional physical act by staff or other person which causes or may cause physical injury to an individual, such as striking or kicking, applying noxious or potentially harmful substances or conditions to an individual.

Psychological abuse. An act, other than verbal, which may inflict emotional harm, invoke fear or humiliate, intimidate, degrade or demean an individual.

Sexual abuse. An act or attempted acts such as rape, incest, sexual molestation, sexual exploitation or sexual harassment and inappropriate or unwanted touching of an individual by another. Any sexual contact between a staff person and an individual is abuse.

Verbal abuse. A verbalization that inflicts or may inflict emotional harm, invoke fear or humiliate, intimidate, degrade or demean an individual.

Improper or unauthorized use of restraint. A restraint not approved in the individual support plan or one that is not a part of an agency’s emergency restraint procedure is considered unauthorized. A restraint that is intentionally applied incorrectly is considered an improper use of restraint.

o Neglect. The failure to obtain or provide the needed services and supports defined as necessary or otherwise required by law or



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regulation. This includes the failure to provide needed care such as shelter, food, clothing, personal hygiene, medical care, protection from health and safety hazards, attention and supervision, including leaving individuals unattended and other basic treatment and necessities needed for development of physical, intellectual and emotional capacity and well-being. This includes acts that are intentional or unintentional regardless of the obvious occurrence of harm.

o Exploitation is defined as Misuse of funds and Rights violation.

Misuse of funds. An intentional act or course of conduct, which results in the loss or misuse of an individual’s money or personal property. Requiring an individual to pay for an item or service that is normally provided as part of the individual support plan is considered financial exploitation and is reportable as a misuse of funds. Requiring an individual to pay for items that are intended for use by several individuals is also considered financial exploitation. Individuals may voluntarily make joint purchases with other individuals of items that benefit the household.

Rights violation. An act which is intended to improperly restrict or deny the human or civil rights of an individual including those rights which are specifically mandated under applicable regulations. Examples include the unauthorized removal of personal property, refusal of access to the telephone, privacy violations and breach of confidentiality. This does not include restrictions that are imposed by court order or consistent with a waiver of licensing regulations.



Appendix I- 1 Financial Integrity

74. Please demonstrate how the state ensure the financial integrity and

accountability for participant-directed providers and other provider(s) that fall

below the $750,000 threshold.

ODP Response: Both traditional and AWC FMS providers are reviewed by

the Department (ODP or AEs) through the Quality Assessment and

Improvement (QA&I) Process on a 3-year cycle. During ODP’s QA&I

process, claims submitted by the traditional and AWC FMS are reviewed by

the AE for accuracy and to ensure that there is documentation to

substantiate the claim and that the service was actually rendered. This

includes individuals that fall below the $750,000 threshold. The Department



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monitors the VF/EA FMS to ensure that the contract deliverables are met

and participants are in receipt of VF/EA FMS services in accordance with

their service plan. The statewide VF/EA FMS is monitored by agents of the

Department. The contract includes a set of minimum standards which the

VF/EA must meet or exceed in order to ensure that claims are processed

corrected. Additionally, the financial integrity and accountability of the

Common-Law Employer is monitored through submission of overtime and

utilization reports. The overtime report is used to ensure that Support

Service Professional overtime is scheduled in accordance with ODP’s

policies. The utilization report is used to ensure that the participant is not

over-utilizing the service. Overutilization usually includes services

rendered above the authorized amount in the service plan, but unusually

high utilizations may also be investigated. This also includes participants

with service authorizations in their service plans that fall below the

$750,000 threshold.

CMS: Please add the abovementioned. No additional comments.


75. Please provide documentation that providers are required to secure an

independent audit of their financial statements.

ODP Response: The document entitled “Audit Requirements for Fiscal

Year 2015-2016 Reporting Period” is attached. This document is reviewed

and updated at least annually (more frequently if necessary) to reflect any

audit requirement changes. The document is released to the provider via

the listserv and posted to the MyODP website.

CMS: The state provided the document referenced above. However, this

document covers audit requirements for FY 2015-16. The state needs to verify

that audit requirements are expected to remain the same for the FY 17/18 period.

If so, update Appendix I-1 to specify that, “Providers expending $750,000 or

more in combined federal and Commonwealth funds during the FY 17/18

reporting period must have an independent audit of their financial statements

conducted in accordance with GAGAS.” Please make the noted revisions. No

additional comments.

ODP Response: The audit requirements are expected to remain the same

for FY 17/18 and noted revisions have been made.

76. Please explain how the State ensures that services billed were actually

rendered. Please detail the states post payment review methods.



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ODP Response: On a quarterly basis, ODP pulls a random, representative

sample of claims using a 95% confidence level and 5% margin of error and

reviews claims for accuracy and to assure that documentation adequately

supports the claim.

CMS: Please add these details to Appendix A-1. No additional comments.

ODP Response: Revisions have been made in Appendix I-1.

77. Please explain how the State accounts for fraudulent and/or inaccurate billings.

Describe the state’s recoupment process for inappropriate billings.

ODP Response: Fraudulent and/or inaccurate billings discovered during

the monitoring process will trigger an expanded review by ODP or referral

to the Bureau of Financial Operations or the Bureau of Program Integrity

depending on the nature and extent of the finding. Inappropriate billings

are required to be refunded by the provider and further remediation up to

termination may occur.



78. Please document what period of claims are monitored by the Office of

Improvement and Integrity.

ODP Response: Claims are monitored on a quarterly basis for the most

recent 3 months.



79. Detail the process for selecting a post-payment review sample. Explain how the

sample is selected and what methods are used.

ODP Response: A statistically valid sample with 95% confidence level is

randomly drawn from the statewide universe of claims for the preceding 3

month period.




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80. Please provide how frequently post-payment review activities are conducted.

ODP Response: Post-payment review activities are conducted quarterly. CMS: Please add these details to Appendix A-1. No additional comments.


Appendix I-2-a Rates, Billings & Claims Fee Schedule Methodology

81. Please submit a copy of the MA fee schedule applicable to the renewal period or

provide a web link.

ODP Response: The document entitled “Fee Schedule Public Notice” is

attached. The fee schedule in this document applies to services in both the

Consolidated and P/FDS waivers.


82. Provide a sample copy of a cost report including a cross walk on how a cost-

based rate is calculated and the items with descriptions that are included in the

calculation. Please describe the rate assignment process.

ODP Response: The documents entitled “Year 9 Cost Report Excel

Template,” “Year 9 Cost Report Instructions,” “Year 9 Transportation Cost

Report Template,” and “Year 9 Transportation Cost Report Instructions”

are attached.

A description of the cost-based rate assignment process is described in

Section I-2-a of the waiver submitted as follows, “ODP assigns rates in the

following manner:

-A provider is assigned the average of the provider's cost-based rates for

an existing service at a new service location if the provider has an

approved cost-based rate at another service location. A provider shall be

assigned the area adjusted average of all provider approved cost-based

rates for new HCBS if:

(1) The cost report of the provider did not contain the new HCBS because

the HCBS was not delivered during the reporting period.



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(2) A provider is a new provider who was not delivering HCBS during the

reporting period of the cost report.

-A provider shall be assigned the lowest rate calculated Statewide based

on all provider cost reports for HCBS if a provider was required and failed

to submit a cost report.

-A provider who is required to submit an audit & then fails to do so shall

receive the lowest rate calculated statewide.

-A provider who submits an audit which indicates the information in the

cost report requires adjustment & the provider does not submit a revised

cost report, shall be assigned the lowest rate calculated statewide.

-A provider that chooses to not submit a cost report or the cost report is

not approved will be assigned the lowest rate calculated statewide for each

cost-based service.


ODP Response: This information was included in the waiver so no

revisions were made.

83. The State mentioned that a single standardized vacation factor is applied to the

final residential rate. Please indicate what percentage of vacancy factor is built

into the rate.

ODP Response: A single, standardized vacancy factor of 96% is applied

for an average number of vacant days.



84. Please describe the process if providers deliver the services at full capacity.

Please describe the vacancy factor exception process.

ODP Response: The sites that operate at full capacity would offset the

sites that operate at less than full capacity. The vacancy exception process

is only approved by ODP if the vacancy for the entire agency operates at

less than the 96% factor built into the rates. The provider may then request

an exception to bring them up to the 96% vacancy. The criteria to calculate

the average annual occupancy rate (one rate for 6400 licensed home and

one rate for all other cost based homes) includes the following:



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The total number of billed residential days plus the billed respite

days plus permanent/transition vacancy day plus days that exceed

federal limit (over 30 consecutive days) divided by

The total number of authorized days respite days plus

permanent/transition vacancy day.

CMS: Please add the abovementioned and provide additional explanation. The State

explained “The sites that operate at full capacity would offset the sites that operate at less

than full capacity.” Can you indicated how many provider sites that operate at full

capacity versus at less than full capacity? Providers may open sites and operate at less

than full capacity in order to get paid with vacancy factor.

ODP Response: Revisions have been made. While we are unable to

provide information on how many provider sites operate at full capacity, we

can tell you that there are vacancies in residential settings for 250

individuals. Approximately 12,000 people in the Consolidated waiver

receive residential services so this tells us that the majority of provider

sites operate at full capacity.

85. Please provide description of the purpose of retention factor. Indicate what

percentage of retention factor is built into the rate within the five years renewal

period.

ODP Response – The retention factor solely applies to cost-based

residential habilitation and life sharing eligible rates, not fee schedule

rates. The purpose of the retention factor is to serve as an incentive for

residential habilitation and life sharing providers to reduce costs by

allowing providers to maintain up to 2% of any reduction in costs that they

are able to achieve. The retention factor is a percentage addition to the

provider’s calculated current FY cost-based residential habilitation eligible

and life sharing eligible rates. The retention factor can be up to a maximum

of 2% of the difference between the current FY unit costs and the prior FY

unit costs, if the total unit cost for a service decreased from the provider’s

prior FY unit cost. The application of the retention factor cannot cause the

provider’s current rate to exceed the provider’s prior year’s PROMISe paid

rate. The retention factor allows providers to maintain up to 2% of any

reduction in costs that they are able to achieve.


86. Please describe the RAF and indicate the percentage use to build into the rates

for the renewal period(s).

ODP Response – There is no reference to a RAF in the waiver and a RAF

was not built into the rates for the renewal period.




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87. Please provide supporting documentation on how the cost of new services are

calculated such as:

o Advanced Supported Employment. o Therapy, Art Therapy and Equine Assisted Therapy. o Supported Living. o Benefits Counseling. o Communication Specialist. o Consultative Nutritional Services. o Family/Caregiver Training and Support. o Housing Transition and Tenancy Sustaining Services. o Life Sharing service. o Community Participation Support as a new umbrella service that encompasses

the previous Licensed Day Habilitation and Prevocational services. o Community Participation Support o 14 hours per day of In-Home and Community Support, Companion and

Community Participation Support. ODP Response: The rates for new services are calculated in accordance with the methodologies enumerated in Section I-2-a of the waiver. Rate assumption logs for residential services (including Supported Living and Life Sharing) and non-residential services can be accessed under the Draft Fee Schedule Documents header at http://dhs.pa.gov/provider/developmentalprograms/2017waiverrenewals/Appendies/index.htm. CMS: The type of providers include agency and individual. The unit cost include employee related expenses. Why do believe paying the same amount for individual provider is reasonable since employee related employees do not apply? Why do you believe 10% administration percentage is reasonable? ODP Response: Individual providers still incur both administrative and employee-related expenses and do not benefit from any economy of scale purchasing of such things as software, training or insurances. Based on provider financial reports and CMS guidance, we believe 10% is an appropriate administration percentage.

Fee Schedule/Agency with Choice Methodology 88. Provide the rate model used to set the fee schedule rates.

ODP Response: The rate assumption logs for residential services and non-

residential services can be accessed under the Draft Fee Schedule

Documents header at

http://dhs.pa.gov/provider/developmentalprograms/2017waiverrenewals/Ap

pendies/index.htm.

CMS: Please revise appendix I-2-a with details above. No additional comments.

http://dhs.pa.gov/provider/developmentalprograms/2017waiverrenewals/Appendies/index.htm






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89. Describe the exception process noted when the needs of the participant require

higher staffing. How is the additional payment amount determined? What is the

process for an individual to receive additional support?

ODP Response – The exception process is for participants who need

enhanced levels of staffing (staff to participant ratio of 2:1 or staffing by a

person who has a certification or bachelor’s degree). This applies to

Community Participation Support, In-Home and Community Support and

Respite services. The exception process also applies to participants who

need more than 14 hours per day of Community Participation Support, In-

Home and Community Support and/or Companion (whether authorized

alone or in combination with one another). When a participant has a need

for any of these services, the ISP team will complete a variance form

describing why a participant needs this level of service. For enhanced

levels of staffing, the completed variance form will be submitted to the AE

for review and approval. There is a fee schedule rate developed and a

unique procedure code for enhanced levels of staffing in accordance with

the fee schedule rate setting methodology. Individuals who need more

than 14 hours per day of Community Participation Support, In-Home and

Community Support and/or Companion would receive the regular fee

schedule rate developed for the hours of service(s) that the participant

receives.


90. Please provide what the specific compensation studies and cost reports were

used as a guide to set payment rates. How did the State decide that these

sources were appropriate to estimate costs?

ODP Response - ODP utilized the most recent Bureau of Labor Statistics

wages specific to Pennsylvania. Cost Reports for residential habilitation

and life sharing were used in the aggregate to ensure the independent data

sources aligned with the current cost trends in Pennsylvania and were

appropriate cost estimates.


91. The State references additional services are in consideration to be transitioned to

fee schedule each year. What prompts the State to consider transitioning a

service to the fee schedule?

ODP Response - Beginning January 1, 2018 all services, except

transportation trip, will be transitioned to the fee schedule. ODP will

determine when and if we could transition transportation trip when staff



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review the service definitions and make a determination of the allowable

cost components which reflect costs that are reasonable, necessary and

related to the delivery of the service, as defined in Uniform Administrative

Requirements, Cost Principles, and Audit Requirements for Federal Awards

(OMB Circular Uniform Guidance, 12/26/14). We will only transition if the

Department can establish the fee schedule rates to fund services at a level

sufficient to ensure access, encourage provider participation and promote

provider choice, while at the same time ensuring cost effectiveness and

fiscal accountability.


Cost-Based Rates 92. Please describe how the retention factor is calculated.

ODP Response: The retention factor is a percentage addition to the provider’s calculated current FY cost-based residential habilitation eligible and life sharing eligible rates. The retention factor can be up to a maximum of 2% of the difference between the current FY unit costs and the prior FY unit costs, if the total unit cost for a service decreased from the provider’s prior FY unit cost. The application of the retention factor cannot cause the provider’s current rate to exceed the provider’s prior year’s PROMISe paid rate. CMS: No additional comments.

93. What is the value of the COLA applied?

ODP Response: As stated in the waiver submitted to CMS, “a COLA is

applied as appropriated by the General Assembly”. It is anticipated that no

COLA will be appropriated by the General Assembly for Fiscal Year 17/18

(waiver year 1). Cost-based services are, however, adjusted annually

based on cost-reports submitted by providers of the applicable services.

CMS: CMS: No additional comments.

Participant-Directed Methodology 94. Provide a summary of the participant-directed rate setting methodology or update

the application to provide a reference to Appendix E.

ODP response – To provide all of the information required by CMS, we

exceeded the character limit for Section I-2-a. To solve this problem we

moved the methodology for participant directed service rates to the Main

Module – Additional Needed Information. The very last sentence in Section

I-2-a states, “Additional information can be found in the Main Module -

Optional.” The summary in the Main Module is as follows,

“4. Participant-directed service rates: Rates for participant-directed

services are established through the development of standard wage



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ranges(which apply to both Vendor Fiscal/Employer Agent [VF/EA] &

Agency with Choice [AWC] models) and a fee schedule(AWC model).

*ODP establishes the VF/EA wage ranges by evaluating various data

sources, such as a PA-specific compensation study.

*ODP establishes wage ranges and fee schedule for AWC rates. The AWC

fee schedule rate development follows the same process as that outlined

previously in this section for non-participant directed fee schedule

services.

*Effective 7/1/17, rates for the following services or components of a

service are developed consistent with the participant-directed

methodologies described above: Homemaker/Chore, Supports Broker,

Companion, Supported Employment, In-Home and Community Support &

Unlicensed Respite. If the participant chooses to self-direct some or all of

these services, he or she will utilize the current VF/EA or AWC wage range

communication issue by ODP. If the participant chooses not to self-direct

any of these services, the MA Fee Schedule rate will be utilized.

The VF/EA and AWC wage ranges are issued by ODP prior to July 1 each

year in a standard ODP communication. In addition, the AWC MA fee

schedule rates are communicated prior to July 1 each year through a

public notice published in the PA Bulletin. Wage ranges and fee schedule

rates are implemented prospectively.

Claims are processed through PROMISe which is administered by the

Office of Medical Assistance Programs (OMAP) and the Department's

Bureau of Information Systems (BIS). Claims and payments are monitored

by ODP and Administrative Entities (AEs) through the use of PROMISe and

HCSIS generated reports.

In the future, ODP may use a variety of mechanisms to obtain public

comment on rate determination methodologies, including stakeholder

workgroup discussions, draft documents distributed for public comment,

communications & public meetings.”

CMS: CMS: No additional comments.

Appendix I-3-d Payments to State or Local Government Providers 95. Please describe what type of entity are the Supports Coordination Organizations.

Can they perform other services aside from supports coordination and/or administration functions delegated by the State?

ODP Response: Supports Coordination Organizations (SCOs) are either private businesses or businesses run by a county. SCOs cannot perform other services aside from supports coordination. The provider



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qualification requirements submitted to CMS for SCOs states that the organization must “Function as a conflict free entity. A conflict-free SCO, for purposes of this service definition, is an independent, separate, or self-contained agency that does not have a fiduciary relationship with an agency providing direct services and is not part of a larger corporation. To be conflict free, an SCO may not provide direct or indirect services to participants. The following are considered direct and indirect services: Direct Services:

All intellectual disability services provided to base-funded individuals and waiver participants with the exception of Waiver Supports Coordination, Targeted Service Management and State-funded Case Management as well as transportation and ICF/ID services where the SCO shares a Federal Employer Identification Number (FEIN) with the provider.

Indirect Services:

All services related to Health Care Quality Units, Independent Monitoring Teams, Organized Health Delivery System Providers, Financial Management Service Providers/Organizations for Waiver participants, and the Statewide Needs Assessment with the exception of Family Driven Support Service funds and the administration of Money Follows the Person (MFP) as approved by CMS.

CMS: No additional questions. ODP Response: Revisions were made as requested in the IRAI for the

P/FDS waiver.

Appendix I-3-e Amount of Payment 96. Please provide the definitions and descriptions of the following providers, what

type of providers and what type of services are they providing. Provide a sample

copy of their agreements with the State (scope of work). If the State is using

same agreement, forward only one copy.

a. AEs

b. FMS

c. OHCDS

d. SCs

ODP Response: Currently all AEs are County MH/ID programs that have signed an AE Operating Agreement that stipulates the administrative functions they will perform. When a County MH/ID program is unwilling or unable to perform AE functions, ODP will select a nongovernmental entity



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to perform delegated functions. ODP may select a multi-county MH/ID program or non-profit entity. The AE Operating Agreement is included as an attachment. AEs perform the following delegated waiver administration functions:

1. Participant waiver enrollment – Receive/review applications, ensure initial and annual completion of PUNS or its successor and refer applicants for an eligibility decision.

2. Level of care (LOC) determination – Compile necessary documentation for a LOC determination, review documentation and make a determination regarding whether the applicant/participant meets LOC criteria.

3. Review of service plans – Includes review, clarification and approval of service plans.

4. Qualified provider enrollment – Provider recruitment. 5. Quality assurance and improvement activities – Conduct qualified

provider reviews, oversee provider corrective action plans, refer providers to ODP for sanctions and/or disqualification.

As specified in Appendix E-1-a of the waiver, participants who wish to self-direct services through the utilization of a Financial Management Service (FMS) Organization may do so though one of two FMS models: Agency with Choice (AWC) or Vendor Fiscal/Employer Agent (VF/EA). The AWC FMS model is provided by provider agencies enrolled with ODP. AWC FMS providers are responsible for activities that include, but are not limited to:

Hiring qualified Support Service Professionals (SSP) referred by participants or surrogates;

Processing employment documents;

Verifying that qualified SSPs meet the qualification standards outlined in Appendix C-3;

Obtaining criminal background checks and child abuse checks, if applicable, on prospective SSPs;

Submitting claims to the Department for services authorized and rendered;

Preparing and disbursing payroll checks;

Providing workers compensation for SSPs;

Providing Managing Employer skills training;

Conducting SSP training, and

Fulfilling any responsibilities established by ODP bulletins. The waiver services available through the AWC FMS model are listed at Appendix E-1-g of the waiver. Provider agencies who render AWC FMS services are required to complete an ODP Waiver Provider Agreement, available at https://www.hcsis.state.pa.us/hcsis-ssd/custom/OMR_MAProviderAgreement.pdf.

https://www.hcsis.state.pa.us/hcsis-ssd/custom/OMR_MAProviderAgreement.pdf




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The VF/EA FMS model is provided by an entity under contract with the Department to serve as the FMS Agent. Under the VF/EA model, the FMS is responsible for functions such as but not limited to:

Functioning as the employer agent on behalf of the participant or surrogate;

Withholding, filing, and paying Federal employment taxes, State income taxes, and workers compensation for SSPs on behalf of the participant or surrogate;

Paying SSPs and vendors for services rendered as per the participant’s authorized service plan;

Verifying that SSPs meet established qualification criteria for the service(s) they provide;

Conducting criminal background checks and child abuse checks, if applicable, on prospective SSPs;

Providing Common-Law Employers with informational materials relating to the VF/EA FMS model; and

Fulfilling any responsibilities established by the Department’s contract with the VF/EA FMS and ODP bulletins.

The waiver services available through the VF/EA FMS model are listed at Appendix E-1-g of the waiver. As of this writing, the VF/EA FMS Agent under contract with the Department is Public Partnerships, LLC. A copy of the contract, including statements of work and contract addendums, may be viewed by visiting http://contracts.patreasury.gov/search.aspx, entering Contract Number 4100061881 in the “Contract Number” box, and clicking the “search” button. The contracted VF/EA FMS Agent is also required to complete an ODP Waiver Provider Agreement, available at https://www.hcsis.state.pa.us/hcsis-ssd/custom/OMR_MAProviderAgreement.pdf. Organized Health Care Delivery Systems (OHCDS) are businesses that provide at least one direct waiver service. This can be any direct waiver service with the exception of Supports Coordination. In their function as an OHCDS, the business must ensure that the vendor meets the qualification standards for the service being rendered, ensure that the service is delivered in accordance with the service definition, ensure that the amount charged by the vendor is the same as what the public pays and maintain documentation on the service delivered by the vendor. OHCDS sign a ODP Waiver Provider Agreement which can be accessed at

http://contracts.patreasury.gov/search.aspx





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https://www.hcsis.state.pa.us/hcsis-ssd/custom/OMR_MAProviderAgreement.pdf. Supports Coordination Organizations (SCOs) provide Supports Coordination services and performs administrative functions delegated by the AE in accordance with the AE Operating Agreement. SCOs are either private businesses or businesses run by a county. When an SCO performs administrative functions delegated by the AE, these functions are prohibited from being billed as an SC service. ODP looks at documentation of services rendered when monitoring SCOs to ensure that claims submitted as an SC service are appropriate. To provide Supports Coordination services, the SCO signs a ODP Waiver Provider Agreement which can be accessed at https://www.hcsis.state.pa.us/hcsis-ssd/custom/OMR_MAProviderAgreement.pdf. CMS: Please add the abovementioned. No additional questions.

ODP Response: The system does not allow us to enter information in

Appendix I-3-e.

Appendix I- Quality Improvement Systems 97. Please add a new performance measure, or modify the existing performance

measure that specifies how the State ensures that claims are coded and paid for

in accordance with the reimbursement methodology specified in the approved

waiver.

ODP Response: The following revisions (indicated in red italicized font) will be made: Performance Measure Number and percent of claims coded and paid for in accordance with the reimbursement methodology specified in the approved waiver. Numerator = number of claims coded and paid for in accordance with the reimbursement methodology specified in the approved waiver. Denominator = number of claims paid. b. Methods for Remediation/Fixing Individual Problems i. Performance Measure FA3. Number and percent of claims coded and paid for in accordance with the reimbursement methodology specified in the approved waiver. CMS: Please make the revisions noted above. No additional comments.

ODP Response: Revisions were made.

Appendix J-2-c Derivation of Estimates







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98. Provide the FY 17-18 rates, the FY 16-17 user counts and the FY 15-16 paid

waiver claims data used to project Factor D and corresponding waiver service

estimates WY 1-5.

ODP Response: The document entitled “Fee Schedule Public Notice” is

attached and includes the FY 17-18 rates. The document entitled “User

Counts” is attached and contains the FY16-17 user counts, the document

entitled “Claims Paid” is also attached and contains FY 15-16 paid waiver

claims data.


99. Per the 372 reports Factor D’ has increased each year but the State estimates that

Factor D’ will remain stagnant over a 5-year waiver period. Why does the State

estimate Factor D’ to remain stagnant for 5 years?

ODP Response: Pennsylvania’s legislature approves funding on an annual

basis. ODP develops a budget request on an annual basis and operates

within the approved budget. The Factor D’ estimates will be updated via

amendment as funding is approved.

CMS: Please add details noted above to appendix J-2-c, Factor D’. No additional

comments.


100. How did the State use the 2014-2015 372 report Factor G (189,554) to estimate

Factor G (217,159)?

ODP Response: The 2014-2015 372 report information was the most current

and accurate information available at the time that Factor G was developed

for the waiver renewal. Current year cost data was compared to the 372 for

consistency and annualized to arrive at a Year 1 estimate.


101. Factor G is projected to remain stagnant all 5 years, but the State references a

projection factor in the application. How did the State apply a projection factor to

Factor G estimates?

ODP Response: As noted in the response above, the projection factor

referenced is to annualize best available information at the time of

submission.


102. Please explain why the State estimates that Factor G will remain stagnant all 5

years.



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ODP Response: Pennsylvania’s legislature approves funding on an annual

basis. ODP develops a budget request on an annual basis and operates

within the approved budget. The Factor G estimates will be updated via

amendment as funding is approved.

CMS: Please update appendix J-2-c, Factor G with the information noted above.

No additional details.


103. How did the State use the 2014-15 372 report Factor G’ (6,347) to estimate

Factor G’ (5,442)?

ODP Response: The 2014-2015 372 report information was the most current

and accurate information available at the time that Factor G’ was developed

for the waiver renewal. Current year cost data was compared to the 372 for

consistency and annualized to arrive at a Year 1 estimate.

CMS: Based on the explanation above, it is still unclear as to what methodology

the state used to establish baseline WY1 Factor G’ estimates. Describe the

process as to how the state annualized its 2014-15 Factor G’ costs to develop its

WY1 estimates.

ODP Response: The waiver has been revised with the following information,

“The projection factor was developed by comparing year over year

expenditures thru the same timeframe.”

104. Factor G’ is projected to remain stagnant all 5 years, but the State references a

projection factor in the application. In addition, Factor G’ is estimated to be lower

than the referenced 372 report Factor G’. What projection factor was used and

how was it applied?

ODP Response: The referenced projection factor means that we annualized current year costs to arrive at the most realistic estimate of Year 1 Factor G’. CMS: No additional questions.

105. Why does the State estimate that Factor G’ will remain stagnant all 5 years?

ODP Response: Pennsylvania’s legislature approves funding on an annual basis. ODP develops a budget request on an annual basis and operates within the approved budget. The Factor G’ estimates will be updated via amendment as funding is approved.

CMS: Please update appendix J-2-c, Factor G’ with the details noted above. No additional comments. ODP Response: Revisions were made.



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Appendix J-2-d Estimate of Factor D 106. Please explain why Factor D in Year 1 or 138,237 is 31,147 or 29% higher than

the most recent 372 report of 107,090.

ODP Response: This increase is due to two factors: 1) The fee schedule

rates were rebased for FY17/18 to current market levels which has resulted

in an increase in the majority of the rates; and 2) Data indicates that

participants who are newly enrolling into the waivers have higher acuity

levels and higher service authorizations on their service plans.


107. Please explain why Factor G in Year 1 of 217,159 is 27,605 or 15% higher than

the most recent 372 report of 189,554.

ODP Response: The number of individuals in Intermediate Care Facilities

continues to decrease each year, however, the costs to serve those

individuals that remain in these facilities do not decline with the census.

This is due to the fact that 1) many of the costs are fixed regardless of the

census in the facility; 2) the individuals in the facilities are aging and require

increased care; and 3) the few individuals who are admitted each year have

higher acuity levels and need intensive staffing.

CMS: Please update appendix J-2-c, Factor G with the details noted above. No

additional comments.


108. Provide an explanation as to why the State estimates that Base-Community

Participant Support will experience a decrease of 58% or $147 million in waiver

service costs in WY 2 in comparison to WY 1.

ODP Response – This was an error. The number of users, average units and

average costs in Section J-2-d will be revised for Base Community

Participation Support.

CMS: Please make revisions as noted above. No additional comments.


109. Provide an explanation as to why the state estimates that Base-Community

Participant Support Services – Level One will experience 225% growth or $124

million growth in WY 2 in comparison to WY 1.



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ODP Response – This was an error. The number of users, average units and average costs in Section J-2-d will be revised for Level One Community Participation Support. CMS: Please make revisions as noted above. No additional comments. ODP Response: Revisions were made. CORRECTIONS MADE

Main Module Home and Community-Based Settings Waiver Transition Plan – Revisions were made to reflect the actions that have been completed to date.

Appendix B-3-c – The reserved capacity for the purpose of “Litigation” was changed to “Community Transfers”.

Appendix C – Community Participation Support service definition and provider qualifications – Level 2 enhanced staff requirements have been updated to align with enhanced qualifications in the In-Home and Community Support service. These qualification requirements will go into effect January 1, 2018.

Appendix C – Assistive Technology – Independent Living Agency Provider Type was listed as individual and was corrected to be agency.

Appendix C – Supported Living – We removed the description of hours associated with each needs group as this is not how rates were ultimately developed for the Supported Living service.

Appendix C - In-Home and Community Support and Companion Service Definitions - The staffing ratios will take effect on 7/1/17, not 1/1/18. The waiver currently states “Effective 1/1/18, this service may be provided at the following levels:” We corrected this date to say “This service may be provided at the following levels:”

Appendix C – References to “exceptions” were replaced with “variances” in the Respite, Assistive Technology and Home Accessibility Adaptations service definitions.

Appendix C – Residential Habilitation – In the provider qualification section there is a requirement for the provider to “have an annual training plan to improve the knowledge, skills and core competencies of staff.” This requirement was removed because training plan requirements for providers will be published in our Chapter 6100 regulations later this year.

Appendix C – Residential Habilitation, Life Sharing and Supported Living – The bold text was added to the sentence in the limits section as follows, “The Residential Habilitation/Life Sharing/Supported Living rate will also include Behavioral Support. Behavioral Support may only be authorized as a discrete services when it is used to support a participant to access



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Community Participation Support or to maintain employment when provided at the participant’s place of employment.”

Appendix C – QP3 refers to qualification on a biennial cycle. This information has been updated to reflect the three year cycle that ODP will be using to qualify all providers and Support Service Professionals.

Appendix G-1-b - The following types of incidents require a formalized investigations to be completed by a Department-certified incident investigator: (1) Death that occurs during the provision of an HCBS.

Appendix I-2-a – Revisions were made to the fee schedule methodology to reflect that there is now one statewide rate for each service.

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