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Elderly Waiver Residential Services Reform October 2016 District Meetings
Elderly Waiver Residential Services Reform
October 2016 District Meetings
Why Reform Elderly Waiver?• Rates set years ago and not reflective of
actual cost of providing services• Process not collaborative and so does not
serve clients’ best interests• Quality measurement efforts are lacking
and uncoordinated• Workforce is a growing challenge and
current payment system not designed to respond
Reform Process to Date• Joint LeadingAge/Care Providers Work Group
Created and Met Several Times • Work group chose goals and identified areas in
need of reform• Work group focused on residential services
(customized living)• Conversations ongoing with other stakeholders,
including work with LeadingAge adult day members on some additional components
Reform Goals• Support person dignity and person-centered
planning• Assure person access to and choice of services
and settings• Create transparent, timely and collaborative
processes• Incent quality and performance measures to
improve outcomes and accountability• Align funding with workforce recruitment,
retention and regulatory requirements
Areas of Reform• Collaboration and Accountability
Towards Person-Centered Care• Quality and Performance
Measurement• Elderly Waiver Residential Services
Payment
Collaboration and Accountability Proposals
• All assessment and workbook data to be shared with provider (including case mix level)
• Clear opportunities for provider input to the assessment and care planning process
• Create standard rules for when a reassessment must be conducted because client has had a “significant change” in condition
Collaboration and Accountability Proposals
• Completed assessments do not expire as long as there is an active application for MA
• Allow for retroactive payment to time of application, up to 90 days
• Allow EW residential services providers to be “designated provider” for spenddown
• Include residential services in AC program
Four Performance Measurement Areas
Formal Customer Satisfaction Surveys
MDH Inspection Results
Workforce Data Amount of Staff Training and Education
Residential Services Payment Reforms
• Create new component rates based on DEED data and include component to cover non-wage costs
• Provide for component rates to be updated regularly using DEED data
• Pay a standard rate (120% of average) for first 60 days, allowing more time to develop individual services plan
Residential Services Payment Reforms
• Create new rate component to cover general costs such as assessment, care planning, supervision, and 24-hour availability
• Create an “in lieu” payment process where rates are temporarily increased to avoid hospitalization
Residential Services Payment Reforms
• Allow specific skilled nursing services to be funded through the workbook process (i.e., wound care, injections)
• Include a disability factor in the workbook to cover supervision and other non-specific costs related to behavior issues
• Adjust dependency triggers to allow better payment for needed ADL assistance
Reform Proposal Next Steps• Determine how to address impact on other
EW providers (adult day, fee for service home care)
• Develop detailed legislation to implement these changes and determine cost of them
• Sell legislators elected on November 8 on the importance of making these changes so EW better serves clients with LTC needs
Reform Proposal: Your Thoughts?• Does this address the key needs? • Anything not clear?• Anything need to be changed or taken out?• Anything missing?• Is this something you can sell to your
legislators?
For More Information on Elderly Waiver Reform…
Jeff Bostic
Director of Data and Financial Policy
HCBS Settings Rule Update
October 2016 District Meetings
Who is Impacted by the New Rule?• All resident and non-residential settings funded
through Medicaid as part of HCBS:
Adult Day Services
Assisted Living/HWSIncluding Memory Care
Group Homes Employment Services
The HCBS Settings Rule DOES NOT apply to independent living providers or providers who only serve
private pay residents or clients in their settings.
Primary Areas of Concern
Settings Presumed to be
Institutional in Nature
Heightened Scrutiny Process
New Construction Guidelines
Ability to Serve Medicaid Beneficiaries
Minnesota Transition Plan• Minnesota in stage 2 of 5-step approval process
for its Transition Plan with CMS.• Transition Plan must include minimal federal
requirements; but states have flexibility in how they apply more stringent standards.
• Revised Transition Plan was released Oct. 3 and DHS is accepting public comments until Nov. 3.
Proposed Changes to 144D in 2017 Legislative Session
• Require right to have and use a lock on unit/apartment door based on assessed needs;
• Require choice of roommate when sharing an apartment;• Require freedom to furnish/decorate bedroom/apartment• Require freedom and support to access food at any time
based on assessed needs, preferences and goals. Restricted access to food must be documented in the person’s support plan; and
• Require right to choose who visits and when they visit, unless otherwise specified in person’s support plan or lease agreement.
Compliance Process • DHS will assess providers for compliance with
the HCBS Settings Rule using a 3-step process:
Assessment Validation Remediation
Step 1: Initial Assessment• Providers will submit Attestation.• Attestation is 13-15 questions designed to:
– Identify settings presumed to be not HCBS due to institutional proximity or having the effects of isolating.
– Report status of compliance and provide supporting evidence.
• Attestation administered to 6,659 settings electronically.
• Timeline: January 2017
Step 2: Validation• DHS will conduct audits of provider-submitted
supporting documentation of a sample of submissions (1,119) determined by:– Setting type– On-site visits and outreach– Person’s experience assessments.
Institutional in Nature Publicly or Privately Owned Facilities that
Provide Inpatient Treatment
Settings on the Ground of or Adjacent to a Public Institution
Settings that have effect of isolating Medicaid-funded Individuals from
Broader Community
Housing with Services in wing of a nursing home; Adult Day program within same building as hospital or nursing home.
Housing with Services or Adult Day program attached to or next door to publicly-owned hospital or nursing home.
Settings designed for people with disabilities or for people with a certain type of disability.
example
example
example
Step 3: Remediation• Settings determined to not be HCBS
(“institutional in nature”) will have the opportunity undergo a Heightened Scrutiny process. – Facilities presumed to be “institutional in nature” will
need to show their setting does not have characteristics of an institution and has qualities of HCBS setting.
– DHS will evaluate each setting to determine if there is enough evidence it can overcome presumption of not being HCBS, which includes one-on-one outreach and/or an on-site visit.
Compliance Plan – site specific• Providers that do not meet 100 percent
compliance from the attestation and submitted evidence will be required to complete a site-specific compliance plan.
• DHS will provide a template for the plan to have a uniform method of documenting remediation.
• Providers will need to transition to compliance by March 2018 and will be required to report progress toward compliance goals monitored by state staff.
Heightened Scrutiny Decision• If DHS believes a setting is HCBS, they submit
an evidentiary packet to CMS who will make the final determination. This process includes a public comment period.
• If setting is unable to take necessary steps to comply with HCBS requirements, DHS will implement relocation protocols.– Note: DHS will send notices to beneficiaries in March
2017 to notify them of the settings’ inability to meet compliance by March 2019.
New Construction• Applies to settings presumed to be institutional
in nature.• Does not apply to stand alone assisted living or
adult day programs. • Nothing in HCBS settings rule mentions
limitations on new construction, but CMS guidance would limit growth of co-located settings.
• Compliance cannot be determined on plans or physical descriptions.
Ability To Serve• New rules may limit ability of assisted living and
memory care providers to serve Medicaid beneficiaries, especially in rural Minnesota.
• New rules could force Medicaid HCBS into more expensive and more restrictive care settings.
• If provider does not comply with new rule, they will not be certified as a Medicaid HCBS provider but can continue to serve private pay individuals.
DHS Timeline2016
• Set standards, criteria and expectations.
• Establish process for compliance.
• Develops provider attestation.
• Holds public comment period.
• Submits revised plan.
2017
• Implements provider attestation, validation, and remediation processes.
• Proposes changes to state law and federal waiver plans to reach alignment.
• Develops tools/resources and provides technical assistance.
2018-2020
• Determines which settings will be submitted to CMS for heightened scrutiny. (2018)
• Establish process to verify compliance. (2018)
• Verifies compliance (2018-2020)
What You Should Do
ASSESS
• Measure your setting against the new requirements to see if you are in compliance or will need to undergo Heightened Scrutiny.
ENGAGE
• Participate in the public comment period(s) for the State Transition Plan to help shape the heightened scrutiny and compliance process.
PREPARE
• Read Advantagefor ongoing updates.
• Use resources provided by DHS (when available) to show compliance, get in compliance and prepare for heightened scrutiny.
Resources• LeadingAge Minnesota Web Site
– Go to Provide Resources Page– Click on HCBS Settings Rule
• CMS Toolkit: What You Should Know, Settings Presumed to be Institutional & Heightened Scrutiny Process
• Links to DHS HCBS Settings Rule information • Additional material will be added, including information on
heightened scrutiny as well as tools and resources to prepare for and verify compliance
For More Information on the Settings Rule…
Bobbie Guidry
Vice President of Housing and Community Services
MDH Home Care Survey Process and Results
October 2016 District Meetings
Assisted Living Comeprehensive Home Care
1.MDH – Helpful Links2.Trends in Surveys3.Survey Readiness4.ALNET
http://www.health.state.mn.us/divs/fpc/homecare/
1. Laws and Statutes
2. Links to all of the Surveyor forms
3. Survey results
4. Frequently asked Questions
SURVEY FINDINGS (HANDOUT)
MOCK SURVEY TOOLKIT (HANDOUT)
•Southwest: Tuesday, Nov. 1 from 11 a.m. to 3 p.m. at Bella Cucina in Marshall.•Northeast: Wednesday, Nov. 2 from 11:30 a.m. to 2:30 p.m. at Grandma's at the Canal in Duluth•Northwest/Central: Friday, Nov. 4 from 11 a.m. to 3 p.m. at the Speak Easy Restaurant in Detroit Lakes•Metro: Tuesday, Nov. 8 from 12:30 p.m. to 3:30 p.m. at LeadingAge Minnesota in Saint Paul
ALNET 2016 Fall Meeting Schedule
For More Information on Home Care Survey Issues…
Liz Sether
Nurse Consultant / Policy Analyst
