The Executive Office of Elder Affairs

Shannon K. Philbrick, MSM

Home Care Program Coordinator

Home Care Program 2020

EOEA Mission The Executive Office of Elder Affairs

promotes the independence, empowerment, and well-being of older

adults, individuals with disabilities, and their caregivers.

EOEA/OLTSS Program Units Assisted Living Operations – Certification & Ombudsman

Aging & Disability Resource Consortia

Home Care Programs

Nutrition Title III Programs

Protective Services

Family Caregiver Support Program

Information & Referral

Community Care Ombudsman

Long Term Care Ombudsman

Council on Aging

Prescription Advantage

Senior Employment

SHINE

Office of Long Term Supports and Services/MassHealth – PCA, HHA, AFC, GAFC, SCO, PACE, DME, ADH

EOEA Home Care Program Team

• Lynn C. Vidler – Director of Home & Community Programs

• Devon Garon – Assistant Director Home & Community Programs

• Brenda Correia – Coordinator of Elder Community & Support

Programs

• Desiree Kelley – Clinical Nurse Manager

• Melissa Enos – Home Care & Program Analytics Nurse

• Brian Glennon – Waiver Program Manager

• Shannon Philbrick –Home Care Program Coordinator

• Richard Sannon – Budget Analyst of Home & Community Programs

Brief history of Aging Services Access Points (ASAPs)

• 27 Home Care Corporations (HCCs) established 1973-1975 • Unique geographic service areas • Community based non-profits • 51% of board members must be aged 60+ • ASAP law passed in 1997 – c.19a§4b • Request for Responses (RFR) issued 2010

• designation of 27 ASAPs • currently 25 ASAPs

• Statutory responsibilities of ASAPs: • Information & Referral • Clinical Assessment & Eligibility for Medicaid-funded institutional

& community based care • Care management &service coordination • Authorization & purchase of services • Protective Services

ASAPs perform many functions

• Information and Referral

• Nursing facility pre-admission screening

• Clinical eligibility determinations

• Home Care Program eligibility determinations

• Interdisciplinary Case Management and In-home Support services • Care Plan development

• Authorization of services

• Monitoring of service delivery

• Family Caregiver Support Services

• Options Counseling

• Protective Services

Coordination of Care

The Role of the ASAP RN:

Clinical Assessment & Eligibility (CAE)

MassHealth Screenings: Adult Day Health Group Adult Foster Care

Eligibility screens completed by Coastline Elderly Services only

Frail Elder Waiver Clinical Eligibility Nursing Facility Clinical Eligibility

Pre-Admission Screenings Post-Admission Screenings

State Home Care Screenings: ECOP Clinical Eligibility Personal Care Determinations (PC, SHCA, HHA)

Comprehensive Service & Screening Model (CSSM)

A program for MassHealth members/applicants

residing in a nursing facility

CSSM team works with the member/applicant, family, & nursing facility to overcome the barriers & assist with discharge planning by formulating & implementing a care plan that meets the member/applicant’s needs in the community

Home Care Program

Eligibility for State Home Care

•Age & Residence

• Income

•Functional Impairment Level (FIL)

•Exceptions to Home Care Eligibility (formerly Uniform Intake Policy)

Eligibility for State Home Care • Age and residence:

• 60 years of age or under 60 with a diagnosis of Alzheimer’s or related disorder

• Resident of Massachusetts and not living in an institutional setting or Assisted Living Residence.

• Income: • Based on a sliding scale, monthly co-payments of $10-$141/$18-

$152 are required for individuals/couples with income above the Federal Poverty Level.

• Respite/Over-Income and Over-Income eligible, monthly cost sharing of 50% - 100% of the service plan cost is required.

• MassHealth members whose income is at or below 300% SSI FBR ($2,349 in 2020) will not have a co-payment for Home Care Services.

Eligibility for State Home Care • Functional Impairment Level (FIL):

• Require assistance with at least One Activity of Daily Living (ADL)

OR • 6 or more IADL impairments

AND • a critical unmet need (any ADL, meal preparation, food shopping,

home health services, medication management, Respite, transportation for medical treatments)

• Exceptions to the Home Care Eligibility (only need 4 IADLs): • At Risk: Elders who are at risk due to a variety of factors, including, but

not limited to substance abuse, mental health problems or cultural and linguistic barriers.

• Protective Services: Elders who are receiving or are eligible to receive Protective Services.

• Congregate Housing: Consumers residing in a Congregate Housing Facility.

• Waiver Consumers: Consumers who are eligible for the Home and Community based Waiver Program.

The Home Care Program

Home Care Basic/Non-Waiver

Community Choices*

Home Care Basic/Waiver*

Respite Over Income

Home Care Over Income

Enhanced Community Options

* Frail Elder Waiver Program, MassHealth Standard (Expanded Income Eligibility – 300% SSI FBR)

State Home Care Programs

•Home Care Basic - a program for elders who:

• meet the Home Care enrollment eligibility

• require assistance with I/ADLs

• have an Average service cost per consumer of $318.70/month (not a per person limit)

State Home Care Programs

• Enhanced Community Options Program (ECOP) – a subset of Home Care Basic consumers who are:

• 60 years of age (under 60 with a diagnosis of Alzheimer’s or related disorder)

• State Home Care Program eligible

• Meet the Clinical eligibility criteria for nursing facility services (MH regulations 130 CMR 456.409)

• Not MassHealth Standard eligible

• Service plan monthly cost minimum of $557/month (1.75 times the Home Care Basic purchased service rate)

State Home Care Program

• Over-Income Programs - supports consumers with or without caregivers in meeting the needs of elders who: • Meet the Home Care Program eligibility criteria of

• 60 years of age or under 60 with a diagnosis of Alzheimer’s or related disorder

• Residents of Massachusetts

• Functional Impairment Level (FIL)

• have an annual income over $28,866 (single) or $40,843 (couple) and are willing to pay an income-based percentage of the cost of services (50% to 100%)

• Are not MassHealth eligible* (CommonHealth exception)

• Are not eligible for other programs

• Respite Over-Income (for consumers with a caregiver)

• Home Care-Over Income (for consumers without a caregiver)

Home & Community Based Services Waiver Programs

• Home Care Basic Waiver – a subset of Home Care Basic consumers who are:

• 60 years of age or over

• State Home Care Program eligible

• Meet the Clinical eligibility criteria for nursing facility services (MH regulations 130 CMR 456.409)

• MassHealth Standard eligible

• In need of and/or receiving a Waiver Service

• Service plan monthly cost of $533 or less

Home & Community Based Services Waiver Programs

• CHOICES - a subset of waiver consumers who are:

• 60 years of age or over

• State Home Care Program eligible

• Meet the Clinical eligibility criteria for nursing facility services (MH regulations 130 CMR 456.409)

• MassHealth Standard eligible

• In need of and receiving a Waiver Program Service

• Service plan monthly cost minimum of $534

Frail Elder Waiver (FEW) Expanded Income Eligibility

Frail Elder Waiver (FEW) Expanded Income Eligibility for MassHealth Standard:

• Elders who meet all waiver program eligibility criteria except for MassHealth Standard eligibility:

With income at or below 300% SSI FBR

($2,349 month in 2019)

Have countable assets below $2,000

• If applicable: Spouse has countable assets at or below $128,640 in 2020

• Can apply for MassHealth Standard using the FEW expanded income eligibility rule

How to access the waiver for your consumers

1. Referral to Information & Referral Department at ASAP – 1-800-Age-Info

2. Consumer must be willing to: a. disclose income b. have an in-home assessment c. accept a “waiver” service

3. Once determined eligible for Home Care program, the waiver program may be identified as a program to meet consumer’s needs

4. An ASAP Nurse must conduct a clinical assessment to determine clinical eligibility (Nursing Facility level of care in accordance with 130 CMR 456.409)

How to access the waiver for your consumers

MassHealth oversees the eligibility process: 1. Clinical eligibility submitted to MassHealth*

a. If elder already has MassHealth

b. If elder does not have MassHealth, clinical eligibility submitted with new MassHealth application (SACA-2)

2. MassHealth determines financial eligibility a. Income and Asset verification

b. If elder is under age 65, MassHealth must verify disability status

Maintaining Waiver Eligibility

• Consumers are visited & assessed a minimum of 2 x year for an in-home assessment

• Consumers must have one waiver service scheduled monthly in order to maintain waiver status

• Waiver clinical eligibility is re-determined every year to ensure consumer remains Nursing Facility eligible

• MassHealth will collect updated income & asset information annually

Care Planning/Care Management

Initial on-site assessment (OSA) to determine consumer eligibility

Initial Service Plan developed with consumer to address identified unmet needs

Visit schedule of an OSA at least every six months

Annual re-determination of home care program eligibility

Review of care plan/service plan at least annually

Annual re-determination of personal care needs, as well as clinical eligibility for waiver and ECOP by ASAP RN

Home Care Services Adult Day Health* Alzheimer’s/ Dementia Coaching Behavioral Health

Services* Chore Companion Complex Care

Training & Oversight (Skilled Nursing)

*delivered through MH State Plan -waiver consumers

Environmental Accessibility Adaptations

Evidence Based Education Programs (New)

Goal Engagement Program (New)

Grocery Shopping/Delivery Services

Home Care Services Home Based

Wandering Response Systems

Home Delivered Meals Home Delivery of Pre-

packaged Medication Homemaker Home Health Aide

Home Safety/ Independence Evaluations (Occupational Therapy)

Laundry Services Medication

Dispensing System

Nutrition Assessment/

Counseling*

*delivered through MH State Plan -waiver consumers

Home Care Services

Orientation & Mobility (New)

Peer Support (New)

Personal Care

PERS/Enhanced PERS*

Respite

Supportive Day Program

Supportive Home Care Aide

Transportation*

Transitional Assistance

Vision Rehabilitation

*delivered through MH State Plan -waiver consumers

Service Delivery Options • Consumer Directed Care

• A service delivery option for non-waiver enrolled consumers in accordance with EOEA PI-18-02

• Consumer can choose to recruit, train and hire their own worker for personal assistance services

• ASAP assesses need & authorizes an average number of hours per week, is responsible for the overall management of program service costs within the limits for HCB-NW and ECOP program

• Services Offered • Homemaking • Personal Care • Home Health Aide • Transportation • Chore • Companion

Veteran’s Independence Plus Program (VIP)

• VIP Program serves • Veterans of any age • at risk of nursing home admission • Supports family Caregivers

• VIP Program qualifications • Receive primary care at Bedford or Boston VAMC

(Veteran’s Administration Medical Center) • Have a VA primary care team • Meet the eligibility criteria for home and community

based services as determined by VA • Receive a referral to VIP Program from the VA Medical

Center • ASAP case manage VIP enrollees (Care Advisor)

Service Delivery Options

• Personal Care Assistance (PCA)

• Consumer may have PCA (qualified through

MassHealth)

• Home Care services may not duplicate tasks

completed by PCA

• Home Care services/tasks are not permitted since

provided through PCA • Homemaking • Personal Care • Home Health Aide • Transportation

• PCA consumers may qualify for HC non-waiver or

waiver programs

ASAP Appeals: When can a consumer appeal?

651 CMR: 3.07 (5) A

• An applicant/consumer shall be informed in writing of his or her right to request a review, where the ASAP makes a decision to deny, terminate, or reduce Home Care Services

When a consumer can not appeal?

• An ASAP shall inform the consumer when there has been a change in the source of funding of the services but the type of and amount of such services remain unchanged.

• The consumer shall not have the right to appeal a decision by the ASAP where there is or has been a change in the source of funding of his or her services.

ASAP Appeal Process

• When an ASAP sends an Notice of Action (NOA) to the consumer to reduce, or terminate Home Care services, or a Notice of Ineligibility to deny services it must be accompanied by the List of Appeal Rights to the ASAP and a Request for ASAP Review.

• ASAPs give the consumer 14 days, 30 days for waiver consumers, to appeal the decision(s) stated in NOA.

• Consumer appeal by returning the Request for ASAP Review.

Notice of Action

Notice of Action Waiver Consumers

List of Appeal Rights

Request for ASAP Review

ASAP Appeal Process

•Once the consumer returns the Request for ASAP Review to the ASAP, the ASAP has 7 calendar days to schedule a review and notify the consumer of the date and time of hearing. Utilizing the Notice of ASAP Review Date, which is mailed to the consumer.

Notice of ASAP Review Date

ASAP Appeal Process • The ASAP has 7 days after the meeting to make a

decision.

• Once the ASAP Review has concluded and a determination is made the ASAP shall send a Notice of ASAP Review Decision to the consumer. Two forms must accompany this form; Appeal Rights to Elder Affairs and a Request to Appeal ASAP’s Review Decision.

• The Elder then has the option to Appeal to an Elder Affairs Hearing Officer within 14 days, 30 days for Waiver consumers, of receiving the Notice of ASAP Review Decision.

Notice of ASAP Review Decision

Appeal Rights to Elder Affairs

Request to Appeal ASAP’s Review Decision

EOEA Appeal Process

• Once Elder Affairs Receives the Request to Appeal the ASAP’s Review Decision from the consumer, the ASAP will be notified.

• The ASAP then has 7 days to submit a Summary of Decision to EOEA which includes; a copy of the Decision Review, Any written materials which were considered during ASAP’s review, the most recent copy of the consumers assessment and journal notes.

EOEA Hearing Officer

• Independent of EOEA

•Designated by the Secretary

•Conducts, Schedules, and Holds Appeal Hearings

•Rules on Motions

•Renders Decisions on Appeals

EOEA Appeal Process • Within 30 days of receiving the Appeal Request,

Elder Affairs will offer the consumer a hearing date either in-person or by phone. If necessary the time period may be extended.

• Hearing Officer will have 60 days from the hearing date to make a decision. Extenuating circumstances provide up to 90 days.

• Upon decision Elder Affairs will forward decision to the ASAP and consumer.

EOEA Appeal Process

• In the event of an adverse decision there are circumstances when a consumer can make an appeal past the EOEA Hearing Officer.

Service Terminations

• A consumer who returns a Request for Review to ASAP within 14 days, 30 days for Waiver Consumers, shall continue to receive Home Care Services at current level in effect prior to ASAP’s Decision.

ASAP Role in Service Terminations • In the event of a service denial,

termination, or reduction:

• The ASAP shall present information to the applicant or client on alternative services which are available in the community and shall take appropriate steps to assist the applicant or client in gaining access to such services.

Other Program Options

Title III Meals • The Senior Nutrition Program provides nutritious meals to seniors

who are unable to leave their homes due to illness, disability or frailty through the Home Delivered Meals Program. • Supper & weekend meals are also available in some areas.

• Nutrition assessments & nutrition counseling provided to homebound elders at nutritional risk.

• Who Qualifies? • People age 60 or older if they:

• Have physical, emotional, or cognitive impairments, or have inadequate kitchen facilities, resulting in an inability to prepare nutritionally adequate meals

• Are unable to attend congregate meal sites

• Have no one to help with meal preparation

• Meet home delivered meals intake criteria

• Act as a caregiver to an immediate family member, and the family member is disabled or homebound.

• No income eligibility review required

Family Caregiver Support Program

•National Program implemented by Elder Affairs through ASAPs

• Funded primarily with Federal Title III-E funds; with limited state and local agency funds

•Program with a multi-faceted approach that supports the Caregiver.

Caregiver Specialist

•Caregiver Specialist focuses on supporting the Caregiver • Conducts caregiver assessments • Develops a caregiver action plan • Provides personal assistance in connecting

caregivers with resources and services which may include • Respite care options • Supplemental Services

• One-on-one counseling & coaching • Identified training in group settings or for

individuals • Facilitates family meetings

Who is eligible to be a Caregiver

• A family or informal caregiver who is

• caring for an elder 60 or older, or someone with Alzheimer’s

• a grandparent aged 55 or older caring for a child age 18 or younger

• over the age of 55 caring for a disabled individual between the ages of 18-59; can be the parent

• Contact the Massachusetts Family Caregiver Support Program: Local ASAP 1-800-AGE-INFO or www.mass.gov/caregiver

MassHealth OLTSS Programs

• AFC – Adult Foster Care

• GAFC – Group Adult Foster Care

• HHA- Home Health Aide Services

• SCO- Senior Care Option

• PACE- Program of All-inclusive Care for the Elderly

• PCA- Personal Care Attendant Program

Certified Home Health Agency (CHHA)

• CHHA’s are home care providers certified by Federal Medicare Program • provide and bill for services

• meet requirements for patient care and management

• CHHA’s provide the following: • In-home assessment

• Developed plan of care

• Skilled care health services for 60 day increments

Qualifying for Certified Home Health Care (CHHA)

To qualify for Medicare home health coverage, a person must: ◦ Need skilled care (SN, OT, PT)

◦ Have a physician’s order for care and have seen by the physician ordering care either within 90 days before care or 30 days after starting care

◦ Be homebound, i.e. unable to seek medical attention without “severe taxing effort”

Discharge from an acute or rehabilitation/hospital is not necessary

Family members or others can refer to CHHA

◦ Physician’s order for care is required (see above)

Private Home Care • Private pay home care services can be

purchased in hourly blocks of time or as overnight or live in services

• Private pay home care companies provide a broad range of services

• Private pay home care services are not subject to eligibility rules and restrictions, or ASAP/EOEA monitoring requirements

• Private pay home care companies can be a company within a Certified Home Health Agency, but not always

Information and Referral

Aging Services Access Point (ASAP)

1-800-AGE-INFO

www.800ageinfo.com

Mass Options

Aging & Disability Resource Consortia (ADRC)

1-844-422-6277

https://www.massoptions.org/massoptions