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Proposed Amendment to the Home and Community-Based Services Waiver for the Elderly and Persons with Physical Disabilities (EPD Waiver)

November 12, 2019 Update:

The draft proposed waiver amendment posted on November 8, 2019, included a technical error that created an inconsistency with the summary that DHCF shared. DHCF has uploaded an updated version of the draft amendment that correctly removes the reference to the 50-bed limit for Assisted Living Facilities on page 105 of the attachment.

The Director of the Department of Health Care Finance (DHCF), pursuant to the authority set forth in the Department of Health Care Finance Establishment Act of 2007, hereby gives notice of the intent to submit an amendment to the District Medicaid Program’s 1915(c) Home and Community-Based Services (HCBS) Waiver for the Elderly and Persons with Physical Disabilities (EPD Waiver) to the Centers for Medicare and Medicaid Services (CMS) for review and approval.  

DHCF intends to submit an EPD waiver amendment proposing updates to specific services and changes to improve the coordination of services across the waiver program, with an effective date of April 4, 2020. The proposed waiver amendment would remove underutilized services, extend coverage of certain services by reclassifying as state plan benefits, modify the service delivery provisions for personal care aide (PCA) services and community transition services (CTS), change the frequency of staff-administered participant/representative employer satisfaction surveys in the participant-directed services program, remove duplicate reimbursement of PCA hours for individuals living in assisted living facilities, update case load restrictions for case managers, and edit performance measures used to assess compliance with the waiver’s assurances.  These changes are necessary to ensure the continued financial viability of the waiver and part of a broader effort the District is undertaking to restructure how long term services and supports are delivered for Medicaid beneficiaries.  The proposed changes will also support the District’s initiative to better tailor long term care services to beneficiaries’ needs and to reduce inappropriate or overutilization of services  

Specifically, this amendment proposes the following changes to the EPD waiver: 

1. Removes the following services from the waiver:  

  • Physical therapy and occupational therapy. Physical therapy and occupational therapy services are already covered under the State Plan home health benefit and may be accessed by EPD waiver participants.  Physical therapy and occupational therapy were added to EPD waiver services in 2015 to ensure that waiver participants could receive these services on a more frequent and continuous basis than offered under the state plan benefit.  However, to date, waiver participants have not requested these services in their person-centered service plans.  To reduce redundancy in the service array, the District is proposing to eliminate these services as part of the EPD waiver benefit, but they will remain as part of the State Plan home health benefit.,
  • Respite services (18-24 hours/day). Daily respite services are currently offered to all waiver participants at two different rates. One rate is for individuals needing between one and seventeen hours per day (1-17 hours/day) and the other rate is for those needing eighteen to twenty-four hours per day (18-24 hours/day).  This amendment deletes the provision of 18-24 hours/day respite services, which have not been utilized by any waiver participants since November 2015.
  • Personal Emergency Response System (PERS). This amendment removes the coverage of PERS services from the waiver.  Instead, as will be proposed in a corresponding State Plan Amendment (SPA), PERS will be covered under the state plan Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) benefit. Waiver participants will continue to be eligible for PERS, but as a result of this change, coverage will be extended to those beneficiaries not enrolled in the waiver, but for whom PERS has been determined necessary. A description of proposed updates to the scope of PERS services to be covered under the state plan DMEPOS benefit can be found in the corresponding SPA referenced above, which are planned to be proposed and effective concurrent with the EPD waiver amendment approval.  

2. Clarifies that EPD PCA service benefits are separate and distinct from State Plan PCA benefits and establishes a limit on EPD waiver PCA services to sixteen (16) hours per day.  PCA services under the waiver are currently delivered to waiver participants as an extension of the state plan PCA services benefit.  Under current practice, State Plan PCA services are capped at eight (8) hours per day and must be exhausted before EPD waiver participants can access additional PCA services under the waiver up to sixteen (16) hours per day. This current practice means that waiver participants can receive up to twenty-four (24) hours of PCA services per day total.  The proposed amendment would change the designation of PCA under the waiver to clarify that it is a distinct benefit and no longer require exhaustion of State Plan PCA.  As a result of this change, this amendment limits PCA services for waiver participants to sixteen (16) hours per day.  Beneficiaries currently receiving more than sixteen (16) hours per day of PCA services will have no change to the hours of services allotted until otherwise determined by their annual face-to-face reassessment for long term care services and supports that services between 17 and 24 hours are not needed.  

3. Removes duplicative reimbursement of PCA hours for beneficiaries residing in Assisted Living Facilities (ALFs). This amendment removes from the PCA service description the provision allowing residents of ALFs to receive additional assistance with activities of daily living through the receipt of the waiver’s PCA service. 

4. Changes the frequency of the Services My Way staff-administered survey to once per year. This amendment changes the frequency at which satisfaction surveys are administered to Services My Way participants/ representative employers, from every sixty days (60) days to annually.  

5. Updates the Community Transition Services (CTS) description to: 

  • Clarify that an individual must be successfully enrolled in the waiver prior to the submission of a bill for reimbursement for CTS; and  
  • Reduce the number of days prior to discharge that an individual in a long-term care facility is eligible for CTS. Currently, an individual is eligible for CTS individual one-hundred and twenty (120) days prior to discharge from a long-term care facility; this amendment changes the period of time that an individual is eligible to sixty (60) days prior to discharge. 

6. Removes the daily cap of sixteen (16) combined hours of PCA services and Adult Day Health Program (ADHP) services for beneficiaries determined eligible for and/or receiving both types of services. 

7. Updates the waiver's quality improvement measures as follows: 

  • Removes duplicative quality improvement measures. In accordance with CMS recommendations, this amendment deletes any duplicate performance measures used to assess compliance with waiver assurances concerning health and welfare, administrative authority, qualified providers, and financial accountability.  
  • Changes a health and welfare performance measure by increasing the period of time within which providers must inform beneficiaries of critical incident investigation outcomes. Currently, providers must inform beneficiaries of such outcomes within twenty-four (24) hours of closure of the investigation; this amendment extends the period of time to five (5) business days from the closure of the investigation. 

8. Removes the 50-bed limit for Assisted Living Facilities (ALFs). 

9. Updates requirements concerning the case loads of case managers. This amendment adds the following two provisions: 

  • The case load for each case manager is limited to no more than forty-five (45) cases total, across all case management agencies, at any given point in time; and 
  • The case load for each case manager must be commensurate with his/her number of hours worked per week. 

10. Restricts enrollment in the waiver to those beneficiaries not currently enrolled in another 1915(c) waiver.  This amendment clarifies that a beneficiary is not permitted to concurrently participate in multiple 1915(c) HCBS waiver programs. For example, a beneficiary may not be concurrently enrolled--and receiving benefits as a participant--in both the District's EPD waiver and IDD waiver. 

11. Updates the tuberculosis (TB) testing requirements for direct care staff to align with the national standards.  This amendment removes the annual TB testing requirement and replaces it with a requirement that TB testing be done in accordance with the guidelines published by the U.S. Centers for Disease Control (CDC). 

Please note that although this amendment proposes removing or limiting some EPD waiver services like physical therapy, occupational therapy and respite (18-24 hours), DHCF does not anticipate these changes resulting in a reduction of these services to waiver participants. The proposed removal of physical therapy, occupational therapy, and respite (18-24 hours) services from the waiver is due solely to a lack of utilization by waiver participants.  Physical therapy and occupational therapy services will continue to be available to all waiver participants under the state plan home health benefit. Likewise, because there has been no utilization of respite services for 18-24 hours, its removal from the waiver will have no effect on the respite services currently received by waiver participants.  

This amendment also proposes removing Personal Emergency Response System (PERS) services from the waiver. However, DHCF intends to submit a corresponding State Plan Amendment (SPA) to CMS proposing the addition of PERS coverage to be effective concurrent with the proposed EPD waiver amendment —updated to account for recent technological advancements—under the State Plan Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) benefit. If approved by CMS, these proposed changes to PERS would expand access to and coverage of these services for waiver participants, as well as other District Medicaid beneficiaries not enrolled in the EPD waiver. 

Lastly, as noted above, this amendment proposes changing the classification of personal care aide (PCA) services under the waiver, from “extended state plan” service to “other” service to clarify the distinct nature of the EPD waiver PCA services benefit.  While this change has the effect of reducing the maximum number of PCA hours covered for waiver participants to sixteen (16) hours per day, those waiver participants currently receiving between seventeen (17) and twenty-four (24) hours of PCA services per day will not face an immediate reduction in PCA hours upon approval of this amendment. Instead, they will continue to receive PCA services in accordance with their person-centered service plan until their annual face-to-face reassessment. Any reduction in allotted PCA hours following the reassessment's determination will be offset by the inclusion of appropriate alternative services in the waiver participant's person-centered plan (e.g., adult day health, PERS, PT/OT, homemaker, chore aide) as determined by the participant, case manager, primary care provider, and other persons or providers, to facilitate functional independence and community integration as appropriate. 

An electronic copy of the draft proposed waiver amendment is attached below. A printed copy of the proposed waiver amendment is available for viewing at the Department of Health Care Finance, 441 4th Street NW, 9th Floor South, Washington DC 20001, upon request to [email protected]

Public Comment Period 

The District’s thirty (30) day public comment period for this proposed waiver amendment is open from November 8, 2019 through December 9, 2019 at 6 pm.  

Written comments on the proposed amendment should be submitted to Melisa Byrd, Senior Deputy Director/State Medicaid Director, Department of Health Care Finance, 441 Fourth Street NW, Suite 900S, Washington, DC 20001, or via e-mail at [email protected]

DHCF will hold a public meeting during the comment period, where written and oral comments on the proposed amendment will be accepted. An audio recording of this meeting will be made available on this website.  

Public Meeting on Proposed EPD Waiver Amendment 

Date: Wednesday, December 4, 2019  
Time:  2:30 to 4 pm
Location: Main Street Conference Room (#1028) on the 10th floor of 441 Fourth Street NW, Washington, DC 20001.  

Please note that picture identification is required to enter the building. 

Individuals can also participate in the public meeting via phone by dialing 1-650-479-3208 and using access code: 731 781 405, or by web conference by going to https://dcnet.webex.com/webappng/sites/dcnet/meeting/info/13ff1a3210084ba784e9b9ea5a786654?siteurl=dcnet&MTID=m378f7f9df35987af482750dfb07780a9 and using the password bPS2qRnp. 

For further information, please contact Ieisha Gray, Director, Long Term Care Administration, DC Department of Health Care Finance, at [email protected]

Attachment(s):