October 28, 2020 Update:
CMS has approved the District’s proposed EPD Waiver Amendment, effective October 1, 2020. DHCF is delaying the effective date of changes under the waiver that would result in service reductions or terminations due to the COVID-19 public health emergency, from October 1, 2020 until at least the end of the public health emergency. To support the proposed delay, DHCF will submit a COVID-19 1915(c) Appendix K for review and approval by CMS in early October.
To protect beneficiaries and providers of adverse consequences during the public health emergency, DHCF will be delaying implementation of the following changes approved under the District’s EPD Waiver Amendment:
- Removal of respite services 18-24 hours/day
- Limitation of personal care aide (PCA services) to 16 hours/day
- Termination of external home health aide (HHA) services for EPD Waiver beneficiaries living in assisted living facilities (ALFs);
- Reduction in number of days prior to discharge from long-term care (LTC) facility that an individual is eligible for community transition services (CTS) (from 120 days to 60 days); and
- Removal of personal emergency response services (PERS) from EPD Waiver. This is an administrative change to ensure continuity of services for individuals who have yet to receive a prior authorization of coverage of under the State Plan’s Home Health benefit. Effective October 1, 2020, coverage of PERS is available as a State Plan benefit, so DHCF will prioritize the transition of all waiver enrollees to receive services under the State Plan.
To promote public understanding of the policy changes under the EPD Waiver Amendment and the timeframe for implementation, DHCF is updating the summary provided below on all the changes included under the waiver. The changes that are being delayed under the proposed Appendix K are flagged below in bold.
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 approval of 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) by the Centers for Medicare and Medicaid Services (CMS). Effective October 1, 2020, the EPD Waiver amendment is removing underutilized services, extending coverage of certain services by reclassifying as state plan benefits, modifying the service delivery provisions for personal care aide (PCA) services and community transition services (CTS), changing the frequency of staff-administered participant/representative employer satisfaction surveys in the participant-directed services program, removing duplicate reimbursement of PCA hours for individuals living in assisted living facilities, updating case load restrictions for case managers, and editing performance measures used to assess compliance with the waiver’s assurances. These changes were 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 changes also support the District’s ongoing initiative to better tailor long term care services to beneficiaries’ needs and to reduce inappropriate or overutilization of services
Specifically, the approval finalizes 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 eliminated 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 approved amendment deletes the provision of 18-24 hours/day respite services, which have not been utilized by any waiver participants since November 2015.
- This Respite change will be delayed until the conclusion of the PHE.
- 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 is effective as of October 1, 2020.
- Removal of PERS from the waiver will be delayed until the conclusion of the PHE.
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.
Implementation of the 16 hour/day cap on PCA services will delayed until the conclusion of the PHE.
3. Removes 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.
- This PCA change will be delayed until the conclusion of the PHE
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.
- This CTS change will delayed until the conclusion of the PHE.
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).
An electronic copy of the approved waiver amendment is attached below.
If you have any questions or concerns about these proposed changes please contact Katherine Rogers, Program Manager, Long Term Care Administration at [email protected] or (202) -834-1927.