The Director of the Department of Health Care Finance (DHCF), pursuant to authority set forth in an Act to enable the District of Columbia to receive federal financial assistance under Title XIX of the Social Security Act for a medical assistance program, and for other purposes, approved December 27, 1967 (81 Stat. 744; D.C. Official Code § 1-307.02) (2012 Repl. & 2015 Supp.)), and Section 6(6) of the Department of Health Care Finance Establishment Act of 2007, effective February 27, 2008 (D.C. Law 17-109; D.C. Official Code § 7-771.05(6) (2012 Repl.)), hereby gives notice of the intent to submit a renewal application for the District of Columbia Medicaid program’s Home and Community-Based Services (HCBS) Waiver for the Elderly and Persons with Physical Disabilities (EPD) to the federal Centers for Medicare and Medicaid Services (CMS) for approval. The renewal application contains proposed changes to add a new service, makes substantive changes to the service descriptions of existing waiver services, adds procedures for streamlining the recertification process for enrollment in the EPD Waiver, changes provider qualification and verification criteria and proposes a new method and standards for setting payment rates for a service.  

 

Proposed substantive changes in the renewal application that correlate to existing EPD services for Waiver Year 1, effective January 4, 2017, or upon approval by CMS, whichever is later, may include but may not be limited to:

 

1) Personal Care Aide (PCA) Services: This service description will be amended to include “safety monitoring” among the PCA’s duties.  Safety-monitoring, as an independent stand-alone function, is currently outside of the scope of PCA services.  Adding safety monitoring to a PCA’s scope of duties will allow aides to bill for the time they spend monitoring the beneficiary closely to prevent beneficiary harm, injury or accidents. 

 

2) Participant-Directed Community Support (PDCS) and Individual-Directed Goods and Services:  The renewal application will modify these two service definitions to clarify that a participant may receive the full number of assessed hours of PDCS services, without regard to the limitations governing hours of Medicaid State Plan agency-based PCA services, and to require execution of a Medicaid provider agreement for all vendors of individual-directed goods and services. The involuntary termination process for the participant-directed services program will be revised to include provisions related to substantiated findings of fraud, theft or other criminal behavior. These modifications are based on the District’s experience during its initial year of enrollment of waiver participants in the participant-directed services option.

 

3) Case Management: This service definition will be modified to reflect the proposed changes to streamline the recertification process for enrollment in the EPD Waiver as explained below.  

 

The following summarizes the changes proposed in the renewal application with regard to streamlining the recertification process for enrollment in the EPD Waiver to be effective in EPD HCBS Waiver Year 1, effective January 4, 2017, or upon approval by CMS, whichever is later:

 

The recertification process for enrollment in the EPD Waiver will be streamlined to reduce the burden on beneficiaries and ensure continuity of care.  Specifically, once determined initially eligible for the waiver based upon a registered nurse conducted  face to- face, conflict free assessment of functional, cognitive and skilled care needs, a new, face-to-face reassessment of needs shall only be required if there has been a change in the beneficiary’s  health status.  If there is no change in health status, the case manager shall attest that the individual continues to meet the nursing facility level of care and communicate the attestation to DHCF’s designated entity for a financial disposition of Medicaid eligibility.  As a quality check, beginning one year from the date of approval of this waiver and on an annual basis thereafter, DHCF or its designee shall conduct face-to-face reassessments of a random sample of beneficiaries who had no change in health status and whose continued eligibility for the waiver is based upon a case manager’s attestation.  

 

The following summarizes the changes proposed in the renewal application to the provider qualification and provider verification criteria to be effective EPD HCBS Waiver Year 1, effective January 4, 2017, or upon approval by CMS, whichever is later:

 

The renewal application will modify provider qualification criteria to include training requirements.  The renewal application will propose that all assisted living, adult day health, and home care agency providers of EPD Waiver services shall complete mandatory training in Person-Centered Thinking, Supported Decision-Making, Supporting Community Integration, and any other topics as determined by DHCF. 

 

In the approved EPD Waiver, DHCF’s Long Term Care Administration and DHCF’s Division of Public and Private Provider Services will verify provider readiness during initial provider application review process as well as the re-enrollment process (every three years).  In the EPD Waiver renewal application, DHCF will propose conducting telephone surveys in lieu of on-site visits to verify provider readiness for out-of-state providers. 

 

The following summarizes the changes proposed in rate methodologies and reimbursements to be effective in the last quarter of FY 2017 during EPD HCBS Waiver Year 1, effective July 2017, or upon approval by CMS, whichever is later:

 

The assisted living rate reimbursement methodology will be modified to reflect a new daily rate structure. The daily rate will provide a better correlation between reimbursements and the actual cost of providing assisted living services.

 

The proposed Assisted Living rate reimbursement methodology will be amended to increase the daily rate from sixty ($60) dollars per day to one hundred and fifty five dollars ($155) per day.

 

The methodology for establishing the proposed assisted living daily rate includes the following key elements: (1) PCA wage, which is based on the District Living Wage rate of $13.84 per hour, plus overtime and time off calculations; (2) the number of hours for Licensed Practical Nurse staffing plus overtime and time off calculations to address the Medication Administration rules of the District; (3) the compensation for a registered nurse oversight for medication administration and health assessments per District policy of 1:12 HCBS individuals; (4) the compensation for House Manager for PCA supervision per District policy of 1:12 HCBS waiver individuals.

 

The assisted living rate reimbursement methodology daily rate is to be calculated based on the key elements noted in the preceding paragraph and the following factors: (1) a 20% fringe benefit rate for each employee applied so as to reflect actual costs in the District; (2) a general and administrative percentage of 13% is applied based on the total costs of all services. This percentage is based on a reasonable comparison with other comparable residential care provider categories; and (3) a 93% occupancy rate is applied to the rate to account for hospitalization, long term-care, and vacation time that is not billable to the HCBS waiver program.

 

The proposed daily rate will be inflated annually beginning with FY 2016, by any adjustment to the Living Wage or the inflation based on the CMS Skilled Nursing Facility Market Basket Index.

 

Proposed substantive changes in the renewal application that correlate to a new EPD service during Waiver Year 1, to become available October 2017, or upon approval by CMS, whichever is later, may include but may not be limited to:

 

1) Community Transition Services: This new service will enable persons who are transitioning from an institution or other long term care facility to the community to access various household set-up expenses.  Allowable expenses shall be those that are necessary to enable an individual to establish a basic household that does not constitute room and board and may include: (a) application fees and security deposits in the amount of the first month’s rent or greater that are required to obtain a lease on an apartment or home; (b) essential household furnishings and moving expenses required to occupy and use a community domicile, including furniture, window coverings, food preparation items, and bed/bath linens; (c) set-up fees or deposits for utility or service access, including telephone, electricity, heating and water; (d) services necessary for the individual's health and safety such as pest eradication and one-time cleaning; (e) moving expenses; (f) necessary home accessibility adaptations not obtained from another source; and (g) activities to assess need, arrange for and procure needed resources.

 

Copies of the proposed amendments may be obtained on the DHCF website at http://dhcf.dc.gov  or upon request from Ieisha Gray, Director, Long Term Care Administration, D.C. Department of Health Care Finance, 441 Fourth Street NW, 10th Floor South, Washington, DC 20001.  

 

There are two opportunities to provide comments on the proposed HCBS waiver amendments:

 

Written comments on the proposed waiver amendments shall be submitted to Ieisha Gray,  Director, Long Term Care Administration, D.C. Department of Health Care Finance, 441 Fourth Street NW, 10th Floor South, Washington, DC 20001, or via e-mail at [email protected], during the thirty (30) day public comment period, starting from the date this notice is published.    

 

DHCF will hold a public forum during which written and oral comments on the proposed amendments will be accepted.  The public forum will be held at the D.C. Department of Health Care Finance, 441 Fourth Street NW, Washington, DC 20001, Main Street Conference Room, 10th Floor on Wednesday, June 1, 2016, from 10:30 am to 12:00 pm.

 

Copies of this notice and the proposed Waiver Amendment will be published on the DHCF website at http://dhcf.dc.gov. For further information, please contact Trina Dutta, Special Projects Officer, DC Department of Health Care Finance, (202) 719-6632 or [email protected].