Missouri – Medically Fragile Adult Waiver (40190.R04.00)

Waiver Title

Medically Fragile Adult Waiver (40190.R04.00)

Description of Emergency

The Department of Health and Senior Services (DHSS) and the Centers for Disease Control and Prevention (CDC) are responding to an outbreak of respiratory disease caused by a novel (new) coronavirus. Novel coronavirus (COVID-19) is a virus strain that was first detected in December 2019 and is now an international health emergency. The World Health Organization (WHO) has declared a global pandemic. COVID-19 has been detected in all states in the U.S. The virus, while having mild effects in most people, can cause severe illness and pneumonia in others such as the elderly or those with underlying medical conditions. All participants of the Medically Fragile Adult Waiver have complex medical conditions and are more susceptible to succumb to severe impacts from COVID-19.

Waiver Description

Medically Fragile Adult (40190.R04.00): Provides waiver attendant care, private duty nursing, specialized medical supplies for individuals who are medically fragile ages 21 – no max age and w/DD ages 21 – no max age

Start Date

02-01-20

End Date

26-01-21

Description of Transition Plan

All activities will take place in response to the impact of COVID-19 as efficiently and effectively as possible based upon the complexity of the change.

Area(s) Affected

Area Affected

These actions will apply across the waiver to all individuals impacted by the COVID-19 virus; all counties in the state of Missouri.

Access and Eligibility

Increase Cost Limits

N/A

Modify Targeting Criteria

N/A

Services

Modify Scope or Coverage

Flexibility in requiring the provision of waiver services at least monthly. Case management contacts will continue to be conducted monthly, at a minimum.

Exceed Service Limitations

The following is a summary of flexibilities relative to the PHE, which impact services through the Medically Fragile Adult Waiver. A. Waiver Attendant Care (WAC) • Deliver services not prior authorized by the state in order to ensure timely delivery of services. • Deliver personal care services not in accordance with a service plan approved by the state on an emergent basis or under the constraints of availability of staff as impacted by the COVID-19 pandemic. • Conduct RN Supervisory Visits via telehealth as appropriate. B. Private Duty Nursing (PDN) • On site supervisory visits for the purpose of evaluation will be conducted via telehealth as appropriate. • RN Supervisory Visits for participants receiving LPN services are suspended. • Provider re-assessments may be completed through telehealth. • Services not prior authorized by the state may be provided in order to ensure timely delivery of services. ) When NEMT is not available, providers may transport participants to medical appointments at the current service rate only if another caregiver is available in the vehicle to provide direct care.

Add Services

N/A

Expand Settings

N/A

Provide Service Out of State

N/A

Allow Payment for Services by Families

Family members must be employed by or contracted with a MHN contracted provider. For WAC, family members who do not live in the same residence and are not legally responsible individuals, spouses or legal guardians, may provide services when no other caregiver is available. For PDN, family members residing with the participant, including legally responsible individuals, spouses and legal guardians are eligible to be paid caregivers. This will be extremely critical in situations where a participant may be diagnosed with COVID-19 and the family member is the only willing individual to provide services. Family members must receive training on the participant’s needs and care plan for whom they are rendering these services. When family members render a waiver service, the provider agency authorized to render the service is responsible for ensuring that services are provided and that billing occurs in accordance with billing and service documentation requirements. Family Care Safety Registry (FCSR) filing is still required but services can begin before results are returned. If a Good Cause Waiver is required, staff can still begin services for participants, excepting a finding reported by the FCSR listed in Section 192.2495.6.

Modify Provider Qualifications

Modification of Provider Qualifications

In anticipation of the need to bring staff on quickly to deliver care: • All WAC direct care staff training, orientation, and eligibility requirements, are temporarily suspended except as indicated in the paragraph below. • All PDN RN and LPN new employee training and orientation requirements, are temporarily suspended with the exception of universal precaution procedures and as indicated in the paragraph below. All staff will be trained specific to the participant they are serving and their current needs. The training will include all information regarding abuse, neglect and exploitation of participants and the importance of reporting fraudulent activities to the State. The participant will be informed of their rights and responsibilities as a service recipient of HCBS. Graduate LPNs and RNs may provide PDN services. Provider in-home visits for supervisor oversight related to staff performance and review of certain tasks being performed in person in the home is temporarily waived as providers should focus on oversight related to care and participant needs at this time. The provider is still responsible to ensure staff are conducting job duties accurately and according to all HCBS programmatic rules and regulations. Regarding background checks, Family Care Safety Registry (FCSR) filing is still required but services can begin before results are returned. If a Good Cause Waiver is required, staff can still begin services for participants, excepting a finding reported by the FCSR listed in Section 192.2495.6.

Modify Provider Types

N/A

Modify Licensure/Requirements for Waiver Settings

N/A

Modification LOC Eval and Re-Eval Processes

All assessments, including initial assessments, completed by Special Health Care Needs (SHCN) staff shall be conducted via telephone.

Increase Payment Rates

N/A

Modifications of ISP

All person-centered service plan development, including initial service plans, completed by SHCN staff shall be conducted via telephone. The state will ensure the person-centered service plan is modified to allow for additional supports/and or services to respond to the COVID-19 pandemic. The specificity of such services including amount, duration and scope will be appended as soon as possible to ensure that the specific service is delineated accordingly to the date it began to be received. The care coordinator must submit the request for additional supports/services, as well as the date the verbal consent was provided, no later than 30 days from the date the service begins. The state is allowing verbal consent by telephone for signatures as authorized by Section 1135 authority.

Modify Incident Reporting/Med Management Safeguards

N/A

Allow Payment for Services During Acute Care Hospital/Short Term Institutional Stay

For individuals hospitalized, a provider may bill waiver services to assist with supports, supervision, communication, and any other supports that the hospital is unable to provide. The services will: be identified in an individual’s person-centered service plan; provided to meet needs of the individual that are not met through the provision of hospital services; not substitute for services that the hospital is obligated to provide through its conditions of participation or under Federal or State law, or under another applicable requirement; and be designed to ensure smooth transitions between acute care settings and home and community-based settings, and to preserve the individual’s functional abilities.

Inclusion of Retainer Payments

N/A

Institute/Expand Opportunities for Self-Direction

N/A

Increase Factor C

N/A

Other Changes Necessary

The timeframes for the submission of the CMS 372s and the evidentiary package(s) will be extended as needed pursuant to the emergency. In addition, the state may suspend the collection of data for performance measures other than those identified for the Health and Welfare assurance and notes that as a result the data will be unavailable for this time frame in ensuing reports due to the circumstances of the pandemic.

Addendum

HCBS Regulations

Not comply with the HCBS settings requirement at 42 CFR 441.301(c)(4)(vi)(D) that individuals are able to have visitors of their choosing at any time, for settings added after March 17, 2014, to minimize the spread of infection during the COVID-19 pandemic.

Services

Add Electronic Method of Service Delivery

Case management, personal care services that only require verbal cueing, monthly monitoring; other: Allow for the modification of the face-to-face requirements in all other waiver services, including PDN. Traditional face-to-face services may be delivered through non-face-to-face methods (i.e., telephone, video, text, email), if practical and necessary.

Add Home Delivered Meals

N/A

Add Medical Supplies, Equipment and Appliances

N/A

Add Assistive Technology

N/A

Conflict of Interest

Other Changes Necessary

Provider Qualifications

Allow Spouses and Parents of Minor Children to Provide Personal Care Servcies

N/A

Allow a Family Member to be Paid to Render Services to an Individual

X Family members must be employed by or contracted with a MHN contracted provider. For WAC, family members who do not live in the same residence and are not legally responsible individuals, spouses, or legal guardians, may provide services when no other caregiver is available.

Allow Other Practitioners in Lieu of Approved Providers Within the Waiver

N/A

Modify Service Providers for Home-Delivered Meals to Allow for Additional Providers, Including Non-Traditional Providers

N/A

Processes

Allow an Extension for Reassessments and Reevaluations for up to One Year Past the Due Date

Allow the Option to Conduct Evaluations, Assessments, and Person-Centered Service Planning Meetings Virtually/Remotely in lieu of Face-to-Face Meetings

Adjust Prior Approval/Authorization Elements Approved in Waiver

Adjust Assessment Requirements

Add an Electronic Method of Signing Off on Required Documents Duch As The Person-Centered Service Plan

Link To Application

Missouri Appendix K Application (PDF)

Link to Approval Letter

Missouri Appendix K Approval Letter (PDF)