Ohio – Individual Options (0231.R05.00), Level One (0380.R03.00), and Self-Empowered Life Funding Waiver (SELF) (0877.R01.00)

Waiver Title

Individual Options (0231.R05.00), Level One (0380.R03.00), and Self-Empowered Life Funding Waiver (SELF) (0877.R01.00)

Description of Emergency

On March 11, 2020, the World Health Organization declared the rapidly spreading coronavirus (COVID-19) outbreak will likely spread to all countries around the globe. Earlier, on March 9, 2020, Ohio Governor Mike DeWine declared a statewide state of emergency to protect the health, safety and well-being of Ohioans from the dangerous effects of COVID-19. All citizens have been urged to heed the advice of the Ohio Department of Health (ODH) and other emergency officials regarding this public health emergency. State agencies, including those serving individuals through Ohio Medicaid, are authorized to coordinate the State response to COVID-19, and to develop and implement procedures, including suspending or adopting temporary rules within an agency’s authority, consistent with recommendations from ODH designed to prevent or alleviate this public health threat. The Ohio Department of Medicaid (ODM) is submitting this Appendix K for the purpose of establishing processes aimed at reducing risks and ensuring access to home and community-based services (HCBS) to individuals through the Individual Options (IO), Level One, and Self-Empowered Life Funding (SELF) Waivers who are at greatest risk from COVID-19.

Current enrollment on each of the three waivers is as follows:

• IO: 24,282

• L1: 14,960

• SELF: 1,866

Slots for the respective waivers are as follows:

• IO: 26,100 during Waiver Year 1

• L1: 18,560 during Waiver Year 4

• SELF: 3,600 during Waiver Year 5

All three intermediate care facility for individuals with intellectual and developmental disabilities (ICF/IID) level of care waivers service individuals ages birth and older. The State is assuming all enrolled individuals on the IO, L1, and SELF programs are currently at risk of contracting the infection which causes COVID-19.

The single State Medicaid Agency (ODM) assures compliance with this waiver by: delegating specific responsibilities to the Operating Agency the Department of Developmental Disabilities (DODD) through an interagency agreement; managing Medicaid provider agreements; establishing general Medicaid rules; approving the Operating Agency’s program-specific rules related to Medicaid requirements; processing claims for federal reimbursement, conducting audits; conducting post-payment review of Medicaid claims; monitoring the compliance and effectiveness of the Operating Agency’s operations; leading the development of quality improvement plans; and facilitating interagency data-sharing and collaboration.

The single State Medicaid Agency’s (ODM) oversight of the Operating Agency’s (DODD) performance occurs through a combination of reviews of performance data and management reports, interagency quality briefings, interagency quality forums, and fiscal reviews.

The state is seeking approval from CMS to make changes to the following areas under the Individual Options, Level One, and SELF waiver programs:

Waiver Description

Individual Options (0231.R05.00): Provides community respite, habilitation – adult day support, homemaker/personal care, specialized medical equipment and supplies, assistive technology, career planning, community transition service, environmental accessibility adaptations, group employment support, habilitation – vocational habilitation, home delivered meals, homemaker/personal care – daily billing unit, individual employment support, interpreter, money management, non-medical transportation, nutrition, participant-directed homemaker/personal care, remote supports, residential respite, shared living, social work, transportation, waiver nursing delegation, waiver nursing for individuals with ID/DD ages 0 – no max age. Level One (0380.R03.00): Provides community respite, habilitation- adult day support, habilitation- vocational habilitation, homemaker/personal care, specialized medical equipment and supplies, assistive technology, career planning, environmental accessibility adaptations, group employment support, home delivered meals, individual employment support, informal respite, money management, non-medical transportation, participant-directed homemaker/personal care, remote supports, residential respite, transportation, waiver nursing delegation for individuals with ID/DD ages 0 – no max age. Self Empowered Life Funding (SELF) (0877.R01.00): Provides participant-directed homemaker/personal care, residential respite, participant-directed goods and services, participant/family stability assistance, support brokerage, assistive technology, career planning, clinical/therapeutic intervention, community inclusion, community respite, functional behavioral assessment, group employment support, habilitation – adult day support, habilitation – vocational habilitation, individual employment support, non-medical transportation, remote supports, transportation, waiver nursing delegation for individuals w/ID and DD ages 0 – no max age

Start Date

27-01-20

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

Access and Eligibility

Increase Cost Limits

N/A

Modify Targeting Criteria

N/A

Services

Modify Scope or Coverage

N/A

Exceed Service Limitations

The State will permit the following: Individual Options Waiver

• Waiving the combined service limitation based on assessment for Homemaker Personal Care (HPC), Participant-Directed HPC (PD-HPC), Residential Respite, Community Respite to enable participants to receive all services required during this crisis period. Waiving of limitations within the individual services, such as, but not limited to, the 90-day maximum for Residential Respite.

o Residential Respite may be authorized for an additional 90 days for a total of 180 days during an individual’s twelve-month waiver span;

o Community Respite may be authorized for an additional 60 days for a total of 120 days during an individual’s twelve-month waiver span.

 The increased limitation will not exceed what has been approved in the Appendix K document (i.e. no more than 180 days for Residential Respite or 120 days for Community Respite) and the increased limitation will not cross a new twelve-month waiver span (i.e. unused Respite limits will not carry over into a new waiver span).

o Residential and Community Respite will remain short term and temporary in length.

o On an individual specific basis, and when identified by the individual’s care team, DODD may prior authorize additional time needed for residential or community respite.

 This prior authorization will only occur if a health and welfare risk is identified by the care team, and the team supports the continued stay of an individual in a facility within the guidelines prescribed by the Ohio Department of Health.

• All prior authorizations exceeding the funding range determined by the Ohio Developmental Disabilities Profile (ODDP), as specified in C-4 in the waiver application, are waived.

• Allowing Shared Living services to be billed on the same day as HPC and/or PD-HPC, but not by the same direct support professional (DSP).

o In this instance, billing will not be permitted at the same time for Shared Living and HPC and/or PD-HPC. Level One Waiver: Combining the current budget limitations for residential and non-residential services to allow individual access to more funds for their waiver service needs.

o Individuals will have access to a total amount of $58,232

o Individuals will still have access to emergency funds which total $8,520 within a three-year period

• Waiving of limitations within the individual services, such as, but not limited to, the 90-day maximum for Residential Respite. o Residential Respite may be authorized for an additional 90 days for a total of 180 days during an individual’s twelve-month waiver span;

o Community Respite may be authorized for an additional 60 days for a total of 120 days during an individual’s twelve-month waiver span.

 The increased limitation will not exceed what has been approved in the Appendix K document (i.e. no more than 180 days for Residential Respite or 120 days for Community Respite) and the increased limitation will not cross a new twelve-month waiver span (i.e. unused Respite limits will not carry over into a new waiver span).

o Residential and Community Respite will remain short term and temporary in length.

o On an individual specific basis, and when identified by the individual’s care team, DODD may prior authorize additional time needed for residential or community respite.

 This prior authorization will only occur if a health and welfare risk is identified by the care team, and the team supports the continued stay of an individual in a facility within the guidelines prescribed by the Ohio Department of Health. SELF Waiver: Waiving of limitations within the individual services for Community Respite and Residential Respite.

o Residential Respite may be authorized for an additional 90 days for a total of 180 days during an individual’s twelve-month waiver span;

o Community Respite may be authorized for an additional 60 days for a total of 120 days during an individual’s twelve-month waiver span.

 The increased limitation will not exceed what has been approved in the Appendix K document (i.e. no more than 180 days for Residential Respite or 120 days for Community Respite) and the increased limitation will not cross a new twelve-month waiver span (i.e. unused Respite limits will not carry over into a new waiver span).

o Residential and Community Respite will remain short term and temporary in length.

o On an individual specific basis, and when identified by the individual’s care team, DODD may prior authorize additional time needed for residential or community respite.

 This prior authorization will only occur if a health and welfare risk is identified by the care team, and the team supports the continued stay of an individual in a facility within the guidelines prescribed by the Ohio Department of Health.

Add Services

N/A

Expand Settings

The state will permit the following: Individual Options, Level One, and SELF Waivers Expanding services setting to allow Day Habilitation (Adult Day Supports) and Vocational Habilitation to be delivered temporarily in an individual’s residential setting, for the health and welfare of participants and workers. Residential setting is defined as:

o The participant’s home;

o A provider owned or controlled extended family home or congregate residential setting; or

o Other residential setting, such as a hotel or shelter.

• The State may allow Adult Day Supports and Vocational Habilitation services to extend to those times when the individual is not physically present while the provider is performing Adult Day Support or Vocational Habilitation activities on behalf of the individual (e.g., picking up needed food and or supplies during state of emergency). Services can occur either in-person or remotely via technology.

o This service option shall only be utilized upon approval and authorization by the County Board of Developmental Disabilities Service and Support Administrator (SSA), by the individual’s Individual Service Plan (ISP) team, and when there is a documented need for such support.

o The remote service delivery option for Adult Day and/or Vocational Habilitation is only available to individuals who are not in receipt of any other authorized residential support services during the daytime hours when the individual is typically at a non-residential service setting site.

Provide Service Out of State

N/A

Allow Payment for Services by Families

The State will permit the following: Individual Options, Level One, and SELF Waivers

• Permit payment for direct care services rendered, to minor children by family caregivers or legally responsible guardians, if not already permitted under the waiver

o Family caregivers and legally responsible guardians must be employed by an agency in order to render services to minor children temporarily.

Modify Provider Qualifications

Modification of Provider Qualifications

The State will permit the following: Individual Options, Level One, and SELF Waivers Temporary modifications to provider training and onboarding requirements in order to allow agency providers to hire agency staff in an expedited fashion during the crisis. Temporary modifications include the following:

o Agency providers hiring currently certified independent providers for direct services may forgo obtaining a Bureau of Criminal Investigation (BCI) check if the independent provider is currently certified by DODD; and

o Agencies can assume initial training requirements have been met as part of the independent provider certification process but must provide the independent provider with major unusual incidents (MUIs) and unusual incidents (UI) training specific to the agency; and

o Agencies must provide person-specific training and emergency response training for the locations in which the independent provider will be working. The condensed training referenced in the Resources for Onboarding DSPs guidance is acceptable; and

o Online Cardiopulmonary Resuscitation (CPR)/First Aid classes will be accepted.

• Allowing waiver providers with an active Medicaid provider agreement to furnish waiver services across delivery systems without being subject to additional provider standards and certification processes specific to the waiver programs.

o DODD certified waiver providers meet the minimum standards to furnish same or similar waiver services in Ohio Department of Aging (ODA)-operated waivers and the ODM- operated waivers.

o ODA certified waiver providers meet the minimum standards to furnish same or similar waiver services in the DODD-operated waivers and ODM-operated waivers.

o ODM approved waiver providers meet the minimum standards to furnish the same or similar services in the DODD-operated waivers and the ODA- operated waivers.

 All provider types which furnish the same or similar services between delivery systems are affected by these modifications.

Modify Provider Types

The State will permit the following: Individual Options and Level One Waivers Adult Day Habilitation, Vocational Habilitation, and Non-Medical Transportation (NMT) providers may become certified to provide HPC and/or Participant-Directed HPC services in the residential setting to individuals who are unable to attend a day program due to either their health or a mandatory closure of the program.

• Adult Day Habilitation and Vocational Habilitation providers may become quickly certified to provide all respite services to individuals in emergency need of this service.

SELF Waiver

• Adult Day Habilitation, Vocational Habilitation, and NMT providers may become certified to provide Participant-Directed HPC services in the residential setting to individuals who are unable to attend a day program due to either their health or a mandatory closure of the program.

• Adult Day Habilitation and Vocational Habilitation providers may become certified in an expedited process to provide all respite services to individuals in emergency need of this service.

Modify Licensure/Requirements for Waiver Settings

Individual, Level One, and SELF Waivers: Will suspend the DODD Office of System Support and Standards (OSSAS) regularly scheduled compliance reviews and regulatory work (including Plans of Correction and Plans of Correction-Verification).

o Reviews are temporarily postponed until at least May 31st, or until the direction of the Director of DODD.

o OSSAS will continue to conduct special compliance reviews if necessary and will issue citations regarding health and safety or infection control, which will require provider to immediately correct issues.

Modification LOC Eval and Re-Eval Processes

Individual Options, Level One and SELF Waivers: Initial and redetermination level of care assessments may be completed by the Service and Support Administrator temporarily using telephone or email to complete the required assessment, in accordance with Health Insurance Portability and Accountability Act (HIPAA).

o No more than 120 days after the Appendix K expires, Service and Support Administrators will be asked to verify assessments conducted during the emergency period using a face-to-face method.

Increase Payment Rates

N/A

Modifications of ISP

Individual Options, Level One and SELF Waivers: Services may be authorized by telephone or email, in accordance with HIPAA, prior to updating the person’s service plan. The Service and Support Administrator will update the plan within the next 60 days.

• The annual redetermination process may temporarily take place without a face to face meeting, but rather by telephone or other electronic means, in accordance with HIPAA. A focus on health and welfare will always be present and ensured.

o The plan will be authorized through the following methods:

 A verbal authorization, with a subsequent confirmation in writing by the individual or an authorized representative through utilizing the U.S. Postal Service to provide signatures to the Service and Support Administrator prior to the next face-to-face visit; or

 An email authorization by the individual or guardian on the date of the meeting.

 Meeting dates and signatures dated on the date of the meeting must be reflected in documentation sent to the Service and Support Administrator.

o No more than 60 days after the Appendix K expires, Service and Support Administrators will be asked to verify assessments conducted during the emergency period using a face-to-face method.

• Face to face monitoring as outlined in a person’s individualized service plan will temporarily be extended and will resume after at least 60 days. Health and welfare must be ensured during this time.

Modify Incident Reporting/Med Management Safeguards

N/A

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

N/A

Inclusion of Retainer Payments

N/A

Institute/Expand Opportunities for Self-Direction

N/A

Increase Factor C

N/A

Other Changes Necessary

Individual Options, Level One, and SELF Waivers: On March 22, 2020, by order of the Director of the Ohio Department of Health, “all individuals currently living within the State of Ohio are ordered to stay at home or at their place of residence…” with exceptions specified in the order. For this reason, the State has checked the below box relative to non-compliance with HCBS regulations regarding visitation at the time of an individual’s choosing.

• During the period of emergency, the State is allowing flexibility with payment sequencing requirements to help ensure immediate health and safety needs. This includes, but is not limited to, waiver nursing and all equipment related services offered under the waiver programs.

o Where an extended state plan service is available through the waiver, the individual may access the service via the state plan or the waiver based on where there is a provider available. In addition, the individual will not exceed any limits imposed in the state plan and waiver in their totality.

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, in-home habilitation, monthly monitoring

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

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

Allow Other Practitioners in Lieu of Approved Providers Within the Waiver

X RN, LPN, OT licensed in good standing in another state per

Executive Order 2020/05.

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

N/A

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

Ohio Appendix K Application (PDF)

Link to Approval Letter

Ohio Appendix K Approval Letter (PDF)