Source: https://portal.ct.gov/-/media/Departments-and-Agencies/DSS/Health-and-Home-Care/Medicaid-Waiver-Applications/Application-for-1915c-HCBS-Waiver-Draft-CT0200601--Apr-01-2018.htm?la=en
Timestamp: 2019-04-22 02:23:31+00:00

Document:
The Medicaid Home and Community-Based Services (HCBS) waiver program is authorized in §1915(c) of the Social Security Act. The program permits a State to furnish an array of home and community-based services that assist Medicaid beneficiaries to live in the community and avoid institutionalization. The State has broad discretion to design its waiver program to address the needs of the waivers target population. Waiver services complement and/or supplement the services that are available to participants through the Medicaid State plan and other federal, state and local public programs as well as the supports that families and communities provide.
The Centers for Medicare & Medicaid Services (CMS) recognizes that the design and operational features of a waiver program will vary depending on the specific needs of the target population, the resources available to the State, service delivery system structure, State goals and objectives, and other factors. A State has the latitude to design a waiver program that is cost-effective and employs a variety of service delivery approaches, including participant direction of services.
The State of Connecticut requests approval for an amendment to the following Medicaid home and community-based services waiver approved under authority of §1915(c) of the Social Security Act.
Original Base Waiver Number: CT.0140.
The State of Connecticut requests approval for a Medicaid home and community-based services (HCBS) waiver under the authority of §1915(c) of the Social Security Act (the Act).
Waiver(s) authorized under §1915(b) of the Act.
The state is requesting a 1915b(4) concurrent with this submission for selective contracting for the provision of the care management service.
A program operated under §1932(a) of the Act.
A program authorized under §1915(i) of the Act.
A program authorized under §1915(j) of the Act.
A program authorized under §1115 of the Act.
Dual Eligiblity for Medicaid and Medicare.
This waiver provides services for individuals who are eligible for both Medicare and Medicaid.
Brief Waiver Description. In one page or less, briefly describe the purpose of the waiver, including its goals, objectives, organizational structure (e.g., the roles of state, local and other entities), and service delivery methods.
The Department of Social Services, as the state Medicaid agency pursuant to CT General Statutes (CGS) 17b-1, operates the Home and Community Based Services Waiver according to CGS 17b-342 for individuals age 65 and over to enable frail elders to be deinstitutionalized or diverted from nursing home placement. The Department's Alternate Care Unit administers the waiver, accepts applications, does the initial level of care determination and refers the client to a contracted case management provider for the initial evaluation, confirmation of the level of care and development of the service plan. DSS is responsible for determining both financial and functional eligibility for the waiver. The case management providers maintain ongoing contact with the clients and are required to do semi-annual face to face evaluations with the comprehensive evaluation being required annually. The case management organizations are also responsible for loading authorized service plans into the MMIS contractor portal so that enrolled providers can bill directly but only for services authorized as part of the care plan. For PCA services, a fiscal intermediary processes the weekly payroll. The same fiscal intermediary will credential the waiver providers. Providers then enroll directly with the Department. Quality assurance and improvement activities are conducted by both the care management agencies and the Department. The Department has extensive reporting requirements of the case management agencies including quarterly quality assurance summaries. Services provided by the waiver include Case Management, Homemaker, Adult Family Living/Foster Care, Companion, Chore, Adult Day Health,Personal Emergency Response Systems, Personal Care (Agency based), Assistive Technology, Respite, Transportation, Home Delivered Meals, Mental Health Counseling, Personal Care Assistant, and Environmental Accessibility Adaptations. Personal Care Assistant will be available to clients either as a fully self directed model or as agency with choice thus giving the participants more options for care. With this renewal we are intending to add a tiered care management service, Care Transitions and Chronic Disease Self-Management Program (both of which are evidence-based programs), Bill Payer Service, Recovery Assistant and Independent Support Broker. Support Broker may be provided as a self directed or agency based service and will be available after the participant has utilized a $500 benefit under the 1915k state plan option. Additionally we are adding a NF sub-acute level of care to accommodate the increasing care needs of program applicants. We are removing self directed PCA from this waiver as the state will be operating a 1915k state plan option for PCA services. Our intention is to align the removal of the service with the approval date of the CFC application. the transition will be seamless to both the participant and the providers.
The waiver application consists of the following components. Note: Item 3-E must be completed.
Waiver Administration and Operation. Appendix A specifies the administrative and operational structure of this waiver.
Participant Access and Eligibility. Appendix B specifies the target group(s) of individuals who are served in this waiver, the number of participants that the State expects to serve during each year that the waiver is in effect, applicable Medicaid eligibility and post-eligibility (if applicable) requirements, and procedures for the evaluation and reevaluation of level of care.
Participant Services. Appendix C specifies the home and community-based waiver services that are furnished through the waiver, including applicable limitations on such services.
Participant-Centered Service Planning and Delivery. Appendix D specifies the procedures and methods that the State uses to develop, implement and monitor the participant-centered service plan (of care).
Yes. This waiver provides participant direction opportunities. Appendix E is required.
No. This waiver does not provide participant direction opportunities. Appendix E is not required.
Participant Rights. Appendix F specifies how the State informs participants of their Medicaid Fair Hearing rights and other procedures to address participant grievances and complaints.
Participant Safeguards. Appendix G describes the safeguards that the State has established to assure the health and welfare of waiver participants in specified areas.
Quality Improvement Strategy. Appendix H contains the Quality Improvement Strategy for this waiver.
Financial Accountability. Appendix I describes the methods by which the State makes payments for waiver services, ensures the integrity of these payments, and complies with applicable federal requirements concerning payments and federal financial participation.
Cost-Neutrality Demonstration. Appendix J contains the State's demonstration that the waiver is cost-neutral.
Comparability. The State requests a waiver of the requirements contained in §1902(a)(10)(B) of the Act in order to provide the services specified in Appendix C that are not otherwise available under the approved Medicaid State plan to individuals who: (a) require the level(s) of care specified in Item 1.F and (b) meet the target group criteria specified in Appendix B.
Geographic Limitation. A waiver of statewideness is requested in order to furnish services under this waiver only to individuals who reside in the following geographic areas or political subdivisions of the State.
Limited Implementation of Participant-Direction. A waiver of statewideness is requested in order to make participant-direction of services as specified in Appendix E available only to individuals who reside in the following geographic areas or political subdivisions of the State. Participants who reside in these areas may elect to direct their services as provided by the State or receive comparable services through the service delivery methods that are in effect elsewhere in the State.
Assurance that all facilities subject to §1616(e) of the Act where home and community-based waiver services are provided comply with the applicable State standards for board and care facilities as specified in Appendix C.
Financial Accountability. The State assures financial accountability for funds expended for home and community-based services and maintains and makes available to the Department of Health and Human Services (including the Office of the Inspector General), the Comptroller General, or other designees, appropriate financial records documenting the cost of services provided under the waiver. Methods of financial accountability are specified in Appendix I.
Evaluation of Need: The State assures that it provides for an initial evaluation (and periodic reevaluations, at least annually) of the need for a level of care specified for this waiver, when there is a reasonable indication that an individual might need such services in the near future (one month or less) but for the receipt of home and community-based services under this waiver. The procedures for evaluation and reevaluation of level of care are specified in Appendix B.
Given the choice of either institutional or home and community-based waiver services. Appendix B specifies the procedures that the State employs to ensure that individuals are informed of feasible alternatives under the waiver and given the choice of institutional or home and community-based waiver services.
Average Per Capita Expenditures: The State assures that, for any year that the waiver is in effect, the average per capita expenditures under the waiver will not exceed 100 percent of the average per capita expenditures that would have been made under the Medicaid State plan for the level(s) of care specified for this waiver had the waiver not been granted. Cost-neutrality is demonstrated in Appendix J.
Actual Total Expenditures: The State assures that the actual total expenditures for home and community-based waiver and other Medicaid services and its claim for FFP in expenditures for the services provided to individuals under the waiver will not, in any year of the waiver period, exceed 100 percent of the amount that would be incurred in the absence of the waiver by the State's Medicaid program for these individuals in the institutional setting(s) specified for this waiver.
Institutionalization Absent Waiver: The State assures that, absent the waiver, individuals served in the waiver would receive the appropriate type of Medicaid-funded institutional care for the level of care specified for this waiver.
Reporting: The State assures that annually it will provide CMS with information concerning the impact of the waiver on the type, amount and cost of services provided under the Medicaid State plan and on the health and welfare of waiver participants. This information will be consistent with a data collection plan designed by CMS.
Habilitation Services. The State assures that prevocational, educational, or supported employment services, or a combination of these services, if provided as habilitation services under the waiver are: (1) not otherwise available to the individual through a local educational agency under the Individuals with Disabilities Education Act (IDEA) or the Rehabilitation Act of 1973; and, (2) furnished as part of expanded habilitation services.
Services for Individuals with Chronic Mental Illness. The State assures that federal financial participation (FFP) will not be claimed in expenditures for waiver services including, but not limited to, day treatment or partial hospitalization, psychosocial rehabilitation services, and clinic services provided as home and community-based services to individuals with chronic mental illnesses if these individuals, in the absence of a waiver, would be placed in an IMD and are: (1) age 22 to 64; (2) age 65 and older and the State has not included the optional Medicaid benefit cited in 42 CFR §440.140; or (3) age 21 and under and the State has not included the optional Medicaid benefit cited in 42 CFR § 440.160.
Note: Item 6-I must be completed.
Service Plan. In accordance with 42 CFR §441.301(b)(1)(i), a participant-centered service plan (of care) is developed for each participant employing the procedures specified in Appendix D. All waiver services are furnished pursuant to the service plan. The service plan describes: (a) the waiver services that are furnished to the participant, their projected frequency and the type of provider that furnishes each service and (b) the other services (regardless of funding source, including State plan services) and informal supports that complement waiver services in meeting the needs of the participant. The service plan is subject to the approval of the Medicaid agency. Federal financial participation (FFP) is not claimed for waiver services furnished prior to the development of the service plan or for services that are not included in the service plan.
Inpatients. In accordance with 42 CFR §441.301(b)(1)(ii), waiver services are not furnished to individuals who are in-patients of a hospital, nursing facility or ICF/IID.
Room and Board. In accordance with 42 CFR §441.310(a)(2), FFP is not claimed for the cost of room and board except when: (a) provided as part of respite services in a facility approved by the State that is not a private residence or (b) claimed as a portion of the rent and food that may be reasonably attributed to an unrelated caregiver who resides in the same household as the participant, as provided in Appendix I.
Access to Services. The State does not limit or restrict participant access to waiver services except as provided in Appendix C.
Free Choice of Provider. In accordance with 42 CFR §431.151, a participant may select any willing and qualified provider to furnish waiver services included in the service plan unless the State has received approval to limit the number of providers under the provisions of §1915(b) or another provision of the Act.
FFP Limitation. In accordance with 42 CFR §433 Subpart D, FFP is not claimed for services when another third-party (e.g., another third party health insurer or other federal or state program) is legally liable and responsible for the provision and payment of the service. FFP also may not be claimed for services that are available without charge, or as free care to the community. Services will not be considered to be without charge, or free care, when (1) the provider establishes a fee schedule for each service available and (2) collects insurance information from all those served (Medicaid, and non-Medicaid), and bills other legally liable third party insurers. Alternatively, if a provider certifies that a particular legally liable third party insurer does not pay for the service(s), the provider may not generate further bills for that insurer for that annual period.
Fair Hearing: The State provides the opportunity to request a Fair Hearing under 42 CFR §431 Subpart E, to individuals: (a) who are not given the choice of home and community-based waiver services as an alternative to institutional level of care specified for this waiver; (b) who are denied the service(s) of their choice or the provider(s) of their choice; or (c) whose services are denied, suspended, reduced or terminated. Appendix F specifies the State's procedures to provide individuals the opportunity to request a Fair Hearing, including providing notice of action as required in 42 CFR §431.210.
Quality Improvement. The State operates a formal, comprehensive system to ensure that the waiver meets the assurances and other requirements contained in this application. Through an ongoing process of discovery, remediation and improvement, the State assures the health and welfare of participants by monitoring: (a) level of care determinations; (b) individual plans and services delivery; (c) provider qualifications; (d) participant health and welfare; (e) financial oversight and (f) administrative oversight of the waiver. The State further assures that all problems identified through its discovery processes are addressed in an appropriate and timely manner, consistent with the severity and nature of the problem. During the period that the waiver is in effect, the State will implement the Quality Improvement Strategy specified in Appendix H.
The state sought public input from multiple sources in preparation of the renewal. A presentation was also made to the Home Care Advisory Committee consisting primarily of the provider network including the CT Home Care Association and the Adult Day Care Association of CT as well as representatives from the legal services community and the Commission on Aging. The Department has solicited input from the two tribal nations in Connecticut. Both tribes were provided with a copy of the Notice of Intent that was published in the CT Law Journal and were provided copies of the waiver application via email. Neither of the tribes responded. In addition to the CT law Journal posting, the Department posted the renewal notice on its web site under Latest News. No comments were received from the postings. Additional posting were made via the DSS web on 4/20/15 and printed in the CT Law Journal on 5/5/15.
Notice to Tribal Governments. The State assures that it has notified in writing all federally-recognized Tribal Governments that maintain a primary office and/or majority population within the State of the State's intent to submit a Medicaid waiver request or renewal request to CMS at least 60 days before the anticipated submission date is provided by Presidential Executive Order 13175 of November 6, 2000. Evidence of the applicable notice is available through the Medicaid Agency.
Limited English Proficient Persons. The State assures that it provides meaningful access to waiver services by Limited English Proficient persons in accordance with: (a) Presidential Executive Order 13166 of August 11, 2000 (65 FR 50121) and (b) Department of Health and Human Services "Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons" (68 FR 47311 - August 8, 2003). Appendix B describes how the State assures meaningful access to waiver services by Limited English Proficient persons.
This document, together with the attached revisions to the affected components of the waiver, constitutes the State's request to amend its approved waiver under §1915(c) of the Social Security Act. The State affirms that it will abide by all provisions of the waiver, including the provisions of this amendment when approved by CMS. The State further attests that it will continuously operate the waiver in accordance with the assurances specified in Section V and the additional requirements specified in Section VI of the approved waiver. The State certifies that additional proposed revisions to the waiver request will be submitted by the Medicaid agency in the form of additional waiver amendments.
Note: The Signature and Submission Date fields will be automatically completed when the State Medicaid Director submits the application.
Check the box next to any of the following changes from the current approved waiver. Check all boxes that apply.
Replacing an approved waiver with this waiver.
Splitting one waiver into two waivers.
Adding or decreasing an individual cost limit pertaining to eligibility.
Adding or decreasing limits to a service or a set of services, as specified in Appendix C.
Reducing the unduplicated count of participants (Factor C).
Adding new, or decreasing, a limitation on the number of participants served at any point in time.
Making any changes that could result in some participants losing eligibility or being transferred to another waiver under 1915(c) or another Medicaid authority.
Making any changes that could result in reduced services to participants.
Specify the state's process to bring this waiver into compliance with federal home and community-based (HCB) settings requirements at 42 CFR 441.301(c)(4)-(5), and associated CMS guidance.
Consult with CMS for instructions before completing this item. This field describes the status of a transition process at the point in time of submission. Relevant information in the planning phase will differ from information required to describe attainment of milestones.
To the extent that the state has submitted a statewide HCB settings transition plan to CMS, the description in this field may reference that statewide plan. The narrative in this field must include enough information to demonstrate that this waiver complies with federal HCB settings requirements, including the compliance and transition requirements at 42 CFR 441.301(c)(6), and that this submission is consistent with the portions of the statewide HCB settings transition plan that are germane to this waiver. Quote or summarize germane portions of the statewide HCB settings transition plan as required.
Note that Appendix C-5 HCB Settings describes settings that do not require transition; the settings listed there meet federal HCB setting requirements as of the date of submission. Do not duplicate that information here.
Update this field and Appendix C-5 when submitting a renewal or amendment to this waiver for other purposes. It is not necessary for the state to amend the waiver solely for the purpose of updating this field and Appendix C-5. At the end of the state's HCB settings transition process for this waiver, when all waiver settings meet federal HCB setting requirements, enter "Completed" in this field, and include in Section C-5 the information on all HCB settings in the waiver.
The following language was included in amendment 020.05.04 and was approved by CMS in February of 2015. In preparing for the amendment, the state reviewed the waiver and identified 3 services and one setting that required further review to assure compliance with the new HCBS requirements. The three services are Adult Day Health, Adult Family Living and Assisted Living. The settings requiring review are the Residential Care Homes. Adult Day Health: This is a community based service that brings waiver participants to a center to receive services, meals care and opportunities to participate in activities both within the center and in the greater community. Some centers are located adjacent o or on the grounds of long term care facilities. The certification process requires that there be a separate entrance and separate bathing and bathroom facilities. The service is freely chosen by the participant from a range of services and providers as part of the person centered planning process. In reviewing this service, the state has determined that it is fully compliant with the new CMS regulations but will work on several enhancements to ensure the home based look and feel the is expected under the regulations. As part of the overall transition plan, the department will review its own regulations regarding this service and make modifications and be more explicit about the expectations of community integration and the overall look and feel of the setting itself. In addition, the department has already engaged in conversations with the certification reviewers and there is agreement to make modifications to the certification process to describe expectations of community inclusion and activities as well as a clear description of the expectations of the appearance of a home like environment. As part of the transition plan, the state will include sample of monthly calendars from a range of Day Centers that illustrate activities to promote community inclusion that comply with the new rules. Adult Family Living: This service is provided in either the home of the participant or the caregiver. This service is freely chosen by the participant from a range of services by qualified providers as part of the person centered plan. Assisted Living: The state reviewed the settings in which assisted living services are provided and also met with representatives of the Ct Assisted Living association. Our analysis concluded that the state is in full compliance with the new HCBS settings requirements. Assisted living services are provided in a managed residential community. The community assists residents in integrating into the greater community, is a setting freely selected by the waiver participant, ensures the individuals rights to privacy and dignity and facilitates choice for services available outside of the bundled assisted living service. All persons residing in managed residential communities have a lease with eviction protections, their doors are lockable, they have cooking facilities and access to food at any time, are free to decorate their unit as they choose, can have visitors at any time and the setting is physically accessible. The setting is a private apartment unless a roommate option is selected by the waiver participant. Residential Care Homes: Initially, the department set out to identify the number of waiver participants residing in residential care homes. An analysis indicates there are 254 participants residing in RCHs. These locations in the state vary widely in the appearance, size and home like qualities. The state recognizes that some of the settings will be fully compliant with the new regulations while others will need to make changes to become compliant. To accomplish this, the state has a number of steps it needs to take. First, all case managers were trained on the new rules and were introduced to a survey to be utilized from September 1, 2014 through February 28, 2015 when performing the annual or semi-annual reassessment at the RCH. Each client will be asked about the choice of setting they prefer to live in and will also focus on areas such as privacy, dignity and respect as well as choice of HCBS waiver providers. Case managers will evaluate if the setting was clearly chosen by the participant as part of the person centered plan. A survey will also be developed and distributed to all RCHs in the state to do a self assessment of compliance during the same time period. It is anticipated that a meeting with the association would need to take place either prior to or after the analysis of the survey data. The department will also engage in conversations with the CT Department of Public Health that licenses residential care homes to determine if regulatory changes might be needed to ensure compliance with the HCBS settings rules. This will be accomplished by June 30, 2015. Our goal will be to include language from the new rules to be incorporated into the RCH regulations. A summary of the survey findings will identify areas that changes will need to be made to bring the setting into full compliance. The state will engage with stakeholders to provide input on a final transition plan that will be submitted to CMS for final approval by 10/31/14. Notice was published in the CT Law Journal on 7/8/2014 outlining both the changes resulting in the amendment and the transition plan. In addition, the tribes were notified of the amendment and transition plan on 6/26/14. A second notice soliciting comments was published on the DSS web site on July 22, 2014. The state received comments from Leading Age CT and three of the four contracted Access Agencies who do the care management under this waiver. All commenters were supportive of the plan developed by the department. Leading Age supported the department's conclusion that the Adult Day programs and Assisted Living are compliant with the new rules. They also committed to assisting with the assessment process for the residential care homes. The Access Agencies commented that the survey process of the residential care homes will provide valuable information to assess compliance and variation across the range of settings. One suggestion was to convene regional housing groups to explore housing options in light of the new rules. Overall, there was agreement with the department's conclusion that Adult Day and Assisted Living were compliant with the new rules.
The waiver is operated by the State Medicaid agency.
Another division/unit within the State Medicaid agency that is separate from the Medical Assistance Unit.
Specify the division/unit name. This includes administrations/divisions under the umbrella agency that has been identified as the Single State Medicaid Agency.
The waiver is operated by a separate agency of the State that is not a division/unit of the Medicaid agency.
In accordance with 42 CFR §431.10, the Medicaid agency exercises administrative discretion in the administration and supervision of the waiver and issues policies, rules and regulations related to the waiver. The interagency agreement or memorandum of understanding that sets forth the authority and arrangements for this policy is available through the Medicaid agency to CMS upon request. (Complete item A-2-b).
As indicated in section 1 of this appendix, the waiver is not operated by another division/unit within the State Medicaid agency. Thus this section does not need to be completed.
As indicated in section 1 of this appendix, the waiver is not operated by a separate agency of the State. Thus this section does not need to be completed.
Yes. Contracted entities perform waiver operational and administrative functions on behalf of the Medicaid agency and/or operating agency (if applicable).
The department contracts with Access Agencies as defined in CGS 17b-342(b). The Access Agency is required to hire appropriate staff to perform case management functions. The case managers conduct the initial assessment of the client for the purpose of developing a comprehensive plan of care and confirming the level of care determination that has been made by Department staff. Once the initial plan is developed, department approval of the plan is required. From that point forward, the Access Agency can modify plans as long as the plan remains within the nursing home cost cap. The Access Agency performs a supervisory level review of service plans. As part of the case management process, the Access Agency is responsible for evaluating the utilization of the authorized services. The Access Agencies have extensive quality assurance and quality improvement plans in place. The plans are presented to the Department for review at the time the contract is awarded. The Department's fiscal intermediary credentials the providers who wish to be enrolled as a waiver service provider. They also act as the fiscal agent for the self directed personal care assistants. The direct service waiver providers will directly enroll with the Department's MMIS contractor and bill the HCBS claims directly through a portal developed by the MMIS contractor where the claim is compared to the authorized service plan. This occurs only after the provider has been credentialed by the fiscal intermediary. The contract for the Access Agencies and the fiscal intermediary were both awarded as the result of a competitive procurement.
No. Contracted entities do not perform waiver operational and administrative functions on behalf of the Medicaid agency and/or the operating agency (if applicable).
Applicable - Local/regional non-state agencies perform waiver operational and administrative functions.
Local/Regional non-state public agencies perform waiver operational and administrative functions at the local or regional level. There is an interagency agreement or memorandum of understanding between the State and these agencies that sets forth responsibilities and performance requirements for these agencies that is available through the Medicaid agency.
Local/Regional non-governmental non-state entities conduct waiver operational and administrative functions at the local or regional level. There is a contract between the Medicaid agency and/or the operating agency (when authorized by the Medicaid agency) and each local/regional non-state entity that sets forth the responsibilities and performance requirements of the local/regional entity. The contract(s) under which private entities conduct waiver operational functions are available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
Not applicable - Local/regional non-state agencies do not perform waiver operational and administrative functions.
The Department of Social Services HCBS unit is responsible for overseeing the contractual operations of the Access Agencies. This is done through on site administrative reviews as well as clinical record reviews, client and provider visits and consumer satisfaction surveys. Monitoring of reporting requirements takes place on a monthly basis. The Department's Division of Quality Assurance also conducts regular audits to ensure the Access Agencies' compliance with billing and claims submission. The state also monitors the fiscal intermediary via reports and on site audits by the Department's Quality Assurance division.
The Department oversees performance of contracted entities by conducting comprehensive client record reviews through onsite or desk audit reviews. These reviews monitor access agency compliance with state and federal law in additon to contractual compliance. The department reviews 100% of assessment outcomes on new client admissions to the program to verify level of care and authorize the service plan. The Department manages the waiver expenditures against the approved levels by utilizing paid claims data reports from our data warehouse. Our ability to do this has been enhanced by the creation of the MMIS portal through which all service authorizations and claims flow. Both department HCBS staff and Access Agency staff assume responsibility for utilization management functions. All new Total Plans of Care and a sample of reassessment Total Plans of Care are reviewed by Alternate Care staff nurses. Additionally, Alternate Care staff conduct record audits of the Access Agencies client records and the appropriateness of the Total Plan of Care is compared to the identified needs. Access Agency supervisors do ongoing utilization review as they review clinical records. The Department has a formal reporting process for the Access Agencies to report the data captured in the supervisory record reviews. As new providers are seeking enrollment as a waiver provider, the fiscal intermediary reviews the application and determines if the provider meets the qualifications to be a waiver provider. They then facilitate the application through the Department's provider enrollment process. The final decision on enrollment is made by the Department's Quality assurance staff who ensure that all qualifications are met. The Access Agencies and fiscal intermediary are also contractually obligated to provide reports to the Department either monthly, quarterly, semiannually or annually. Quality assurance reports to the Department from the Access Agencies are reviewed by Department staff for trends and the possible need for remediation. Receipt of the reports is tracked by HCBS staff. Appropriate remedial actions are taken if needed.
In accordance with 42 CFR §431.10, when the Medicaid agency does not directly conduct a function, it supervises the performance of the function and establishes and/or approves policies that affect the function. All functions not performed directly by the Medicaid agency must be delegated in writing and monitored by the Medicaid Agency. Note: More than one box may be checked per item. Ensure that Medicaid is checked when the Single State Medicaid Agency (1) conducts the function directly; (2) supervises the delegated function; and/or (3) establishes and/or approves policies related to the function.
As a distinct component of the States quality improvement strategy, provide information in the following fields to detail the States methods for discovery and remediation.
The Medicaid Agency retains ultimate administrative authority and responsibility for the operation of the waiver program by exercising oversight of the performance of waiver functions by other state and local/regional non-state agencies (if appropriate) and contracted entities.
For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.
If applicable, in the textbox below provide any necessary additional information on the strategies employed by the State to discover/identify problems/issues within the waiver program, including frequency and parties responsible.
ACU unit staff meetings are held as needed to collaborate and diseminate information with regards to waiver functions. Access Agency meetings are held on a bi-monthly basis. These meetings are used as a forum to exchange information and identify any problems/issues or trends occuring in the waiver program. Multiple levels of record review occur on a regular basis. The Access Agency supervisors review records and the Department is requiring that a uniform tool be established for aggregate quarterly reporting to the Department. The Access Agencies also have an external quarterly audit process where outside professionals perform record reviews. That data is provided to the Department in an annual summary report. In addition, department staff perform record audits of all the Access Agencies on a rotating basis to measure compliance with contract deliverables and quality of care provided to waiver participants. Sampling of chart reviews is not a representative sample. Remediation is to increse the number of client chart reviews to reduce the margin of error and increase our confidence level.
Describe the States method for addressing individual problems as they are discovered. Include information regarding responsible parties and GENERAL methods for problem correction. In addition, provide information on the methods used by the State to document these items.
When problems are identified, communications both written and within meetings provide opportunities for resolution of issues of concern. Audits result in issuance of formal reports and minutes are generated for meetings.
When the State does not have all elements of the Quality Improvement Strategy in place, provide timelines to design methods for discovery and remediation related to the assurance of Administrative Authority that are currently non-operational.
Please provide a detailed strategy for assuring Administrative Authority, the specific timeline for implementing identified strategies, and the parties responsible for its operation.
The following transition planning procedures are employed for participants who will reach the waiver's maximum age limit.
No Cost Limit. The State does not apply an individual cost limit. Do not complete Item B-2-b or item B-2-c.
Cost Limit in Excess of Institutional Costs. The State refuses entrance to the waiver to any otherwise eligible individual when the State reasonably expects that the cost of the home and community-based services furnished to that individual would exceed the cost of a level of care specified for the waiver up to an amount specified by the State. Complete Items B-2-b and B-2-c.
A level higher than 100% of the institutional average.
The state is proposing to increase the individual cost cap to 125% of the average Medicaid cost of nursing home effective 7/1/18 and to 130% of the average Medicaid cost of nursing home effective 7/1/19. All plans in excess of 100% of the average institutional cost will be subject to prior authorization by the department.
Institutional Cost Limit. Pursuant to 42 CFR 441.301(a)(3), the State refuses entrance to the waiver to any otherwise eligible individual when the State reasonably expects that the cost of the home and community-based services furnished to that individual would exceed 100% of the cost of the level of care specified for the waiver. Complete Items B-2-b and B-2-c.
Cost Limit Lower Than Institutional Costs. The State refuses entrance to the waiver to any otherwise qualified individual when the State reasonably expects that the cost of home and community-based services furnished to that individual would exceed the following amount specified by the State that is less than the cost of a level of care specified for the waiver.
Specify the basis of the limit, including evidence that the limit is sufficient to assure the health and welfare of waiver participants. Complete Items B-2-b and B-2-c.
May be adjusted during the period the waiver is in effect. The State will submit a waiver amendment to CMS to adjust the dollar amount.
DSS refers the prospective client to an Access Agency for the initial assessment and development of the plan of care. The care manager is responsible to develop the plan to maintain the client's health and safety while staying within the cost cap specified in the waiver. This is done in consultation with the client and/or their responsible party. The development of the care plan is based on a multidimensional assessment that covers the domains of health, function, psychosocial, cognition, environment, support system and finances. Risk factors are identified and mitigated through service plans. Once the plan is agreed upon, the costs are determined. Each service on the plan of care is evaluated to determine if a back-up plan is necessary to ensure client health and/or safety. If an applicant's health and safety needs cannot be met, they are denied access to the waiver. The applicant, if denied, receives a Medicaid Notice of Action (NOA) advising of their rights to a hearing. Any plan that exceeds 100% (inclusive)of the average cost of nursing home are subject to prior authorization by HCBS Unit nurses.
The participant is referred to another waiver that can accommodate the individual's needs.
Additional services in excess of the individual cost limit may be authorized.
Services beyond the monthly cap may be authorized on a short term basis to meet health and safety needs as long as there is evidence that the plan on an annualized basis will be equal to or less than 115% of the cost of nursing facility care. Applicants whose needs cannot be met within the caps are assisted in accessing other state plan services but are determined to be ineligible for the waiver. The client is issued a NOA and advised of their right to a fair hearing. Services are continued at the client's request while the hearing decision is pending. Clients are given a minimum of 10 days notice of any adverse action.
The State does not limit the number of participants that it serves at any point in time during a waiver year.
The State limits the number of participants that it serves at any point in time during a waiver year.
Not applicable. The state does not reserve capacity.
The State reserves capacity for the following purpose(s).
The state reserves capacity to accommodate persons mandated to transition from the PCA Waiver when they turn 65.
The estimate is based on the current enrollees expected to turn 65 in the next two waiver years.
The state reserves 184 slots in year 4 of the waiver and 241 slots in year 5 to accommodate transitions from the Money Follows the Person Demonstration.
Based on the average number of transitions and current applications as well as historical trends.
The state serves CT residents 65 and older who are less than nursing facility level of care under a 1915i state plan option.
Historically, as these residents age in place, some of them experience increased care needs resulting in functional eligibility for the waiver. We estimate, based on historical trends that an average of 10% of the 1915i recipients will have increased care needs that result in waiver eligibility.
The waiver is not subject to a phase-in or a phase-out schedule.
The waiver is subject to a phase-in or phase-out schedule that is included in Attachment #1 to Appendix B-3. This schedule constitutes an intra-year limitation on the number of participants who are served in the waiver.
Waiver capacity is allocated/managed on a statewide basis.
Waiver capacity is allocated to local/regional non-state entities.
Applications are processed on a first come first serve basis. There is no waiting list for the waiver program. Applicants are screened by department HCBS Unit nurses and social workers for level of care, financial eligibility, and whose care needs are consistent with the need for institutionalization. Applicants must meet nursing facility level of care to be included in the waiver.
Answers provided in Appendix B-3-d indicate that you do not need to complete this section.
% of FPL, which is lower than 100% of FPL.
Persons defined as qualified severely impaired individuals in section 1619(b) and 1905(q) of the Social Security Act.
No. The State does not furnish waiver services to individuals in the special home and community-based waiver group under 42 CFR §435.217. Appendix B-5 is not submitted.
Yes. The State furnishes waiver services to individuals in the special home and community-based waiver group under 42 CFR §435.217.
Select one and complete Appendix B-5.
A dollar amount which is lower than 300%.
% of FPL, which is lower than 100%.
In accordance with 42 CFR §441.303(e), Appendix B-5 must be completed when the State furnishes waiver services to individuals in the special home and community-based waiver group under 42 CFR §435.217, as indicated in Appendix B-4. Post-eligibility applies only to the 42 CFR §435.217 group.
Note: For the five-year period beginning January 1, 2014, the following instructions are mandatory. The following box should be checked for all waivers that furnish waiver services to the 42 CFR §435.217 group effective at any point during this time period.
Spousal impoverishment rules under §1924 of the Act are used to determine the eligibility of individuals with a community spouse for the special home and community-based waiver group. In the case of a participant with a community spouse, the State uses spousal post-eligibility rules under §1924 of the Act.
Complete Items B-5-e (if the selection for B-4-a-i is SSI State or §1634) or B-5-f (if the selection for B-4-a-i is 209b State) and Item B-5-g unless the state indicates that it also uses spousal post-eligibility rules for the time periods before January 1, 2014 or after December 31, 2018.
Note: The following selections apply for the time periods before January 1, 2014 or after December 31, 2018 (select one).
Spousal impoverishment rules under §1924 of the Act are used to determine the eligibility of individuals with a community spouse for the special home and community-based waiver group.
Use spousal post-eligibility rules under §1924 of the Act.
Spousal impoverishment rules under §1924 of the Act are not used to determine eligibility of individuals with a community spouse for the special home and community-based waiver group. The State uses regular post-eligibility rules for individuals with a community spouse.
Note: The following selections apply for the time periods before January 1, 2014 or after December 31, 2018.
Regular Post-Eligibility Treatment of Income: SSI State.
Answers provided in Appendix B-4 indicate that you do not need to complete this section and therefore this section is not visible.
Regular Post-Eligibility Treatment of Income: 209(B) State.
A dollar amount which is less than 300%.
Specify dollar amount: If this amount changes, this item will be revised.
Specify dollar amount: The amount specified cannot exceed the higher of the need standard for a family of the same size used to determine eligibility under the State's approved AFDC plan or the medically needy income standard established under 42 CFR §435.811 for a family of the same size. If this amount changes, this item will be revised.
Necessary medical or remedial care expenses recognized under State law but not covered under the State's Medicaid plan, subject to reasonable limits that the State may establish on the amounts of these expenses.
Not Applicable (see instructions) Note: If the State protects the maximum amount for the waiver participant, not applicable must be selected.
The State does not establish reasonable limits.
The State uses the post-eligibility rules of §1924(d) of the Act (spousal impoverishment protection) to determine the contribution of a participant with a community spouse toward the cost of home and community-based care if it determines the individual's eligibility under §1924 of the Act. There is deducted from the participant's monthly income a personal needs allowance (as specified below), a community spouse's allowance and a family allowance as specified in the State Medicaid Plan. The State must also protect amounts for incurred expenses for medical or remedial care (as specified below).
If the allowance for the personal needs of a waiver participant with a community spouse is different from the amount used for the individual's maintenance allowance under 42 CFR §435.726 or 42 CFR §435.735, explain why this amount is reasonable to meet the individual's maintenance needs in the community.
The State uses the same reasonable limits as are used for regular (non-spousal) post-eligibility.
Note: The following selections apply for the five-year period beginning January 1, 2014.
Regular Post-Eligibility Treatment of Income: SSI State or §1634 State - 2014 through 2018.
Regular Post-Eligibility Treatment of Income: 209(B) State - 2014 through 2018.
Answers provided in Appendix B-5-a indicate the selections in B-5-c also apply to B-5-f.
Post-Eligibility Treatment of Income Using Spousal Impoverishment Rules - 2014 through 2018.
The State uses the post-eligibility rules of §1924(d) of the Act (spousal impoverishment protection) to determine the contribution of a participant with a community spouse toward the cost of home and community-based care. There is deducted from the participant's monthly income a personal needs allowance (as specified below), a community spouse's allowance and a family allowance as specified in the State Medicaid Plan. The State must also protect amounts for incurred expenses for medical or remedial care (as specified below).
Answers provided in Appendix B-5-a indicate the selections in B-5-d also apply to B-5-g.
As specified in 42 CFR §441.302(c), the State provides for an evaluation (and periodic reevaluations) of the need for the level(s) of care specified for this waiver, when there is a reasonable indication that an individual may need such services in the near future (one month or less), but for the availability of home and community-based waiver services.
By an entity under contract with the Medicaid agency.
The initial Level of Care evaluation is performed by nurses and social workers employed by DSS in the HCBS Unit utilizing a uniform health screen. The client is referred to the Access Agency that performs a comprehensive assessment and submits a summary of that assessment to the Department's Utilization Review staff for review to confirm the level of care. Level of care reevaluations are conducted by Access Agency Care Managers with oversight by the Department's Utilization Review staff.
HCBS Unit staff that conduct the inital level of care evaluations are either Utilization Review Nurses or Social Workers with experience in long term care. The care manager who conducts the assessments and reassessments, develops care plans and provides ongoing monitoring shall be either a registered nurse licensed in the State where care management services are provided or a social services worker who is a graduate of an accredited four-year college or university. The nurse or social services worker shall have a minimum of two years of experience in health care or human services. A bachelors degree in nursing, health, social work, gerontology or a related field may be substituted for one year of experience. Care managers shall have the following additional qualifications: 1.demonstrated interviewing skills which include the professional judgment to probe as necessary to uncover underlying concerns of the applicant; 2.demonstrated ability to establish and maintain empathetic relationships; 3.experience in conducting social and health assessments; 4.knowledge of human behavior, family/caregiver dynamics, human development and disabilities; 5.awareness of community resources and services; 6.the ability to understand and apply complex service reimbursement issues; and 7. the ability to evaluate, negotiate and plan for the costs of care options. 8.Care management supervisors shall meet all the qualifications of a care manager plus have demonstrated supervisory ability, and at least one year of specific experience in conducting assessments, developing care plans and monitoring home and community based services.
Level of Care Criteria. Fully specify the level of care criteria that are used to evaluate and reevaluate whether an individual needs services through the waiver and that serve as the basis of the State's level of care instrument/tool. Specify the level of care instrument/tool that is employed. State laws, regulations, and policies concerning level of care criteria and the level of care instrument/tool are available to CMS upon request through the Medicaid agency or the operating agency (if applicable), including the instrument/tool utilized.
A Uniform Health Screen is utilized to determine nursing facility level of care. Nursing Facility Level of Care is defined as an individual requiring substantial daily assistance as defined by the following criteria: Substantial daily personal care is defined by: 1. Supervision or cueing ≥ 3 ADLs daily + need factor 2. Hands-on ≥ 3 ADLs daily 3. Hands-on ≥ 2 ADLs daily + need factor 4. A cognitive impairment which requires a professionally staffed environment for monitoring on a daily basis. Need factors are: 1. Cognitive Need: Requires daily supervision to prevent harm due to a cognitive impairment 2. Behavioral Need: Requires daily supervision to prevent harm 3. Medication supports: Requires assistance for administration of physician ordered daily medications. Includes supports beyond set up. For the nursing facility sub-acute level of care, the individual would meet all of the above criteria with the addition of the need for comprehensive medical monitoring, intensive medical supervision such as intermittent nursing services throughout the day or have high intensity rehabilitative needs, are ventilator dependent, have complex wound care needs or a need for specialized infusion therapy.
The same instrument is used in determining the level of care for the waiver and for institutional care under the State Plan.
A different instrument is used to determine the level of care for the waiver than for institutional care under the State plan.
Describe how and why this instrument differs from the form used to evaluate institutional level of care and explain how the outcome of the determination is reliable, valid, and fully comparable.
The same care manager who conducts the initial evaluation visits the client for the annual reevaluation and conducts a comprehensive, multidimensional assessment. The assessment covers seven domains: health, function, psychosocial, cognition, support system, environment and finances. The assessment identifies unmet needs and risk factors. After completion of the assessment, they are required to specify the level of care based on the findings of the reevaluation. The department reviews a random sample of reevaluations that summarize the reevaluation findings. Plans of care are also reviewed to evaluate if services meet the identified needs.
The qualifications of individuals who perform reevaluations are the same as individuals who perform initial evaluations.
The department maintains an electronic database of all clients and their reevaluation schedule. Six weeks prior to the beginning of the month when reevaluations are due, the Department sends the list of reevaluations due to be completed. Compliance with this is also audited by the Department via record review.
Records are retained in both the HCBS Unit of the Department of Social Services as well as in the offices of the Access Agencies. The Department's policy for record retention is seven years.
The state demonstrates that it implements the processes and instrument(s) specified in its approved waiver for evaluating/reevaluating an applicant's/waiver participant's level of care consistent with level of care provided in a hospital, NF or ICF/IID.
Sub-assurance: An evaluation for LOC is provided to all applicants for whom there is reasonable indication that services may be needed in the future.
For each performance measure the State will use to assess compliance with the statutory assurance (or sub-assurance), complete the following. Where possible, include numerator/denominator.
Sub-assurance: The levels of care of enrolled participants are reevaluated at least annually or as specified in the approved waiver.

References: §1915
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 §1924
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 §1634
 §1924
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 §435
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 §1634
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 §441