SPECIAL BULLETIN COVID-19 #6: Temporary Policy Modifications for 1915 Waivers (Appendix K)

Thursday, March 19, 2020

The Centers for Medicare & Medicaid Services has granted NC Medicaid the authority to move forward with Home and Community-Based (HCBS) waiver flexibilities requested March 13, 2020. Note that final approval of the requests, known as “Appendix K,” has not been received; however, CMS and NC Medicaid are working collaboratively to quickly respond to NC Medicaid beneficiary needs due to the COVID-19 public health crisis.

In this Medicaid Bulletin are descriptions of the waiver policy flexibilities for:

  • Community Alternative Program for Children (CAP/C) and Community Alternative Program for Disabled Adults (CAP/DA) Waivers
  • Innovations Waiver
  • Traumatic Brain Injury Waiver

An Appendix K request waives specific requirements and limitations under the authority of the 1915(c) HCBS waiver by allowing flexibilities in access and eligibility; services; settings in- and out-of-state; payments and retainer payments to the caregivers; and the required due date to complete annual reviews of need and monthly and quarterly monitoring tasks. 

The flexibilities extended through an approved Appendix K are intended only for waiver beneficiaries affected by the COVID-19 public health emergency either directly or due to their staff being affected and unable to provide services. 

CAP/C and CAP/DA Waiver Flexibilities 

The CAP case management entities should assess the need for flexibilities of all Medicaid services for each CAP beneficiary and assist the beneficiary to assess such flexibilities. When determined necessary, the CAP unit at NC Medicaid will provide specific instructions on how to use and access flexibilities provided through an Appendix K. 

  • Access and Eligibility
    • The allowance to extend the cost limit that identifies ability of the state to manage cost needs of waiver beneficiary while participating in the 1915(c) HCBS waiver. 
    • The allowance to waive the requirement of receiving one waiver service per month, for a period of time, to prevent an action of disenrollment when the waiver beneficiary, caregiver or paid provider is directly impacted by COVID-19. 
  • Services
    The allowance for waiver beneficiary to temporarily exceed service limitations including limits on sets of services as described in the approved CAP/C and CAP/DA waivers in Appendix C-4 or extending the amount, duration and prior authorization to address health and welfare issues presented by COVID-19 such as additional in-home aide, personal assistant and pediatric nurse aide hours, goods and services directly needed to manage COVID-19 symptoms and case management hours to maintain linkage to Medicaid and other community resources. 
  • Settings
    • The allowance of waiver beneficiary to receive services in alternative settings when directly impacted by COVID-19. 
    • The allowance of waiver beneficiary to receive services in a different state than North Carolina when waiver beneficiary or primary caregiver is directly impacted by COVID-19. 
  • Payments and Retainer Payments to Caregivers:
    • The allowance to temporarily permit the payment of services rendered by a family caregiver or legally responsible individual when the assigned paid caregiver/provider is directly impacted by COVID-19. 
    • The allowance to temporarily pay the In-Home or Home Health Agency a retainer fee to maintain the assigned in-home aide, personal assistant or pediatric caregiver when the CAP beneficiary, family member or paid caregiver is impacted by COVID-19. 
  • Due date for assessment and monitoring tasks: 
    • The allowance to approve retroactive approval dates when services are needed and the waiver beneficiary, caregiver or the provider is impacted by COVID-19 and cannot complete the service plan. 
    • The allowance to extend monitoring due dates or skip required monitoring face-to-face visits when waiver beneficiary, caregiver or the provider is directly impacted by COVID-19. 
    • The allowance to extend the annual reassessment of need (level of care-LOC) to a date when the assessment cannot be conducted due to the waiver beneficiary, caregiver or the provider being directly impacted by COVID-19. 

Innovations Waiver Flexibilities

  • Waive $135k individual limit on a case-by-case basis for individuals who are currently receiving waiver services.
  • Allow for an increase in service hours from what is in the person-centered plan without prior authorization for this time period. 
  • Allow for Respite to be provided when family is out of state due to evacuation/displacement until they return home. Out of home Respite may be provided in excess of 30 days on a case by case basis.
  • Allow for Direct care provider to provide direct care services in a hotel, shelter, church, or alternative facility-based setting or the home of a direct care worker when the waiver participant because of COVID-19 related issues. 
  • Waive HCBS Settings requirements in alternative settings on a case-by-case basis (quarantine/social distancing/etc.).
  • Allow Day Supports and Community Networking to be provided in the home of the participant, the home of the direct care worker, or the residential setting.
  • Allow for relatives of adult waiver beneficiaries to provide services to beneficiaries in Supported Living arrangements prior to background checks and training for 90 days.
  • Allow relatives of adult waiver beneficiaries who reside in the home and out of the home to provide services prior to background check and training for 90 days. It is understood that the background check will be completed by the agency as soon as possible after the service begins and training will occur as soon as possible without leaving the beneficiary without necessary care.
  • Allow for existing staff to continue to provide service, for 90 days, when CPR and NCI re-certification has lapsed.
  • Allow for additional services to be provided by relatives who live in the home of the adult waiver beneficiary (current waiver only allows for Community Living and Supports) to include Community Networking and Supported Employment for 90 days. 
  • Allow for Annual reassessments of level of care that exceeds the 60-calendar day approval requirement beginning on 3/13/2020, to remain open, and services will continue for three months to allow sufficient time for the care coordinator to complete the annual reassessment paperwork
  • Allow for Person centered plans/revisions to be approved with a retroactive approval date dating back to 3/13/2020, for service needs identified to mitigate harm or risk directly related to COVID-19. Service limits in the service plan template may be exceeded in the amount, frequency and duration to plan the needs of waiver participants who were impacted by COVID-19 and need new waiver services.
  • Allow For service plans that are expiring and currently meeting an affected waiver participant’s needs, but a new person-centered plan is unable to be developed due to ongoing COVID-19 recovery efforts, the time limit to approve the plan by the last day of the birth month may be extended by 3 months after the birth month, when monthly telephonic monitoring is provided to ensure the plan continues to meet the participant’s needs. 
  • Allow for Community Living and Supports and respite to be provided in acute care hospital or short-term institutional stay, when the waiver participant is displaced from home because of COVID-19 and the waiver participant needs direct assistance with ADLs, behavioral supports, or communication supports on a continuous and ongoing basis for 3 or more hours per day. Room and board is excluded.
  • Include retainer payments to direct care workers to address emergency related issues.
  • Allow beneficiaries to receive fewer than one service per month during this amendment without being subject to discharge
  • Waive monthly face-to-face care coordinator/beneficiary meeting for individuals receiving residential supports, new to waiver, or relative as provider during this amendment. Waive quarterly face-to-face care coordinator/beneficiary meeting on case-by-case basis during this amendment.
  • Waive Support Intensity Scale Assessments/reassessment during this amendment.
  • Waive requirement for a beneficiary to attend the Day Supports provider once per week.

Effectively immediately, Local Management Entities/Managed Care Organizations (LME-MCOs) may temporarily implement Desk Reviews, including use of videos of the site, for managing onsite alternate family living (AFL) reviews and new admissions to unlicensed AFLs.

We are collecting specific feedback from provider groups, LME-MCOs and other key stakeholders to inform these policy decisions through BHIDD.COVID.Qs@dhhs.nc.gov. If future policy modifications are made, general and service-specific guidance will be issued. 

NC Medicaid supports providers coordinating with their LME-MCO to determine what accommodations can be made to ensure there is no interruption in service access and delivery while this official guidance is being developed.

Traumatic Brain Injury Waiver Flexibilities

  • Waive $135k individual limit on a case-by-case basis for individuals who are currently receiving waiver services.
  • Allow for an increase in service hours from what is in the person-centered plan without prior authorization for this time period. 
  • Allow for Respite to be provided when family is out of state due to evacuation/displacement until they return home. Out of home Respite may be provided in excess of 30 days on a case by case basis.
  • Allow for Direct care provider to provide direct care services in a hotel, shelter, church, or alternative facility-based setting or the home of a direct care worker when the waiver participant because of COVID-19 related issues. 
  • Waive HCBS Settings requirements in alternative settings on a case-by-case basis (quarantine/social distancing/etc.).
  • Allow Day Supports and Community Networking to be provided in the home of the participant, the home of the direct care worker, or the residential setting.
  • Allow for existing staff to continue to provide service, for 90 days, when CPR and NCI re-certification has lapsed.
  • Allow for Annual reassessments of level of care that exceeds the 60-calendar day approval requirement beginning on 3/13/2020, to remain open, and services will continue for three months to allow sufficient time for the care coordinator to complete the annual reassessment paperwork
  • Allow for Person centered plans/revisions to be approved with a retroactive approval date dating back to 3/13/2020, for service needs identified to mitigate harm or risk directly related to COVID-19. Service limits in the service plan template may be exceeded in the amount, frequency and duration to plan the needs of waiver participants who were impacted by COVID-19 and need new waiver services.
  • Allow For service plans that are expiring and currently meeting an affected waiver participant’s needs, but a new person-centered plan is unable to be developed due to ongoing COVID-19 recovery efforts, the time limit to approve the plan by the last day of the birth month may be extended by 3 months after the birth month, when monthly telephonic monitoring is provided to ensure the plan continues to meet the participant’s needs. 
  • Allow for Personal Care, Life Skills Training and Respite to be provided in acute care hospital or short-term institutional stay, when the waiver participant is displaced from home because of COVID-19 and the waiver participant needs direct assistance with ADLs, behavioral supports, or communication supports on a continuous and ongoing basis for 3 or more hours per day. Room and board is excluded.
  • Include retainer payments to direct care workers to address emergency related issues.
  • Allow beneficiaries to receive fewer than one service per month during this amendment without being subject to discharge
  • Waive monthly face-to-face care coordinator/beneficiary meeting for individuals receiving residential supports, new to waiver, or relative as provider during this amendment. Waive quarterly face-to-face care coordinator/beneficiary meeting on case-by-case basis during this amendment.
  • Waive requirement for a beneficiary to attend the Day Supports provider once per week.

Effectively immediately, LME/MCOs may temporarily implement Desk Reviews, including use of videos of the site, for managing on-site AFL reviews and new admissions to unlicensed AFLs.

We are collecting specific feedback from provider groups, LME-MCOs and other key stakeholders to inform these policy decisions through BHIDD.COVID.Qs@dhhs.nc.gov. If future policy modifications are made, we will issue general as well as service specific guidance. 

NC Medicaid supports providers coordinating with their LME-MCO to determine what accommodations can be made to ensure there is no interruption in service access and delivery while this official guidance is being developed.
 

Author: 
GDIT, (800) 688-6696