NOTE: The Centers for Medicare & Medicaid Services (CMS) have approved Appendix K flexibilities mentioned below. In addition, "for a period of 90 days" was removed from item 7 below. - April 9, 2020
NC Medicaid has implemented flexibilities on how Medicaid providers and beneficiaries may access and receive Medicaid services in the wake of COVID-19. Utilization and prior approval limits for specific State Plan Medicaid services will be relaxed for all Medicaid beneficiaries impacted by COVID-19 including individuals participating in the NC Innovations Waiver and the NC TBI Waiver. NC Medicaid has created an emergency planning document called Appendix K to seek approval to modify the scope, frequency, amount and setting of how waiver services are used and approved.
An Appendix K was submitted to the Centers for Medicare & Medicaid Services (CMS) on March 13, 2020. When the Appendix K is approved, this emergency planning document will be effective from March 13, 2020, to March 12, 2021, or until the COVID -19 pandemic is no longer a public health emergency, whichever is sooner. An Appendix K waives specific requirements and limitations under the authority of the 1915(c) HCBS waiver by allowing flexibilities in the areas of access and eligibility, services, settings (in and out of the state), payments and retainer payments to the caregivers, the required due date to complete annual reviews of need, and monthly and quarterly monitoring tasks.
The flexibilities extended through this approved Appendix K are intended only for the NC Innovations Waiver and NC TBI Waiver beneficiaries impacted by COVID-19 either directly or due to their staff being impacted and unable to provide services. This includes requesting prior approval, completing background checks and training staff. Waiver beneficiaries will transition to pre-emergency service status as soon as they are able. Beneficiaries who qualify for additional services or waiving of waiver rules and requirements because of COVID-19 will be reassessed at least 30-days before the expiration of the Appendix K to determine ongoing needs.
NC Medicaid has submitted an Appendix K for the NC Innovations and NC TBI waivers to the Centers for Medicare & Medicaid Services (CMS) to include the following modifications in scope and coverage during the COVID-19 pandemic:
- Allow the $135,000 waiver limit to be exceeded on a case-by-case basis due to additional services, or enhanced rates due to COVID -19.
- Allow for an increase in service hours from what is in the Individual Support Plan (ISP) without prior authorization.
- Allow retainer payments to direct care workers to address emergency related issues. Retainer payments cannot be provided for more than 30 consecutive days; however, there may be more than one 30 consecutive day period. Retainer payments are for direct care providers who are providing services that include habilitation or personal care. Retainer payments cannot be made for Respite. Staff retainer payments may only be made for currently authorized NC Innovations or TBI Waiver services.
- Waive the face-to-face requirements, including monthly face-to-face care coordinator and beneficiary meeting for individuals receiving residential supports, new to waiver, or relative as provider, quarterly face-to-face care coordinator and beneficiary meeting case-by-case. Both monthly and quarterly monitoring will occur telephonically. This Telephonic assessment / monitoring will be conducted in accordance with HIPAA requirements.
- Waive requirement for a beneficiary to attend the Day Supports provider once per week.
- Allows for direct care to be provided in a hotel, shelter, church, or alternative facility-based setting or the home of a direct care worker when the waiver participant is displaced from the home because of COVID-19 Virus, or the provider facility is not accessible.
- Waive service requirement and allow beneficiaries who receive fewer than one service per month to not be subject to discharge.
- Allow annual reassessments of level of care to be postponed by 90 calendar days to allow sufficient time to complete the annual reassessment and accompanying paperwork.
- Allow for existing staff to continue to provide service, for 90 days, when CPR and NCI re-certification has lapsed. For NC Innovations, this applies to Community Living and Supports, Crisis Services, Community Networking, Day Supports, Respite, Residential Supports, Supported Living, and Supported Employment. For them NC TBI Waiver, this applies to Life Skills Training, Personal Care, Crisis Services, Community Networking, Day Supports, Adult Day Health, Respite, Residential Supports, and Supported Employment
- 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. It is recommended that a relative residing in the home of the beneficiary provide no more 40 hours per week of service to the person. This must be reported to the PIHP, but does not require approval by the PIHP. If over 40 hours are needed to be provided by relatives residing in the home of the beneficiary, then the provider must maintain justification on the individual’s needs and why there is no other qualified provider. This applies to relatives, Legal Guardians, Employers or Record and Representatives. (NC Innovations Only)
- Allow Day Supports, Community Living and Supports, Supported Employment and Community Networking to be provided in the home of the participant, the home of the direct care worker, or the residential setting. Residential setting refers to the setting types listed in the Residential Service definition in the approved NC Innovations Waiver. (NC Innovations Only)
- Allow relatives of waiver beneficiaries who reside in the home or out of the home to provide services prior to a 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. Once conducted, if the background check demonstrates the individual should not continue working with the participant long-term, that individual will be immediately determined unqualified to render services. Relatives of adult waiver beneficiaries may provide Community Living and Supports, Day Supports, Supported Employment and Supported Living. This applies to relatives, Legal Guardians, Employers or Record and Representatives. (NC Innovations Only)
- Allows for more than the maximum number of hours and additional services to be provided by relative who resides with an adult beneficiary for up to 90 days. The relative may also provide Community Networking, Day Supports and Supported Employment for 90 days. This can only be used when staff is unavailable due to COVID-19 related (NC Innovations Only)
- Allow for payment for Community Living and Supports for purposes of supporting 1915(c) enrollees in acute care hospital or short-term institutional stay when the participant needs direct assistance with ADLs, behavioral supports on a continuous and ongoing basis. This supplemental service provided in the hospital will not exceed 30 consecutive days; however, there may be more than one 30 consecutive day period (NC Innovations Only)
- Waive Support Intensity Scale Assessments/Reassessments. (NC Innovations Only)
- Allow Day Supports, Supported Employment and Community Networking to be provided in the home of the participant, the home of the direct care worker, or the residential setting. Residential setting refers to the setting types listed in the Residential Service definition in the approved NC TBI Waiver. (NC TBI Waiver Only)
- Allow payment for Life Skills Training (for behavioral intervention) and Personal Care for purposes of supporting 1915(c) enrollees in acute care hospital or short-term institutional stay when the participant needs direct assistance with ADLs, behavioral supports on a continuous and ongoing basis, This supplemental services provided in the hospital will not exceed 30 consecutive days; however there may be more than one 30 consecutive day period (NC TBI Waiver Only)
Under State authority, NC Medicaid can allow NC Innovations waiver services and NC TBI Waiver services to be provided out-of-state without prior approval by the LME-MCO. Respite may also be provided out-of-state for individuals who have been displaced.
Providers must resume compliance with normal NC Medicaid rules and regulations as soon as they are able to do so.