Alabama – Home and Community-Based Waiver for Persons with Intellectual Disabilities (0001.R08.00) HCBS Living at Home Waiver for Persons w/ID (0391.R03.00)

Waiver Title

Home and Community-Based Waiver for Persons with Intellectual Disabilities (0001.R08.00) HCBS Living at Home Waiver for Persons w/ID (0391.R03.00)

Description of Emergency

COVID-19 pandemic. This amendment will apply waiver-wide for each waiver included in this Appendix, to all individuals impacted by the virus or the response to the virus (e.g. closure of day programs, etc.)

Waiver Description

Home and Community-Based Waiver for Persons with Intellectual Disabilities (0001.R08.00): Provides day habilitation, employment support, personal care, prevocational services, residential habilitation, respite, adult companion services, assistive technology services, benefits and career counseling, community experience, community specialist, crisis intervention, environmental accessibility adaptations, housing stabilization service, individual directed goods and services, occupational therapy, personal emergency response system, physical therapy, positive behavior support, skilled nursing, specialized medical supplies, speech and language therapy, supported employment transportation, supported living service for individuals w/ID ages 3 – no max age. HCBS Living at Home Waiver for Persons w/ID (0391.R03.00): Provides day habilitation, employment support, personal care, prevocational services, respite, assistance in community integration, assistive technology services, benefits and career counseling, community experience, crisis intervention, environmental accessibility adaptations, in home habilitation services, individual self-directed goods and services, occupational therapy, personal emergency response system, physical therapy, positive behavior support, skilled nursing, specialized medical supplies, speech and language therapy, supported employment transportation for individuals w/IID ages 3 – 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

Increase Cost Limits

N/A

Modify Targeting Criteria

ID and LAH: For the duration of the emergency period, all persons enrolled in the Waivers may receive fewer than one service without being subject to discharge. However, all persons enrolled in the waiver will continue to receive monitoring/review of services by a Support Coordinator as needed, and on a quarterly basis as a minimum.

Modify Scope or Coverage

Residential Habilitation (ID), Personal Care (ID & LAH); Adult Companion Services (ID and LAH); Respite (ID and LAH); Skilled Nursing (ID and LAH); Specialized Medical Supplies (ID and LAH); Assistive Technology Services (ID and LAH); Positive Behavior Support (ID and LAH); Physical Therapy (ID and LAH); Occupational Therapy (ID and LAH); Speech & Language Therapy (ID & LAH);

Exceed Service Limitations

ID and LAH: When circumstances related to COVID-19 diagnoses or potential contact require it, and upon explicit approval by the Operating Agency, the State will permit temporary increases beyond the currently defined waiver service caps and limitations to allow the needed amount, duration or change in scope within the Waiver to effectively address emergent health, safety and welfare-related needs of participants. The temporary modifications described below apply to the following services, as applicable: Residential Habilitation, Personal Care, Adult Companion, and Respite. • Limitations on the number of participants served with Residential Habilitation in each certified home may be exceeded, but only when all other alternatives for supports have been exhausted. • Minimum staffing ratios in Residential Habilitation settings may be exceeded due to staffing shortages, so long as the health and safety of participants is preserved and required minimum staffing ratios are implemented as often and as soon as possible. • Any previously authorized Personal Care or Adult Companion services, or any combination of these services, may be modified up to a maximum of 18 hours per day without requesting a variance in order to meet the needs of the participants. • Respite services, including any combination of In-Home or Out-of-Home Respite, may exceed the fiscal year limit of 4320 units. The Support Coordinator and/or the service provider/self-directed Employer of Record (EOR) will be responsible to review and substantiate a need and capacity to increase traditional Waiver services to effectively address emergent health, safety and welfare-related needs of program participants during the COVID-19 pandemic. Emergency modifications to a participant’s personcentered plan must be both reasonable and necessary. The Operating Agency will perform retrospective reviews to assure that fraud, waste and program abuse do not occur as a result of this emergency response measure. Temporarily allow verbal orders from a physician or other licensed health care provider for nonprescription Specialized Medical Supplies authorized in an individual’s care plan as of the date of the COVID 19 PHE, including adult protective undergarments, catheter bags, and other supplies covered under that service, and for nonprescription Assistive Technology authorized in an individual’s care plan as of the date of the COVID-19 PHE. This modification will be in effect beginning March 13, 2020 and extend through the end of the month in which the PHE terminates, not to exceed the end date of the approved Appendix K.

Add Services

N/A

Expand Settings

ID and LAH: When circumstances related to COVID-19 diagnoses or potential contact require it, and upon explicit approval by the Regional Office of the Operating Agency, Out-of-Home Respite services may be provided in an alternative (e.g., non-certified) setting to ensure the health and safety of participants. The provider must submit a detailed plan for staffing, supplying, and monitoring the provision of Out-of-Home Respite in the alternative setting and must supply the appropriate Support Coordination agency and the Regional Office with full contact information and a list of proposed staff members for the alternative setting in advance of its utilization. Out-ofHome Respite is not provided in facility-based settings. ID and LAH: Temporarily suspend any requirements for services to be provided in community locations, so as to consistently observe social distancing necessities and minimize potential exposure to COVID-19. To the extent that the services may be administered while safely observing social distancing guidelines, they may be provided in an alternative, non-community setting (e.g., a provider facility such as a gymnasium or home with sufficient space to allow for ample distancing). Any alternative setting for service provision must be reported to, and approved by, the applicable Regional Office.

Provide Service Out of State

N/A

Allow Payment for Services by Families

N/A

Modification of Provider Qualifications

ID and LAH: Provider staff training qualifications may be modified as follows: • Required staff training for beginning employment, including Nurse Delegation Program training, may be conducted on-line, by telephone, or electronically, as appropriate. • Any staff persons not fully trained must work under supervision of a fully trained staff person. • Annual refresher training of staff due through 7/1/2020 may be extended for 90 days. These modifications apply to the following services and provider types: Adult Companion Services Certified Waiver Hourly Services Provider Skilled Nursing Alabama-licensed LPN Personal Care Certified Waiver Hourly Services Provider (including Personal Care Workers) / Self-Directed Personal Care Workers Positive Behavior Support Individual employed or contracted by a certified agency (Level 1 Professional, Certified Level 2 Professional Level 3 Technician) Residential Habilitation Certified Residential Facility (includes BCBA, QIDP, Direct Support Staff) Respite Certified Waiver Hourly Services Provider (for inhome respite) Self-Directed In-home Respite Services Out of Home Respite, Community Residential Facility • For Residential Habilitation, Adult Companion or Personal Care services, if family members are temporarily approved to provide these services in order to cover gaps in care resulting from issues related to the COVID-19 pandemic, the Operating Agency will temporarily suspend routine employee screening for said family members (e.g., TB, background checks, drug screens). Suspension of said screenings is temporary, and all required screenings will be required to be completed once the emergency period ends.

Modify Provider Types

ID and LAH: Providers may be reimbursed at the approved waiver service limits, per existing Waiver limits and guidelines, when purchasing Specialized Medical Supplies and Assistive Technology items from any available vendor, regardless of inclusion on the existing approved vendor list, who can provide necessary and potentially short-supplied items in stock when supply shortages or costs are impacted by circumstances related to the COVID-19 pandemic.

Modify Licensure/Requirements for Waiver Settings

ID and LAH: • Temporarily suspend annual and follow-up certification reviews of existing provider agencies until 7/1/2020. All suspended certification reviews will be completed within 90 days of 7/1/20; however, if the PHE continues beyond 7/1/20, the Operating Agency will conduct desk and electronic reviews, instead of on-site reviews, through the end of the month in which the PHE terminates, not to exceed the end date of the approved Appendix K. Notwithstanding the foregoing, the Operating Agency will continue to complete “For Cause” on-site certification visits when needed based on any pattern of incident reports, complaints or other information indicating concerns regarding individuals’ health, safety, rights, access to services, or other aspects of the provider organization’s operations. • For the duration of the PHE and through the end of the month in which the PHE is terminated, provider applications for new settings and/or services may be submitted electronically.

Modification LOC Eval and Re-Eval Processes

ID and LAH: For a new applicant for waiver services, in the event that a qualifying evaluation is not possible, and substantiating documentation of all eligibility criteria is not available, the State will temporarily accept limited sources of substantiated data, including the most recent IQ test prior to age 18 with an IQ score less than 70, an ID diagnosis without an adaptive assessment prior to age 18, or a physician’s statement verifying an ID diagnosis prior to age 18 that directly causes an adaptive behavior impairment.

Increase Payment Rates

ID and LAH: • Temporarily increase Residential Habilitation rates by 19% for all providers, to account for greater needs for staffing and direct service, given the suspension of Day services, including Day Habilitation, Prevocational Services, and Community Experience. This rate increase will begin on March 1, 2020 and extend through the end of the month in which the PHE terminates, not to exceed the end date of the approved Appendix K. • Temporarily increase rates for the following services to account for excessive overtime pay for direct support personnel, to cover staffing needs in the event of unusual numbers of sick employees and to account for additional infection control supplies (including personal protective equipment (PPE)) and service costs: Personal Care, Adult Companion, Respite, and Skilled Nursing (LPN Nursing and RN Nursing.) The rate setting methodology remains the same. Upward adjustments are made to account for the supply costs and anticipated overtime for direct support personnel. Resulting temporary rate increases will not exceed 50%. The exact increase will be determined based on current market factors and substantiated, additional costs incurred by providers. This rate increase will begin on March 1, 2020 and extend through the end of the month in which the PHE terminates, not to exceed the end date of the approved Appendix K. • Self-directed employees may not work more than 16 hours per day, and the sum total of their hours worked in a given week cannot exceed 40. If an exception is required due to issues related to the COVID-19 pandemic, a specific request must be made via Support Coordination through the established request process. In the event an exception is made to allow overtime, the Operating Agency will permit, with documentation of substantiated need, overtime work to allow the needed amount, duration or change in scope within the Waiver to effectively address emergent health, safety and welfare-related needs of participants during the COVID19 pandemic. This change applies to the following self-directed services: Personal Care, Adult Companion, Respite and Skilled Nursing (LPN Nursing and RN Nursing.) List of Provider Types and Rates by Service Service Base Rate New Overtime Rate Adult Companion Services $3.12 $4.68 LPN Nursing per hour $20.80 $31.20 Personal Care $4.12 $6.18 Respite In Home $3.12 $4.68 Respite Out of Home $3.12 $4.68 RN Nursing per hour $36.40 $54.60 Supported Employment Small Group $3.84 $5.76 Self-Directed Adult Companion $2.75 $4.13 Self-Directed LPN $20.80 $31.20 Self-Directed RN $36.40 $54.60

Modifications of ISP

ID and LAH: The state will ensure the person-centered service plan is modified to allow for additional supports/and or services to respond to the COVID-19 pandemic. The specificity of such services including amount, duration and scope will be appended as soon as possible but no later than 30 days to ensure that the specific service is delineated accordingly to the date it began to be received. For service needs identified to mitigate harm or risk directly related to the COVID19 pandemic (and substantiated via documentation submitted to RCS via ADIDIS), necessary changes to PCP’s and/or Plans of Care (POC’s) may be approved retroactively to 3/12/2020. The use of e-signatures that meets privacy and security requirements will be added as a method for the participant or legal guardian signing the PCCP to indicate approval of the plan. Services may start while waiting for the signature to be returned to the case manager, whether electronically or by mail. Signatures will include a date reflecting the PCCP meeting date. An electronic or written signature is required within 45 days of the change(s) made to the PCCP.

Modify Incident Reporting/Med Management Safeguards

ID and LAH: Providers must submit incident reports for participants who test positive for COVID-19 within 48 hours of receiving notification and disclose any exposure of the COVID-19-positive participant to any other waiver participants and/or staff persons. Incident reports must also be submitted within 48 hours for each other participant potentially exposed. While incident reports are required in these instances, there is no automatic requirement for an investigation or corrective action plan, unless the Medicaid Agency or Operating Agency specifically directs that either/both be completed.

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

N/A

Inclusion of Retainer Payments

ID and LAH: In response to the defined emergency, and in order to maintain a viable workforce, the state may elect to make retainer payments to waiver providers. Retainer payments are for direct care providers who normally provide services that include habilitation that have a personal care component (Day Habilitation, Prevocational Services, Community Experience, and/or Supported Employment – Small Group), but are currently unable to due to complications experienced during the COVID-19 pandemic (i.e., because the program has been directed to close and the provider cannot enter the participant’s home or otherwise provide services through other electronic platform.) The State confirms that retainer payments are for direct care providers who normally provide services that include habilitation that includes a component of personal care and personal care, but are currently unable to due to complications experienced during the COVID-19 pandemic because the waiver participant is sick due to COVID-19; or the waiver participant is sequestered and/or quarantined based on local, state, federal and/or medical requirements/orders. The state will implement a distinguishable process to monitor payments to avoid duplication of billing. The personal assistance retainer will begin March 1, 2020, and the time limit may not exceed the lesser of 30 consecutive days or the number of days for which the State authorizes a payment for “bed-hold” in nursing facilities

Institute/Expand Opportunities for Self-Direction

N/A

Increase Factor C

N/A

Other Changes Necessary

N/A

Addendum

HCBS Regulations

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

Services

Add Electronic Method of Service Delivery

Case management, personal care services that only require verbal cueing, in-home habilitation, monthly monitoring, other: ID/LAH: Behavior Supports Professionals, Nurses, and Occupational,
Physical & Speech/Language Therapists

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

N/A

Other Changes Necessary

N/A

Provider Qualifications

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

X

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

X

Allow Other Practitioners in Lieu of Approved Providers Within the Waiver

X For the following provider types, temporarily waive requirements for outof-state providers to be certified and located in Alabama, so long as they
are actively licensed/certified by another state’s Medicaid agency and so
long as they provide services required to cover gaps in care resulting from
issues related to the COVID-19 pandemic: RN, LPN, Psychologist, Board
Certified Behavior Analyst or Assistant, Occupational Therapist, Physical
Therapist, Speech/Language Therapist.

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

X

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

X

Adjust Prior Approval/Authorization Elements Approved in Waiver

X

Adjust Assessment Requirements

X

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

X

Link To Application

N/A

Link to Approval Letter

N/A