California – 0138.R04.00

Waiver Title

Home and Community Based Alternatives Waiver (0139.R05.00)

Description of Emergency

1) Nature of Emergency: Coronavirus disease 2019 (COVID-19) is a respiratory illness caused by a novel virus that has been spreading worldwide. Community-acquired cases have now been confirmed in California. The Governor’s Office of Emergency Services (OES), the California Department of Public Health (CDPH), and the Department of Health Care Services (DHCS) are gaining more understanding about the spread and impact of COVID-19 as time progresses, and the situation is changing daily. The State of California has been working in close collaboration with the United States’ Department of Health and Human Services and local Medi-Cal Home and Community-Based Services (HCBS) providers to monitor and plan for COVID-19. APPENDIX K: Emergency Preparedness and Response Appendix K-1: General Information 2) Number of Individuals Affected and the State’s Mechanism to Identify Individuals at Risk: On March 4, 2020, the State of California declared a State of Emergency in response to the COVID-19 outbreak. As of March 12, 2020, there are 1,215 presumptive cases of COVID-19 in the United States, including 198 confirmed cases and four fatalities in California. Public Health officials expect the number of cases in California to increase, and while the general population is expected to experience mild flu-like symptoms, the population receiving HCBS Waiver services is at a greater risk for experiencing more severe symptoms, hospitalization, and death. 3) Roles of State, Local, and Other Entities Involved in Approved Waiver Operations: As of March 12, there are 4,681 participants receiving HCBS through the HCBA Waiver. DHCS contracts with nine entities that administer an Organized Health Care Delivery System (OCHDS) at the local level within defined service areas. The State operates the “10th waiver agency” directly for all areas not covered by a contracted entity. DHCS, the State Medicaid Agency, is responsible for all HCBS Waiver programs, and is directly responsible for the statewide administration of the HCBA Waiver, which includes contracting with qualified organizations to provide administrative and comprehensive care management services to HCBA Waiver applicants and participants. DHCS is also responsible for verifying the eligibility of applicants to the waiver for enrollment into the Waiver, developing policies and guidance related to federal and state statute and regulations, and monitoring the contracted HCBA Waiver Agencies for compliance. HCBA Waiver Agencies maintain a network of Medi-Cal home and communitybased service providers to ensure Waiver participants have access to authorized medically necessary HCBA Waiver services within the Waiver Agency’s contracted service area. 4) Expected Changes needed to Service Delivery Methods: To prevent Waiver Participant exposure to COVID-19, California will allow the following changes to current HCBA Waiver service delivery methods: a) Permit payment for services rendered by family caregivers or legally responsible individuals; b) Modify provider qualifications to permit unlicensed WPCS providers as long as they are currently IHSS providers; c) Modify provider types to allow for Certified Nurse Assistants (CNA) to provide Private Duty Nursing (PDN), in addition to currently authorized HCBS Waiver Nurse Providers (Registered Nurses, Licensed Vocational Nurses, and Certified Home Health Aide (CHHA)) and Home Health Agencies; d) Modify licensure or other requirements for settings where waiver services are furnished – specifically, allowing telehealth (telephonic, or virtual live video conferencing) as an alternative option to face-to-face interactions; e) Modify processes for waiver eligibility level of care (LOC) evaluations and reevaluations via telephonic or virtual live video conferencing as an alternative option to face-to-face interactions, in accordance with HIPAA requirements; f) Pause waiver disenrollments of participants who are re-institutionalized, beyond the 30-day limit, because they or their caregiver(s) have contracted the virus, and/or if it is unsafe for them to return to the community because they would be exposed to the virus or without medically necessary services, through June 30, 2020; and g) Temporarily allow forms that require participant, or legal representatives’ signatures to be signed, scanned, and emailed to the Waiver Agency, or for the documents to be signed digitally, through June 30, 2020. The hard copies with wet signatures can be kept in the member’s residence file until Waiver Agencies can retrieve them. DHCS anticipates that the COVID-19 outbreak will directly impact HCBA Waiver service delivery methods for two to three months, and possibly longer. Therefore, the State reporting requirements related to performance measures data may be impacted by a decrease in face-to-face visits; however, HCBA Waiver Agencies will attempt telephonic or video assessments instead, and include documentation in the case file.

Start Date

04-02-20

End Date

30-06-20

Description of Transition Plan

The HCBA Waiver Agency Care Management Teams (CMTs) will inform participants via telephone of the plan provide telephonic or video conferencing contact and conduct desk/virtual assessments in lieu of, or as an option for, face-to-face visits. The CMTs will also provide resources to participants and family members about the COVID-19 virus as more information becomes available.

Area(s) Affected

Area Affected

statewide

Increase Cost Limits

N/A

Modify Targeting Criteria

N/A

Modify Scope or Coverage

Comprehensive Care Management is a collaborative and interdisciplinary approach to providing intensive and comprehensive care management services to individuals enrolled in the HCBA Waiver by responding to a participant’s multiple and changing needs, and playing a pivotal role in coordinating required services from across multiple delivery systems. Comprehensive Care Management is only provided to HCBA Waiver participants by a qualified CMT (Care Management Team) comprised of an RN and MSW, who are either directly employed or contracted by the Waiver Agency. The CMT works with the participant, legal representative/legally responsible adult and/or circle of support to identify and coordinate State Plan and waiver services, and other resources necessary to enable the participant to transition to the community and/or remain in his or her own home. Comprehensive Care Management ensures access to services, regardless of the funding source. The Waiver Agency receives a flat rate payment per member each month for the provision of the Comprehensive Care Management services, which is based upon the tiered acuity level of the participant. Only Waiver Agencies are able to bill for and provide the Comprehensive Care Management waiver service. The CMT works with the participant, his or her legal representative/legally responsible adult and/or circle of support, and primary care physician in developing goals and identifying a course of action to respond to the assessed needs and individual circumstances and desires of the participant, and in the development of the participant’s current primary care physiciansigned POT. In signing the POT, the participant’s current primary care physician is attesting to the medical necessity of the waiver services scope, frequency and duration as identified in the POT. Comprehensive Care Management services will ensure stabilization and access to Home and Community-Based Services (HCBS). Services will include but are not limited to, an initial faceto-face telephonic or live virtual video conferencing, comprehensive nursing and psychosocial assessment, monthly service plan monitoring through face-to-face or telephonic contact by the CMT, coordination of both waiver and state plan services, integration within the local community, and ongoing comprehensive reassessments at least every 365 days that provide information about each participant’s service needs. The CMT is also responsible for the development, implementation, and periodic evaluations of the written participant centered service plans. Comprehensive Care Management services under the waiver differ from the scope and nature of case management services under the State Plan and in areas without a Waiver Agency. Comprehensive Care Management services are concentrated on the coordination and monitoring of cost-effective, quality direct care services for the waiver participant, while in areas without a Waiver Agency, case management services are concentrated on referring and coordinating services. Under the Comprehensive Care Management service, the CMT establishes a care coordination schedule based upon the needs and acuity of the participant as determined by their initial LOC Assessment and subsequent reassessments. The CMT will coordinate all services by providers involved in the participants’ care by providing the following components of Care Management: • Assess medical needs including diagnosis, functional and cognitive abilities, and environmental and social needs; • Care planning to mitigate risk and assist in adjusting care plans as appropriate; • Service plan implementation, coordination and monitoring delivery and quality of services; • Ongoing Waiver participant contact (including a monthly face-to-face or telephonic visit) to monitor for changes in health, social, functional and environmental status; and • Annual face-to-face visits, reassessment and care plan updates. Comprehensive Care Management also includes the provision of Transitional Case Management and the coordination of any Community Transition services needed. In areas where there is a Waiver Agency, the provision of Transitional Case Management and the coordination of Community Transition services are only available through the CMT. Comprehensive Care Management is intensive case management as described above. Transitional Case Management supports participants in transitioning from an inpatient setting to a community setting and may include coordinating services such as housing, equipment, supplies or transportation that may be necessary to leave a health care facility. Transitional Case Management services may be provided up to 89 days prior to discharge from a health care facility. Coordination of Community Transition Services is organizing and prioritizing nonrecurring set-up expenses for individuals who are transitioning from a licensed health care facility to a living arrangement in a private residence where the person is directly responsible for his or her own living expenses. Comprehensive Care Management, Transitional Case Management, and the coordination of Community Transition expenses are included in the flat rate payment received by the Waiver Agency for the provision of Comprehensive Care Management services to each member every month. The rate for Comprehensive Care Management is based on the tiered acuity level of the participant. Actual Community Transition expenses are billable by the CMT as a separate service. HCBA Waiver participants may choose to be involved in all aspects of the design, delivery, and modification of their services and be able to determine when, where and how they receive services. Participants may request a review of their service plan at any time. A Waiver Agency’s LOC determination should not differ from a DHCS LOC determination. Comprehensive Care Management services are authorized only where an HCBA Waiver
Agency is present and is only provided to HCBA participants by a qualified CMT comprised of
an RN and MSW, who are either directly employed or contracted by a Waiver Agency.

Exceed Service Limitations

N/A

Add Services

N/A

Expand Settings

N/A

Provide Service Out of State

N/A

Allow Payment for Services by Families

Temporarily allow spouses/parents of minor children to be allowed to provide Waiver Personal Care Services (WPCS) when authorized WPCS providers are prevented from providing services because of COVID-19. By temporarily allowing participants to receive personal care services from their spouse or parent living with them, participants reduce their potential for exposure to the virus. Family caregivers or legally responsible individuals, shall only be authorized to provide WPCS in accordance with the Plan of Treatment (POT), for the number of hours that are not provided by other direct service providers within a 24-hour period. Spouses/parents of minor children providing WPCS hours must document the number of hours they provide WPCS in time sheets that are submitted to the State’s Case Management Information and Payrolling System (CMIPS) II for payment.

Modification of Provider Qualifications

In the event existing direct care service providers (licensed and unlicensed) test positive for the virus, an expansion of the pool of service providers would help Waiver agencies find backup caregivers during the emergency. Unlicensed Providers Temporarily allow Waiver Personal Care Service (WPCS) Providers to provide WPCS to waiver participants enrolled in and receiving personal care services through the federally funded State Plan Personal Care program (In Home Supportive Services (IHSS)), when the provider is not enrolled as an IHSS provider. In cases in which a participant’s WPCS provider is unable to provide care, the State would allow WPCS to be provided by an individual who is not enrolled as an IHSS provider through the County Public Authority, by way of temporary approval by the Waiver Agency. The expectation would be that the individual would be required to enroll as an IHSS provider within 60 days of Waiver Agency approval to receive retro payments for services provided during the emergency.

Modify Provider Types

Use of Certified Nurse Assistant (CNA) in addition to currently authorized HCBS Waiver Nurse Providers (Registered Nurses, Licensed Vocational Nurses, and Certified Home Health Aide (CHHA)) and Home Health Agencies, as this will open up the pool of caregivers who can provide custodial type care in the home. Many health plans and others allow CNAs to provide this level of care in lieu of a CHHA. PDN is the only service that would be affected by the provider type modification.

Modify Licensure/Requirements for Waiver Settings

N/A

Modification LOC Eval and Re-Eval Processes

The HCBA Waiver population is one of the highest risk populations for exposure to the COVID-19 because eligibility is based on the need for nursing level of care services. Although extensive education and outreach is being provided at the local, state, and federal levels, the most effective preventative measure for reducing contagion is limiting participants’ exposure to people in the community. Waiver Agencies’ CMT provide waiver case management, and practice Universal Precautions while visiting participants at homes, Congregate Living Health Facilities (CLHF), Skilled Nursing Facilities, and Hospitals; however, they would still increase the potential for spreading COVID-19 when visiting multiple participants at different locations. Enrollment LOCs are required to be completed in person; however, to prevent spread of COVID-19, they may be completed by record review and by phone or via video conferencing. The in-person visit may be delayed until the COVID-19 has been contained. California will temporarily allow HCBA CMTs to perform reassessments and provide monthly case management telephonically or by virtual video conferencing with participants to continue to monitor the health and safety of the population. California requires affected Waiver Agencies to document the reasons for the delayed in-person visits and that any late requirements will be completed the following month, or as soon as possible, no later than June 30, 2020.

Increase Payment Rates

N/A

Modifications of ISP

The CMT will conduct telephonic or live virtual video conferencing for initial assessments and ongoing home visits as an option for, or in lieu of, face-to-face required visits. In addition, California will temporarily allow forms that require participant or legal representatives’ signatures to be signed, scanned, and emailed to the Waiver Agency, or for the documents to be signed digitally, through June 30, 2020. The hard copies with wet signatures can be kept in the member’s residence file until Waiver Agencies can retrieve them.

Modify Incident Reporting/Med Management Safeguards

N/A

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

N/A

Inclusion of Retainer Payments

N/A

Institute/Expand Opportunities for Self-Direction

N/A

Increase Factor C

N/A

Other Changes Necessary

Temporarily pause waiver dis-enrollments of participants who are reinstitutionalized beyond the 30-day limit, because they or their caregiver(s) have contracted the virus, and/or if it is unsafe for them to return to the community because they would be exposed to the virus or without medically necessary services, through June 30, 2020.

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

N/A

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

Temporarily pause waiver dis-enrollments of participants who are reinstitutionalized beyond the 30-day limit, because they or their caregiver(s) have contracted the virus, and/or if it is unsafe for them to return to the community because they would be exposed to the virus or without medically necessary services, through June 30, 2020.

Other Changes Necessary

Temporarily pause waiver dis-enrollments of participants who are reinstitutionalized beyond the 30-day limit, because they or their caregiver(s) have contracted the virus, and/or if it is unsafe for them to return to the community because they would be exposed to the virus or without medically necessary services, through June 30, 2020.

Provider Qualifications

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

N/A

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

N/A

Allow Other Practitioners in Lieu of Approved Providers Within the Waiver

N/A

Modify Service Providers for Home-Delivered Meals to Allow for Additional Providers, Including Non-Traditional Providers

N/A

Processes

Allow an Extension for Reassessments and Reevaluations for up to One Year Past the Due Date

N/A

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

N/A

Adjust Prior Approval/Authorization Elements Approved in Waiver

N/A

Adjust Assessment Requirements

N/A

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

N/A

Link To Application

https://www.medicaid.gov/state-resource-center/downloads/ca-0139-appendix-k-appvl.pdf

Link to Approval Letter

https://www.medicaid.gov/state-resource-center/downloads/ca-appendix-k-appvl-ltr.pdf