District of Columbia – Elderly and Persons with Physical Disabilities (EPD Waiver) DC.0334.R04.03 – Individuals with Intellectual and Developmental Disabilities (IDD Waiver) DC.0307.R04.01

Waiver Title

Elderly and Persons with Physical Disabilities (EPD Waiver) DC.0334.R04.03 – Individuals with Intellectual and Developmental Disabilities (IDD Waiver) DC.0307.R04.01

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

Elderly and Persons w/Disabilities (0334.R04.00): Provides adult day health, case management, homemaker, personal care aide, respite, assisted living, chore aide, community transition services, environment accessibility and adaptation services, individual directed goods and services, occupational therapy, participant-directed community support services, personal emergency response system (PERS), physical therapy for aged individuals 65-no max age and physically disabled ages 18-64. Persons with Intellectual and Developmental Disabilities (0307.R04.00): Provides day habilitation, employment readiness, in-home supports, residential habilitation, respite, supported employment, personal care services, skilled nursing, assistive technology services, behavioral supports, companion services, creative arts therapies, dental, family training, host, home, individualized day supports, occupational therapy, one-time transitional services, parenting supports, physical therapy, small group supported employment, speech, hearing and language services, supported living with transportation, supported living, wellness services for individuals with ID/DD ages 18+ no max

Start Date

11-03-20

End Date

10-03-21

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

N/A

Modify Scope or Coverage

N/A

Exceed Service Limitations

IDD Waiver The following services may temporarily exceed the limitation of twenty (20) percent of total hours being provided by telephone or other technology to communicate. For the duration of the public health emergency, the following services may be provided by telephone or other technology to communicate for up to (100) percent of the total hours of services that an individual receives each week. The use of telephone or other technology to communicate shall continue to ensure the effective provision of the service and the health and safety of the individual. The use of telephone or other technology to communicate shall be documented in the ISP, meet the individual’s level of need, ensures health and safety, and be approved by the individual and the support team. The affected services include: – Supported Employment – Supported Living Periodic – In-Home Supports

Add Services

N/A

Expand Settings

IDD Waiver Companion Services may be provided by the residential provider should that provider be an approved companion services provider. The day providers that are also residential providers may use the day staff to cover the residential shifts, if the day program is suspended. Staff qualified by one agency may begin working for another agency during the emergency. Subject to the prohibition on duplication of services/reimbursement; providers may not bill for/receive payment for services provided to an individual concurrently. Respite services may be provided in any setting necessary to ensure the health and safety of the participants (i.e. non-traditional, non-licensed, or non-institutional setting, such as but not limited to: churches, hotels, emergency shelters, community centers, etc.). Providers will be expected to observe best practices to ensure beneficiary health and safety in these alternative settings (social distancing, PHE, etc.). Host Home service recipients may receive Companion services if the person was previously receiving day services and is unable to attend the day program as a result of the public health emergency. In-Home and Community Support, Companion, and Behavioral Support services may be provided using remote technology or telephonic support when this type of support meets the health and safety needs of the participant. The use of telephone or other technology to communicate shall be documented in the ISP.

Provide Service Out of State

N/A

Allow Payment for Services by Families

EPD Waiver Temporarily allow payment for participant-directed services provided by family members of EPD waiver beneficiaries currently enrolled in the Services My Way program whose approved participant-directed worker (PDW) is unable to provide services as a result of the COVID-19 emergency. This option is only available to beneficiaries actively enrolled in the Services My Way program as of the start date of the COVID-19 emergency. The family members shall receive payment only for services provided in accordance with the beneficiary’s authorized plan of care, and shall comply with all requirements for participant-directed workers under the Services My Way program

Modification of Provider Qualifications

EPD Waiver Temporarily extend the CPR and First Aid training and certification deadline for Service My Way participant-directed workers (PDWs) with current CPR and First Aid certification at the start of the public health emergency, but whose CPR and First Aid certification expired during the public health emergency period (i.e., the effective dates of this Appendix K). DHCF will temporarily allow PDWs to continue to provide services for the duration of the public health emergency. Following the conclusion of the public health emergency period, the affected PDWs will be required to attend the mandated CPR and First Aid training and update their CPR and First Aid certification. IDD Waiver Allow currently approved HCBS supported living, residential habilitation, and host home providers be considered qualified to provide companion services. Day providers that are qualified residential providers may use staffing for adequate coverage in residential settings and ensure compliance with labor agreements. Subject to the prohibition on duplication of services/reimbursement; providers may not bill for/receive payment for services provided to an individual concurrently. The District is seeking temporary authority to suspend the following qualification requirements for Direct Support Professional (DSP) staff: Initial and annual training including CPR and First Aid, pre-service and in-service training described in DDS policy, etc.) until 45 days after the end of the public health emergency. Provider agencies may choose to provide on-line training such as CPR and First Aid in lieu of in-person training. On-line CPR and First Aid trainings offered during the public health emergency are effective only until 45 days after the end of the public health emergency. • Pre-employment background checks until 45 days after the end of the public health emergency. The following qualification requirements will remain in place for DSP staff: • 18 years of age and possessing a high school diploma, • Certificate of Individual Educational Program (IEP) Completion, • General educational development (GED) certificate, or, if the person was educated in a foreign country, its equivalent. Training on the person’s Individual Support Plan (ISP), Health Management Care Plan, Behavior Support Plan, Individual Program Plan (IPP), Personal Emergency Preparedness Plan (PEP), Nutrition, Specialized Dining Techniques, Transfer and Mobility Procedures, Seizure Disorders/Protocols, Medication/Sides Effects, etc., Intro to Human Rights, Incident Management, Intro to DD, and Adaptive Equipment must be provided within 14 calendar days of hiring. . Trainings may also be conducted by telephone/electronic means (Skype/Zoom). If member-specific training is provided electronically, it must be through a secure network to protect the member’s confidentiality. There must be fully trained staff onsite at all times.

Modify Provider Types

N/A

Modify Licensure/Requirements for Waiver Settings

IDD Waiver In cases where the emergency back-up plan cannot be met, the staffing ratio may be modified. Providers must ensure the health and safety of the participant and must maintain documentation. Required staffing ratios for a participant, as outlined in the ISP, may be modified to allow the participant to receive services in a safe and accessible manner; such changes to staffing ratios must ensure the participant’s needs are met. Temporarily allow for Provider Certification Review (PCR) staff to postpone agency certification reviews for the following impacted agencies: supported living, residential habilitation, host home, and in-home supports. Provider Certification Review shall commence within 45 days following the end of the public health emergency.

Modification LOC Eval and Re-Eval Processes

EPD Waiver Temporarily allow the District’s Long Term Care Services and Supports (LTCSS) assessment contractor to conduct level of care (LOC) assessments/reassessments via video conferencing/other electronic modality (e.g., Skype, Zoom, FaceTime) or telephone for the duration of the emergency in accordance with HIPAA. LOC assessments/reassessments conducted telephonically may be followed up with in-person face-to-face assessments after the conclusion of the emergency period. If an LOC reassessment cannot reasonably be conducted, due to the inability to access the beneficiary, assessment contractor, or provider, or other unforeseen circumstances resulting from the public health emergency, the annual LOC assessment requirement may be extended for a period of up to twelve (12) months. Initial request for LOC assessment and request for re-assessment will not require physician or APRN authorization for the duration of the emergency period. IDD Waiver The Service Coordinators may review a participant’s current level of need and extend the efficacy of the current annual level of care for a period of up to twelve (12) months. The annual Level of Care (LOC) recertification requirement will be extended for a period of up to twelve (12) months when, as a result of the public health emergency, the DDS DDA Service Coordinator cannot have physical access to the participant. The DDS DDA Service Coordinator will document, in the ISP, the contact with the participant, guardian, and team to discuss the extension, as well as the projected date on which the LOC will be able to be completed. Temporarily allow the annual physical examination requirement to be extended by a period of up to 180 days, if a participant is recommended by the physician or support team not to travel into the physician’s office or clinic during this public health emergency. All documents requiring the Person or Guardian/Representative signature may be obtained via electronic signature.

Increase Payment Rates

IDD Waiver Temporarily increase reimbursement rates to IDD providers to support increased costs associated with services provided by Direct Support Professionals (DSP) who, due to a reduction in total available workforce, will work and receive compensation for overtime. Maximum overtime reimbursement for services provided by DSPs shall not exceed $32 per hour ($8/per 15min), except for reimbursement to specific IDD Waiver providers for services provided by DSPs for the following services: • In Home Support – $37 ($9.25/per 15 min) • Behavioral support services – $38 ($9.50/ per 15 min) • Respite – $35 ($8.75/ per 15 min) • Supported Living Periodic – $40 ($10/per 15 min) Temporarily increase reimbursement rates to IDD providers to support increased costs associated with services provided by DSPs because IDD providers, due to a reduction in total available workforce, utilize staffing agencies charging a rate higher than that reimbursed by DHCF. Reimbursement for services provided by such staff may vary, but shall reflect the reasonable, additional costs to the IDD provider. To receive the increased rate, an IDD provider will be required to: 1) identify the staffing agency in the original claim; and 2) submit an invoice for reimbursement that includes the invoice from the staffing agency showing the amount charged. Maximum reimbursement for services provided by DSPs hired through a staffing agency shall not exceed the standard DSP rate by more than 50%. Maximum overtime reimbursement for services provided by DSPs hired through a staffing agency shall not exceed the standard DSP rate by more than 100%. Temporarily increase reimbursement rates to IDD providers to support increased costs associated with DSPs providing services to and working with persons who have been medically quarantined. IDD providers will be reimbursed an increased rate for the first 40 hours worked; and IDD providers will then be reimbursed an overtime rate for any hours worked over 40 hours. For the first 40 hours worked, maximum reimbursement to IDD providers for services provided by DSPs working with persons who have been medically quarantined shall not exceed $32 per hour ($8/per 15min). For any work over 40 hours, the overtime rate for DSPs working with persons who have been medically quarantined shall not exceed $48 per hour ($12/per 15min). Reimbursement to specific IDD Waiver providers for services provided by DSPs for the following services shall not exceed: . • In Home Support – $37 ($9.25/per 15 min); Overtime rate of $56 ($14/per 15 min) • Behavioral Support Services – $38 ($9.50/ per 15 min); Overtime rate of $57 ($14.25/per 15 min) • Respite – $35 ($8.75/ per 15 min); Overtime rate of $53 ($13.25/per 15 min) • Supported Living Periodic – $40 ($10/per 15 min); Overtime rate of $60 ($15/per 15 min). EPD Waiver: Temporarily increase reimbursement rates to home health agencies (HHAs) to support
increased costs associated with services provided by personal care aides (PCAs) because
HHAs, due to a reduction in total available workforce, utilize staffing agencies charging
a rate higher than that reimbursed by DHCF. Reimbursement for services provided by
such staff may vary, but shall reflect the reasonable, additional costs to the HHA
provider. To receive the increased rate, an HHA will be required to: 1) identify the NPI
of the staffing agency in the original claim; and 2) submit an invoice for reimbursement
that includes the invoice from the staffing agency showing the amount charged.
Maximum reimbursement for services provided by PCAs hired through a staffing
agency shall not exceed the standard PCA rate by more than 50%. Maximum overtime
reimbursement for services provided by PCAs hired through a staffing agency shall not
exceed the standard PCA rate by more than 100%.
Temporarily increase reimbursement rates to HHAs for PCA services to accommodate
additional costs associated with the need to pay overtime compensation to individual
staff who, due to a reduction in total available workforce, will work over 40 hours per
hours a week. Maximum overtime reimbursement for services provided by PCAs shall
not exceed $32 per hour ($8/per 15min).
Temporarily increase reimbursement rates to HHAs to support costs associated with
PCAs working with persons who have been medically quarantined. The District will
reimburse for a quarantine period not to exceed to 14 consecutive days. HHAs will be
reimbursed an increased rate for the first 40 hours a PCA works; and will then be
reimbursed an overtime rate for any hours a PCA works over 40 hours. For the first 40
hours worked, maximum reimbursement for services provided by PCAs working with
persons who have been medically quarantined shall not exceed $32 per hour ($8/per
15min). For any work over 40 hours, the overtime rate for services provided by PCAs
working with persons who have been medically quarantined shall not exceed $48 per
hour ($12/per 15min).
Temporarily allow payments equal to 75% of the FFS per diem rate to Adult Day Health
Programs (AHDPs) for wellness checks provided via video conferencing/other
electronic modality (e.g., Skype, Zoom, FaceTime) or telephone for the duration of the
public health emergency, in accordance with HIPAA requirements. A qualifying
wellness check includes, but is not limited to, inquiries/reminders on the following:
• Overall health status, including emotional well-being, need for care, and any
signs or symptoms of illness
• Meals, routines, and medication adherence
• Social isolation and self-quarantine, including the availability/use of informal
supports and access to groceries or emergency supplies
ADHPs shall document all wellness checks in the District’s case management system,
DC Care Connect. Reimbursement is not available for wellness checks provided
simultaneously while a supervisory nurse is present with the beneficiary or the
beneficiary is receiving similar services from another Medicaid State Plan or EPD
Waiver provider.

Modifications of ISP

EPD Waiver and IDD Waiver Temporarily allow case managers to conduct person-centered service plan (PCSP) initial and annual meetings with beneficiaries via video conferencing/other electronic modality (e.g., Skype, Zoom, FaceTime) or telephone for the duration of the emergency in accordance with HIPAA. IDD Waiver Temporarily allow, for the duration of the public health emergency, the use of alternative settings and the use companion services in place of day services. The use of companion services, the increase of in-home supports as needed, and other required changes may be authorized prior to updating the participant’s individual service plan (ISP). The ISP process during the public health emergency is being modified to allow for it to be conducted electronically, in accordance with HIPAA requirements, in lieu of in person. The Service Coordinator, in consultation with the team via telephone or virtually using other electronic communication systems (e.g., Skype), to verify that the current assessed needs, services and supports, including service providers, are still appropriate and should continue to be authorized through the next review period. Additionally, those with service or support needs changes, the ISP will be amended or modified as necessary to ensure the health and safety of the individual. The Service Coordinator will verify by obtaining electronic signatures and documenting in the ISP. The Service Coordinator will monitor the services through a minimum of monthly contact via telephone or virtually, in accordance with HIPAA requirements. The process to monitor service delivery as specified in the service plan will continue as outlined in the approved waiver. All documents requiring the beneficiary’s or Guardian’s/Representative’s signature may be obtained via electronic signature. The Service Coordinator will document in the ISP the type of contact with the participant, guardian/representative, and team.

Modify Incident Reporting/Med Management Safeguards

IDD Waiver Incident Management changes: • The requirement to conduct an investigation of any incident of deviation in staffing as outlined in an individual plan may be suspended. • The requirement to submit an incident report for any deviation in staffing as outlined in an individual plan may be suspended. If this requirement is suspended, providers must report any incidents in which staffing shortages result in a failure to provide care. The Incident Review Committee that meets daily, in conjunction with the IMEU Supervisory Investigator or designee will make a determination on the level of risk or harm to the person and whether an immediate face-to-face follow-up visit is required. Face-to-face follow-up may be extended virtually, such as utilizing Skype. The Incident Review Committee, Supervisory Investigator, or designee can waive the 72-hour faceto-face visit. The IMEU supervisor or designee will review all reported incidents within 72 hours to determine whether employees who are targets of an investigation may return to work. Investigations will be reviewed by the Supervisory Investigator and Service Coordinator to determine if an extension of the time frame for closure is required, to ensure that all evidence can be gathered relative to social distancing recommendations during this public health emergency. The District’s submission of the 372 reports will be delayed by up to thirty (30) days during the public health emergency. EPD Waiver The District’s submission of evidentiary reports will be delayed up to thirty (30) days during the public health emergency

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

IDD Waiver Participants that require hospitalization due to a diagnosis of COVID-19 may receive the following services in a hospital setting when the participant requires these services for communication, behavioral stabilization and/or intensive personal care needs: • Residential Habilitation Supported Living • In Home and Companion

Inclusion of Retainer Payments

EPD and IDD Waiver Retainer payments will be made in accordance with the limitations and requirements set forth in Olmstead update letter #3 (July 25, 2000). EPD Waiver Temporarily allow retainer payments equal to 25% of the standard per diem rate to an AHDP if a participant was unable to attend the ADHP because services could not be rendered as a result of the public health emergency. Retainer payments are not available to ADHP providers that also providing traditional ADHP services or providing services via video/telephonic/electronic conferencing to the same beneficiary on a given date of service. Authorized ADHP providers may receive retainer payments for periods up to18 consecutive days. Reimbursement is available for multiple consecutive day periods. Authorized ADHPs may bill for retainer payments for the duration of the public health emergency. IDD Waiver Temporarily allow retainer payments for authorized day program services providers if a participant was unable to attend day program services as a result of the public health emergency, and the participant instead received natural supports, companion services, or in-home supports. Retainer payments are not available to day program providers that also provide the participant with residential services, in-home supports, or companion services. Authorized day program providers may submit claims for retainer payments for up to 18 consecutive days. Reimbursement is available for multiple consecutive day periods. A day program provider seeking a retainer payment must document that the individual was unable to attend the day program as a result of the public health emergency and immediately notify the DDA Service Coordinator. Providers must submit claims for retainer payments within 90 days from the date on which the participant was unable to attend the day program. Retainer payments will not be authorized when a provider is providing services. Day programs are eligible for retainer payments as follows: • Day Habilitation – 33% of standard rate • Day Habilitation 1:1 – 43% of standard rate • Day Habilitation Small Group –46% of standard rate • Individualized Day Supports – 30% of standard rate • Individualized Day Supports 1:1 – 52% of standard rate • Supported Employment – 33% to 35% of standard rate • Employment Readiness – 28% of standard rate Day Program Service Providers that have stopped or reduced services in response to the COVID-19 public health emergency may bill for retainer payments. Retainer payments are received by billing for units authorized in an individual’s service plan that were not provided due to the COVID-19 public health emergency. Units billed shall not exceed the amount, scope, and duration otherwise authorized for the Day Program Service provider. Retainer payments may not be billed when the individual chooses to receive day program services through a different provider. Retainer payments for day services are limited to 5 days per week (Mon-Sun).

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, in-home habilitation, monthly monitoring, other: Participant-directed services (Services My Way) support broker visits
– Adult Day Health Program (ADHP) services, including but not limited to
daily wellness checks

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

N/A

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

N/A

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

X

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

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

Link to Approval Letter

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