Georgia – Comprehensive Supports Waiver Program (COMP) (0323.R04.00) & New Options Waiver (NOW) (0175.R06.00) [combined]

Waiver Title

Comprehensive Supports Waiver Program (COMP) (0323.R04.00) & New Options Waiver (NOW) (0175.R06.00) [combined]

Description of Emergency

Submission of Appendix K is in response to COVID-19 Pandemic. Approximately, 8,800 members receiving COMP waiver services are impacted and 4,800 members receiving NOW waiver services. Georgia is utilizing the support coordination service within the waiver to identify individuals at risk. The Department of Community Health (DCH), as the single state Medicaid Agency, has administrative oversight over all 1915 (c) waivers including, the COMP and NOW waivers. DCH through the Healthcare Facilities Regulation Division is responsible for licensing and monitoring healthcare facility providers. The Department of Behavioral Health and Developmental Disabilities is the operating agency responsible for several administrative activities associated with the waiver. The Georgia Department of Public Health is the lead agency for coordination and response related specifically to the COVID-19 Pandemic. Georgia will utilize telehealth resources as much as possible and where clinically appropriate as a modification to service delivery areas. Georgia is requesting statewide modification through this Appendix K submission.

Waiver Description

Comprehensive Supports Waiver Program (0323.R04.00) Provides community access, community living support – basic, community living support – extended services, prevocational services, support coordination, supported employment, nutrition services, specialized medical equipment, specialized medical supplies, community guide, financial support services, additional staffing, adult dental, adult occupational therapy services, adult physical therapy services, adult speech and language therapy services, behavior support services – level 1, behavior support services – level 2, community living support (CLS) – personal assistance retainer, CLS-shared 2-person basic, CLS- shared 2-person extended, CLS- shared 3-person basic, CLS-shared 3-person extended, community residential alternative (CRA) group home 3-person residence- tier 1, CRA group home 3-person residence- tier 2, CRA group home 3-person residence- tier 3, CRA group home 3-person residence- tier 4, CRA group home 4-person residence- tier 1, CRA group home 4-person residence- tier 2, CRA group home 4-person residence- tier 3, CRA group home 4-person residence- tier 4, CRA group home 5 person residence, CRA host home- category 1, CRA host home- category 2, environmental accessibility adaptation, individual directed goods and services, intensive support coordination, interpreter services, natural support training, nursing services (SNS), respite- out-of-home daily, respite- 15 minute out-of-home, respite- 15 minute in-home, transition community integration services, transition services and supports, transportation, vehicle adaptation for individuals w/ID, DD ages 0 – no max age. New Options Waiver (0175.R06.00) Provides community living support, prevocational services, respite-15 minutes, adult occupational therapy services, adult physical therapy services, adult speech and language therapy services, nutrition services, specialized medical equipment, specialized medical supplies, community guide, financial support services, adult dental services, behavioral supports consultation, behavioral supports services, community access, community living support – extended services, community living support-personal assistance retainer, community living supports – shared, environmental accessibility adaptation, individual directed goods and services, intensive support coordination, natural support training, respite services – 2 participants, respite services – 3 participants, respite services – daily category 1, respite services daily category 2, skilled nursing services (SNS), support coordination, supported employment services, transportation, vehicle adaptation for individuals with DD/ID ages 0-no max.

Start Date

01-03-20

End Date

28-02-21

Description of Transition Plan

The proposed changes outlined in Appendix K for the COMP and NOW waivers are temporary policy allowances, rate increases for target services, and retainer payments. The Appendix K request represents a full year of emergency operations. At the conclusion of the state of emergency, preemergency service plans will be re-implemented unless the member has experienced a change in condition or circumstance that requires reassessment and development of an edited service plan. In utilizing retainer payments it is the hope of the Department of Community Health that service capacity will be maintained through the emergency response for the choice of Community Residential Alternative, Community Living Support Services, Supported Employment Services, Prevocational Services, and Community Access services, and the full options of waiver services. No new services or target populations are being proposed.

Area(s) Affected

Area Affected

Statewide

Increase Cost Limits

New Options Waiver Only- The annual cap is temporarily suspended for the duration of the appendix K.

Modify Targeting Criteria

N/A

Modify Scope or Coverage

Behavior Support Services – Level 1 and Level 2; Adult Occupational Therapy Services; Adult Physical Therapy Services; Community Access; Community Living Supports-Basic; Community Living Supports-Extended Services; Community Residential Alternative (COMP ONLY) All Tiers; Skilled Nursing Services; Specialized Medical Supplies; Support Coordination; Intensive Support Coordination; Supported Employment; Financial Support Services; Respite (In-home and Out of Home);

Exceed Service Limitations

Community Living Support Services- The cap may be exceeded while Appendix K is effective. The amount of authorized services will not be in the form of a prior authorization and does not need to be in the participant’s approved annual budget. The service, amount, and scope may not be reflected in an individual service plan. Community Access- The cap may be exceeded while Appendix K is effective. The amount of authorized services will not be in the form of a prior authorization and does not need to be in the participant’s approved annual budget. The service, amount, and scope may not be reflected in an individual service plan. In-Home and Out- of Home Respite services- The cap may be exceeded while Appendix K is effective. The amount of authorized services will not be in the form of a prior authorization and does not need to be in the participant’s approved annual budget. The service, amount, and scope may not be reflected in an individual service plan. Specialized Medical Supplies Services – The annual cap is temporarily suspended while Appendix K is effective. The amount of authorized services will not be in the form of a prior authorization and does not need to be in the participant’s approved annual budget. The service, amount, and scope may not be reflected in an individual service plan.

Add Services

N/A

Expand Settings

Community Living Services, Additional Staffing Services, Community Access, and Out-ofHome Respite may be delivered on a temporary basis in alternative settings which include: extended family home, hotel, shelter, or other emergency placement while Appendix K is effective. The location that the service is being rendered may not be reflected in an individual service plan. Out-of-Home Respite reimbursement rates do not include room and board payment.

Provide Service Out of State

Community Living Support and Respite services may be provided out of state as approved by DCH as a result of the COVID-19 Emergency. Such situations may involve waiver members moving with family caregivers across state lines for additional support.

Allow Payment for Services by Families

Family caregivers or legally responsible individuals are temporarily authorized to render the following COMP and NOW services during the duration that Appendix K is effective: 1. Community Living Supports 2. In Home and Out of Home Respite Services 3. Community Access The provider network may hire family caregivers to provide Community Living Supports, Community Access, and/or Respite Services in lieu of existing provider staff if the provider is unable render the service due to health and safety concerns for either the provider staff or the participant. The service, amount, scope, and/or familial or legal relationship of the paid caregiver may not be reflected in an individual service plan, however, will be recorded in the information system which supports the NOW and COMP waiver programs

Modification of Provider Qualifications

Every effort should be made to complete training and background checks when possible. Background checks and training requirements for any function that requires face-to-face action or availability of third-party vendors will be temporarily suspended for the duration that Appendix K is effective for all waiver services in the event the provider is unable to complete a training and/or background check. At the termination of Appendix K, trainings and background checks will need to be completed retroactively for all employees who were hired while Appendix K was effective and according to policy. In lieu of face-to-face training, the following methods and enhanced supervision will be employed: While the State plans to suspend required face-to-face training for newly hired staff during the COVID-19 State of Emergency, family members serving as reimbursed caregivers, who have experience delivering required care, will be supported, as needed, by provider agency supervisory staff telephonically or electronically. Newly hired staff with previous experience will be supervised telephonically or electronically and those with no previous experience will be provided electronic video training by agency supervisory staff. Required staffing ratios for a participant, as outlined in the participants Individual Service plan, may be modified to allow the participant to receive services in safe and accessible environments, as long as the participant’s needs are still being met. State certification survey staff postpones on-site provider certification and other reviews for provider agencies and individual providers rendering COMP and NOW services unless there is an immediate jeopardy and/or health and safety concern as defined by the state agency.

Modify Provider Types

N/A

Modify Licensure/Requirements for Waiver Settings

N/A

Modification LOC Eval and Re-Eval Processes

The annual Level of Care (LOC) re-assessment requirements will be suspended for all participants while Appendix K is effective. The state office and case management agency (support coordination) will document, in the ISP, the contact with the participant, guardian, and team to discuss the extension, as well as the projected date in which the LOC will be able to be completed. The required 5% LOC recertification requirement of the operating agency will be waived while Appendix K is effective.

Increase Payment Rates

Support Coordination (case management)- the rate increase is being requested due to a substantial temporary increase in workload. Many modifications as a result of Appendix K will require service changes which are generated by the support coordination agency. Support Coordination agencies are also being asked to provide additional oversight during COVID-19 crisis to ensure the health and safety needs of the individuals are being met. Support Coordination temporary rate increase reflects parity with other Georgia Waiver programs. Requesting Support Coordination (case management) services (T2022) – temporarily increases rate from $152.88 to $175.00 per monthly unit. Fiscal Intermediaries (FI)- there are approximately 2,400 individuals who participantdirect NOW or COMP waiver services. Due to COVID-19, FIs will have a temporary increase in administrative burden to process family hire, payroll, unemployment benefits, customer service to representatives, families, support coordinators and will also have to modify internal coding in their data systems to implement Appendix K approved payments changes. An adjustment of approximately 20% increase was elected due to the temporary increased administrative burden delineated above. Fiscal Intermediary (T2040-UC)- temporarily increases rate from $75.00 per month to $95.00 per month. The new rate is within the accepted range for similarly delivered services from surrounding states. Requesting for LPN nursing service only (T1003-U1)- temporarily increase in rate from $8.75 per 15-min unit to $10.00 per 15 min unit [parity with other waiver nursing services] and to account for increased risk, needed protective measures and anticipated provider shortage.

Modifications of ISP

The only modification to service plan development involves the current requirement for face-toface interaction with the waiver member and any invited family members. DCH has determined that potential risk to both support coordination agency staff and waiver members requires modification of the onsite interaction. Rather than face-to-face ISP planning and development, support coordinators will use telephonic or video conferencing for ISP development and editing. Consent and agreement signatures can be obtained electronically using current HIPPA standards. 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 to ensure that the specific service is delineated accordingly to reflect the date it began to be received. The PCSP will be updated no later than 30 days from the date the service was initiated.

Modify Incident Reporting/Med Management Safeguards

N/A

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

The state temporarily authorizes Community Living Support Services to be rendered in acute care settings.

Inclusion of Retainer Payments

Community Residential Alternative (COMP only service), Community Living Support Services, Supported Employment Services, Prevocational Services, and Community Access services will be authorized for retainer payments in the event that the provider is not serving the member under other comparable services or using differential staff such as family caregivers to provide service. The retainer payment will be authorized at the level, duration, and amount as outlined in the prior authorization. Retainer payments can be made throughout the temporary authorization period. Community Residential Alternative retainer payment is only authorized in the event the individual is hospitalized or receiving care in an alternative setting. The state permits retainer payments for all habilitation programs which includes Community Access, Supported Employment, Prevocational Services and Community Residential Alternative. Personal care is a component of Community Access, Supported Employment, Prevocational Services and Community Residential Alternative. Retainer payments 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

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

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

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/ga-0323-0175-combined-appendix-k-appvl.pdf

Link to Approval Letter

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