Hawaii – 0013.R07.00

Waiver Title

Home and Community Based Services for People with Intellectual and Developmental Disabilities (I/DD Waiver) (0013.R07.00)

Description of Emergency

1) On March 13, 2020, President Donald J. Trump issued a “Proclamation on Declaring a National Emergency Concerning the Novel Coronavirus Disease (COVID-19) Outbreak” under presidential authority and the laws of the United States of America, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.) and consistent with section 1135 of the Social Security Act (SSA), as amended (42 U.S.C. 1320b-5). The Secretary of Health and Human Services (HHS) declared a public health emergency on January 31, 2020, under section 319 of the Public Health Service Act (42 U.S.C. 247d), in response to COVID-19. It allowed the Secretary of HHS to exercise the authority under section 1135 of the SSA to temporarily waive or modify certain requirements of the Medicare, Medicaid, and State Children’s Health Insurance programs and of the Health Insurance Portability and Accountability Act Privacy Rule throughout the duration of the public health emergency declared in response to the COVID-19 outbreak. 2) As of March 20, 2020, there are 3,039 individuals enrolled in the 1915(c) waiver. The Department of Health, Developmental Disabilities Division (DOH-DDD) is the operating agency for the 1915(c) waiver through a Memorandum of Agreement with the Department of Human Services, Med-QUEST Division (DHS-MQD). The DOHDDD has implemented a protocol for identifying those most at risk using Centers for Disease Control criteria, Supports Intensity Scale assessment results, and living setting. Participants identified with highest risk include: • Those who live on their own, AND who are elderly and/or have underlying health conditions, AND who depend on a direct support worker (DSW) to meet basic needs. • Those who live in any setting AND who depend on one or more DSWs to prevent harm to themselves or others. • Those whose families need exceptional supports in order to care for their family member. Case review has identified the participants in each of these categories. 3) DOH-DDD is the single agency that operates the 1915(c) statewide waiver through a network of private provider agencies across the islands of Oahu, Kauai, Maui, Molokai, Lanai and Hawaii Island. 4) Hawaii seeks temporary changes to the 1915(c) waiver to accommodate potential issues with staffing shortages and need for service provision outside of approved service descriptions to ensure participant health and safety needs can be accommodated during the emergency.

Start Date

01-03-20

End Date

28-02-21

Description of Transition Plan

Participants will be supported participants will be supported to transition to enhanced services as needed due to the impacts of COVID-19. Once the emergency ends, participants will be supported to transition to waiver services that meet their needs. All due process rights will be provided.

Area(s) Affected

Area Affected

On March 4, 2020, Governor David Ige declared a state of emergency in Hawaii in response to the emerging public health threat posed by COVID-19 pursuant to Hawaii Revised Statutes Chapter 127A. The Governor issued a supplementary proclamation on March 16, 2020.

Increase Cost Limits

N/A

Modify Targeting Criteria

N/A

Modify Scope or Coverage

N/A

Exceed Service Limitations

Prior Authorizations Additional Residential Supports (ARS), Adult Day Health (ADH), Chore, Community Learning Service-Individual/Group (CLS-I, CLS-G), Discovery & Career Planning (D&CP), Individual Employment Supports (IES), Non-Medical Transportation (NMT), Personal Assistance/Habilitation (PAB), Private Duty Nursing (PDN), Residential Habilitation (ResHab), Respite, Specialized Medical Equipment and Supplies (SMES), Training & Consultation (T&C), Waver Emergency Services To ensure participant health and safety needs can be met in a timely manner, the prior authorization and/or exception review process may be modified as deemed necessary by DOHDDD. a. In emergent situations where the participant’s immediate health and safety needs must be addressed, retrospective authorization may be completed. b. Documentation of verbal approval or email approval of changes and additions to individual plans will suffice as authorization for providers to deliver services while awaiting data input into the case management system and MMIS. Services in Appendix C1/C3 Private Duty Nursing: Suspend the per-day limits and short-term time limits on Private Duty Nursing as needed to protect participant health and safety. Additional Residential Supports: Expand the allowable use of the service to provide supports in licensed and certified settings when needed to replace community services that the participant can no longer access. Respite: Suspend the annual limit of 760 hours of Respite when needed to address potential health and safety issues due to the unavailability of services and/or natural supports that the participant has been receiving. Specialized Medical Equipment and Supplies: Expand allowable purchases to include personal protective equipment (PPE) and infection control supplies when not otherwise covered in the Medicaid state plan. Appendix C-4 Grant exceptions to the individual budget limits described in Appendix C-4 when needed to accommodate changes in service availability for a variety of circumstances that may arise from COVID-19 (e.g., instances when participants are forced to substitute group services with one-toone services such as when a participant’s ADH program closes due to COVID-19 and they convert to using PAB, or when paid supports are needed to substitute for natural supports that become unavailable).

Add Services

Additional residential supports; Private Duty Nursing; Respite; Specialized Medical Equipment and Supplies;

Expand Settings

Adult Day Health (ADH): ADH may be provided in participants’ homes, whether in a licensed or certified setting or a private home. When provided in a licensed or certified setting, the service cannot be provided by a member of the household. Respite: Respite services may be provided in any non-institutional setting where the participant is located (e.g., hotel/ motel or in someone else’s home with a staff person). Services in these expanded settings will be reimbursed based on the current rate methodology, which does not include room and board expenses.

Provide Service Out of State

N/A

Allow Payment for Services by Families

N/A

Modification of Provider Qualifications

Staff qualification requirements other than being 18 years of age and legally able to work in the United States (e.g., criminal history check, staff training, CPR and first aid certification, etc.) will be suspended during a declared public health emergency. Providers may choose to provide training on-line in lieu of in-person training. Trainings may also be conducted by telehealth. Telehealth that meets privacy requirements must be used to conduct participant-specific training in the ISP. Personal Assistance/Habilitation, Additional Residential Supports, Community Learning Services, Respite, Private Duty Nursing, Chore: Expand provider qualifications to include any provider agencies enrolled in QUEST Integration health plan networks performing similar work. Adult Day Health (ADH), Personal Assistance/Habilitation (PAB), Individual Employment Supports (IES), Discovery & Career Planning (D&CP), Training & Consultation (T&C), Waiver Emergency Services – Emergency Outreach: These services may be provided through telehealth that meets privacy requirements when the type of supports meets the health and safety needs of the participant.

Modify Provider Types

N/A

Modify Licensure/Requirements for Waiver Settings

Adult Day Health, Community Learning Services – Group: Minimum staffing ratios as required by the waiver service definition, provider standards and/or specified in the Individualized Service Plan (ISP) may be exceeded due to staffing shortages.

Modification LOC Eval and Re-Eval Processes

Allow the initial level of care evaluation to be conducted using telehealth, in accordance with HIPAA requirements, in lieu of face-to-face visits. Level of care annual redeterminations may be extended for up to one year past the due date of the approved DHS1150-C during the declared public health COVID-19 pandemic.

Increase Payment Rates

N/A

Modifications of ISP

1. Case Managers may use telehealth that meets privacy requirements in lieu of face-to-face meetings to conduct Individualized Service Plan (ISP) meetings, assessments, individual monitoring and check-ins. 2. The State may modify timeframes or processes for completing the Individualized Service Plan (ISP) as described below. a) Adjustments to the ISP may be approved with a retroactive approval date for service needs identified to mitigate harm or risk directly related to COVID-19 impacts. b) 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 ISP 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 ISP meeting date. 3. In order to limit the transmission of COVID-19, suspend requirements for allowing visitors (providers may prohibit/restrict visitation in-line with CMS recommendations for long term care facilities) and for individuals’ right to choose with whom to share a bedroom. The I/DD waiver program will adhere to all local, state and federal requirements for social distancing and other approaches to limit transmission of COVID-19. These limits do not require modifications to the ISP during the declared public health emergency. Other limits not required by the COVID-19 pandemic will be addressed through the ISP process.

Modify Incident Reporting/Med Management Safeguards

Modify verbal and written timelines for reporting as deemed necessary by DOH-DDD and DHSMQD (e.g., limiting the focus to the most critical adverse incident reports requiring both verbal and written notification). Permit the case manager assessment and 24 hour face-to-face visits for instances of suspected abuse or neglect to be conducted using telehealth that meets privacy requirements unless an onsite assessment is deemed necessary by DOH-DDD. The DOH-DDD staff will be alert for potential evidence of abuse, neglect and exploitation through their remote strategies for oversight.

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

Additional Residential Supports (ARS), Personal Assistance/Habilitation (PAB) : Temporarily permit payment for certain waiver services provided to participants who are in a hospital or other short-term facility (excluding ICF/IID). Such payments shall not exceed 30 consecutive days. For participants residing in their own home or their family’s home, the authorized service is PAB. For participants residing in licensed or certified settings, the authorized service is ARS. These services will include assistance with communication and behavior support. The provider will document that these services are not covered in the settings where the participant is located. The case manager will review the continued need for this service monthly during the participant’s stay in the hospital or short-term facility

Inclusion of Retainer Payments

Residential Habilitation: DDD will make retainer payments to Residential Habilitation providers when an individual is absent from the home for more than 21 days. Such retainer payments will be limited to the lesser of 30 days or the number of days for which Hawaii authorizes similar payments in nursing facilities. Adult Day Health, Community Learning Services – Group and Individual Employment Supports: In order to preserve shared day service programs and employment programs that include a personal care component and that may not be provided during the declared public health emergency and to maintain a stable workforce, DDD will make retainer payments for Adult Day Health (ADH), Community Learning Service-Group (CLS-G) supports, and Individual Employment Supports (IES). Retainer payments will be billed at 75 percent of the current rates for authorized and scheduled hours from which the participant is absent. Such retainer payments will be limited to the lesser of 30 days or the number of days for which Hawaii authorizes similar payments in nursing facilities. Since the retainer payments include the goal of maintaining a stable workforce, providers will need to attest that they did not layoff staff in any month for which they receive a retainer payment. Personal Assistance/Habilitation – Consumer Directed (CD PAB): DDD will make retainer payments to consumer-directed workers for the authorized hours per week not to exceed 40 hours per week when the participant they serve is unable to receive services. Such retainer payments will be limited to the lesser of 30 days or the number of days for which Hawaii authorizes similar payments in nursing facilities.

Institute/Expand Opportunities for Self-Direction

N/A

Increase Factor C

N/A

Other Changes Necessary

Annual on-site provider validations and reviews for quality management, performance measure reporting, and financial audits may be delayed or cancelled during the declared public health COVID-19 pandemic. Reviews by desk audit or other methods may be used as deemed appropriate by DOH-DDD. Allow participants to receive fewer than one waiver service per month for a period of 120 days without being subject to discharge. The case manager will provide monthly monitoring to ensure the plan continues to meet the participant’s needs. Monitoring may be done using telehealth that meets privacy requirements

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

Annual on-site provider validations and reviews for quality management, performance measure reporting, and financial audits may be delayed or cancelled during the declared public health COVID-19 pandemic. Reviews by desk audit or other methods may be used as deemed appropriate by DOH-DDD. Allow participants to receive fewer than one waiver service per month for a period of 120 days without being subject to discharge. The case manager will provide monthly monitoring to ensure the plan continues to meet the participant’s needs. Monitoring may be done using telehealth that meets privacy requirements

Other Changes Necessary

Annual on-site provider validations and reviews for quality management, performance measure reporting, and financial audits may be delayed or cancelled during the declared public health COVID-19 pandemic. Reviews by desk audit or other methods may be used as deemed appropriate by DOH-DDD. Allow participants to receive fewer than one waiver service per month for a period of 120 days without being subject to discharge. The case manager will provide monthly monitoring to ensure the plan continues to meet the participant’s needs. Monitoring may be done using telehealth that meets privacy requirements

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/hi-0013-appendix-k-appvl.pdf

Link to Approval Letter

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