Indiana – Community Integration and Habilitation (CIH) IN.0378.R03.06

Waiver Title

Community Integration and Habilitation (CIH) IN.0378.R03.06

Description of Emergency

1. On March 6, 2020, Indiana Governor Eric Holcomb declared a public health emergency in all 92 Indiana counties. This statewide declaration from the Governor complements President Donald Trump’s declaration of a national emergency on March, 13, 2020. In response to the emergence and spread of Coronavirus disease (COVID-19) and the serious health risk it poses to Indiana’s intellectual and developmental disabilities population living in the community, Indiana Division of Disability and Rehabilitative Services (DDRS) anticipates providers will encounter difficulty delivering CIH waiver services according to current wavier requirements. DDRS seeks temporary amendments to its waiver authority to ensure the health and safety of both individuals receiving and providers delivering CIH waiver services. 2. This waiver amendment is applicable to participants in all 92 Indiana counties as part of the statewide public health emergency. Indiana’s CIH waiver serves approximately 20,000 participants throughout the 92 counties. DDRS will rely on case managers and waiver providers as front-line contacts for addressing concerns of waiver participants (and family members). Additionally, case managers and waiver providers will assist waiver participants in developing a plan to continue services to the extent feasible during this public health emergency. DDRS will continue to communicate regularly with case managers and waiver providers with updates on the waiver. DDRS will continue to direct participant and provider general questions about COVID-19 to the ISDH Epidemiology Resource Center. 3. These roles are defined in Appendix A in section A-1 and 2. 4. For all CIH waiver participants and providers statewide, the Indiana DDRS’ Bureau of Developmental Disabilities Services (BDDS) will enact the following temporary changes to service delivery methods: • Allow initial and annual level of care assessments to be completed by telephone. • Annual level of care assessments timeline extended. • Allow person-centered service planning activities to be completed by phone with electronic signature or email consent. • Allow services in alternative sites. • Allow flexibility in day service ratios. • Allow RHS reimbursement for time when staff/paid caregiver is asleep • Waive the 40 hour per week paid caregiver limitation on family members when existing services on the participant’s Person-Centered Individualized Support Plan (PC/ISP) have been interrupted due to circumstances related to COVID-19. • Allow flexibility on potential staff’s limited criminal history checks. • Allow potential staff to be hired by and work for an existing Medicaid/BDDS approved waiver provider to provide direct supports to participants prior to being trained. • Allow potential staff to be hired by and work for an existing Medicaid/BDDS approved waiver provider to provide direct supports to participants prior to having a TB test. • Allow staff to work 90 days beyond CPR/First Aid certification expiration date. • Allow any BDDS approved HCBS provider to become an approved BDDS Respite Care provider a Rent and food for unrelated live-in caregiver supports provider. • All non-ANE incidents to be reported within 48 hours. • Allow telehealth as a service delivery option when warranted as authorized by BDDS. The state is requesting immediate implementation to avoid any adverse effect on participants’ health and safety and providers’ capacity to deliver services. Should a provider be unable to deliver services during this emergency, another enrolled BDDS approved HCBS Family Supports Waiver (CIH) service provider or providers will be authorized immediately and the participant’sservice plan

Waiver Description

Provides adult day, case management, prevocational, rent and food for unrelated live-in caregiver, residential hab and support, respite, supported employment follow along, OT, PT, psychological therapy, speech/language therapy, behavioral support, community based hab-group, community based hab-individual, community transition, electronic monitoring, environmental mods, extended services, facility based hab-group, facility based hab-individual, facility based support services, family and caregiver training, intensive behavior intervention, music therapy, personal emergency response system (PERS), recreational therapy, residential habilitation and support – daily, specialized medical equipment and supplies, structured family caregiving, transportation, wellness coordination, workplace assistance for individuals w/autism, ID, DD ages 0 – no max age

Start Date

01-03-20

End Date

31-08-20

Description of Transition Plan

Indiana DDRS proposes in this Appendix K to temporarily waive certain service limitations and temporarily expand the possible service settings and provider qualifications. These temporary changes do not relax CIH waiver eligibility criteria and are not expected to result in an increase in waiver participation enrollment. Indiana DDRS does not anticipate the temporary changes captured in this Appendix K to have any adverse on waiver participants either during the effective period of Appendix K or in the transition period back to the current approved CIH waiver. At the expiration of Appendix K, service limitations, service settings and provider qualifications will revert back to the levels found in the currently approved CIH waiver.

Area(s) Affected

Area Affected

92 of 92 counties.

Increase Cost Limits

N/A

Modify Targeting Criteria

N/A

Modify Scope or Coverage

Rent and Food for Unrelated Live-In Caregiver Supports; Respite Services; Residential Habilitation; Facility Based Habilitation; Adult Day Services; Prevocational Services; Transportation; Structured Family Caregiving (AKA Adult Foster Care); Community-Based Habilitation; Extended Services;

Exceed Service Limitations

The 40-hour-per-week paid caregiver limitation will be temporarily modified to exceed service limitations for • Residential Habilitation and Support (RHS) available on the CIH Under this temporarily modified service allowance, paid caregivers may exceed the 40 hour per week paid caregiver limit. Exceeding the 40-hour rule could be accomplished by more than one paid caregiver to provide over 40 hours of services, therefore in some cases multiple paid caregivers combined could provide more than 40 hours, and in some cases one sole caregiver could be providing these hours. When applicable, paid caregiver hours would be subject to overtime rules.

Add Services

N/A

Expand Settings

The agency will temporarily expand settings where residential and habilitation and support (RHS) or structured family caregiving (SFC) may be provided. If a participant’s SFC setting is compromised due to COVID-19 related reasons, RHS and SFC services may be temporarily provided at a day program setting or an Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID). The day program waiver setting or ICF/IID must be accessible to participants and ensure participant health and safety to the fullest extent possible. The temporary service setting may not exceed thirty (30) days for each participant for these services. Due to the need to limit social interaction in response to COVID-19, the agency will temporarily expand settings where Community-Based Habilitation (CHIO/CHG) may be provided. CHIO/CHG services may be temporarily provided at a facility-based waiver day program, the home of the participant, an Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID), or, upon approval from the participant’s team, the home of a direct support professional. The alternate service delivery setting must be accessible to the participant and ensure the participant’s health and safety to the fullest extent possible. The alternate service delivery in an ICF setting may not exceed thirty (30) days for each participant. Due to the need to limit social interaction in response to COVID-19, the agency will temporarily expand settings where Facility Habilitation, Prevocational Services and Adult Day Services may be provided. Facility Habilitation, Prevocational Services and Adult Day Services may be temporarily provided at a facility-based waiver day program, the home of the participant, an Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID), or, upon approval from the participant’s team, the home of a direct support professional. The alternate service delivery setting must be accessible to the participant and ensure the participant’s health and safety to the fullest extent possible. The alternate waiver service delivery in an (ICF) setting may not exceed thirty (30) days for each participant. The agency will temporarily expand settings where Structured Family Caregiving (SFC) may be provided. If the support for a participant’s Residential Habilitation and Support (RHS) setting is compromised due to COVID-19 related reasons and a direct support staff is residing in the home to ensure continuity of care, BDDS will temporarily allow the RHS setting to be converted to a SFC setting and be provided in the participant’s home. This is not a requirement in cases where a direct support staff is temporarily residing in an individual’s home, but rather an option for the team to consider. In unique and rare situations, the home of a direct service professional familiar to the individual may be used as a temporary/alternate residential setting for a participant when the participant’s primary caregiver has been diagnosed with COVID-19 or has been quarantined due to COVID19. To utilize this option, the service must be designated as a Structured Family Caregiving setting. The participant’s support team must approve of the temporary/alternate residential setting. The case manager will submit an emergency transition with the support team’s approval within seven (7) days of relocating the individual to the alternate residential setting. The alternate service delivery setting may not exceed sixty (60) days for each participant.

Provide Service Out of State

N/A

Allow Payment for Services by Families

When existing services on the participant’s Person-Centered Individualized Support Plan (PC/ISP) are interrupted due to circumstances related to COVID-19, • Parent(s), stepparent(s), and legal guardian(s) will temporarily be allowed to provide services (as direct support staff via an existing BDDS approved provider) to adults and minors who are currently using or have a documented intent to use only the following services: o Community based habilitation (CHIO) available on the CIH o Residential Habilitation and Support (RHS) available on the CIH • An adult spouse will temporarily be allowed to provide services to an adult individual in the following services: o Structured family caregiving (SFC) available on the CIH Temporarily allow for Respite services to be provided by a participant’s spouse, who is not the primary caregiver, when existing services on the Person-Centered Individualized Support Plan (PC/ISP) have been interrupted due to circumstances related to COVID-19. Temporarily allow for RHS services to be provided by a participant’s spouse or any combination of relative(s) (defined in this section) when existing services on the Person-Centered Individualized Support Plan (PC/ISP) have been interrupted due to circumstances related to COVID-19.

Modification of Provider Qualifications

BDDS will temporarily accept a copy of a limited criminal history checks conducted through the Indiana Central Repository within the last six (6) months from another entity. BDDS is also temporarily suspending the requirement for an existing, approved BDDS provider agency to conduct a criminal history check for potential staff prior to hire from each county in which the employee, officer, or agent involved in the management, administration, or provision of services has resided during the three (3) years before the criminal history check is requested from the county. This is instead is required to be done within 60 days of hire. The BDDS provider agency will still be required to ensure the individual is otherwise qualified to be staff. In the event the employee does not pass the background check, they must immediately suspend delivery of direct supports to individuals in services. s BDDS is temporarily suspending the requirement for a provider to conduct a tuberculosis (TB) test on a potential staff prior to hire and will issue guidance on requirements and timelines. BDDS is suspending the requirement for direct care staff to be trained prior to working with individuals and has issued specific guidance to providers on required trainings. BDDS will allow a direct support professional to
continue providing HCBS services for a period of ninety (90) days after CPR certification has expired.

Modify Provider Types

Removing requirement that a respite provider must be either a licensed home health agency, or a currently BDDS approved entity providing residential services or an adult day service provider. Would remain as
FSSA/DDRS Approved Respite Agency. Removing requirement that a Rent and Food for Unrelated Live-in
Caregiver Supports provider must be
a BDDS approved HCBS provider
of community habilitation and
participation services or residential
habilitation and support services. Would remain as FSSA/DDRS Approved Rent and Food for Unrelated Live-in Caregiver Supports.

Modify Licensure/Requirements for Waiver Settings

ICF/ID: BDDS, the issuer of the licenses for these settings, would not enforce licensure requirements related to the number of participants in a given ICF setting for COVID19-specific situations where waiver services need to be temporarily delivered on a short-term basis. An Indiana Code waiver for IC 12-11-1.1-1- (e)(1), (2) was obtained via a Governor’s Executive order to allow an Intermediate care facility (ICF) to temporarily be below the minimum of 4 residents while also allowing an ICF to temporarily exceed the maximum of 8 residents.

Modification LOC Eval and Re-Eval Processes

BDDS will temporarily allow: 1) LOC determinations may be completed by phone (or virtual) in accordance with HIPAA requirements; and 2) Annual LOC re-assessments that are due on or before June 30, 2020 are extended until December 31, 2020. 3) BDDS will temporarily modify the requirement for a Confirmation of Diagnosis to complete Level of Care for re-entries to waiver services.

Increase Payment Rates

The state will offer the current, existing Residential Habilitation rate of $21.97/hour for staff to stay overnight in the residence to be available in emergent situations under needs determine by the level of involvement of the individual due to complications from the COVID pandemic (e.g. in an emergency situation when an individual must be immediately temporarily relocated or staffed in a temporary residential setting due to COVID-19 exposure or positive testing, and no other means to support the individual have been established (remote supports/electronic monitoring, family or natural supports). Instances of overnight stays in these situations are occurring as a result of existing authorized services that would have normally been provided by shift staff, that would now allow flexibility for shift staff to continue supporting someone when relief staff or new shift staff are in shortage or not otherwise available due to COVID-19. No new services are being created, and no new rate or increase in rate is being realized by the Residential Habilitation provider.

Modifications of ISP

To ensure continuity of service planning and team meetings, BDDS will temporarily authorize the use of phone (or virtual) meetings in accordance with HIPAA requirements as an alternative to face-to-face meetings. BDDS issued specific guidance related to virtual meetings and telemedicine to providers. Person-Centered Service Plans that are due to expire within the next 60 days require case management contact to the participant using allowable remote contact methods to verify with the participant or representative that the current assessment and services, including providers, remain acceptable and approvable for the upcoming year. The state will verify by obtaining electronic signatures/or electronic verification via secure email consent from service providers and the individual or representative in accordance with the state’s HIPAA requirements dated the day of the meeting. The state will ensure the 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 the date it began to be received. The case manager must submit the request for additional supports/services no later than 30 days from the date the service begins.

Modify Incident Reporting/Med Management Safeguards

BDDS will require the following incidents to be reported within 24 hours or 24 hours of knowledge: • alleged abuse, • alleged neglect, • alleged exploitation; and, • any incident where an individual is found to be presumed positive (Presumed positive means individuals with at least one respiratory specimen that tested positive for the virus that causes COVID-19 at a state or local laboratory. All other incidents must be reported within 48 hours or 48 hours of knowledge.

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

BDDS will delay the enrollment of new service providers during the COVID-19 pandemic. The timeframes for the submission of the CMS 372s and the evidentiary package(s) will be extended as needed pursuant to the emergency. In addition, the state may suspend the collection of data for performance measures other than those identified for the Health and Welfare assurance and notes that as a result the data will be unavailable for this time frame in ensuing reports due to the circumstances of the pandemic.

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 rehabilitation, monthly monitoring, and other: Behavior Management, Therapies (including PT, OT, Speech, Psychological, Music, and Recreational), Extended Services, Wellness Coordination, and Family and Caregiver Training are permitted to utilize telemedicine options to delivery services. All other services may use telemedicine as a last resort option, only with individuals who need only verbal prompting and guidance, and must relate to an individualized need or interest. When utilized, some element of the underlying service definition must be provided and documented.

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

BDDS will delay the enrollment of new service providers during the COVID-19 pandemic. The timeframes for the submission of the CMS 372s and the evidentiary package(s) will be extended as needed pursuant to the emergency. In addition, the state may suspend the collection of data for performance measures other than those identified for the Health and Welfare assurance and notes that as a result the data will be unavailable for this time frame in ensuing reports due to the circumstances of the pandemic.

Other Changes Necessary

BDDS will delay the enrollment of new service providers during the COVID-19 pandemic. The timeframes for the submission of the CMS 372s and the evidentiary package(s) will be extended as needed pursuant to the emergency. In addition, the state may suspend the collection of data for performance measures other than those identified for the Health and Welfare assurance and notes that as a result the data will be unavailable for this time frame in ensuing reports due to the circumstances of the pandemic.

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

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

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/in-0378-appendix-k-appvl.pdf

Link to Approval Letter

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