Kentucky – Appendix K

Waiver Title

Acquired Brain Injury/ Acquired Brain Injury Long Term Care/Supports for Community Living/Michelle P Waiver/Home and Community Based Waiver/Model II Waiver

Description of Emergency

1) On March 6, 2020, Governor Andy Beshear declared a state of emergency in Kentucky related to COVID-19 (also known publicly as “coronavirus’). The virus spreads quickly and can cause mild to severe symptoms. The spread of the virus poses a threat to health and safety of our 1915(c) HCBS waiver participants and necessitates changes in service delivery methods and approaches. 2) As of March 17, 2020, Kentucky has 26 confirmed cases and 1 fatality. The population served by the Acquired Brain Injury (ABI) waiver includes individuals with an acquired brain injury who need acute rehabilitation in order to re-enter community life. These populations are not only at a higher risk of contracting the virus, but are more likely to suffer complications up to, and including, death. At the same time, participants actively rely on waiver-funded support with activities of daily living, instrumental activities of daily living, supervision and oversight of care, and overall well-being. Many receive services in congregate settings, including adult day health cares. There are approximately 27,000 individuals currently enrolled in Kentucky’s 1915(c) HCBS waivers and 700 receiving services via the ABI waivers. 3) The Department for Medicaid Services is working with our sister agencies, the Department for Behavioral Health and Intellectual Disabilities and the Department for Aging and Independent Living to provide direction and technical assistance to providers and participants. The Departments are following guidance provided by the Department of Public Health (DPH) and key federal agencies, including the Centers for Medicare and Medicaid and the Centers for Disease Control. Kentucky has created a website (kycovid19.ky.gov) that is being continually updated with information related to COVID19. In addition, DPH is manning a 24-hour hotline for inquiries related to COVID-19 at 1- 800-722-5725. 4) Kentucky seeks temporary changes to the ABI waiver to proactively address potential staffing shortages, projected access to care issues and need for service provision beyond the terms of approved service descriptions to address participant health, safety and welfare for the duration of the emergency.

Start Date

06-03-20

End Date

05-03-21

Description of Transition Plan

Individuals will transition back to pre-emergency service status once federal and/or state health officials have determined that the virus outbreak is adequately contained and possesses minimal risks to revert to existing waiver practices. This transition will be implemented no sooner than 48 hours after the public has been made aware of pandemic containment and Medicaid providers have been notified of the intent to repeal emergencybased standards described herein. In keeping with existing practices, individualized needs will be re-assessed on a case-bycase basis, as indicated, if any long-term changes are required to an individual’s personcentered service plan once the Commonwealth resumes standard program rules and policies approved in the active 1915(c) HCBS waiver applications.

Area(s) Affected

Area Affected

statewide

Increase Cost Limits

N/A

Modify Targeting Criteria

N/A

Modify Scope or Coverage

Addition of home delivered meals (max 2/day) Home Delivered Meal Service is defined as the provision of meals to a waiver participant who has a
need for a home delivered meal based on a deficit in an activity of daily living or an instrumental
activity of daily living identified during the assessment process. The service includes the preparation,
packaging and delivery of safe and nutritious meals to a consumer at his or her home. A participant
may be authorized to receive one home delivered meal per day. Also, for the purposes of this service,
reheating a prepared home delivered meal is not the same as preparing a meal.
Home delivered meals:
1) Shall be provided to participants who are unable to prepare their own meals and for whom there
are no other persons available to do so.
2) Shall take into consideration the participant’s medical restrictions
4) Shall be individually packaged if they are heated meals.
5) May include frozen meals
5) May be individually packaged if they are unheated, shelf-stable meals, or may have components
separately packaged.

Exceed Service Limitations

The Department will permit a temporary increase beyond the currently defined waiver service caps and limitations including overtime to allow the needed amount, duration or change in scope within the waiver, as necessary, to effectively address emergent health, safety and welfare-related needs of program participants during the COVID-19 pandemic. The following services will have limitations increased: • Personal Care/Personal Assistance (ABI/ABI LTC/SCL/MPW) • Companion (ABI/ABI LTC) • Respite (All programs except MW II) • Home Delivered Meals (All programs except MW II) • PDS Services – (All programs except MW II) • Specialized Medical Equipment and Goods and Services (All programs except MW II) • Behavioral Support Services ( MP II, ABI, ABI LTC) • Consultative Clinical (SCL) • Counseling (ABI, ABI LTC) • Nursing supports (ABI LTC) • Registered Nurse (MW II) • Licensed Practical Nurse (MW II) • Registered Respiratory Therapist (MW II) The Department will also allow for a temporary increase in Case Management services beyond one unit per month to address a participant’s increased and emergent needs for information and referral, service linkage, crisis management and to promote timely access to services. The case manager and the servicing provider will be responsible to review and substantiate a need and capacity to increase services to effectively address emergent health, safety and welfare-related needs of program participants during the COVID-19 pandemic. The Department does expect emergency modifications to a participant’s person-centered plan to be both reasonable and necessary and will be performing retrospective reviews to assure that fraud, waste and program abuse does not occur as a result of this emergency response measure.

Add Services

Home Delivered Meal Service

Expand Settings

Residential or Respite services can be provided in a Day Training or Adult Day Health Care centers according to federal guidance on safe practices related to mitigating COVID-19 spread. If space is sufficient to allow distancing and the center has the needed facilities (kitchen, bathrooms, sleeping arrangements and treatment rooms, including safe storage of medication). The following services can be provided remotely using telephonic, video-conferencing, or web-based conferencing platforms that enable direct communication with the participant. • Adult Day Training • Adult Day Health • Personal Assistance or Community Living Supports for reminders, cueing and/or monitoring of participant self-medication administration. Adult Day Training and Adult Day Health applicable Services may also temporarily be provided in the home setting. Consideration should be given to the number of people who are accessing the home to decrease the potential exposure or spread of infection Services whose scope allows for the provision of telehealth services such as ancillary therapies, counseling and behavior services may provide and bill those covered waiver services using that delivery method.

Provide Service Out of State

N/A

Allow Payment for Services by Families

N/A

Modification of Provider Qualifications

Required Training/Qualifications for non-skilled or non-licensed direct service providers including first aid, CPR and college of direct support required trainings, can be delayed to allow employees to begin immediately. Training required to support participants safely such as training on an individual’s person centered plan, specific needs and medication administration when applicable are required. The Department is amending provider standards for personal assistance, attendant care, home and community supports, respite, community living supports, and companion to qualify a direct worker while his/her background check and pre-employment screenings are in pending status. This allowance will be applied to both traditional and participant-directed service (PDS) arrangements. Further, should a pending screening come back demonstrating concerns with the background check and/or pre-employment screening that would not allow the worker to continue employment long term that worker continues to be qualified until an alternative employee is identified unless the worker poses an immediate jeopardy to health, safety, and/or welfare of the participant (e.g. has tested positive for infectious disease) or is found to be guilty of past abuse, neglect, exploitation or violent felony and therefore is immediately unqualified. The Department will temporarily suspend all DAIL (Department of Aging and Independent Living) employee screening of immediate family members who will be temporarily authorized to provide PDS, if these services are required to cover gaps in care resulting from emergency-related inability to access waiver services. Preemployment screenings (TB, background checks and drug testing will continue to be required with the exceptions noted above) The Department will also temporarily waive requirements that out of state providers be licensed and located in Kentucky when they are actively licensed by another state Medicaid agency.

Modify Provider Types

The Department will allow actively Medicaid-approved adult day health care providers to provide the following services: • Home Delivered Meals • In-Home Nursing Services (as long these services are furnished by a registered nurse and delivered in accordance with standards established by the Kentucky Board of Nursing) Additionally, standards are being relaxed to permit any enrolled waiver provider to provide Home Delivered Meals, as a precautionary measure that allows for service consolidation to limit an unnecessarily high volume of different providers and staff entering an individual’s home environment, which limits potential opportunities for viral exposure. If the only willing and able service provider in the participant’s area is the case management provider, the Department or its designee will review the request for a conflict-free exemption utilizing the approved process in the approved waiver Appendix D 1. . Services will be approved for 180 days or less and will require a new review at that time to assess the availability of additional providers.

Modify Licensure/Requirements for Waiver Settings

N/A

Modification LOC Eval and Re-Eval Processes

To effectively respond to the COVID-19 outbreak, the state requires flexibility to adjust providers’ rates in certain geographic areas to ensure that sufficient providers are available for participants. The state will determine the rates based on the severity of the situation in specific geographic region coupled with an individualized review of circumstances and extent of need and risk in light of unmet need that necessitates single-case agreement to increased rates to implement a sound and sustainable emergency person-centered service plan. Increased payment rates would follow the approved rate methodology in the waivers and allow up to an additional 50% of the max rate based on department approval.

Increase Payment Rates

To effectively respond to the COVID-19 outbreak, the state requires flexibility to adjust providers’ rates in certain geographic areas to ensure that sufficient providers are available for participants. The state will determine the rates based on the severity of the situation in specific geographic region coupled with an individualized review of circumstances and extent of need and risk in light of unmet need that necessitates single-case agreement to increased rates to implement a sound and sustainable emergency person-centered service plan. Increased payment rates would follow the approved rate methodology in the waivers and allow up to an additional 50% of the max rate based on department approval.

Modifications of ISP

The State will modify mandated processes and required timeframes for completing person-centered service plans as permitted by HIPAA: • 1) Case managers may complete the person-centered service planning process using telephonic, video-conferencing, or web-based conferencing platforms that enable direct communication between the case manager and participant / participant’s representative. in accordance with HIPAA requirements. 2) 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 PCSP assessment and service, including providers, remain acceptable and approvable for the upcoming year. The state will verify by obtaining electronic signatures from service providers and the individual or representative, in accordance with the state’s HIPAA requirements. If requested and/or necessary, modifications to a person-centered plan may be made, as driven by individualized participant need, circumstance and consent reviewed on an individualized basis, without the input of the entire person-centered service team. The Department will temporarily allow changes to be modified primarily by the case manager and participant/participant’s representative – with signature from the provider to deliver modified services as documented in the updated plan. Physical signature to the plan can be obtained from third parties using remote transmission methods. The case manager may share forms requiring signature and receive documented signature consenting to a modified plan using fax or by sharing scanned documents via secured email. Consent may also be provided electronically via email. Electronic signature is also acceptable during the emergency period Planning and development of modified person-centered service plans may be conducted using remote contact methods, in keeping with all other allowances for case management activities during the emergency period. 3) 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 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

Providers must submit critical incident reports to report any waiver-funded disruption extending beyond three calendar days to services documented in the participant’s person-centered service plan. This includes waiver-funded service disruptions that occur due to staff unavailability directly related to COVID-19 staff infection, quarantine or other pandemic-related circumstance. Providers must submit critical incident reports for participants who tested positive for COVID-19, and disclose in the critical incident report the exposure of COVID-19 positive participants with any other 1915(c) HCBS waiver participants and/or staff. While reports will be required, providers do not need to conduct an investigation or submit a corrective action plan related to these reports, unless instructed directly to do so at the Department’s discretion. Provider must ensure that participants without natural or other supports continue to receive services.

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

N/A

Inclusion of Retainer Payments

In response to the defined emergency, and in order to maintain a viable workforce, the state may elect to make retainer payments to waiver providers in instances where the agency has been directed to close and the provider cannot enter the participant’s home or provide services through other electronic platforms. The state will determine the rate and scope of retainer payments based on the severity of the situation. Retainer payments will only be allowed for habilitation and personal care services and will not exceed 24 consecutive days as specified in Olmstead Letter #3, Personal Assistance Retainer.

Institute/Expand Opportunities for Self-Direction

The Department will temporarily suspend all required additional screening (potential financial conflict and pre-employment screenings) specifically required for immediate family members to approve them as an employee under PDS. It should be noted that this suspension is temporary – PDS employees, including immediate family members, will be required to undergo this screening once the emergency period has ended, however, a future determination of eligibility will not be applied to service rendered during the emergency period.

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/ky-combined-appendix-k-appvl.pdf

Link to Approval Letter

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