Maine – Home and Community Based Services for Members Brain Injury (ME 1082), the Elderly and for Adults with Disabilities (ME 0276), the Home and Community Based Services for Adults with Other Related Conditions (ME 0995), the Home and Community Based Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder (ME 0159), and the Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder (ME0467)

Waiver Title

Home and Community Based Services for Members Brain Injury (ME 1082), the Elderly and for Adults with Disabilities (ME 0276), the Home and Community Based Services for Adults with Other Related Conditions (ME 0995), the Home and Community Based Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder (ME 0159), and the Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder (ME0467)

Description of Emergency

On March 13, 2020, the President of the United States declared the 2019 coronavirus (COVID19) a nationwide emergency pursuant to Sec 501(b) of the Stafford Act. On March 15, 2020 Governor Janet Mills declared a civil state of emergency as 7 positive cases and 5 presumptive positive cases were announced in Maine. As of April 13, 2020, the number had grown to 698 confirmed cases. The five approved 1915(c) waivers serve some of the most vulnerable individuals within the State of Maine. Several conditions/factors/variables present increased risk to this population including underlying health conditions, congregate housing within residential settings, difficulty engaging in social distancing mandates due to reliance on support from staff and others for basic needs and to follow infection control procedures. Potential increased workforce shortages resulting from illness of frontline care staff and/or family caregivers will surely lead to greater crisis for the served population. Maine seeks temporary changes to the five aforementioned waivers to mitigate the current risks, to allow flexibility in service delivery systems, and to ultimately ensure that member health and safety needs are accommodated throughout the state of emergency.

Waiver Description

HCBS for Member with Brain Injury (1082.R01.00): Provides care coordination, career planning, home support- 1/4 hour-level I, home support-per diem level II, community/work reintegration-group, community/work reintegration-individual, self-care/home management reintegration group, self-care/home management reintegration-individual, assistive technology, employment specialist services, home support- remote support, home support-per diem level III increased neurobehavioral, non-medical transportation, work ordered day club house, work support-individual services for individuals with brain injury ages 18 – no max age; Elderly and Adults with Disabilities (0276.R05.00): Provides care coordination, personal care, respite, financial management services, skills training, assistive technology, attendant care services, environmental modifications, home delivered meals S5170, home health services, living well for better health (chronic disease self-management), matter of balance (falls prevention), personal emergency response system (PERS), transportation for aged 65 – no max age and individuals w/physical disabilities age 18-no max age; HCBS for Adults w/Other Related Conditions (0995.R01.00): Provides care coordination, career planning, community support, home support-(1/4 hour), home support-per diem, personal care, work support, assistive technology, communication aids, consultation and assessment, employment specialist services, home accessibility adaptations, home support-remote support, non traditional communication consultation, non-medical transportation, non-traditional communication assessments, occupational therapy (maintenance), physical therapy (maintenance), specialized medical equipment and supplies, speech therapy (maintenance) for aged individuals ages 65 – no max age and other disabilities ages 21-64; Home and Community Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder (0159.R06.00): Provides community support, home support (1/4 hr), per diem home support, work support-group, adult foster care/shared living, assistive technology, career planning, communication aids, consultation, counseling, crisis assessment, crisis intervention, employment specialist services, home accessibility adaptations, home support-remote support, home support-residential hab-family centered support, non-traditional communication consultation, non-medical transportation, non-traditional communication assessment, OT (maintenance), PT, (maintenance), specialized medical equipment and supplies, speech therapy (maintenance), work support-individual for individuals w/autism, IID ages 18 – no max age; Support Services for Adults w/ID or Autistic Disorder (0467.R02.00): Provides community support, home support 1/4 hr, respite, work support-group, adult foster care/shared living, assistive technology, career planning, employment specialist services, home accessibility adaptations, home support-remote support, non-medical transportation, work support-individual for individuals w/autism and ID ages 18 – no max age;

Start Date

01-03-20

End Date

28-02-21

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 waivers 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

The budget allocation and service limitation provisions of this section are subject to prior approval by the Department and are in effect from 3/1/20 through 5/31/20. Prior approval will be based on identification of factors related to the emergency which necessitate the additional budget or services. If the Department finds a continuing need, the Department may extend the budget allocation and service limitation provisions beyond 5/31/20 but not to exceed the end date approved in the Appendix K. Appendix C-4: The budget allocations enumerated in Appendix C-4 of the Home and Community Based Services for Members Brain Injury (ME 1082), the Elderly and for Adults with Disabilities (ME 0276), the Home and Community Based Services for Adults with Other Related Conditions (ME 0995), the Home and Community Based Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder (ME 0159), and the Support Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder (ME0467) waivers may be temporarily exceeded to provide needed services for emergency care provision. Service Limits in Sections C-1/C-3 ME.0276.R05.03 1) Increase the limit of available hours within Personal Care Services by up to 20 percent (%) per week. 2) Increase the limit for the provision of care coordination by up to 20 percent (%) per month 3) Increase the limit on Assistive Technology Device and Services to $6,000 and $200 per month for Assistive Technology- Transmission with prior authorization, and remove these services from the monthly program cap. 4) Increase the limit on Respite Services by up to 20 percent (%) per week. 5) Increase the limit on Home Delivered Meals from one meal/day to 2 meals/day and remove the total cost from the monthly cap of combined Personal Care, Attendant Care, Respite, Assistive Technology and Living Well/Matter of Balance services. 6) Remove budget allocation limits and individual caps on service to accommodate these temporary service increases. ME.1082.R01.02, ME.0995.R01.01, ME.0159.R06.04, ME.0467.R02.04 1) Increase the service limits to Quarter Hour Home Supports to up to 64 units per day 2) Allow up to three (3) members to receive Shared Living in one setting for ME.0159.R06.04 and ME.0467.R02.04. 3) For Per Diem Home Support, an agency may deliver less direct support than authorized and continue to receive the approved reimbursement rate. An agency will not be subject to minimum staffing requirements if the agency determines that it may provide for members’ health and safety with fewer staff and maintains staffing of at least 50 percent (%) of authorized levels. 4) Increase the limit on Assistive Technology Transmission to $200 per month for data transmission with prior authorization and remove Assistive Technology Transmission from the overall cap for 1082.R01.02 and ME.0995.R01.01. 5) Modify limitations on Respite Services for ME.0467.R02.04. 6) Modify limits on Care Coordination units for ME.1082.R01.02 and ME.0995.R01.01.

Add Services

1) Temporary Service—Emergency Quarantine Services for Waiver Participants with COVID19—is described in Section A. The Department will pay $27.72 per hour for this service. This rate is based on the Department’s Emergency Transitional Housing (ETH) contracted service rate. ETH does not include funding for room and board, nor will the rate for this temporary service. ETH is not a waiver service. It is a state-funded service used in the state’s Crisis Services Program when individuals in crisis must be served in an alternative setting. 2) Temporary Service—Adult Foster Care—“Shared Living” is described in Section A. This service currently exists in ME.0159.R06.04 and ME.0467.R02.04 and is being added to ME.0995.R01.01, using the same rate as in the two waivers where it already exists.

Expand Settings

ME.0276.R05.03 1) Personal Care and Home Health Services can be provided in alternate settings such as hotels, shelters, churches or other settings approved by the Department should members require evacuation from current settings or quarantine. 2) Settings (facility respite) awaiting licensing approval or currently vacant will receive temporary approval for occupancy in the absence of full licensure provided that health and safety can be assured. Agencies/Providers will be expected to resume actions to acquire full licensure following the date the Department has declared the emergency has ended. 3) Services can be delivered via telehealth when appropriate to meet the needs of the individual. ME.1082.R01.02, ME.0995.R01.01, ME.0159.R06.04, ME.0467.R02.041) 1) Service definition limitations on the number of people serviced in each licensed or unlicensed setting can be exceeded or decreased to meet the health and safety needs of participants. 2) Community support day habilitation can be delivered in alternate settings such as hotels, shelters, participants’ own homes or family homes. 3) All habilitative and rehabilitative supports can be provided in hotels, shelters, churches or other settings approved by the Department. Providers must include staffing provided in approved alternative settings when tracking established per diem staffing ratios. 4) A participant has the flexibility to move among settings to ensure their needs during this emergency can be met 5) Allow occupancy of unlicensed settings and allow for the provision of services in this setting 6) Services can be delivered via telehealth when appropriate to meet the needs of the individual.

Provide Service Out of State

N/A

Allow Payment for Services by Families

Services including personal support and attendant care may be rendered by relatives or spouses of waiver participants when hired by the provider agency or when established as a contractor with the provider agency authorized to render the services. The provider agency is responsible for ensuring that services are provided as authorized in the PCP and that billing occurs in accordance with the corresponding section of MaineCare. All services provided, other than non-medical transportation, must continue to be prior authorized. MaineCare enrolled providers must maintain documentation to include each relative or spouse rendering services. ME.0276.R05.03 1) Training and Personal Support Specialist certification requirements for waiver participants’ relatives or spouses will not be required before a relative or spouse can begin providing services, but training and certification must be completed by the end date of appendix K. 2) Prospective staff will be deemed eligible to provide support to members prior to background check clearance. Orientation and initial training for all newly hired direct care staff will be suspended until such time as can be safely provided. ME.1082.R01.02, ME.0995.R01.01, ME.0159.R06.04, ME.0467.R02.041 1) Training and Direct Support Professional certification requirements for waiver participants’ relatives and spouses will not be required before a relative or spouse can begin providing services, but training and certification must be completed by the end date for appendix K. 2) Prospective staff will be deemed eligible to provide support to members prior to background check clearance. Orientation and initial training for all newly hired direct care staff will be suspended until such time as can be safely provided.

Modification of Provider Qualifications

Provider Qualifications in Appendix C-1/C-3 To allow redeployment of direct care and clinical staff to needed service settings during the emergency, staff qualified under any service definition in the waiver may be used for provision of any non-professional service under another service definition in C-1/C-3. Professional services exempt from this include nursing assessments and other nursing services. ME.1082.R01.02, ME.0276.R05.03, ME.0995.R01.01, ME.0159.R06.04, ME.0467.R02.04 1) Providers will use reasonable discretion in developing and reducing residential staffing patterns and ratios adequate to maintain the health and safety of members. Upon the date the Department has declared that the statewide emergency has ended but not to exceed the effective end date for appendix K, services will resume automatically, without further action by the Department or the agency, to adhere to the ratio directed by the person-centered-plan requirements for each covered service in place prior to the emergency. 2) The age limit for prospective employees will be lowered to 17 years-of-age through the period of the emergency to increase prospective hiring pool but not to exceed the effective end date for appendix K. 3) Prospective candidates will be considered for employment in the absence of having a high school diploma or GED from a qualifying educational institution or GED through the period of the emergency to increase the prospective hiring pool but not to exceed the effective end date for appendix K. 4) Prospective staff will be deemed eligible to provide support to members prior to background check clearance. Orientation and initial training for all direct care staff will be suspended until such time as it can be safely provided to newly hired staff following the period of emergency. 5) Training and certification requirements (i.e. Direct Support Professional, and Personal Support Specialist) for Family Caregiver, Friends, Spouse and Guardians may be waived through the period of the emergency. The aforementioned individuals will be required to obtain required trainings as soon as is reasonably possible following the date the Department has declared that the statewide emergency has ended but not to exceed the effective end date for appendix K.

Modify Provider Types

N/A

Modify Licensure/Requirements for Waiver Settings

ME.1082.R01.02, ME.0276.R05.03, ME.0995.R01.01, ME.0159.R06.04, ME.0467.R02.04 1) Programs/Agencies will be allowed to maintain occupancy within a facility/home if license expires during the emergency period. Agencies/programs will be required to submit renewal/reapplication for licensure within 60 days of the emergency end date not to exceed the end date approved in the Appendix K.. Waiver participants will be allowed to occupy unlicensed facilities/programs should it be necessary for them to be moved/evacuated from a setting due to infection or need for quarantine.

Modification LOC Eval and Re-Eval Processes

Level of Care assessments can be completed via telehealth for ME.1082.R01.02, ME.0276.R05.03, ME.0995.R01.01 ME.1082.R01.02, ME.0276.R05.03, ME.0995.R01.01 1) Initial Level of Care assessment can be conducted telephonically or by other remote technology to protect health and safety of members. 2) Reassessment can be conducted up to 30 days late. ME.0159.R06.04, ME.0467.R02.04 1) Renewal Level of Care assessments can be completed up to 30 days late.

Increase Payment Rates

1) Rates will be temporarily increased by 10 percent (%) to account for additional costs related to operating during the COVID-19 emergency including, but not limited to: excess overtime or premium pay to ensure sufficient direct care workers to cover staffing needs; infection control supplies and other additional or unanticipated service costs. These temporary increases will be in effect from 3/1/20 through 5/31/20. If the Department finds a continuing need, the Department may extend the temporary rate increases beyond 5/31/20 not to exceed the end date approved in the Appendix K. Providers will be asked to report to the Department within 30 days of the end of the State Civil emergency how the temporary increase was expended, including the percentage allocated to direct care staffing costs. The rate setting methodology is not changed. The rate for each service listed is increased temporarily by the percentage indicated above. Services subject to this provision are listed by waiver program: Home and Community Based Services for Members with Brain Injury (ME 1082): Work Support- Individual Care Coordination Home Support- Level II Home Support- Level III, Increased Neurobehavioral Home Support- Level I Home Support- Remote Elderly and Adults with Disabilities (ME 0276) Attendant Care Services Certified Nursing Assistant Respite Care Personal Care Services Skilled Nursing Visit, RN Nursing Visit, LPN Skills Training and Development Care Coordination Home and Community Based Services for Adults with Other Related Conditions (ME 0995), Work Support- Individual Care Coordination Personal Care Services Home Support- Quarter Hour Home Support- Remote Home Support- Per Diem Community Support Home and Community Based Services for Adults with Intellectual Disabilities or Autism Spectrum Disorder (ME 0159). Work Support- Individual
Shared Living- One member served
Shared Living- One member served, increased level of support
Career Planning
Home Support- Agency
Home Support- Agency with Medical Add On
Family-Centered Support, One member served- increased level of support
Family-Centered Support, One member served
Family-Centered Support, Two members served- increased level of
support
Family-Centered Support, Two members served
Family-Centered Support, Three members served- increased level of
support
Family-Centered Support, Three members served
Family-Centered Support, Four members served- increased level of
support
Family-Centered Support, Four members served
Family-Centered Support, Five or more members served- increased level
of support
Family-Centered Support, Five members served
Home Support- Quarter Hour
Home Support- Quarter Hour with Medical Add On
Community Support
Crisis Intervention Services
Support Services for Adults with Intellectual Disabilities or Autism
Spectrum Disorder (ME0467)
Shared Living- One member served
Shared Living- One member served, increased level of support
Respite Services- Per Diem
Career Planning
Home Support- Quarter Hour
Community Support
2) Shared Living-Modified Rate for more than one Person. Applicable Only to Home and
Community Based Services for Adults with Intellectual Disabilities or Autism Spectrum
Disorder (ME 0159) and Support Services for Adults with Intellectual Disabilities or Autism
Spectrum Disorder (ME0467). The rate setting methodology for more than one person in
Shared Living setting will be modified temporarily as follows: For 2 people, rate becomes
75 percent (%) of 1-person rate for each waiver participant served. For 3 people, rate
becomes 60 percent (%) of 1-person rate for each waiver participant served.

Modifications of ISP

Modification to Person-Centered-Planning ME.1082.R01.02, ME.0276.R05.03, ME.0995.R01.01, ME.0159.R06.04, ME.0467.R02.04 1) Modify face-to-face meeting requirements for the development, implementation and monitoring of the person-centered plan: 2) Allow for completion of meetings and contacts for the development, implementation and monitoring of the person-centered planning process to be completed via phone, videoconferencing or other electronic communications that enable direct contact with the recipient, recipient’s representative and any contracted service providers, as needed, in accordance with HIPAA requirements. 3) Allow for electronic signature of person-centered planning documents. 4) The person-centered plan may be updated to allow for additional or modified supports to respond to individualized needs during the COVID-19 pandemic. Modifications to the person-centered plan that are needed due to recipient’s needs and circumstance may be completed without the input of the entire person-centered planning support team. The support plan, including the amount, duration and scope of service, will be updated within – 60 days from the date the service begins. Verbal approval or email approval of changes and additions to individual plans and services will suffice as authorization to begin services while awaiting the signed documents dated the date of the meeting to avoid delays that may occur due to staff working remotely. 5) Person-centered plans can be renewed for an additional 12 months if a meeting is held via phone, video-conferencing or other electronic communications and the recipient / recipient’s representative agree that current services are appropriate and do not need to be updated, and service providers agree to continue to render continued services. Electronic signature is allowed for approval of continued person-centered planning documents. Restriction of Visitors 1) Due to the nature of this public health emergency, the State is temporarily modifying 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.

Modify Incident Reporting/Med Management Safeguards

372 Reporting 1) Temporarily delay the submission deadline for the state’s 372 CMS Reports and quality reporting by up to 90 days but not to exceed the end date approved in the Appendix K to account for the resources necessary to address efforts to support waiver members during the pandemic.

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

Subject to prior authorization, it is permissible for waiver services to be delivered in an acute setting, to support the communication, intensive personal care and behavioral support needs as identified in the person-centered plan , when the service is distinct from what is provided by the Acute Setting provider. The Department will ensure no duplication of billing of performance activities through documentation of tasks provided and a waiver form completed by the acute setting staff attesting that specific tasks needed during the acute care hospital or short-term institutional stay cannot be done by the facility staff and that the participant may have a trained attendant complete the specific tasks.

Inclusion of Retainer Payments

N/A

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

Link to Approval Letter

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