Waiver Title
TBI (40199.R04.00)
Description of Emergency
1) Nature of emergency In December 2019, an outbreak of COVID-19 caused by a novel coronavirus began in Wuhan, China. As of March 2020, cases of COVID-19 have been detected in 90 locations internationally, including the US. On January 30, 2020, the World Health Organization (WHO) declared the outbreak a public health emergency of international concern, and on January 31, 2020, the US Health and Human Services Secretary declared a public health emergency in the US and on March 11, 2020, the World Health Organization has declared the coronavirus outbreak a pandemic. On March 6, 2020, the first confirmed case of COVID-19 was identified in Nebraska. People who are aged or disable are at higher risk of serious illness if they contract this virus, and the CDC has recommended that those at higher risk of serious illness take action to avoid contracting the virus, including avoiding crowds and staying home as much as possible. 2) Participants, providers, and their families are affected. As of March 6, 2020, Nebraska DHHS Division of Public Health and local public health departments have advised those who contacted the first person diagnosed with the virus to self-quarantine or follow the CDC guidelines for those who are aged or have disabilities for 14 calendar days. This waiver amendment is applicable to all participants at risk of exposure. Participants of the TBI waiver are at high risk of serious illness. 3) As of March 19, 2020 the 23rd case of COVID-19 was reported to DHHS. The second case through community contact was confirmed. Many assisted living facilities have closed their doors to visitors, schools have canceled classes, and the University of Nebraska will move to on-line education for the remainder of the semester. 4) Roles of state, local, and other entities involved in approved waiver operations are defined in Appendix A in section A-1 and 2. 5) Expected changes needed to the service delivery methods: For anyone affected by the potential outbreak of COVID-19, recommended closures, and quarantines due to potential exposure, or for those following the CDC guidelines for those who are aged or disabled, the Nebraska Department of Health and Human Services Division of Medicaid and Long Term Care will: • Allow the services in alternative sites to be authorized and delivered prior to updating the participant’s service plan; • Allow modifications to person-centered service planning; • Allow Assisted Living services to be provided in another Skilled Nursing Facility or Assisted Living Facility during a relocation while seeking a new residence, or waiting to return to their Assisted Living; • Provide for flexibility to raise rates. • Level of Care (LOC) assessments may be conducted by the telephone or by electronic means in accordance with HIPPA requirements. • Delay the annual Level of Care (LOC) re-assessment requirement, when the Service Coordinator cannot complete the re-assessment by phone or by electronic means in accordance with HIPPA requirements; • Allow for monthly contact to occur via telephone or other electronic means in accordance with HIPPA requirements; • Remove the requirement for quarterly face-to-face contact; • A reduction in non-essential transportation and community inclusion for participants residing at Assisted Living Facilities; • If AD Waiver services are not used during the time of the COVID-19 community response, the Service Coordination will continue and the individual will remain eligible for the TBI waiver unless the participant dies, moves, or request the case to close. The state is requesting immediate implementation to avoid any adverse effect on participants’ health and safety and providers’ capacity to deliver services. Affected participants will be allowed to receive waiver services modified as defined below until the need to close day sites, quarantine, or follow the CDC guidelines for people who are aged or disabled has passed. The projected timeline is from 3/6/2020 through 9/6/2020.
Waiver Description
Provides assisted living service for individuals w/brain injury ages 18-64
Start Date
End Date
Description of Transition Plan
N/A
Area(s) Affected
Area Affected
Community spread is expected to become statewide
Access and Eligibility
Increase Cost Limits
N/A
Modify Targeting Criteria
N/A
Services
Modify Scope or Coverage
Assisted Living Service,
Exceed Service Limitations
N/A
Add Services
N/A
Expand Settings
Assisted Living Facilities, services may be provided in another Skilled Nursing Facility or Assisted Living Facility during a relocation.
Provide Service Out of State
N/A
Allow Payment for Services by Families
N/A
Modify Provider Qualifications
Modification of Provider Qualifications
N/A
Modify Provider Types
N/A
Modify Licensure/Requirements for Waiver Settings
Staffing for Assisted Living Facilities that relocated to another facility may be provided by the temporary location to allow participant to receive services in a safe and accessible environment, as long as the participant’s needs are still being met. Allowed temporary locations include hotels, shelters, schools, churches, or local health department designated areas for displaced families. A reduction in non-essential transportation, community inclusion, and visitors will occur if the individual Assisted Living Facilities chose to limit these services to avoid risk of exposure to viruses. State settings initial and annual reviews for the HCBS Final Rule will be reviewed through a phone call with the administrator/director/owner and outcomes will be addressed via telephone, e-mail or mail. The on-site assessment will be scheduled with the setting when local or facility restrictions allow.
Modification LOC Eval and Re-Eval Processes
The initial Level of Care (LOC) assessments may be conducted by the telephone, or by electronic means in accordance with HIPAA requirements. The LOC will be reviewed upon the next available face to face evaluation to ensure the participant’s needs are correctly documented. The annual Level of Care (LOC) re-assessment requirements will be delayed for participants in which Service Coordinators cannot complete the re-assessment by phone, or electronic means in accordance with HIPAA requirements. The Service Coordinator will document, as applicable, the alternative method of completing the LOC re-assessment. The LOC will be reviewed upon the next face to face evaluation to ensure the participant’s needs are correctly documented. The LOC re-assessment will not be extended more than 9 months from the original due date. Additionally, the monthly contact will be allowed to occur via telephone or other electronic means in accordance with HIPAA requirements. The requirement for quarterly face-to-face contact will be removed.
Increase Payment Rates
During the emergency period and not to extend past the end date of this Appendix K amendment, there will be flexibility to raise rates not to exceed 15%
Modifications of ISP
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 verifications via secure email consent from service providers and the individual or representative, in accordance with the state’s HIPAA requirements. 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 care coordinator 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
N/A
Allow Payment for Services During Acute Care Hospital/Short Term Institutional Stay
In a scenario where the participant had to be relocated from an assisted living facility and was placed temporarily in a Hospital or Skilled Nursing Facility, but was not formally admitted as an institutional patient, assisted living waiver services may be provided in the institutional setting. Room and board is excluded. The Assisted Living Facilities have arrangements related to delivering services and billing practices to ensure services are still provided to the individuals in the temporary setting. A reduction in assistance with bathing and transportation is expected dependent on staffing levels.
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