New Hampshire – In Home Support (0397.R03.02); Developmental Disabilities (0053.R06.02); Acquired Brain Disorder (4177.R05.02); Choices for Independence (0060.R07.02 )

Waiver Title

In Home Support (0397.R03.02); Developmental Disabilities (0053.R06.02); Acquired Brain Disorder (4177.R05.02); Choices for Independence (0060.R07.02 )

Description of Emergency

1.) On January 31, 2020 the United States Secretary of Health and Human Services declared a public health emergency due to an outbreak of Coronavirus Disease 2019 (COVID-19). The President of the United States declared a national emergency due to COVID-19 on March 13, 2020. 2.) New Hampshire has confirmed an increasing number of cases of COVID-19 and as of April 29, 2020 has 2,054 confirmed cases with 66 deaths attributed to COVID-19. The people served through New Hampshire’s home and community based waivers may be particularly vulnerable to infection and resulting illness due to: (1) underlying health conditions; (2) reliance on support from others for activities of daily living; (3) deficits in adaptive functioning that inhibit ability to follow infection control procedures and readily adapt to extreme changes in daily living. The state has identified potential negative impact for people served by the waivers and for the providers that deliver services. 3.) The Division of Long Term Services and Supports (DLTSS) provides the oversight for the state’s four Home and Community Based Services (HCBS) 1915 (c) waivers that are managed programmatically through the Bureau of Developmental Services (BDS) and Bureau of Elderly and Adult Services (BEAS). The Division of Long Terms Supports and Services works with the Division of Medicaid Services (DMS) to ensure that New Hampshire’s Department of Health and Human Services is operating in accordance with the Center for Medicare and Medicaid Center (CMS). 4.) New Hampshire seeks temporary changes to the four 1915 (c) Home and Community Based Services (HCBS) waivers to accommodate potential issues with staffing shortages and the need for service provision outside of approved service descriptions to ensure that participant health and safety needs are addressed during the emergency. In addition, the state is looking at flexible options to ensure the stability of the HCBS system that has been firmly established as a cost effective option for participants, their families, and others engaged in care.

Waiver Description

In Home Supports for Children w/DD (0397.R03.00): Provides enhanced personal care, consultations, environmental and vehicle mods, family support/service coordination, respite care for individuals w/autism, ID, DD ages 0-21; Developmental Disabilities Waiver (0053.R06.00): Provides community participation services, residential habilitation/personal care services, respite, service coordination, supported employment, assistive technology support services, community support services (CSS), crisis response services, environmental and vehicle modification services, participant directed and managed services (PDMS) formerly consolidated developmental services, specialty services, wellness coaching for individuals w/autism, DD and ID from 0 – no max age; Acquired Brain Disorder Waiver (4177.R05.00): Provides community participation services, respite, service coordination, supported employment services, assistive technology support services, community support services (CSS), crisis response services, environmental and vehicle modification services, participant directed and managed services – PDMS (formerly consolidated acquired brain disorder services), residential habilitation/personal care services, specialty services, wellness coaching for individuals w/brain injury ages 22 – no max age; Choices for Independence Waiver (0060.R07.00): Provides adult medical day services, home health aide, homemaker, personal care, respite, supported employment, financial management services, adult family care, adult in-home services, community transition services, environmental accessibility services, home-delivered meals, non medical transportation, participant directed and managed services, personal emergency response system, residential care facility services, skilled nursing, specialized medical equipment services, supportive housing services for aged individuals ages 65 yrs – no max age and physically disabled and other disabilities ages 18-64

Start Date

01-03-20

End Date

28-02-21

Description of Transition Plan

Any temporary modifications made during the state of emergency will revert to original form when the declarations of emergency have been revoked and the threat of COVID-19 has ended. This transition will be implemented only after Medicaid providers have been given a minimum of five business days’ notice. In the event it is determined that this change may adversely affect a member, the member and his/her team, led by the case manager and/or service coordinator, will discuss the member’s needs and options available to meet those needs. Person centered planning is used in all phases of the service development process. In keeping with existing practices, individualized needs will be re-assessed on a case-by-case basis if any long term changes are required to an individual’s person centered plan once the state resumes standard program rules and policies for the 1915 (c) HCBS services.

Area(s) Affected

Area Affected

Statewide — These actions will apply to all individuals impacted by the COVID-19 virus across the state of New Hampshire.

Increase Cost Limits

IHS Waiver The state will increase the maximum cap of the In Home Support Waiver (IHS) to an upper limit of $33,000 according to state guidance issued by the Bureau of Developmental Services to allow for additional Respite and Enhanced Personal Care for those participants who were at the $30,000 cap at the time of the State of Emergency.

Modify Targeting Criteria

N/A

Modify Scope or Coverage

In Home Support: Respite Care Services; Developmental Disabilities Waiver: Respite; Residential Habilitation / Personal Care Services; Community Participation Services (CPS), Supported Employment Program (SEP), Community Support Services (CSS), Participant Directed and Managed Services (PDMS); Acquired Brain Disorder Waiver: Respite; Community Participation Services (CPS); Supported Employment Program (SEP); Acquired Brain Disorder Waiver: Community Support Services (CSS); Participant Directed and Managed Services (PDMS) formerly Consolidated Developmental Services; Choices for Independence Waiver for the Elderly and Chronically Ill – Respite; Adult Family Care; Residential Care Facility Services; Supportive Housing Services; Adult Day Health /Adult Medical Day; Supportive Housing Services; Home Delivered Meals.

Exceed Service Limitations

IHS Waiver The Department will permit temporary flexibilities as follows:  The respite cap of 15% of the total IHS budget will be removed even if it is outside of the participant’s approved budget or if the participant has already met the annual cap outlined in the Individual Service Agreement (ISA) to allow a participant’s family additional flexibility in obtaining supports to care for their family member during the COVID-19 crisis for emergency care provision. DD and ABD Waivers The Department will permit temporary flexibilities as follows:  The respite cap of 15% of the total Participant Directed and Managed Services (PDMS) budget will be removed to allow a participant’s family additional flexibility in obtaining supports to care for their family member.  Required staffing ratios for a participant, as outlined in their Individual Service Agreement, may be modified to allow the participant to receive services in safe and accessible environments, as long as the participant’s needs are still being met and guardian approval is documented. CFI Waiver The Department will permit temporary flexibilities as follows:  The respite cap of 30 days will be increased to 90 days. Respite services require prior authorization under CFI preventing duplicate billing for both HCBS and Institutional Care Services.  The limit for Community Transition Services may be increased, not to exceed a $2,500 upper limit, as needed. Community Transition Services are not being used to set up temporary isolation residences.

Add Services

N/A

Expand Settings

All Waivers Individuals that are moved into a facility based setting will continue to receive 1915(c) HCBS services and will not be admitted to the facility or receive services offered by that facility. During times of emergency declaration, the following services may be provided in a setting necessary to ensure the health and safety of participants. These settings may include hotel, motel, shelter, church, or any facility based setting which will not duplicate service regularly provided by the facility based setting. IHS, DD, and ABD Waivers Respite services (see above settings) IHS Waiver Consultation services (see above settings) may be provided using remote/telephonic support when this type of support meets the health and safety needs of the participant. Consultation Services include evaluation, training, mentoring, therapeutic recreation, assistive technology, and/or special instruction. DD and ABD Waivers Specialty Services (see above settings) are intended for recipients whose needs in the areas of medical, behavioral, therapeutic, health and personal well-being require services which are specialized pertaining to unique conditions and aspects of developmental disabilities. Specialty Services are utilized to provide assessments and consultations and are used to contribute to the design, development and provision of services, training support staff to provide appropriate supports as well as the evaluation of service outcomes. Residential Habilitation Services (see above settings) may be provided in uncertified and unlicensed homes upon the approval of the individual/guardian. Community Participation Services (see above settings) Community Support Services (see above settings) Supported Employment Services (see above settings)  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 may provide and bill those covered services using that delivery method. CFI Waiver During times of emergency declaration, homemaker services may be provided in Adult Family Care settings. Personal Care services may be provided in a setting necessary to ensure the health and safety of participants. These settings may include hotel, motel, shelter, church, or any facility based setting which will not duplicate service regularly provided by the facility based setting. Adult Medical Day services may also be temporarily provided in a home setting provided the method comports with Center for Disease Control (CDC) recommendations and that will ensure the health and welfare of the individuals served. These additional services will be documented in a schedule within the individual’s care plan and will require a prior authorization and will be billed separately Adult Medical Day Services may continue remotely through an enrolled provider that has suspended in-facility operations due to the COVID-19 emergency. Adult Medical Day Services providers may provide daily services and contacts to enrolled participants in the home environment through remote technology or in a method that is consistent with safety recommendations from the CDC or state to ensure the health and well-being of individuals. Allow Personal Emergency Response Services to be provided in Residential and Adult Family Care Settings.

Provide Service Out of State

N/A

Allow Payment for Services by Families

IHS, DD and ABD Waivers Enhanced Personal Care, Residential Habilitation, Community Participation Services (CPS), Community Support Services (CSS), Participant Directed and Managed Services (PDMS) and Supported Employment Services (SEP) may be rendered by relatives or legally responsible individuals when they have been hired or contracted by the service provider agency authorized on the Individual Service Agreement (ISA). Relatives and legally responsible individuals must receive training on the participant’s ISA for whom they are rendering these services. Training on the ISA must consist of basic health and safety support needs for that participant. When one of these services is rendered by relatives or legal guardians, the service provider agency authorized to render the service is responsible for ensuring that services are provided as authorized in the ISA and that billing occurs in accordance with waiver requirements.

Modification of Provider Qualifications

IHS, DD, and ABD Waivers In circumstances when there is a delay in obtaining driver and criminal record checks due to the COVID-19 emergency, accommodations will be made as follows during times of emergency declaration:  If the prospective staff has a background check on file with a different organization, which includes a criminal record check, driver record check, and Bureau of Elderly and Adult Services registry check, it may be transferrable to another agency regardless of how long ago it was conducted. Staff training is also transferable between agencies.  If the prospective staff is new and does not have a driver or criminal record check on file, the agency must obtain a self-attestation from the applicant that the applicant meets the requirements outlined in rules relative to background checks.  The agency must still submit a request for the required background checks prior to hiring and in the meantime, a 90-day extension will be granted to obtain these documents and have them on file for all new staff. Where the extension of provider qualifications falls outside of the Appendix K the state will submit either an amended Appendix K or a simple waiver technical amendment. If an employee does not pass the background check once the state resumes conducting background checks, the provider agency will submit a waiver request which will be reviewed by the state and receive a waiver if appropriate, or the employee will be terminated. Additional accommodations include:  TB testing requirements will be suspended for up to 60 days to reduce the burden on the healthcare system and reduce exposure of new employees to environments where sick people are present.  Allow for existing med-trained staff to continue to administer medications for up to 90 days, when their re-certification has lapsed with documented nursing approval.  Non-individual specific provider training requirements outlined in rules will be extended from 60 to 90 days. Each Service Affected  All Services in all HCBS waivers are affected. Each Provider Type  Any provider that is providing direct support.

Modify Provider Types

N/A

Modify Licensure/Requirements for Waiver Settings

DD and ABD Waivers When necessary, suspend provider certification or licensing requirements for residential and community participation service providers when COVID-19 pandemic affects the ability for providers to obtain license or certification due to state staff or service provider availability. Providers have 90 days to come into compliance with certification requirements at the end of the Covid-19 Emergency. Certification or licensing requirements will not apply to services that are delivered as an emergency alternative to the certified or licensed setting. Community Participation Services:  The certification requirement to provide services in community locations is suspended. CPS will be allowed to be provided in residential settings as an alternative to the community. CFI Waiver Adult Family Care:  The certification requirement that indicates that the maximum number of individuals served in a service location (licensed or certified) may be exceeded to address staffing shortages or accommodate use of other sites as quarantine sites.

Modification LOC Eval and Re-Eval Processes

All Waivers Level of Care (LOC) re-evaluation can be extended for 12 months. IHS, DD, and ABD Waivers Delay Support Intensity Scale Assessments (SIS) reassessment for up to 12 months.

Increase Payment Rates

N/A

Modifications of ISP

All Waivers Service coordination/case management planning may also be conducted remotely through telephonic support or with other remote service access technology if the parties are able in accordance with HIPAA. If requested and/or necessary, modifications to a person-centered plan may be made, as driven by individualized participant need, circumstance and consent on an individualized basis. An electronic signature will be accepted. A phone call or text may be used for individual/legal guardian approval, but it must be followed with electronic email or paper documentation dated and/or signed on the date the change is authorized. The process to monitor services are delivered as specified in the service agreement/plan of care will continue as outlined in the approved waiver, with the exception of in-person contact. Remote contact may replace in person contact. IHS, DD, and ABD Waivers Service coordination staff will monitor the services through a minimum of monthly contact. CFI Waiver Case Management staff will monitor the services through a minimum weekly contact.

Modify Incident Reporting/Med Management Safeguards

COVID-19 related deaths are considered “unanticipated deaths” for the purpose of sentinel event reporting for individuals receiving DHHS funded services captured in the Sentinel Event Reporting Policy PO.1003. The following updates are for agencies reporting sentinel events to assist with administrative burden in completion of written reporting forms:  During the COVID-19 pandemic, Bureau of Program Quality (BPQ) is waiving the 72-hour written notification requirement and instituting a 7-calendar day timeframe for the completion and uploading of the Sentinel Event Reporting Form. The 24-hour verbal notification to the appropriate DHHS Bureau Administrator or designee remains in effect.  On the reporting form, for those events that are believed to be COVID-19 related, in Section III, Sentinel Event Details, #13a, please start the description with a header of “COVID-19 Related”. IHS, DD, and ABD Waivers A remote / electronic option for medication administration certification will be made available to provider agencies. The Bureau of Developmental Services will track all positive COVID-19 results for waiver participants as reported by Area Agencies. State certification survey staff are, on a case-by-case basis, postponing agency certification reviews for those agencies impacted for residential and day service settings, which is defined as Habilitative Workshops, extended family homes, and congregate residential habilitation settings until the area is no longer in a state of emergency. If a temporary service site is identified for a certification review, as long as the site is deemed safe and sensible for the service being provided and there is no non-compliance with regulations that could reasonably be complied with, the site will be determined to be in compliance with certification requirements. CFI Waiver The Bureau of Elderly and Adult Services will track all positive COVID-19 results for waiver participants as reported by Independent Case Management Agencies.

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

All Waivers Participants that require hospitalization may receive temporary HCBS waiver services in a hospital setting where the participant requires these services for communication, behavioral stabilization and/or intensive personal care support needs. The services that apply include:  Residential Habilitation  Enhanced Personal Care  Home Health Aide HCBS services may be delivered in an acute care hospital if: 1) They are part of a plan of care; 2) They meet needs of the individual that are not addressed by hospital services; 3) They do not substitute services that the hospital is required to provide; and 4) They are designed to provide smooth transitions to home and community-based settings and to preserve functionality.

Inclusion of Retainer Payments

All Waivers In response to the defined emergency, the state may elect to make retainer payments to waiver service providers. Retainer payments may be allowed for habilitation, that include a personal care component, and/or personal care services (e.g. assistance with activities of daily living) to ensure continuous operations and sustainability of waiver services. Retainer payments may only be provided in circumstances in which service closures are necessary due to COVID-19 containment efforts and after any therapeutic leave has been exhausted, provided there are not duplicative payments for the same service. The retainer time limit may not exceed the lesser of 30 consecutive business days or the number of bed hold days the state specifies in its institutional bed hold policy in its state plan. In addition, retainer payments may only be paid to providers with treatment relationships to beneficiaries that existed at the time the PHE was declared and who continues to bill for personal care services or habilitation, services as though they were still providing these services to those beneficiaries in their absence. The retainer payments may not exceed the approved rate(s) or average expenditure amounts paid during the previous quarter for the service(s) that would have been provided. State confirms that retainer payments are for direct care providers who normally provide services that include habilitation, that include a personal care component, and/or personal care services, but are currently unable to due to complications experienced during the COVID-19 pandemic because the waiver participant is sick due to COVID-19; or the waiver participant is sequestered and/or quarantined based on local, state, federal and/or medical requirements/orders. The state will implement a distinguishable process to monitor payments to avoid duplication of billing.

Institute/Expand Opportunities for Self-Direction

N/A

Increase Factor C

N/A

Other Changes Necessary

The state will adapt data collection and reporting for waiver assurances and sub-assurances accordingly during the emergency. Due to the COVID-19 Emergency, agency certification review data may be unavailable and temporary service site data may not be in compliance with certification requirements. The timeframes for the submission of the CMS 372s and the evidentiary package(s) will be extended for up to one year 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

service coordination, personal care services that only require verbal cueing, residential habilitation, Community support services, supported employment, participant directed and managed services, monthly monitoring; other: consultation services & specialty services

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

The state will adapt data collection and reporting for waiver assurances and sub-assurances accordingly during the emergency. Due to the COVID-19 Emergency, agency certification review data may be unavailable and temporary service site data may not be in compliance with certification requirements. The timeframes for the submission of the CMS 372s and the evidentiary package(s) will be extended for up to one year 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

The state will adapt data collection and reporting for waiver assurances and sub-assurances accordingly during the emergency. Due to the COVID-19 Emergency, agency certification review data may be unavailable and temporary service site data may not be in compliance with certification requirements. The timeframes for the submission of the CMS 372s and the evidentiary package(s) will be extended for up to one year 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

X

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

N/A

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

Link to Approval Letter

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