North Carolina – Community Alternatives Program for Children (4141.R06.00)

Waiver Title

Community Alternatives Program for Children (4141.R06.00)

Description of Emergency

On January 31, 2020, Secretary Azar used his authority pursuant to Section 318 of the Public Health Services Act to declare a public health emergency (PHE) in the entire United States. On March 11, 2020, as authorized under Title V of the Stafford Act, President Donald J. Trump announced the World Health Organization officially announced that novel coronavirus (COVID-19) is a global pandemic. As authorized under Section 1135 of the Social Security Act, North Carolina is respectfully requesting waivers of certain Medicaid and CHIP requirements to ensure continuity of care and to make it easier for health care providers to deliver Medicaid services while protecting the health, safety and well-being of waiver participants at risk of or impacted by COVID-19 because of their higher risk of severe illness. 2) number of individuals affected and the State’s mechanism to identify individuals at risk There are currently 2,720 CAP/C waiver participants being served across the State of North Carolina. Potentially, all those participants are affected by novel coronavirus (COVID-19) outbreak due to their higher risk of severe illness and the potential to spread. To facilitate access for waiver participant experiencing COVID symptoms and to limit close contact of other individuals experiencing COVID symptoms, it is important to take actions to reduce the risk of exposure of the virus to these medically fragile children and make it easier for health care providers to deliver Medicaid services. To identify at-risk waiver participants, the State will identify all enrolled waiver participants by an active service plan. A communication notice will be provided to all actively enrolled waiver participants and their assigned case managers informing them of higher risk of severe illness and the potential of spread. The case manager will assist each waiver participant to create a COVID19 emergency plan that will consist of the following elements: health care needs of the waiver participant and family members; how waiver participant or caregivers will be cared for if services were not able to be provided; identification of resources in the community to assist with COVID-19; update to emergency contact list; identification of a safe zone in the home to separate sick individuals from non-sick individuals; plan to obtain prescriptions and food and identification of a plan if the “family’s routine day” is altered due to school closures or workplace changes. The State is requesting the waiving of service limits as described in Appendix C-1/C-3; the ability to offer retainer payments to in-home aide agencies and direct service providers to promote continuity of care; and the ability to conduct initial and annual level of care and reasonable indication of need assessments telephonically. 3) roles of state, local and other entities involved in approved waiver operations; and • NC Medicaid is administrator and overseer of waiver operations and functions; assigned case management entities provide day-to-day oversight to waiver beneficiaries through case management. • Area case management entities complete assessments, plans of care, make service authorization requests and approvals. Case Management entity staff conduct safety and welfare checks. • VieBridge/eCAP is the system by which assessments are completed, POCs developed, and reviews/service authorizations conducted. This system transfers authorizations to prior approvals and forward to the MMIS for reimbursement for services rendered. • NC Tracks is the state’s MMIS which provides for reimbursement to providers of services rendered 4) expected changes needed to service delivery methods, if applicable. The State should provide this information for each emergency checked if those emergencies affect different geographic areas and require different changes to the waiver.

Start Date

13-03-20

End Date

12-03-21

Description of Transition Plan

Waiver participants who qualify for waiving of Appendix C-1/C-3 and other waiver rules and requirements because of COVID-19 will be monitored monthly through the duration of this pandemic to ensure health, safety and well-being and linkage to the most appropriate services and care regiment. When the pandemic is resolved, the assigned case managers will conduct a face-to-face home visit to fully assess needs to assure the accuracy of the service plan.

Area(s) Affected

Area Affected

Statewide – 100 counties of North Carolina

Increase Cost Limits

Exceed cost limit of $129,000 per waiver entry and annual assessment years, however, ensuring the waiver year cost neutrality in the aggregate.

Modify Targeting Criteria

Waiver participant does not have to use planned waiver services in the amount, frequency and duration listed in the plan of care during the period of this amendment and will not be subjected to discharge due to an inability to access services because of COVID-19.

Modify Scope or Coverage

N/A

Exceed Service Limitations

Modification of service identified in Appendix C-1/C-3 in scope and coverage to allow flexibilities of the utilization to prevent spread and to best manage the health, safety and well-being of waiver participant. Services that are proposed to be modified: 1. Case management – only monthly telephonic contact with waiver participant and quarterly telephonic contact with service providers to monitor COVID-19 service plan which will be conducted in accordance with HIPAA requirements. Availability of initial and annual telephonic assessment of level of care and reasonable indication of need which will be conducted in accordance with HIPAA requirements. 2. Participant goods and services – coverage of sanitation (disinfectant) wipes, hand sanitizer and disinfectant spray, when they are not provided in the state plan, for CNAs or personal assistants who can continue to render in-home, pediatric and nurse care to waiver participant. The coverage of facial tissue, thermometer and specific colored trash liners to distinguish dirty linen of infected household member to prevent spread when they are not provided in the state plan. The coverage of over-the counter prescription medication and supplements for the management of COVID-19 or the prevention of. 3. Training/Education/Consultative Services – coverage of training to the paid worker on PPE and other identified training needs specific to the care needs of waiver participant to prevent the spread of COVID-19 when trainings are not provided in the state plan. 4. In-home care, pediatric nurse aide, personal care assistance and congregate – services are not required to be used on a monthly basis or directly rendered per the amount, frequency and duration as approved in the service plan but not less than what is approved in the service plan. In-home care, pediatric nurse aide, personal care assistance and congregate – coverage of payment to a non-live-in close relative and legally responsible person for waiver participant whose hired worker is not able to render the service because of impact from COVID-19. 5. Community Transition – coverage of a less than 90-day institutionalized Medicaid beneficiary experiencing COVID-19 symptoms who can safely transition to a home and community-based placement using HCBS services. 6. Home accessibility and adaptation – the coverage of germicidal air filters when they are not provided in the state plan. Allowances for expansions of approved waiver services that exceed individual service limitations identified in Appendix C-1/C-3. Based on assessed needs of waiver participant who is experiencing COVID-19 symptoms, the following limits may be exceeded: 1. Home accessibility and adaptation –exceed the service limit of $28,000.00 waiver limit 2. Case management units – additional monthly reimbursement of case management time to manage needs of waiver participant experiencing COVID-19 symptoms to ensure linkage to resources needed for this vulnerable population. 3. Participant goods and services –exceed the $800.00 fiscal limit 4. Assistive technology – exceed the $28,000.00 waiver limit 5. Training/Education/Consultative Services – exceed $500.00 fiscal limit 6. Respite – exceed the 720 in -home respite hours per fiscal year for in-home and coverage of 30 or more days in an institutional. 7. In-home care, pediatric nurse aide, personal care assistance and congregate hours may be increased over the person-centered approvable utilization limits when waiver participant or family member is impacted by COVID-19 due to a change in school attendance, work hours or family status changes.

Add Services

Case management; Participant goods and services; Training, Education and Consultative Services; In-Home Care Aide Service; Pediatric Nurse Aide Services; Institutional and Non-Institutional Respite; Home Accessibility and Adaptation; Community Transition; Financial Management Services

Expand Settings

Services of in-home aide, pediatric nurse aide, congregate care, personal care assistance and respite may be provided in a hotel, shelter, church, or facility-based setting when the waiver participant is displaced from the home because of COVID-19 will not duplicate services regularly provided by facility-based settings. A portable ramp or equipment may be approved to assist with transfers and mobility to allow ease of access in the temporary setting.

Provide Service Out of State

Services of in-home aide, pediatric nurse aide, congregate care, personal care assistance and respite may be provided in a hotel, shelter, church, or any facility-based setting which will not duplicate services regularly provided by facility-based settings outside of North Carolina when the participant is displaced from home because of the COVID-19, and an telephonic assessment which will be conducted in accordance with HIPAA requirements attests that services are required, the provider is qualified and the setting is safe. The case manager will complete the telephonic assessment. An out of state provider agreement will be implemented when services are approved to be provided out of state. A portable ramp or equipment may be approved to assist with transfers and mobility to allow ease of access to setting.

Allow Payment for Services by Families

The coverage of payment of hands on personal care, in-home aide, pediatric nurse aide, congregate and personal care assistant services, for a live-in family member, legally responsible person or close kinship.

Modification of Provider Qualifications

During the pandemic, when live-in family member, legally responsible person or close kinship relative are approved to render services of in-home aide, pediatric nurse care, personal care assistant and congregate, a registry check, statewide criminal background check, competency validation, and consumer direction training overview, particularly fraud, waste and abuse, abuse, neglect and exploitation, critical incident reporting and the enrollment in consumer direction are required. The waiving of the CPR certification upon enrollment will be implemented for a live-in relative, legally responsible person or a kinship relative, and a plan to obtain the CPR certification must be identified within 30 days. When a legally responsible person, live-in family member or a close kinship relative is approved to be the paid caregiver and there are criminal findings on the background check, criminal offenses occurring more than 10 years previous to the date of the criminal report may qualify for an exemption when the exemption does not violate Medicaid guidelines. The financial manager shall inform the CAP case manager when a legally responsible person, live-in family member or a close kinship relative is within the 10-year rule and the CAP beneficiary or the CAP case manager/NC Medicaid shall have the autonomy to approve the exemption. This exemption is consistent with the current criminal background policy guidelines. Payment to a legally responsible person to provide in-home aide, pediatric nurse aide or congregate services to a CAP/C beneficiary may be made when any one of the following extraordinary circumstances is met: a. There are no available certified nursing assistants (CNAs) or personal care assistants in the CAP/C beneficiary’s county or adjunct counties through a Home Health Agency, In-Home Aide Agency or under consumer direction due to the impact of COVID19, and the CAP/C beneficiary needs extensive to maximal assistance with bathing, dressing, toileting and eating daily to prevent an out-of-home placement. b. The CAP/C beneficiary requires short-term isolation, 90-days or less, due to experiencing symptoms of COVID-19 and extensive to maximal assistance with bathing, dressing, toileting and eating, and the CAP/C beneficiary chooses to receive care in his or her home instead of an institution. c. The CAP/C beneficiary requires physician-ordered 24-hour direct observation and, or supervision specifically related to symptoms of COVID-19 and the legally responsible person is not able to maintain full or part-time employment due to multiple absences from work to monitor and, or supervise the CAP/C beneficiary; regular interruption at work to assist with the management of the CAP/C beneficiary’s monitoring or supervision needs; or an employment termination. d. The CAP/C beneficiary has specialized health care needs specific to COVID -19 that can be only provided by the legally responsible person, as indicated by medical documentation, and these health care needs require extensive to maximal assistance with bathing, dressing, toileting and eating to assure the health and welfare of the beneficiary and avoid institutionalization. e. Other documented extraordinary circumstances not previously mentioned that places the CAP/C beneficiary’s health, safety and well-being in jeopardy resulting in an institutional placement that are directly related to COVID-19. The below assurances are implemented: 1. When a live-in family member, legally responsible person or close kinship is authorized to receive payment for providing personal assistance services, the CAP/C beneficiary is temporarily enrolled in the consumer-direction program. The enrollment in this service will provide quality assurance of the health, safety and well-being of the CAP/C beneficiary and provides the controls to ensure that payments are made only for the services authorized to provide. 2. The assigned Case Management Entity (CME) shall monitor the CAP/C beneficiary closely to ensure the services are provided according to the service plan and the waiver participation business requirements are met. Weekly monitoring visits will be conducted telephonically. 3. The COVID-19 Care Management Plan must be completed and fully describes the ability of the caregiver to function in that role. 4. A competency skill checklist must be completed on live-in family member, legally responsible person or close kinship to identify ability and any training needs. 5. A training will be provided in fraud, waste and abuse 6. A training will be provided on critical incident reporting and management 7. A training will be provided in abuse, neglect and exploitation

Modify Provider Types

N/A

Modify Licensure/Requirements for Waiver Settings

N/A

Modification LOC Eval and Re-Eval Processes

The initial level of care assessments may be performed telephonically in addition to the in-person assessments and must be completed within the established timelines. The annual reassessment and change of status assessments may be performed telephonically. The timelines to complete the annual reassessment may be extended for up to 60 calendar days. Telephonic service plan approvals include an electronic signature when in accordance with HIPAA requirements.

Increase Payment Rates

N/A

Modifications of ISP

Service plans may be developed and approved telephonically which will be conducted in accordance with HIPAA requirements. Approved service plans shall be monitored telephonically which will be conducted in accordance with HIPAA requirements by the case manager, monthly. A quarterly telephonic contact which will be conducted in accordance with HIPAA requirements to service providers to monitor COVID-19 service plans and approved service modifications. Telephonic service plan approvals include an electronic signature when in accordance with HIPAA requirements. The approved services listed on the service plan in the amount, frequency and duration will continue to be approved through waiver service authorization updates. Prior approval segments will be transmitted to the MMIS for claims adjudication.

Modify Incident Reporting/Med Management Safeguards

N/A

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

Necessary supports including communication and personal care available through inhome aide, personal care assistance and congregate care may be provided in a hospital, rehabilitation facility, or short-term institution when the waiver participant is displaced from home because of COVID-19 and such supports are not otherwise available in these settings. Supplemental services provided in the hospital or other institutional placement can only be provided for up to 30 consecutive days. There may be more than one 30 consecutive day period.

Inclusion of Retainer Payments

Authorize payment to direct care workers (providers of personal care services) in the amount, frequency and duration as listed on the currently approved service plan when a waiver participant or hired worker is directly impacted by COVID-19 not to exceed a 30- day consecutive authorization period. If nursing facility has a bed hold that is less than 30 days, the retainer payment will not exceed that amount. Retainer payments are for direct care providers who normally provide services that include habilitation and personal care, 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. 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 extension of NC.4141.R06.04 Evidentiary Report through August 30, 2020.

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

The extension of NC.4141.R06.04 Evidentiary Report through August 30, 2020.

Other Changes Necessary

The extension of NC.4141.R06.04 Evidentiary Report through August 30, 2020.

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/nc-4141-appendix-k-appvl.pdf

Link to Approval Letter

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