Tennessee – TN Statewide Home and Community Based Services Waiver (0128.R06.00); Comprehensive Aggregate Cap Home and Community Based Services (CAC) (0357.R04.00); Self-Determination Waiver Program (0427.R03.00)

Waiver Title

TN Statewide Home and Community Based Services Waiver (0128.R06.00); Comprehensive Aggregate Cap Home and Community Based Services (CAC) (0357.R04.00); Self-Determination Waiver Program (0427.R03.00)

Description of Emergency

1) Nature of emergency : This Appendix K submission pertains to the COVID-19 pandemic. Tennessee Governor Bill Lee TN Governor issued Executive Order 14 declaring a State of Emergency to facilitate COVID-19 response on March 12, 2020, one day after the World Health Organization officially characterized COVID-19 as a “pandemic” and one day before the declaration of a national emergency by President Trump. 2) Number of individuals affected and the state’s mechanism to identify individuals at risk This amendment will apply to each of the Section 1915(c) waivers identified above and to all of the approximately 7,150 participants enrolled in these waivers. The COVID-19 emergency poses a unique risk to individuals with Intellectual and Developmental Disabilities (I/DD) served in these programs 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 social distancing guidelines and infection control procedures; and (4) receipt of care in shared living arrangements. In addition, many have underlying lung disease, other serious conditions, or are immuno-compromised – which places them at high risk of infection and complications if exposed to COVID-19. To date, there have been eight (8) confirmed positive COVID-19 cases among the participants in these waivers. 3) Roles of state, local and other entities involved in approved waiver operations Appendix K has been developed and upon approval, will be implemented by TennCare, the Medical Assistance Unit within the Department of Finance and Administration, in collaboration with the Department of Intellectual and Developmental Disabilities, the Operating Agency for these waivers. Upon approval, TennCare will exercise administrative authority and work in partnership with DIDD to determine if and how each of the approved waivers will be implemented in order to assure the health and welfare of waiver participants, and to assure financial accountability and continuity of services and program operations. 4) Expected changes to service delivery methods, if applicable The requested changes will help to reduce potential risk of exposure and spread of COVID-19 among waiver participants and allow flexibility and support for waiver service providers to accommodate the continued provision of services during the emergency and to ensure stability of the provider network to continue services after the emergency, in order to ensure participants’ health, safety and welfare.

Waiver Description

TN Statewide Home and Community Based Services Waiver (0128.R06.00): Provides residential habilitation, respite, support coordination, nursing services, nutrition services, occupational therapy, physical therapy, specialized medical equipment and supplies and assistive technology, speech, language, and hearing services, adult dental services, behavior services, behavioral respite services, community participation supports, environmental accessibility modifications, facility-based day supports, family model residential support, individual transportation services, intermittent employment and community integration wrap-around supports, medical residential services, non-residential homebound support services, orientation and mobility services for impaired vision, personal assistance, personal emergency response systems, semi-independent living, supported employment – individual employment support, supported employment – small group employment support, supported living, transitional case management for individuals with DD ages 0 – 5, and w/IID ages 0 – no max age. Comprehensive Aggregate Cap Home and Community Based Services (CAC) (0357.R04.00): Provides residential habilitation, respite, support coordination, nursing services, nutrition services, occupational therapy, physical therapy, specialized medical equipment and supplies and assistive technology, speech, language, and hearing services, behavior services, behavioral respite services, community participation supports, dental services, environmental accessibility modifications, facility-based day supports, family model residential support, individual transportation services, intermittent employment and community integration wrap-around supports, medical residential services, non-residential homebound support services, orientation and mobility services for impaired vision, personal assistance, personal emergency response system, semi-independent living, supported employment – individual employment support, supported employment – small group employment support, supported living, transitional case management for individuals w/ID ages 0 – no max age. Self-Determination Waiver Program (0427.R03.00): Provides respite, nursing services, nutrition services, occupational therapy, physical therapy, specialized medical equipment and supplies and assistive technology, speech, language, and hearing services, adult dental services, behavior services, behavioral respite services, community participation supports, employment and day services, environmental accessibility modifications, facility-based day supports, individual transportation services, intermittent employment and community integration wrap-around, non-residential homebound support services, orientation and mobility services for impaired vision, personal assistance, personal emergency response systems, semi-independent living services, supported employment – individual employment support, supported employment – small group employment support for individuals w/ID ages 0 – no max age and DD ages 0-5.

Start Date

13-03-20

End Date

12-03-21

Description of Transition Plan

These temporary flexibilities will be implemented as determined by TennCare, working in collaboration with DIDD, to be needed during the COVID-19 emergency and for the most part, discontinued as the risk of exposure and spread of COVID-19 are reduced, and as providers are able to safely resume provision of services as described in the currently approved waiver applications. With regard to the expanded scope of services for Specialized Medical Equipment and Supplies and Assistive Technology to encompass Enabling Technology, we plan to file an amendment to each of these waivers that will provide for the continuation of this service once the period covered by Appendix K has concluded.

Area(s) Affected

Area Affected

Each of these waivers and the populations they serve are statewide, as is the impact of the COVID-19 emergency.

Increase Cost Limits

Applicable only to the Statewide Home and Community Based Services (or “Statewide”) waiver (TN-0128.R06.01) and the Tennessee Self-Determination Waiver Program (TN-0427.R03.03), the COVID+ Residential Special Needs Adjustment (RSNA) and Personal Care Rate Differential (PCRD) shall not be counted against a person supported’s individual cost cap for purposes of determining continued eligibility for the program. A person enrolled in the Statewide waiver (TN-0128.R06.01) or the Tennessee Self-Determination Waiver Program (TN-0427.R03.03) shall not be dis-enrolled if the sole reason the individual cost limit would be exceeded is the temporary rate increases as described in this appendix pertaining to the COVID-19 emergency. Persons supported shall be permitted to exceed the cost limit in order to continue receiving the same type and amount of services before the temporary reimbursement changes went into effect. Except as provided in this section, all other policies applying to the individual cost limit in the Statewide and Self-Determination Waivers shall continue to apply.

Modify Targeting Criteria

N/A

Modify Scope or Coverage

Specialized Medical Equipment and Supplies and Assistive Technology; Semi-Independent Living; Residential Habilitation – Statewide (TN.0128) and CAC (TN.0357) Waivers only; Support Coordination – Statewide (TN.0128) and CAC (TN.0357) Waivers only; Nutrition Services; Occupational Therapy; Physical Therapy; Speech, Language, and Hearing Services; Behavior Services; Family Model Residential Support – Statewide (TN.0128) and CAC (TN.0357)
Waivers only; Medical Residential Services – Statewide (TN.0128) and CAC (TN.0357) Waivers only; Non-Residential Homebound Support Services; Orientation and Mobility Services for Impaired Vision; Personal Assistance; Supported Living – Statewide (TN.0128) and CAC (TN.0357) Waivers only;

Exceed Service Limitations

N/A

Add Services

N/A

Expand Settings

Residential habilitation services (i.e., Supported Living, Residential Habilitation, Medical Residential Services, and Family Model Residential), Semi-Independent Living, Personal Assistance, and any other supportive services a person might otherwise receive in the setting where they live (including therapies) may be temporarily provided in alternative community-based settings or locations when necessary to minimize risk of COVID-19 exposure or spread. Alternative settings may include previously utilized, larger Residential Habilitation dwellings (group homes). There are several of these homes available across the state that we have tentatively planned for use during cases of potential cluster infection or for isolation as needed. This will allow us to continue supports in community settings and avoid institutional placement, while also minimizing the risk of further spread. Additionally, we have contemplated isolation supports in the homes of asymptomatic COVID positive staff who are also supporting persons with a positive diagnosis, and have received offers of availability of space in local churches and community centers as needed. Utilization of any alternative support location would be under emergency pretense, only because the individual has been displaced due to the COVID-19 emergency. This could include the need for isolation supports due to COVID-19 diagnosis or, potentially, agency or network viability concerns. In the event the need for emergency support provision in an alternative location occurs, requirement of notification to the Department of Intellectual and Developmental Disabilities (DIDD), at both a Regional Office and Central Office level, has been mandated. This notification must include the physical address of the proposed location, affirmation that all required and approved services can be executed from the proposed location and an attestation as to the physical appropriateness of the dwelling respective to the needs of the proposed recipient of services. Previous to the implementation of services in any alternative location, approval from the DIDD must be provided. To the extent that is available during these crisis situations, any required clinical assessment process will be provided in the alternative location, previous to move, if possible but post move if necessary. As was previously indicated, any decision to provide services in an alternative location will be based on the emergence of a crisis related directly to the health and safety of the person supported.

Provide Service Out of State

N/A

Allow Payment for Services by Families

N/A

Modification of Provider Qualifications

Training and qualification changes affect all services provided under the Waivers that include direct assistance to persons supported. The provider type pertaining to these changes is the Waiver Service Provider. To ensure the onboarding of adequate staffing resources, effective March 13, 2020, during the COVID-19 emergency, the State may modify certain provider training and hiring requirements—specifically those related to training requirements and background checks. These are monitored as part of the State’s Quality Improvement Strategy. Training is divided into two parts: 1) “Pre-Service” training which must be completed within 30 days of hire and before a person can begin to provide services without another staff or supervisor present; and 2) additional training which must be completed within 60 days of hire (but after the person has begun working). During the PHE, the State wishes to extend the 30-day period to complete pre-service training; however, newly hired staff would still not be permitted to work alone until the pre-service training is completed. Also during the PHE, the State wishes to extend the 60-day period for completion of additional training to up to 120 days from date of hire. In addition, as it relates to training, additional time may be permitted for renewing CPR and First Aid Certifications from the American Heart Association (AHA), American Red Cross (ARC), and American Health and Safety Institute (ASHI/HSI), or alternative certifications may be accepted. Medication administration certifications that expire may be extended to allow additional time for certification renewal. Medication administration class to be taught via webinar. As it relates to background checks, during the PHE, the State is no longer able to complete background checks due to court closures. Pursuant to the Governor’s Executive Order, statutory requirements pertaining to these checks are temporarily waived. Once the PHE is concluded, providers will have 90 days to submit a background check for any employee for whom one has not been completed. However, providers will still be required to perform the following checks prior to a staff person providing support: Tennessee Department of Health Elderly and Vulnerable Abuse Registry; Tennessee Felony Offender List (FOIL); The Tennessee Sexual Offender Registry; Office of Inspector General List of Excluded Individuals and Entities (LEIE). The complete background check must still be completed once the availability of such dispositions resumes, but will not delay the person’s ability to begin providing services in light of current staffing demands and shortages. Once the background check is completed, an employee that does not pass the background check will be terminated in accordance with current policy. Based on the registry checks that are still required to be performed, the State does not anticipate that this will occur in many cases.

Modify Provider Types

N/A

Modify Licensure/Requirements for Waiver Settings

Applicable across all three waivers covered by this Appendix K and for all providers of service that require life safety and environmental inspections, licenses which have not received a licensure survey will be placed in “Extended Status” until such time as surveys can be completed. An extension letter will be emailed to each licensee when a license is placed in “Extended Status”. Licensure surveys will resume once it is safe to do so in accordance with social distancing expectations. All licenses in “Extended Status” will be completed within six (6) months thereafter. Risk Management visits to provider agencies have also been suspended, though auditors are available to make visits for any urgent situations which may arise. Risk Management Surveys will also resume once it is safe to do so in accordance with social distancing expectations. For both licensure surveys and risk management visits, where the extension of the waiver of provider determinations falls outside of the expiration date of the Appendix K, the state will submit either an amended Appendix K or a simple waiver amendment.

Modification LOC Eval and Re-Eval Processes

During the period of the COVID-19 emergency, level of care evaluations or re-evaluations may be conducted remotely.

Increase Payment Rates

HCBS providers are facing severe hardships and without quick financial assistance, some are at risk of closure placing the adequacy of the provider networks in jeopardy. HCBS providers support some of the state’s most vulnerable populations. Medicaid is the most significant revenue source for HCBS providers. Most HCBS providers are not well-capitalized and depend on regular cash flow to meet payroll and day-to-day operating expenses. Certain HCBS providers have been most significantly impacted by the COVID-19 emergency—both in terms of reduced revenues and increased costs of service delivery, including staffing and PPE, regardless of whether any of the persons supported by the provider are confirmed COVID-19 positive. These are providers who deliver in-home support, including residential, personal assistance, and nursing services. These providers are experiencing additional staffing and overtime costs (as staff are not available to provide care due to childcare concerns, illnesses, etc.) and PPE costs. The intent of these rate increases is to help offset increased staffing, PPE, and other costs related to the COVID-19 pandemic that all providers in these groups are experiencing, and to help ensure the sustainability of the HCBS workforce and provider network. Residential and personal assistance services are mutually exclusive. A person cannot be authorized to receive both types of service. Nursing is a distinct service provided by a licensed nurse, but may be provided to a person receiving either residential or personal assistance services when the person has skilled nursing needs that can only be performed by a licensed nurse. Except for Medical Residential Services (where nursing is a component of the service specification), nursing services are delivered by a different person (a licensed nurse) and billed separately from any residential or personal assistance service the person might receive. 10% and 30% rate increases (described below) are effective beginning dates of service March 13, 2020 for a two-month period (3/13/20 – 5/12/20). A 10% temporary rate increase for residential services: Semi-Independent Living Services Supported Living (TN.0128, TN.0357 only); Residential Habilitation (TN.0128, TN.0357 only); Family Model Residential (TN.0128, TN.0357 only)Medical Residential (TN.0128, TN.0357 only); Behavioral Respite (TN.0128, TN.0357 only) A 30% temporary rate increase for Personal Assistance and Nursing Services: 30% rate increase for Personal Assistance aligns with CHOICES Personal Care and ECF CHOICES Personal Assistance; 30% rate increase for Nursing Services aligns with market rate in light of increased demand. 20% of the 30% increase is needed to equalize the Personal Assistance rate with the rate being paid for Personal Care Visits in the CHOICES MLTSS program and Personal Assistance in the ECF CHOICES MLTSS program. This allows agencies serving individuals with I/DD in the 1915(c) waivers to offer a more competitive wage as needed to hire staff during the COVID pandemic. 20% of the 30% increase for Nursing services is needed to allow agencies to adjust the pay offered to Nurses to a more competitive wage in order to recruit and retain sufficient staff to deliver needed care during the pandemic. As a condition of eligibility for the 10% temporary rate increase for residential services and the 30% rate increase for personal assistance and nursing services, the provider must agree to not reduce staff wages/salaries and to use the rate increase to address specific needs related to COVID-19 (which could include paying staff more), and commit to continuing service delivery both during and beyond the public health emergency. All COVID-19 related rate increases are subject to audit and recoupment if these conditions are not met. Among these same provider types on the front lines of delivering HCBS during the pandemic, providers serving individuals confirmed COVID-19 positive are experiencing uniquely severe staff shortages and significantly higher costs to ensure continuity of services for the person in the home and avoid hospitalization, except when medically appropriate. Generally, especially for residential services, the goal is to identify staff who agree to remain in isolation with the person for the duration of the isolation period. It often requires a higher rate of pay to identify staff willing to serve a person who is COVID-19 positive, and considerable additional overtime is also accrued in these circumstances, in addition to a greater need for PPE. The Residential Special Needs Adjustment (RSNA) and COVID+ Personal Care Rate Differential (PCRD) are specifically intended to reimburse hazard pay to direct support staff, as well as the even higher overtime and PPE costs for services provided to a person confirmed COVID-19+. In instances where a provider is providing services to a person who is COVID-19 positive, the provider would be eligible to receive both the applicable rate increase and the RNSA or PCRD, as applicable. (The RSNA and PCRD payments are mutually exclusive.) Note, however, that the RSNA and PCRD payments are expected to continue through July 24, 2020 (the duration of the PHE declared by the HHS Secretary), subject to the availability of funding approved for these purposes—beyond the period covered by the 10 and 30% rate increases. COVID+ Residential Special Needs Adjustment (RSNA): A per diem add-on payment to the existing residential rate to reimburse hazard pay to direct support staff, as well as overtime and PPE costs for services provided to a person confirmed COVID-19+, including: Semi-Independent Living Services (all waivers): Supported Living (TN.0128, TN.0357 only); Residential Habilitation (TN.0128, TN.0357 only); Family Model Residential (TN.0128, TN.0357 only); Medical Residential (TN.0128, TN.0357 only); Behavioral Respite (TN.0128, TN.0357 only). COVID+ Personal Care Rate Differential (PCRD) A per unit add-on to the existing unit rate to reimburse hazard pay to direct support staff, as well as overtime and PPE costs for services provided to a person confirmed COVID-19+ For purposes of this payment, “Personal Care” includes Personal Assistance and Nursing Services. The RSNA and the PCRD is based on an increase wage of $5/hour for hazard pay (reflective of actual provider experience in these circumstances), in addition to overtime costs and employer taxes for these higher payments, and higher cost of additional PPE (projected at $36/day for individuals requiring 24/7 staff and apportioned for RSNAs for individuals requiring less than 24 hours/day paid support and for the per unit PCRD), which will not be included in the overtime calculations.
As a condition of eligibility for the COVID+ RSNA and PCRD payments, the $5/hour hazard pay must have been made to direct support staff, as supported by payroll records. Payments are subject to audit and adjustment or recoupment if it is determined that the $5/hour hazard pay was not paid to direct support staff, or the person for which such RSNA or PCRD, as applicable, was billed was not confirmed COVID-19+.

Modifications of ISP

Effective March 13, 2020, during the period of the COVID-19 emergency, Independent Support Coordination (in the Statewide and CAC Waivers) and Self-Determination Waiver Case Management visits may be conducted remotely, using phone or video conferencing solutions in accordance with HIPAA. When either of these responsibilities are completed in place of a required face-to-face meeting, the ISC or SD Case Manager should document the occurrence in a corresponding service note. For ISC and SD Case Manager meetings that require signature sheets, ISCs and CMs should write down people’s names (the name of everyone who participates in the meeting) on the signature sheet. The ISC/CM should sign and date the form and identify somewhere on the signature sheet the phone call was held in lieu of a face-to-face meeting due to the COVID 19 emergency. The use of e-signatures that meets privacy and security requirements will be added as a method for the participant or legal guardian signing the ISP to indicate approval of the plan. Services may start based on verbal authorization while waiting for the signature to be returned to the case manager, whether electronically or by mail. Signatures will include a date reflecting the ISP meeting date. The State will ensure that the service plan is implemented and that individuals receive services as authorized during the period of the emergency, with the exception of services significantly impacted by state and federal orders and recommendations to practice social distancing (i.e., Community Participation, Employment Services, etc.), which will resume as the risk of exposure and spread of COVID-19 are reduced, and as providers are able to safely resume provision of services as described in the currently approved waiver applications.

Modify Incident Reporting/Med Management Safeguards

Effective March 18th, 2020; DIDD will track all COVID-19 testing for persons supported. Reporting requirements shall include the reporting of COVID-19 testing for any person supported, regardless of results (positive or negative). The Reportable Event Form (REF) is required to be completed as soon as possible, but no later than by the following business day. The provider completing the REF shall select “Other Type of Event” and specify “COVID-19 Testing” in the space provided. Details of the person’s status and test results would be expressed in the narrative section. “COVID-19” needs to be included in the subject line of the REF email. All positive test results shall be reported to the Abuse Hotline (1-888-633-1313) as soon as possible but no later than 4 hours of discovery. Performance Measure a.i.21 (Number and percentage of DIDD providers surveyed who demonstrate they are implementing preventive/corrective strategies when applicable) will be reviewed off-site via desk review.

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

Personal, behavioral, and communication supports may be rendered by Personal Assistance and LPN providers in an acute-care hospital or short-term institutional stay when the waiver participant is displaced from home because of COVID-19 and such supports are not otherwise available in these settings.

Inclusion of Retainer Payments

N/A

Institute/Expand Opportunities for Self-Direction

N/A

Increase Factor C

N/A

Other Changes Necessary

All Quality Assurance surveys have been suspended as necessary to accommodate stay-at-home orders or social distancing recommendations. The State will explore the possibilities of reviewing electronic records remotely if providers have the capability to provide them and having entrance and exit conferences by conference call or via WebEx when that is acceptable. Effective March 13, 2020, Fiscal Accountability Review unit annual reviews can optionally be conducted via off-site review of records (desk review), and this option is extended to all applicable providers that have electronic record systems that allow for the sharing documentation with reviewers.

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

Case management, monthly monitoring, other: Nutrition Services, Occupational Therapy, Physical Therapy, Speech, Language, and Hearing Services, Behavior Services, Orientation and Mobility Services for Impaired Vision, Support Coordination, Transitional Case Management, and Semi-Independent Living in accordance with Section A of this Appendix K Addendum: COVID-19 Pandemic Response – NOTE that any components of these services requiring direct evaluation or interactive, hands-on care to be effective and therapeutic shall not be delivered electronically.

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

All Quality Assurance surveys have been suspended as necessary to accommodate stay-at-home orders or social distancing recommendations. The State will explore the possibilities of reviewing electronic records remotely if providers have the capability to provide them and having entrance and exit conferences by conference call or via WebEx when that is acceptable. Effective March 13, 2020, Fiscal Accountability Review unit annual reviews can optionally be conducted via off-site review of records (desk review), and this option is extended to all applicable providers that have electronic record systems that allow for the sharing documentation with reviewers.

Other Changes Necessary

All Quality Assurance surveys have been suspended as necessary to accommodate stay-at-home orders or social distancing recommendations. The State will explore the possibilities of reviewing electronic records remotely if providers have the capability to provide them and having entrance and exit conferences by conference call or via WebEx when that is acceptable. Effective March 13, 2020, Fiscal Accountability Review unit annual reviews can optionally be conducted via off-site review of records (desk review), and this option is extended to all applicable providers that have electronic record systems that allow for the sharing documentation with reviewers.

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

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

X

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

Link to Approval Letter

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