Exceptional Support Waiver Service Task Force Lisa Lee

Exceptional Support Waiver Service Task Force Lisa Lee, Commissioner Leslie Hoffmann, Behavioral Health Specialist Department for Medicaid Services August 24, 2020

1915(c) Home and Community Based Services (HCBS) waivers… … are designed to give individuals with disabilities an alternative to institutionalization. … should complement available state Medicaid program services, public programs, and family/community supports to meet each individual’s needs. … should allow an individual to live safely in the community. If an individual’s needs exceed what can be safely provided in the community, he or she may not be appropriate for waiver services. 2

To receive Centers for Medicare and Medicaid Services (CMS) approval for a 1915(c) HCBS waiver, states must: Provide the same level of care in the community as an individual would receive in an institution. Demonstrate the cost of care in the community is equal or less than an institution. This is known as budget neutrality. Conduct monitoring to ensure waivers meet the quality standards DMS told CMS it would meet. 3

Kentucky’s 1915(c) HCBS Waivers: The Basics ABI & ABI LTC: For individuals age 18 or older with an acquired brain injury Acquired Brain Injury (ABI) HCB: For individuals age 65 and older or individuals of any age with a physical disability Home and Community Based (HCB) Michelle P. Waiver (MPW) 4 Acquired Brain Injury Long Term Care (ABI LTC) Model II Waiver (MIIW) Supports for Community Living (SCL) MIIW: For individuals dependent on a ventilator 12 or more hours a day or on an active, physician monitored weaning program MPW & SCL: For individuals with intellectual or developmental disabilities

Kentucky’s 1915(c) HCBS Waivers: Budgeting • Waiver budgets are determined by evaluating expenditures from the previous fiscal years. • Budgets must be cost neutral, per CMS. • To be cost neutral, the average per participant expenditure must not exceed the average person cost of furnishing institutional services for an individual with the same level of care. 5

Kentucky’s 1915(c) HCBS Waivers: Expenditures* States receive matching federal funds for services provided in the home or community. CMS provides approximately 70% of funding for waiver services. Kentucky provides the remaining dollars. Not meeting CMS requirements for one waiver puts these funds at risk for ALL the waivers the state operates. Waiver ABI Acute ABI LTC HCB MW II Michelle P SCL Total Population Served 296 263 10, 658 33 10, 212 4, 921 26, 383 Total Paid Claims Amount $23, 035, 476 $26, 674, 621 $159, 288, 787 $2, 351, 010 $342, 408, 962 $386, 802, 581 $940, 561, 437 *The numbers in this table represent calendar year 2019 6 Federal Share $16, 124, 833 $18, 672, 235 $111, 502, 151 $1, 645, 707 $239, 686, 273 $270, 761, 807 $658, 393, 006 State Share $6, 910, 643 $8, 002, 386 $47, 786, 636 $705, 303 $102, 722, 689 $116, 040, 774 $282, 168, 431

Kentucky’s 1915(c) HCBS Waivers: Waiting Lists Waiver Year Funded Slots Active Slots* Waiting List ABI 1/1/20 -12/31/20 383 281 0 ABI LTC 7/1/20 -6/30/21 438 390 38 HCB 8/1/20 -7/31/21 17, 050 12, 574 0 MIIW 9/1/19 – 8/31/20 100 40 0 MPW 9/1/19 – 8/31/20 10, 500 10, 150 7, 305 SCL 3/1/20 -2/28/21 4, 491 4, 774 2, 891** *Number does not include slots assigned to individuals who are not currently accessing services **See following table for additional breakdown by category. Once an individual utilizes the slot by accessing at least one service, the slot will remain assigned to that individual for the entire waiver year. Even if the individual expires, the slot cannot be reallocated until the start of the next waiver year. 7

Kentucky’s 1915(c) HCBS Waivers: SCL Waiting List Categories Emergency Immediate services needed due to: • • • 8 Abuse, neglect, or exploitation of the individual substantiated by DCBS Death of the individual’s primary caregiver and lack of alternative caregiver Lack of appropriate placement due to loss of housing, loss of funding, or imminent discharge from a temporary placement Jeopardy to individual’s health and safety due to the primary caregiver’s physical or mental health status Imminent or current institutionalization Urgent Individual needs services within one year and: • Has a threatened loss of existing funding source for supports due to age or eligibility • Is in a temporary or inappropriate placement but health and safety is assured • Has a primary caregiver with diminished capacity due to physical or mental status and no alternative caregiver • Exhibits an intermittent behavior or action that requires hospitalization or police intervention Future Planning Individual needs services within one year and: • is not currently receiving a service through another funding source and needs are being met • is not receiving services and does not currently need services • Is in the custody of DCBS

Kentucky’s 1915(c) HCBS Waivers: SCL Waiting List Category* Number Emergency 0 Urgent 128 Future Planning 2, 763 *Category definitions on the following slide 9

Kentucky’s 1915(c) HCBS Waivers: SCL Operations Acquired SCL Waiver Brain Injury Long Term Care (ABI LTC) DMS Monitoring and quality assurance to maintain CMS approval of SCL waiver. Program review- create and revise policy 10 DAIL DBHDID Provider and participant activities. Supports related to for participant-directed services Community (PDS) Living (SCL) Exceptional supports approval, waiting list management, review of incident reports and follow up, provider monitoring including certification, training and technical assistance

Exceptional Supports: By The Numbers Exceptional supports claims account for 3% of the total paid dollars for SCL participants. In calendar year 2019, 265 individuals were authorized for an exceptional supports but only 251 received the service based on paid claims data. The table below outlines this information. Waiver Service # Unique Individuals Authorized Total Paid Claim Amount Residential 163 $11, 423, 537 Consultative Clinical & Therapeutic Services 82 $277, 612 Respite 6 $26, 668 Total Supports for 251 Community $11, 727, 817 Living (SCL) In calendar year 2019, only one individual was denied exceptional supports. The denial was for lack of information. 11

KAPP/KARP Recommendation Response Regulation Change Required (takes 5 -10 months) Waiver Amendment Required (takes 9 -12 months) PAs can be extended to 12 months for ADT, and residential services. Extend prior authorization (PA) to 12 months and establish an expedited renewal process PAs for clinical services should not extend beyond six months to allow for monitoring of an individual’s progress and potential need for additional wrap around supports. DMS also suggests a refresher training and quick reference guide to assist providers in submitting complete information at the time of initial request. Currently 39% of requests are returned to the provider at least one time for clarifications or additional information. Use a single assessment tool DMS is currently evaluating the use of a validated, universal assessment tool and is open to suggestions on possible options. Establish a higher level of care while retaining the exceptional supports system 12 Supports for Community (SCL) Medicaid state In addition to waiver services, individuals. Living should receive plan services, services through public programs, and natural supports to meet needs. Those with a level of care beyond what the waiver can safely provide may not be appropriate for waiver services.

KAPP/KARP Recommendation Revise the exceptional support rate methodology Increase the number of units allowed for Consultative Clinical and Therapeutic (CCT) Services Establish an exceptional support rate for case manager 13 Response Regulation Change Required (takes 5 -10 months) Waiver Amendment Required (takes 9 -12 months) CMS requires states to have a documented, evidence-based rate methodology. Kentucky is working to establish a documented evidencebased rate methodology to support provider reimbursement levels. Kentucky will evaluate this possibility, however, it is critical any increase in CCT does not create a duplication of services under the state plan as this is not allowed by CMS. SCL case managers received a 10% increase in their reimbursement rate in 2018. Supports for CMS requires states to have a documented, evidence-based rate Community methodology. Kentucky does not have one at this time and will need to Livingrate (SCL) establish one before creating any additional methodologies.

Let’s work together! If you have ideas, comments, concerns, or questions, we want always to hear them. Email us at 14 Supports for Community Living (SCL) Medicaid. Public. Comment@ky. gov.