Medicaid Home and CommunityBased Settings Rule Choice of

Medicaid Home and Community-Based Settings Rule “Choice of Setting” Requirement A Training Section 18, 20, 21 and 29 Waiver Members and their Families, Guardians and Allies

Presenter Dr. Lisa A. Mills, Ph. D Consultant to State of Maine since 2015 Now assisting Maine with following the HCBS Settings Rule Department of Health and Human Services 2

• What is the Medicaid Home and Community-Based Services (HCBS) Settings Rule? • What opportunities, freedoms and rights are people receiving waiver services expected to have? • What must Care Coordinator’s and Case Manager’s now do? • How does the rule change the Person-Centered Planning process? What We Will Talk About In This Session • What is the requirement to offer each waiver members an informed choice of settings? • What is a “non-disability-specific setting” and when does this type of setting need to be offered to waiver members? • How can Case Managers and Care Coordinators make sure waiver members can make a truly informed choice about the settings (places) where they will receive services? • How are Case Managers and Care Coordinators expected to document choice of settings in the Person -Centered Plan? Department of Health and Human Services 3

• A federal regulation (Rule) that sets standards for places (Settings) where Medicaid HCBS services are provided to waiver members and federal money is used. What is the HCBS Settings Rule? • The Rule is the result of a nearly 5 -year process during which over 2, 000 public comments were sent to the federal government during public comment periods. • The final Rule came out in March 2014. All states have been given until March 2023 (9 years) to bring all current HCBS Settings into line with all of the standards in the Rule. Department of Health and Human Services 4

Why is Federal Medicaid Money Important to Maine’s HCBS Program? • Money from the federal government makes up nearly two-thirds of the total funds used to operate Maine’s HCBS waivers. • This means for every $1 the state spends, 64 cents comes from the federal government. • If waiver service delivery settings are not in full compliance with the HCBS Settings Rule by March 2023, the state can no longer claim the federal match for any setting that is not in full compliance. • Reimbursement rates would need to be reduced by 64% for non-compliant settings… not an option for Maine. Department of Health and Human Services 5

HCBS Setting Standards Are Meant To: Access Give waiver members best opportunities to have full access to the benefits of living in the community rather than an institution Integration Ensure waiver members can fully participate in their communities and receive services in the regular community places Quality Ensure the quality of Home and Community-Based Services Rights Provide rights protections for participants Department of Health and Human Services 6

HCBS Setting Standards for All HCBS Settings Must not be institutional or have the qualities of an institutional setting. • Must not isolate waiver members from the broader community, including community members not receiving waiver services Must be integrated in the community and support full access to the community, including: • Opportunities to seek integrated employment and work in the community • Opportunities to participate in community groups, activities, organizations • Opportunities to control personal resources including money • Opportunities to receive services that support the same access to the community that people not receiving waiver services have Department of Health and Human Services 7

HCBS Setting Standards for All HCBS Settings CONTINUED Must ensure certain rights protections, including: • Rights of privacy, dignity, and respect, and freedom from coercion and restraint. • Support people with opportunity to make life choices, live their own lives and use their skills and abilities to be as independent as they can be. This includes what people choose to do, where they choose to spend time and who they choose to spend time with. • Make sure people have individual choice regarding services and supports, and who provides them. Department of Health and Human Services 8

Additional HCBS Setting Standards Apply to Provider Owned or Controlled Settings Department of Health and Human Services 9

What is a Provider Owned or Controlled Setting? • A setting that is owned, co-owned, or operated by a provider of waiver services • This includes Shared Living if the provider is not a relative (family member) • This does not include Shared Living if the provider is a relative (family member) Department of Health and Human Services 10

Which Settings Are Provider Owned or Controlled? Setting Type Section 18 Waiver Section 20 Waiver Section 21/29 Waiver Non-Residential: Provider Owned or Controlled Work Ordered Day Club House Community Support Facility Work Support-Group Residential: Provider Owned or Controlled Group Home Provider-Owned Residence Provider-Leased Residence Shared Living-Unrelated Provider Family-Centered Home Department of Health and Human Services 11

Which Settings Are Not Provider Owned or Controlled? Setting Type Section 18 Waiver Section 20 Waiver Section 21/29 Waiver Non-Residential: Not Provider Owned or Controlled Work Support-Individual Community Support (if no time spent in facility) Residential: Not Provider Owned or Controlled Member(s) own home Relative owns home Member/relative rents from third party (not provider) Shared Living-Related Caregiver Department of Health and Human Services 12

Additional HCBS Setting Standards for All Provider Owned or Controlled. HCBS Settings Must ensure certain rights protections, including: • The setting is physically accessible • People have freedom and support to control their schedules and activities. • People have freedom and support to access food and eat at any time. • People can have visitors at any time, respecting others they may share their home with. Department of Health and Human Services 13

Additional HCBS Setting Standards for All Provider Owned or Controlled. Residential HCBS Settings Must ensure certain rights protections, including: • A lease, in the person’s name, that gives person appeal rights and eviction protections • An option for a private bedroom, if affordable to person. • A choice in deciding who to share their home with (and choice to share bedroom) • Privacy in their and bedroom. • Lockable entrance door(s) to their home (and bedroom if sharing with others person does not considered immediate family) ØOnly the person and appropriate staff have keys/codes for door(s). • A person can furnish and decorate their home and bedroom as they wish, as long as it is allowed under their lease agreement. Department of Health and Human Services 14

The Case Manager’s and Care Coordinator’s Role All of the setting standards discussed so far are standards that providers delivering waiver services are expected to meet. Case Managers and Care Coordinators have a role in making sure individuals have experiences receiving services that fit with the setting standards. The Individual Experience Assessment (IEA) is the tool developed by DHHS to ask about the person’s experience in receiving waiver services. Department of Health and Human Services 15

The Case Manager’s and Care Coordinator’s Role Beyond the Individual Experience Assessment (IEA) The HCBS Settings Rule includes new expectations and requirements for Person. Centered Planning and the Person-Centered Plan The HCBS Settings Rule requires some setting standards to be addressed, in part, through Person-Centered Planning The HCBS Settings Rule allows “modifications” to some setting standards for health or safety if these “modifications” are in the Person. Centered Plan Department of Health and Human Services 16

Is driven by the waiver member Includes people chosen by the waiver member The HCBS Settings Rule: What is Expected for the Person-Centered Planning Process Provides information and support so the waiver member directs the process as much as possible Is timely and takes place at times/locations that work for the waiver member Reflects the waiver member’s culture and uses plain language Includes strategies for solving disagreements among team members Includes discussion of how the waiver member can request updates to the Person-Centered Plan Department of Health and Human Services 17

The HCBS Settings Rule: More On What is Expected for the Person-Centered Planning Process Finds out the strengths, preferences, needs and goals that are important to the waiver member. Focuses on what is important to the waiver member to make sure services are delivered in the ways the person wants Must make sure services keep people healthy, safe and focused on their goals Includes the waiver member’s own goals and preferences in these areas: relationships; community participation; employment; income and savings; healthcare and wellness; education and other things Includes identifying risks and specific ways to reduce risks while still supporting the waiver member to pursue their goals Department of Health and Human Services 18

NEW The HCBS Settings Rule: Even More On What is Expected for the Person-Centered Planning Process Offers the member choice of services and supports that can help the member achieve their goals Offers the member choice of setting(s), including non-disability-specific setting(s), where the member can receive each waiver service Offers the member choice of providers who can provide each waiver service in the setting(s) the member has chosen Offers the member the option to self-direct waiver services if allowable Department of Health and Human Services 19

A Waiver Member’s Choice Includes Choice of Where To Receive Waiver Services 1. Choice of Services and Supports: Based on: 1. Person’s outcomes/goals 2. Preferences/needs related to these outcomes/goals 3. Services available that can help with the specific outcomes/goals and related preferences/needs 2. Choice of Setting(s) Where the person wishes to receive each waiver service Department of Health and Human Services 3. Choice of Providers that can provide the service where the person wants to receive it May include option to self-direct 20

• Different than “Alternative Settings” that involve services not funded by the waiver. Focus on choice of setting(s) where waiver services will be provided Choice of Settings for Waiver Services • Member must have choice from multiple setting options offered (not just 1; at least 2) • Settings offered must include one or more “non -disability-specific” setting options • The member’s choice of setting should be an informed choice Department of Health and Human Services 21

What is a Non-Disability-Specific Setting? • A setting that is not provider owned or controlled AND • Is not designed or labeled as a setting only for people with disabilities or only for people receiving waiver services AND IF IT’S NOT A RESIDENTIAL SETTING • Is not majority occupied by people with disabilities or other people receiving waiver services and their paid staff Department of Health and Human Services 22

Examples of Non-Disability-Specific Non-Residential Settings Setting Type Section 18 Waiver Section 20 Waiver Section 21/29 Waiver Non-Residential: Non-Disability-Specific Settings Work Support-Individual Settings Typical Places of Employment Career Planning Settings Career Centers Community/Tech Colleges Typical Volunteer Sites Recreational Facilities Health & Fitness Centers Club/Association Meeting Places Religious/Spiritual Venues Non-Residential: Services that Use Non -Disability-Specific Settings Community/Work Reintegration. Individual Career Planning Employment Specialist Work Support-Individual Community Support (outside provider facility) Career Planning Employment Specialist Work Support-Individual Department of Health and Human Services 23

Examples of Non-Disability-Specific Residential Settings Setting Type Residential: Non-Disability. Specific Settings Member(s) own home Relative owns home Member/relative rents from third party (not provider) Residential: Service that Use Non. Disability-Specific Settings Section 18 Waiver Section 20 Waiver Section 21/29 Waiver Apartment Condominium Manufactured/Mobile Home Single-Family Home Duplex Tiny Home Low-Income Housing Mixed-Income Housing Co-operative Housing Home Support ¼ Hour Personal Care Home Support ¼ Hour Home Support: Remote Support (Monitor or Interactive) Home Support-Per Diem (in residence not owned or controlled by provider of service) Home Support: Remote Support (Monitor or Interactive) Shared Living-Related Caregiver Home Support-Per Diem (in residence not owned or controlled by provider of service) Department of Health and Human Services (in residence not owned or controlled by provider of service) 24

Choice of Setting for Residential and Home. Based Services • Multiple setting options must be offered to the member (not just 1; at least 2) • Settings offered must include one or more “non -disability-specific” setting options • For residential services, an option for private room must be offered if the person can afford the room and board costs • The member’s choice of setting should be an informed choice Department of Health and Human Services 25

Choosing Where to Receive Waiver Services: How to Support Members to Have Informed Choice One or more non-disability-specific settings must be included in the setting options offered for each waiver service If a waiver service cannot be provided in a non-disabilityspecific setting because of rules for the service, the member should be offered the most similar service that can be provided in a non-disability-specific setting Examples: Work Support-Group – Offer Work Support-Individual Work-Ordered Day (Clubhouse) – Offer Community/Work Reintegration, Career Planning, or Employment Specialist Family-Centered Home – Offer Home Support ¼ Hour or Per Diem (in residence not owned or controlled by provider of service) Department of Health and Human Services 26

Informed choice is not going to happen if people select providers before they select services and settings More Ideas for Supporting Members to Have Informed Choice of Where to Receive Waiver Services Case Managers/Care Coordinators will do with Person 60 -90 Days Before PCP Meeting as part of Reviewing Services & Providers CMs/CCs Can Put This Into PCP Providers are expected to be able to offer waiver services in non-disability-specific setting(s) if a person chooses/prefers this Case Managers/Care Coordinators should take time to provide examples of non-disability-specific settings where each waiver service could be provided Case Managers/Care Coordinators should offer the person an opportunity to see non-disability-specific residential settings as part of informed choice Offer the person an opportunity to try receiving a non -residential service in non-disability specific setting(s) on a trial or part-time basis Department of Health and Human Services 27

Written in plain language and understandable to the member and people supporting the member The HCBS Settings Rule: Requirements for the Written Person. Centered Plan Reflects member’s strengths and preferences Includes goals and desired outcomes Reflects the needs of the member Identifies individuals important in supporting the member Includes risks and how these risks will be lowered Department of Health and Human Services 28

Includes services and supports that are necessary and best able to address goals, outcomes, preferences and needs The HCBS Settings Rule: More Requirements for the Written Person. Centered Plan Identifies unpaid/natural supports and paid providers of services not funded by the waiver Includes choice of settings offered, including non-disabilityspecific setting(s), for each waiver service and the specific setting(s) chosen by the individual for each waiver service Identifies the providers of the waiver services in the settings chosen by the member Includes option to self-directed services, if available and chosen by the member Department of Health and Human Services 29

Includes any needed modification(s) of HCBS Settings Rule standards that may be modified for health and/or safety including justification and plan for regular review The HCBS Settings Rule: Even More Requirements for the Written Person. Centered Plan Identifies individualized backup plans and strategies when needed Identifies individuals responsible for keeping watch on how the Person-Centered Plan is being put into practice Includes informed consent of the member in writing Includes signatures of all individuals and providers selected Distributed to the individual and others involved in putting the Plan into action, respecting the privacy of the person Department of Health and Human Services 30

Writing a Member’s Choices of Settings in the Person. Centered Plan • Case Managers/Care Coordinators will include information about the choice of settings offered and discussed, including at least one non-disabilityspecific setting, for each waiver service • CMs/CCs will also include information on the specific setting(s) chosen by the member for each waiver service Department of Health and Human Services 31

Section 18: Writing Down Choice of Setting in the Person. Centered Plan FROM 2/1/21 UNTIL NEW “EVERGREEN” SYSTEM IS READY: In the Personal Profile Narrative under Additional Information, Care Coordinators will include: 1. Name of each Section 18 waiver service requested 2. Setting(s) offered for each service, including at least one type of non-disability-specific setting for each waiver service 3. Setting(s) chosen by the person for each service Department of Health and Human Services 32

Section 20: Writing Down Choice of Setting in the Person. Centered Plan FROM 2/1/21 UNTIL NEW “EVERGREEN” SYSTEM IS READY: In the Description of the Care Planning Process Care Coordinators will include: 1. Name of each Section 20 waiver service requested 2. Setting(s) offered for each service, including at least one type of non-disability-specific setting for each waiver service 3. Setting(s) chosen by the person for each waiver service Department of Health and Human Services 33

Section 21/29: Documenting Choice of Setting in the Person. Centered Plan FROM 2/1/21 UNTIL NEW “EVERGREEN” SYSTEM IS READY: In the Summary of Process Coordination (Part 1) Case Managers will include: 1. Name of each Section 21/29 waiver service requested 2. Setting(s) offered for each waiver service, including at least one type of non-disability-specific setting for each waiver service 3. Setting(s) chosen by the person for each waiver service Talk about settings in addition to talking about services and providers when meeting with member before Plan Meeting Department of Health and Human Services 34

New Opportunities for Waiver Members If You Get These Services Opportunities and Supports • Work Support-Group • Work-Ordered Day (Clubhouse) • Help to explore, consider an individual job of your own that matches your interests and abilities where you work for the employer – not your provider of service. • Opportunity to try these services: Career Planning, Employment Specialist, Work Support-Individual, and (for Section 18 members) Community/Work Reintegration Department of Health and Human Services 35

More New Opportunities for Waiver Members If You Get These Services Opportunities and Supports • Family-Centered Home • Home Support • Opportunity to explore living in a place that is not owned or controlled by a service provider • Allows members living together to change service provider without having to give up their home Department of Health and Human Services 36

Even More New Opportunities for Waiver Members If You Get These Services Opportunities and Supports • Community Support • Opportunities to try receiving the service in integrated, ordinary places in the community where people without disabilities go • Opportunities to explore and consider an individual job of your own that matches your interests and abilities where you work for the employer – not your provider of service. • Help to get connected with services that can help you find and keep an individual job Department of Health and Human Services 37

Department of Health and Human Services 38

Questions After This Presentation? Send questions to: HCBS. DHHS@maine. gov Or call 1 -800 -262 -2232 or 207 -287 -6214 and ask for Heidi Bechard Department of Health and Human Services 39