Team 1 Handout - CMS Final Rule on Medicaid HBS Services

Issued January 10, 2014;  Effective March 17, 2014


Revises the regulations implementing Medicaid home and community-based services (HCBS) waivers under section 1915(c) of the Social Security Act (the Act) by providing states the option to combine the existing three waiver targeting groups identified in § 441.301.

In addition, this final rule will include:

  • other changes to the HCBS waiver
  • provisions to convey expectations
  • regarding person-centered plans of care,
  • to provide characteristics of settings that are home and community-based as well as settings that may not be home and community-based,

Highlights of the Final Rule

  • Defines, describes, and aligns home and community-based setting requirements across three Medicaid authorities
  • Defines person-centered planning requirements for persons in HCBS settings under 1915(c) HCBS waiver and 1915(i) HCBS State Plan authorities
  • Implements regulations for 1915(i) HCBS State Plan benefit
  • Provides option to combine multiple target populations within one 1915(c) waiver
  • Provides CMS with additional compliance options for 1915(c) waiver programs
  • Establishes five-year renewal cycle to align concurrent authorities for certain demonstration projects or waivers for individuals who are dual eligible Includes a provider payment reassignment provision to facilitate certain state initiatives

Purpose of the Rule

  • To ensure that individuals receiving long-term services and supports through home and community based service (HCBS) programs under the 1915(c), 1915(i) and 1915(k) Medicaid authorities have full access to benefits of community living and the opportunity to receive services in the most integrated setting appropriate
  • To enhance the quality of HCBS and provide protections to participants

Transitioning to the Rule

  • For renewals and amendments to existing HCBS 1915(c) waivers submitted within one year of the effective date of final rule:

    • The state submits a plan in the renewal or amendment request detailing any actions necessary to achieve or document compliance with setting requirements for the specific waiver or amendment
    • Renewal or amendment approval will be contingent upon inclusion of an approved transition plan
    • For ALL existing 1915(c) HCBS waivers and 1915(i) HCBS State Plan benefits in the state, the state must submit a plan: (not just Developmental Disability services… ALL HCBS waivers)
    • Within 120 days of first renewal or amendment request detailing how the state will comply with the settings requirements in ALL 1915(c) HCBS waivers and 1915(i) HCBS State Plan benefits
    • The level and detail of the plan will be determined by the types and characteristics of settings used in the individual state
    • When a state DOES NOT renew or amend an existing 1915(c) HCBS waiver or 1915(i) HCBS State Plan benefit for HCBS within one year of the effective date of the final rule, the plan to document or achieve compliance with settings requirements must:
      • Be submitted within one year of the effective date of the final rule
      • Include all elements, timelines, and deliverables as required

Home and Community Based Setting Requirements

  • 1915(c)-HCBS Waivers ;-1915(i)- State Plan HCBS -1915(k)-Community First Choice
  • establish an outcome oriented definition that focuses on the nature and quality of individuals' experiences
  • maximize opportunities for individuals to have access to the benefits of community living and the opportunity to receive services in the most integrated setting
  • Is integrated in and supports access to the greater community
  • Provides opportunities to seek employment and work in competitive integrated settings, engage in community life, and control personal resources
  • Ensures the individual receives services in the community to the same degree of access as individuals not receiving Medicaid home and community-based services
  • Ensures an individual's rights of privacy, dignity, respect, and freedom from coercion and restraint
  • Optimizes individual initiative, autonomy, and independence in making life choices
  • Facilitates individual choice regarding services and supports, and who provides them
  • HCB Setting Requirements for Provider Owned or controlled Residential setting
  • Specific unit/dwelling is owned, rented, or occupied under legally enforceable agreement
  • Same responsibilities/protections from eviction as all tenants under landlord tenant law of state, county, city or other designated entity
  • If tenant laws do not apply, state ensures lease, residency agreement or other written agreement is in place providing protections to address eviction processes and appeals comparable to those provided under the jurisdiction's landlord tenant law
  • Each individual has privacy in their sleeping or living unit
  • Units have lockable entrance doors, with the individual and appropriate staff having keys to doors as needed
  • Individuals sharing units have a choice of roommates
  • Individuals have the freedom to furnish and decorate their sleeping or living units within the lease or other agreement
  • Individuals have freedom and support to control their schedules and activities and have access to food any time
  • Individuals may have visitors at any time
  • Setting is physically accessible to the individual

Settings Not Home and Community-Based

  • Nursing facility
  • Institution for mental diseases (IMD)
  • Intermediate care facility for individuals with intellectual disabilities (ICF/IID)
  • Hospital

Presumed Not to be Home and Community-Based

  • Settings in a publicly or privately-owned facility providing inpatient treatment
  • Settings on grounds of, or adjacent to, a public institution
  • Settings with the effect of isolating individuals from the broader community of individuals not receiving Medicaid HCBS

Person Centered Service Plan

  • Identical for 1915 (c) and 1915 (i)
  • Describes person centered plan AND person centered planning process
  • Driven by the person
  • Includes people chosen by the person
  • Ensures person directs the process to the max extent possible
  • Is timely and occurs at time/location of convenience of the person
  • Person Centered Service Plan
  • Cultural considerations/ uses plain language
  • Includes strategies to solve disagreements
  • Offers choice regarding service and supports and from whom
  • Method to request updates
  • What's important to the individual …reflects personal preferences and ensures health and welfare
  • Identifies strengths preferences, needs and DESIRED OUTCOMES of the person
  • May include self-directed services
  • Individually identified goals and preferences related to relationships, community participation, employment, income and savings, healthcare and wellness, education and others and must include

Person Centered Service Plan - Written Document

  • Details on the written plan, some old, some new: must be signed, copy must be provided, and
  • Risk factors and measures in place to minimize risk
  • Individualized backup plans and strategies when needed
  • Individuals important in supporting individual
  • Individuals responsible for monitoring plan

Other Provisions

  • More than one target groups can be served
  • Timing of amendments and public comment
  • Strategies for CMS to assist states Support Development Associates