In case you missed the posting of DMA's Public Comments on the 8M Clinical Coverage Policy proposals in May and July of 2011, I'm posting again as I recently updated the post with additional files - namely the 2 different proposals which were posted for comment, a side-by-side comparison of the two proposals, and the 2010 8M Clinical Coverage Policy prior to the changes.
Here are the documents again:
ORIGINAL PROPOSED CLINICAL POLICIES for CAP-IDD:
NOTE: The 15-day posted proposal drastically differs from the 45-day posted proposal, with a total of 14 pages deleted from the second proposal posted.- Side-by-side document comparison of DMA's two 8M proposals.
- DMA 8M Clinical Coverage Policy for CAP-MR/DD from July 2010.
PUBLIC COMMENTS on CAP-IDD CHANGES:
- DMA Clinical Coverage Policy for CAP-IDD proposal Public Comments from May 12, 2011 thru June 26, 2011 (101 comments; 79 pages).
- DMA Clinical Coverage Policy for CAP-IDD proposal Public Comments from July 28, 2011 thru August 11, 2011 (439 comments; 539 pages).
Comments were made from across North Carolina by many parents and caregivers sharing heartfelt details of their lives as well as professionals, providers, and advocates in the DD field who know well the devastating impact such changes and service cuts would have not only on the recipients and families they serve and care for, but on their small businesses, their livelihood and the lives of staff they employ as well.
It is our sincerest hope that our elected officials - our Governor and members of the North Carolina Senate and House of Representatives - aspiring candidates, policy-makers, Health and Human Services administrators, LME's, MCO's, and other stakeholders and powers that be take the time now to hear that voice as our lives are in your hands... not merely the quality of our lives but rather our ability to live.
Here's a synopsis / overview of the initial 8M Clinical Coverage Policy proposal posted for comment from May 12 - June 26 from special parent, Mary K. Short (Mary's comment in blue, the rest are quotes from the 8M). --Remember, the second proposal is less 14 pages.
There are a couple of things that caught my eye. The most important may be that they have proposed changing the respite policy so that you CANNOT use respite on a day you use Home Supports or are an AFL. I would hope you all contact your child's primary care physician and ask him/her to send in a comment to the DME web site in opposition of that proposal. Remember, the comments are reviewed by the PAG (Physician's Advisory Group) and I think your MD's comments are going to carry more weight than your comments. BUT you should send you comment, too! I have never understood where the "best practice" is that says respite cannot be regular and scheduled, so I certainly cannot understand where the "best practice" is that says the primary caregiver can't use four (4) hours of respite every Sunday so they can attend church services in order to pray for strength to continue fighting the battle against ridiculous proposed clinical policies!
The respite changes are throughout the document! However, in the list of Service Definitions, either Crisis Respite or Respite pretty much spells it out. Page 54 of the document or page 101 and then go to the "Service Limitation."
The next couple of things that caught my eye are outlined below. The first is this idea of "habilitative" and how it jumps in and out throughout the proposed clinical policy. The most disturbing loss of habilitation comes in the form of Residential Services to replace Residential Supports. The new Residential Services is NONHABILITATIVE and that would seem to signal the providers that they could now simply park an individual in front of a TV! I am sure it also signals a tremendous rate change coming to them. But somehow, AFL's, who are paid that service definition of Residential Services, is singled out as HABILITATIVE. Huh? And then that designation as HABILITATIVE for both AFL's and HOME SUPPORTS limits the individual to 129 hours of any combination of habilitative services (day supports, HCS, etc.), yet the Residential Services individual has a limit of 209 hours! That is a HUGE penalty for living in an AFL or in a family home ... or is it a HUGE incentive to move to a group home?
Bottom of page 2: ...
1.1.5 Habilitation Services
Habilitation services are those services designed to assist participants in acquiring, retaining, and improving the self-help, socialization and adaptive skills necessary to reside successfully in home- and community-based settings.
Bottom of page 10: ... this is eliminated:
Top of page 11: ... and is replaced with this:
The service also provides assistance, support, supervision, and monitoring that supports individuals to participate in home or community activities. This service is not a habilitative service; however, the service shall be conducted in a manner that promotes and encourages independence
Page 12: Home Supports remains habilitative:
5.1.3
Home Supports is provided only to adult participants who reside in their natural home with their parents (natural, adoptive or step parents) and other family members, where the parents (natural, adoptive or step parents) of the adult participant request to provide the Home Supports to the participant. Home Supports is a habilitation service, with built-in Personal Care at a daily rate to meet the flexible daily needs of the individual. As a blended service, its range of hours for each NC-SNAP level of service (Level 1 through Level 5) includes both components—personal care and habilitation. This hour range indicates the hours of direct contact services and support expected for each level of the service.
Page 14: The second paragraph says to focus on habilitation needs:
5.3.2 Person Centered Plan Reviews
At a minimum, the responsible professional (Targeted Case Manager) shall review the Person Centered Plan based upon the target date assigned to each goal, when the individual’s needs change, or when a service provider changes. For
review the Person Centered Plan every year prior to the individual’s birthday month.
The person-centered planning team shall focus on the habilitation needs of the
individual. Services that are habilitative in nature are not covered under the State
Plan except in an ICF-MR; however, they may be covered as a distinct waiver
service. In reviewing the Person Centered Plan, the Targeted Case Manager shall
include a review of the individual’s progress toward meeting goals identified on
the existing plan and document adjustments made as necessary.
Page 37: An AFL setting is habilitative:
Alternative Family Living
For the purposes of the CAP-MR/DD CAP-I/DD waiver, an Alternative Family Living (AFL) home or adult foster home is considered an out-of-home setting for a person who chooses this setting. The participant receives 24-hour care and lives in a private home environment with a family who are paid to provide services to address the care and habilitation needs of the participant. The family will continue to reside in this home if they choose to no longer provide supports and the participant moves from their home. The LME and targeted case manager are responsible for monitoring the health and safety of the participant.
Page 64: (Day Supports AND Home & Community Supports service limitations both have this service limit sentence about habilitation hours and residential setting.)
Service Limitations:
The maximum combined habilitation services limit is 129 hours per month for all habilitative services with the exception of individuals receiving Residential Services who may receive up to 204 hours per month for all habilitative services.
Page 75: (Home Supports is habilitative.)
K. Home Supports
Service Definition and Required Components:
The intent of this service is to meet the habilitation and personal care needs of adult participants (18 years or older) who choose to live with and receive supports from their families and whose families wish to provide services to the participant in their family homes. Home Supports is designed to provide flexibility and reflect the natural flow of the participant’s day. ...
... This service is distinctive in that it includes habilitation and training activities, as well as care and assistance with activities of daily living when the participant is dependent on others to ensure health and safety. ...
Bottom of page 77: (Underline indicates STRIKE OUT.) Utilization Management (UM) for Home Supports eliminates habilitation:
f. This service requires identification of goal directed progress
Page 85: (NO STRIKE OUT ?!) UM for Long Term Vocational Supports or Specialized Consultative Services or Supported Employment keeps habilitation:
f. This service requires identification of goal directed progress
g. Habilitation requires goal related process on the Person Centered Plan
Page 93: (COMPLETE STRIKE OUT) Residential Supports eliminated.
Page 97: Residential Services replaces Residential Supports and is now non-habilitative:
Page 100: Again, an AFL is habilitative:
