Note: Below is a Public Comment submitted to DMA regarding the 8M Clinical Coverage Policy proposal for CAP-I/DD during the 15 day comment period from July 28 - August 11, 2011. This exert was pulled from it's original source, a public record, and is posted exactly as it appeared save the removal of the submitter's personal contact information and abbreviation of last name.
[ More on DMA Public Comments. ]
Comment 292
To: Webmedpolicy, Dma
Cc: Bradshaw, Tammie
Subject: 8M policy
Sent: Thursday, August 11, 2011 9:59 PM
DMA,
I am writing in response to the proposed policy recommendations. I own my own Case Management Company, and serve individuals in Mecklenburg, and Pathways LME. I am deeply concerned over the policy recommendations as well as recent increased activity at the State level of changes or proposed changes that will effect folks I serve. I was very involved with advocating against the recently accepted HB 916, and am now seeing my concerns being played out with this proposal, and previous proposals within the last several months. I warned lawmakers (Rep. Earle, and Insko) of the dangers of the HB, and am seeing my predictions being played out even before implementation of HB 916. I have served folks with disabilities for over 25 years, and am disappointed in DMA/DHHS (divisions that are set up to assist folks with disabilities) put out policy that actually hurts the folks they are supposed to support. I have done an analysis of some of my cases (about 5) with the proposed changes in the 8M policy from current services in their cost summary to proposed changes under the 8M policy recommendations. The outcome has been a reduction in cost/services of about 25% per client (good job state!!) without any medical justification for a reduction other than a policy change as recommended by the State. I plan on laying out my issues in this e-mail from my careful review of the 8M policy so you will better understand my concerns as well as the people I support. In an attempt to save money I believe you all have lost sight in the people that are being served. Your attempt at trying to save money by reducing or eliminating services will backfire and create more cost to the state as Families will be forced to place their disabled family members in placements that will cost the State much more money. My issues will be laid out in the following order with reference to the page number in the 8m policy so as to easily follow my point.
1) Respite for Residential Support folks (can they get Respite or not? if so why not on the same day?)
2) Elimination of Home Supports
3) Elimination of Enhanced services
4) change from "guidelines" to "Criteria" in the proposal
5) limitation of Habilitative hours to 129 H/M (30 H/W) for adults/children when out of school
6) Limitation of Habilitative hours to 86 H/M (20 H/W) for school age children
7) Limitation on hours a month for Guardians and family members to 40 H/W or 5.8 H/D
I want to start out this analysis by looking at what was written into the policy. On page 4 of the 8M policy this statement was made "The waiver, Community Alternatives Program for Individuals with Intellectual/Developmental Disabilities (CAP-I/DD) is designed to give persons with intellectual and developmental disabilities, a cost-effective alternative to care in an intermediate care facility for persons with mental retardation (ICF-MR). The goal of this funding source is to enable individuals to have a choice of living in the community instead of in an institutional setting and to have effective support in creating a preferred lifestyle that challenges each individual to live to his or her fullest potential." This I imagine is the driving force behind the waiver. If so, the 8M policy and DMA seems to forget the mission as outlined here. This statement was found on page 5 of the 8M policy that is also significant. "Person-centered planning is a process of determining real-life outcomes with individuals and developing strategies and goals to achieve those outcomes. The participant, the legally responsible person, or both direct the process and share authority and responsibility with system professionals about decisions made" (page 5). These decisions made in this policy were not made by the people that matter (the clients or their team members, but by politicians or people who are not concerned about what is best for the individual served). Another qoute I want to use from the 8M policy is from page 39 under amount and duration of service. "The amount and duration of services provided are determined through the person-centered planning process with the participant’s planning team. Services are based on the needs and priorities of the participant, the availability of other formal and informal supports, and rules of the funding source. The planning team shall ensure that medical necessity criteria are met for Medicaid reimbursement as cited in 10A NCAC 22O .0301.
Authority G.S. 108A-25(b); 42 CFR 440.230(d). In and throughout the policy you put limits on services that are in direct conflict with what is written in the policy. Amount and duration of services is determined by the participants planning team, not DMA.
Point # 1: The 8M policy is unclear on its stand as to Respite for folks recieving Residential supports. On page 11 of the 8M policy it seems to indicate that Respite would not be allowed for RS clients, but on page 94 of the policy it states that it can not be billed on the same day as RS, and then later states that it cannot be billed on the same time time as day as RS. Either way it presents problems. If totally eliminated then staff would have to pay out of pocket for Respite, and then the State would find themselves in a sticky situation because they could not mandate Staff requirements for non Medicaid payment opening themselves for a huge liablity issues and potential lawsuit if the staff have a friend do respite that may potentially abuse the client, and the staff/provider would have to say they had to do that because of state policy requirements. The other matter regards to not doing RS and Respite on the same day presents another issues. If staff provide RS for anytime during the day, and bill for it, and then have someone provide Respite the Respite will be paid out of pocket as illustrated in previous statement (huge state liability). If RS staff do services during the day, and don't bill because they want to use Respite and Respite is billed, then it becomes a labor law issue because the State is mandated staff work free if they provide RS services, and respite on the same day. This once again opens up the State for lawsuit due to policy changes.
Point #2: In the 8M policy it recommends elimination of Home Supports for individuals who live in their own home and recieve services from their Guardian or Family Member with replacement of HCS and personal care services. This is the biggest issues I have with this policy, and where most of the cuts are effected. Many individuals who recieve Home Supports do so because their Family Members have decided to quit their fulltime job to care for their loved one with a disability. Now the State wants to put an additional burden on these families because they consider them natural supports, and it is "their duty to care for their loved one" and so they decide to cut services. This puts an undue burden on the Families to provide the same quality of care with less support. Many of these Families provide this service because of past abuse by staff or because they live in an area that is hard to staff, or the individual has such intense needs no one would work with them. I will cover this in another area, but when the 8M policy limits the habilitative hours to 129 H/M, and the person recieves Day Supports (typically utilized at 30 H/W) then their is no more habilitation to be used even though the consumer needs it so Families are left to use PC, and only 40 H/W or 5.8 H/D of services. Many of these consumer require 12-20 H/D of services so this policy forces Families to care for their family members much more than they are compensated. The end result will be that Families will have to utilize other options such as institutionalization to care for their family member as they will not be able to take on the additional stress of caring for their loved one and meeting the daily responsibilites of paying their bills. This will result in cost increases at the state level.
Policy #3: In regards to elimination of enhanced services I believe that once again the State has failed to take in consideration the individual served and has decided to look at the cost savings. People recieve enhanced services primarily due to behavioral or medical issues that warrant intense need. By eliminating the enhanced services staff and/or Family will have to care for the the needs of the individual without appropriate commpensation due to the additional training required or additonial liability they take on. The long term effect will be an inabilty of providers or Family to provide well trained staff to provide services once again forcing alternative placement that will increase state costs
Policy #4: I am not clear on the differientiation between "Guidelines" and "criteria" when it pertains to limits on services. My understanding is that Guidelines are recommendations, and criteria is limits. Just need clarification
Policy #5: I have concerns that the limitation on Habilitation hours to 129 H/M conflicts with the concept of Person centeredness, and seriously effects folks recieving Home supports. 129 H/M limits folks to 4.2 H/D of habilitation of services if they recieve services 7 days a week. If folks get Day supports (typically done at 30 H/W) it would eliminate any habilitation being done at the home, only PC. This would force families, and staff in providing uncompensated work beyond what is needed to the individual. This has potential labor law issues, and rights violation issues for the State. This will directly effect adult consumers who live at home who reieve additional servcies, and will result in a cut in services. This policy recommendation also appears to comflict with other things in the policy that states that adults may recieve up to 12 H/D of Habilitative services in one day. Many of these individuals served have a treating physician stating they need more services beyond 129 H/M, and yet the State wants to limit services regardless of what the treating Physician states.
Policy #6: Regards to the Policy recommendation on Limitation of Habilitative hours to 86 H/M (20 H/W or 3 H/D) for school age children. I have concerns because it seems to conflict with other things in the policy that states kids can recieve up to 6 H/D of habilitation services (129 H/M) or other places that says they can recieve up to 12 H/D on non school days.
Policy #7: Regards to the policy Limitation on hours a month for Guardians and family members to 40 H/W or 5.8 H/D. As stated earlier this puts an undue burden on Families who have quit their jobs to care for their adult child, and are now looking at a huge reduction in services, and are expected to continue to provide supports, but under the heading of natural supports (because that is what Families should do). This Policy recommendation will seriously effect Families who provide home supports. Many of those adult individuals also recieve Day Supports, and because of the other limitation recommendation of 129 H/M these families will only be able to provide PC which in many case is not sustainable given what they gave up to care for their child forcing many members to rethink caring for their loved one in their which will result in an increased cost at the State level. I have many Family members who provide well over 10 H/D of services due to intense needs of their family members who will now be forced to resign their day jobs or place their Family members in a group home/AFL/Institution due to service limitations put forth in this policy.
I hope I have been clear in my deliberation on my concerns and issues, and my desire to support the individuals, and Families I represent. If you have any questions or need to speak to any of my families on how these policy changes will directly effect tehm please call me at 704-249-7418.
Sincerely,
Paul Peters
Owner
Covenant Case Management Services, LLC
Showing posts with label HCS. Show all posts
Showing posts with label HCS. Show all posts
27 June 2012
26 June 2012
DMA 8M Public Comment on CAP-I/DD 270
Note: Below is a Public Comment submitted to DMA regarding the 8M Clinical Coverage Policy proposal for CAP-I/DD during the 15 day comment period from July 28 - August 11, 2011. This exert was pulled from it's original source, a public record, and is posted exactly as it appeared save the removal of the submitter's personal contact information and abbreviation of last name.
[ More on DMA Public Comments. ]
Comment 270
To: Webmedpolicy, Dma
Cc: R&T Gmail account
Subject: 8M-CAP-I-DD
Sent: Thursday, August 11, 2011 4:43 PM
To whom it may concern,
I am extremely concerned by the proposed changes to the CAP waiver. Please consider the following before you make any changes.
Twenty hours of habilitative care per week during the school year is not sufficient for our autistic son. The improvements in behavior, language and social skills we have seen as a result of the hab techs hard work with our son have been a blessing and are truly invaluable. A decrease in hours would be devastating to all the effort put forth by our family and his workers. I know that we are not the only family that feels this way and this strongly about this proposed change. Please do not cut these hours!!!!!
Do not remove home supports either! Our son is not yet 18, but we know other families that are relying heavily on these services for their kids. I would hope and pray home supports would be available when he is 18 to give him a chance at a better life.
I know each one of you cares about the population supported by CAP. I would hope you would not be in this job otherwise. It took our family six long years from our initial application date until our son received his waiver. It was a devastating time financially for our family from which we have not recovered as we tried to do what we could without any support. I know that these are desperate financial times for everyone in this state and in this country, but this population of people and their families are already deeply in debt and desperately need the invaluable assistance provided by the CAP waiver. I beg you not to make a stressful and difficult situation worse. The autistic population in this state had no choice when it came to being autistic. You can make a choice to support them by not changing the CAP waiver. Thank you for your consideration of our ideas on this matter
[ More on DMA Public Comments. ]
Comment 270
To: Webmedpolicy, Dma
Cc: R&T Gmail account
Subject: 8M-CAP-I-DD
Sent: Thursday, August 11, 2011 4:43 PM
To whom it may concern,
I am extremely concerned by the proposed changes to the CAP waiver. Please consider the following before you make any changes.
Twenty hours of habilitative care per week during the school year is not sufficient for our autistic son. The improvements in behavior, language and social skills we have seen as a result of the hab techs hard work with our son have been a blessing and are truly invaluable. A decrease in hours would be devastating to all the effort put forth by our family and his workers. I know that we are not the only family that feels this way and this strongly about this proposed change. Please do not cut these hours!!!!!
Do not remove home supports either! Our son is not yet 18, but we know other families that are relying heavily on these services for their kids. I would hope and pray home supports would be available when he is 18 to give him a chance at a better life.
I know each one of you cares about the population supported by CAP. I would hope you would not be in this job otherwise. It took our family six long years from our initial application date until our son received his waiver. It was a devastating time financially for our family from which we have not recovered as we tried to do what we could without any support. I know that these are desperate financial times for everyone in this state and in this country, but this population of people and their families are already deeply in debt and desperately need the invaluable assistance provided by the CAP waiver. I beg you not to make a stressful and difficult situation worse. The autistic population in this state had no choice when it came to being autistic. You can make a choice to support them by not changing the CAP waiver. Thank you for your consideration of our ideas on this matter
DMA 8M Public Comment on CAP-I/DD 293
Note: Below is a Public Comment submitted to DMA regarding the 8M Clinical Coverage Policy proposal for CAP-I/DD during the 15 day comment period from July 28 - August 11, 2011. This exert was pulled from it's original source, a public record, and is posted exactly as it appeared save the removal of the submitter's personal contact information and abbreviation of last name.
[ More on DMA Public Comments. ]
Comment 293
To: Webmedpolicy, Dma; Office of the Governor; kpowell@arcnc.org; Michael Cooper; admiral ballard; opinion@charlotteobserver.com
Subject: 8M-CAP-I/DD
Sent: Thursday, August 11, 2011 9:59 PM
To Whom it may concern:
I am writing to share my thoughts on the waiver changes proposed by DHHS/DMA for Community Alternatives Program for Individuals with Intellectual/Developmental Disabilities. I do not understand the details and technical terms as well as I should but I understand enough to know vital services are proposed to be cut. I worked outside the home for the first 18 years of my daughter's life to provide for her and was lucky to have parents to help me with childcare. When Jordan turned 18 I was able to stay home and provide Home Supports through CAP for her which resulted in an amazing improvement in our lives. I was no longer so exhausted from working all day and taking care of her all night that we actually began to enjoy our life rather than getting by.
If Home Support hours are cut I will be forced to work an outside job again to pay our bills. If other support services are cut then who will care for Jordan while I work this other job? My parents have retired, moved and are unable to help me now that they're older. I have never even thought of a group home or institution until now. If I can't care for her and she was to go to a group home or institution then the government would be paying for that. Why would you take my income and give it to a group home or institution when my sole purpose in life is to love and care for her. I would personally live in my car if that's what it took to keep Jordan with me but I would hope it would never come to that. I have worked from the age of 16, paid my taxes, never had government assistance and never plan on it. I don't want food stamps or welfare or my daughter placed outside our home. I want to be paid for the job I am doing which is to provide 24/7 care for Jordan. I love her, want to care for her and grow old with her.
I would hope you wouldn't make these changes so the families of people with disabilities can stay together and have the lives they deserve. I thought that was the purpose of Home Supports and other support services. Stop giving more money to drug addiction programs, released convict programs, etc. and let us keep what our children deserve and need.
Sincerely,
Donna C.
Pineville, NC
[ More on DMA Public Comments. ]
Comment 293
To: Webmedpolicy, Dma; Office of the Governor; kpowell@arcnc.org; Michael Cooper; admiral ballard; opinion@charlotteobserver.com
Subject: 8M-CAP-I/DD
Sent: Thursday, August 11, 2011 9:59 PM
To Whom it may concern:
I am writing to share my thoughts on the waiver changes proposed by DHHS/DMA for Community Alternatives Program for Individuals with Intellectual/Developmental Disabilities. I do not understand the details and technical terms as well as I should but I understand enough to know vital services are proposed to be cut. I worked outside the home for the first 18 years of my daughter's life to provide for her and was lucky to have parents to help me with childcare. When Jordan turned 18 I was able to stay home and provide Home Supports through CAP for her which resulted in an amazing improvement in our lives. I was no longer so exhausted from working all day and taking care of her all night that we actually began to enjoy our life rather than getting by.
If Home Support hours are cut I will be forced to work an outside job again to pay our bills. If other support services are cut then who will care for Jordan while I work this other job? My parents have retired, moved and are unable to help me now that they're older. I have never even thought of a group home or institution until now. If I can't care for her and she was to go to a group home or institution then the government would be paying for that. Why would you take my income and give it to a group home or institution when my sole purpose in life is to love and care for her. I would personally live in my car if that's what it took to keep Jordan with me but I would hope it would never come to that. I have worked from the age of 16, paid my taxes, never had government assistance and never plan on it. I don't want food stamps or welfare or my daughter placed outside our home. I want to be paid for the job I am doing which is to provide 24/7 care for Jordan. I love her, want to care for her and grow old with her.
I would hope you wouldn't make these changes so the families of people with disabilities can stay together and have the lives they deserve. I thought that was the purpose of Home Supports and other support services. Stop giving more money to drug addiction programs, released convict programs, etc. and let us keep what our children deserve and need.
Sincerely,
Donna C.
Pineville, NC
25 June 2012
Leg. Correspondence, CMS, US HHS & Reports
Mary K. Short is a strong and active advocate and the parent caregiver of an adult DD recipient with profound needs. She fights tirelessly for the rights of her daughter, Katie and other special families, as well as a great deal of time keeping folks informed! Posted with Mary's permission.
Mary and her daughter live in NC House District 88 and Senate District 42. Her daughter is being served by Smoky Mountain LME.
From: MaryKShort@aol.com
To: Bev.Perdue@nc.gov, Thom.Tillis@ncleg.net, Phil.Berger@ncleg.net
CC: MaryKShort@aol.com, louis.pate@ncleg.net, justin.burr@ncleg.net, nelson.dollar@ncleg.net, martha.alexander@ncleg.net, william.brisson@ncleg.net, bill.current@ncleg.net, mark.hollo@ncleg.net, pat.hurley@ncleg.net, bert.jones@ncleg.net, marian.mclawhorn@ncleg.net, tom.murry@ncleg.net, fred.steen@ncleg.net, austin.allran@ncleg.net, doug.berger@ncleg.net, stan.bingham@ncleg.net, harris.blake@ncleg.net, jim.davis@ncleg.net, fletcher.hartsell@ncleg.net, eric.mansfield@ncleg.net, martin.nesbitt@ncleg.net, william.purcell@ncleg.net, tommy.tucker@ncleg.net, james.forrester@ncleg.net, andrew.brock@ncleg.net, ralph.hise@ncleg.net, marilyn.avila@ncleg.net, rayne.brown@ncleg.net, tricia.cotham@ncleg.net, beverly.earle@ncleg.net, shirley.randleman@ncleg.net, mitchell.setzer@ncleg.net
Sent: 6/25/2012 11:06:27 A.M. Eastern Daylight Time
Subj: Delay NC Innovations Expansion - URGENT
Dear Gov. Perdue, Speaker Tillis, President Pro Tempore Berger, and ladies and gentlemen of the NCGA:
I have tried over and over again to inform you of the urgent concerns I have had about DHHS/DMA/DMHDDSAS (the Department and its Divisions) in regards to the Medicaid 1915(c) waivers for the IDD/MR/DD/Autism population. I have tried to inform you of my urgent concerns regarding the role of CMS in approving waivers that were in violation of any number of federal statutes beyond CMS's own regulations, particularly the ADA and Olmstead.
On June 12, 2012, the Office of the Inspector General of the U.S. Department of Health & Human Services issued a report entitled, "Oversight of Quality of Care in Medicaid Home and Community Based Services Waiver Programs." I have provided the link to that report and copied the summary posted to the OIG.HHS.GOV web page below. Please see in particular the text I have highlighted in red/underline/bold.
I am once again asking you to stop the further implementation of the NC Innovations waiver. The fact that too much money has already been spent on the ADMINSTRATIVE components of implementation, is no justification for continuing the implementation. None of the LME/MCO's that have already transitioned have been adequately prepared. The absolute proof is NOT whether any one beneficiary has been institutionalized since their transition, but rather, the fact that none of the LME/MCO's is negotiating "enhanced" rates with providers for those beneficiaries who had been receiving CAP-MR/DD Enhanced services. Those Enhanced services are not available in the NC Innovations waiver.
Appendix J: Cost Neutrality Demonstration of the CAP-MR/DD Comprehensive Waiver (CMS NC 0662.R00.02 Jul 01, 2010): d. Estimate of Factor D. i. Non-Concurrent Waiver (chart). This document lists: Enhanced Personal Care Services # Users 366; Respite Nursing LPN # Users 37; Respite Nursing RN # Users 41; and Enhanced Respite Care # Users 415.
PBH, Pam Shipman, stood before the DWAC on Wednesday, June 20, 2012 and said that only 4 persons had a reduction/denial in services due to the transition: "No denials except for 4 requests for services or items not allowed under Innovations." [Link to document: (see page 11) http://www.ncdhhs.gov/mhddsas/providers/1915bcwaiver/dwac/6-20-12/pbh-presentation6-20-12.pdf.]
Please, delay the further implementation of the NC Innovations waiver.
Mary K. Short
828-632-5888 or 704-451-4144 (cell)
http://oig.hhs.gov/oei/reports/oei-02-08-00170.asp
Report (OEI-02-08-00170)
06-21-2012
Oversight of Quality of Care in Medicaid Home and Community Based Services Waiver Programs
Complete Report
Download the complete report: http://oig.hhs.gov/oei/reports/oei-02-08-00170.pdf
Summary
WHY WE DID THIS STUDY
In recent years, States have altered their approach to providing Medicaid-funded long-term care services. Rather than providing the majority of that care in institutions-such as nursing homes-States are now providing more care in homes and other community-based settings. States most often provide this care through 1915(c) home and community-based services (HCBS) waiver programs, and the individuals served by these programs are most commonly disabled and/or over age 65. In fiscal year 2010, Medicaid expenditures for HCBS waiver programs serving this population totaled an estimated $8.9 billion. Strong oversight of waiver programs is critical to ensuring the quality of care provided to HCBS beneficiaries. The beneficiaries who rely on HCBS waiver programs are among Medicaid's most vulnerable, and the nature of these programs puts beneficiaries at particular risk of receiving inadequate care.
HOW WE DID THIS STUDY
States must operate their HCBS waiver programs in accordance with certain "assurances," including three assurances related to quality of care. To meet these assurances, States must demonstrate that they have systems to effectively monitor the adequacy of service plans, the qualifications of providers, and the health and welfare of beneficiaries. We based this study on a review of documents from CMS's most recent quality review of waiver programs from 25 States, as well as information gathered from structured interviews with staff from the 10 CMS regional offices.
WHAT WE FOUND
Seven of the twenty-five States that we reviewed did not have adequate systems to ensure the quality of care provided to beneficiaries. Although CMS renewed the waiver programs in all seven of these States, three did not adequately correct identified problems. Not only did these States fail to correct these problems before renewal of their programs, they also had still not adequately addressed the problems long after renewal. In addition, CMS did not consistently use the few tools it has to ensure that States correct problems related to quality of care.
WHAT WE RECOMMEND
We recommend that CMS: (1) provide additional guidance to States to help ensure that they meet the assurances, (2) require States that do not meet one or more assurances to develop corrective action plans, (3) require at least one onsite visit before a waiver program is renewed and develop detailed protocols for such visits, (4) develop a broader array of approaches to ensure compliance with each of the assurances, and (5) make information about State compliance with the assurances available to the public. CMS concurred with four of the recommendations and partially concurred with our recommendation to require onsite visits.
Mary and her daughter live in NC House District 88 and Senate District 42. Her daughter is being served by Smoky Mountain LME.
From: MaryKShort@aol.com
To: Bev.Perdue@nc.gov, Thom.Tillis@ncleg.net, Phil.Berger@ncleg.net
CC: MaryKShort@aol.com, louis.pate@ncleg.net, justin.burr@ncleg.net, nelson.dollar@ncleg.net, martha.alexander@ncleg.net, william.brisson@ncleg.net, bill.current@ncleg.net, mark.hollo@ncleg.net, pat.hurley@ncleg.net, bert.jones@ncleg.net, marian.mclawhorn@ncleg.net, tom.murry@ncleg.net, fred.steen@ncleg.net, austin.allran@ncleg.net, doug.berger@ncleg.net, stan.bingham@ncleg.net, harris.blake@ncleg.net, jim.davis@ncleg.net, fletcher.hartsell@ncleg.net, eric.mansfield@ncleg.net, martin.nesbitt@ncleg.net, william.purcell@ncleg.net, tommy.tucker@ncleg.net, james.forrester@ncleg.net, andrew.brock@ncleg.net, ralph.hise@ncleg.net, marilyn.avila@ncleg.net, rayne.brown@ncleg.net, tricia.cotham@ncleg.net, beverly.earle@ncleg.net, shirley.randleman@ncleg.net, mitchell.setzer@ncleg.net
Sent: 6/25/2012 11:06:27 A.M. Eastern Daylight Time
Subj: Delay NC Innovations Expansion - URGENT
Dear Gov. Perdue, Speaker Tillis, President Pro Tempore Berger, and ladies and gentlemen of the NCGA:
I have tried over and over again to inform you of the urgent concerns I have had about DHHS/DMA/DMHDDSAS (the Department and its Divisions) in regards to the Medicaid 1915(c) waivers for the IDD/MR/DD/Autism population. I have tried to inform you of my urgent concerns regarding the role of CMS in approving waivers that were in violation of any number of federal statutes beyond CMS's own regulations, particularly the ADA and Olmstead.
On June 12, 2012, the Office of the Inspector General of the U.S. Department of Health & Human Services issued a report entitled, "Oversight of Quality of Care in Medicaid Home and Community Based Services Waiver Programs." I have provided the link to that report and copied the summary posted to the OIG.HHS.GOV web page below. Please see in particular the text I have highlighted in red/underline/bold.
I am once again asking you to stop the further implementation of the NC Innovations waiver. The fact that too much money has already been spent on the ADMINSTRATIVE components of implementation, is no justification for continuing the implementation. None of the LME/MCO's that have already transitioned have been adequately prepared. The absolute proof is NOT whether any one beneficiary has been institutionalized since their transition, but rather, the fact that none of the LME/MCO's is negotiating "enhanced" rates with providers for those beneficiaries who had been receiving CAP-MR/DD Enhanced services. Those Enhanced services are not available in the NC Innovations waiver.
Appendix J: Cost Neutrality Demonstration of the CAP-MR/DD Comprehensive Waiver (CMS NC 0662.R00.02 Jul 01, 2010): d. Estimate of Factor D. i. Non-Concurrent Waiver (chart). This document lists: Enhanced Personal Care Services # Users 366; Respite Nursing LPN # Users 37; Respite Nursing RN # Users 41; and Enhanced Respite Care # Users 415.
PBH, Pam Shipman, stood before the DWAC on Wednesday, June 20, 2012 and said that only 4 persons had a reduction/denial in services due to the transition: "No denials except for 4 requests for services or items not allowed under Innovations." [Link to document: (see page 11) http://www.ncdhhs.gov/mhddsas/providers/1915bcwaiver/dwac/6-20-12/pbh-presentation6-20-12.pdf.]
Please, delay the further implementation of the NC Innovations waiver.
Mary K. Short
828-632-5888 or 704-451-4144 (cell)
http://oig.hhs.gov/oei/reports/oei-02-08-00170.asp
Report (OEI-02-08-00170)
06-21-2012
Oversight of Quality of Care in Medicaid Home and Community Based Services Waiver Programs
Complete Report
Download the complete report: http://oig.hhs.gov/oei/reports/oei-02-08-00170.pdf
Summary
WHY WE DID THIS STUDY
In recent years, States have altered their approach to providing Medicaid-funded long-term care services. Rather than providing the majority of that care in institutions-such as nursing homes-States are now providing more care in homes and other community-based settings. States most often provide this care through 1915(c) home and community-based services (HCBS) waiver programs, and the individuals served by these programs are most commonly disabled and/or over age 65. In fiscal year 2010, Medicaid expenditures for HCBS waiver programs serving this population totaled an estimated $8.9 billion. Strong oversight of waiver programs is critical to ensuring the quality of care provided to HCBS beneficiaries. The beneficiaries who rely on HCBS waiver programs are among Medicaid's most vulnerable, and the nature of these programs puts beneficiaries at particular risk of receiving inadequate care.
HOW WE DID THIS STUDY
States must operate their HCBS waiver programs in accordance with certain "assurances," including three assurances related to quality of care. To meet these assurances, States must demonstrate that they have systems to effectively monitor the adequacy of service plans, the qualifications of providers, and the health and welfare of beneficiaries. We based this study on a review of documents from CMS's most recent quality review of waiver programs from 25 States, as well as information gathered from structured interviews with staff from the 10 CMS regional offices.
WHAT WE FOUND
Seven of the twenty-five States that we reviewed did not have adequate systems to ensure the quality of care provided to beneficiaries. Although CMS renewed the waiver programs in all seven of these States, three did not adequately correct identified problems. Not only did these States fail to correct these problems before renewal of their programs, they also had still not adequately addressed the problems long after renewal. In addition, CMS did not consistently use the few tools it has to ensure that States correct problems related to quality of care.
WHAT WE RECOMMEND
We recommend that CMS: (1) provide additional guidance to States to help ensure that they meet the assurances, (2) require States that do not meet one or more assurances to develop corrective action plans, (3) require at least one onsite visit before a waiver program is renewed and develop detailed protocols for such visits, (4) develop a broader array of approaches to ensure compliance with each of the assurances, and (5) make information about State compliance with the assurances available to the public. CMS concurred with four of the recommendations and partially concurred with our recommendation to require onsite visits.
DMA 8M Public Comment on CAP-I/DD 323
Note: Below is a Public Comment submitted to DMA regarding the 8M Clinical Coverage Policy proposal for CAP-I/DD during the 15 day comment period from July 28 - August 11, 2011. This exert was pulled from it's original source, a public record, and is posted exactly as it appeared, including the commenter's highlights, save the removal of the submitter's personal contact information and abbreviation of last name.
Comment 323
To: Webmedpolicy, Dma
Subject: 8M-CAP-I-DD
Importance: High
Sent: Friday, August 12, 2011 11:46 AM
To Whom It May Concern:
I am a parent of 3 adult males who receive services through the CAP-MR/DD program. They live at home with their Dad and me. I provide paid support services for each one of my sons under home supports ( 2 sons- 9 days mo. each, the 3rd son 12-13 days month) Plus me & their Dad put in countless hrs. of volunteer time. Home Supports has not worked well for my 3 sons. It is not designed for those who have more one person in the home receiving CAP services. I need the flexibility to work with which ever son needs me the most on a given day or divide up a day among 2, sometimes 3 of them for many different reasons (mostly lack of qualified, dependable outside CAP workers, sometimes medical reasons, etc.) “Everybody needs to be on the same page working by the hour so HCS & PC hours can be used by any CAP worker who works with the consumer..” The way things are now the hrs. in POC are divided into too many pots. I am locked in this HOME SUPPORTS POT I can only provide a pre determined days of service to each son per month. For instance say son number (no.) 1 has a need today and I am the only qualified CAP worker available to meet that son’s particular needs, and I have already worked all my allotted number of days with him. I can’t switch son no. 2 that I am working with today over to another CAP worker who is qualified to meet his needs because I have already used all my allotted days for son no. 1. The daily rate I am being paid comes from one pot and her hourly pay comes from another pot, she can meet son no. 2 needs, I can better meet son no. 1 needs, but with all this hoopla there are times when their medically necessary needs are not met, because I am locked in this HOME SUPPORTS POT Also there are times when son no. 3 doesn’t have a CAP worker for several days, I can find a Cap worker for son no.2 & dad volunteers with son no. 1. The problem here is, I am locked into pre alloted days I can work with him. What are we going to do to get their needs met? Another thing, what if something happened to me or another parent and we couldn’t provide HS services for a week or so. The hours locked up in this HOME SUPPORTS POT couldn’t be used by other hab techs to meet the consumer’s PC & HCS needs. Believe me it is virtually impossible to get a CAP worker to provide respite services especially for more than a few hrs.
THIS 8M-CAP-I-DD WAIVER ISN’T DESIGNED TO MEET THE NEEDS OF CONSUMERS WHO ALSO HAVE OTHER PARTICIPANTS LIVING IN THE SAME HOME. “This 40 hour per week thing would really put a hardship upon our family.” . We are always diligently seeking for qualified, dependable CAP workers to work with our 3 sons. Even with me working 7 days per week under home supports we cannot find enough outside help to meet all the hours of their plan of care. It is very difficult to find qualified, dependable CAP workers to work with adult males who are dual diagnosed with some behavior issues at times, plus the job doesn’t pay enough, no benefits and staff have to use their own vehicles & insurance with very little mileage pay. When we can find help someone has to be off a day or 2, a week, sometimes longer, come in late or leave early. Right now I have one worker who is quitting Aug. 27, another one who comes to work very sick and in a few days is going to have to have part of her bowels removed, the other one says she can work 3 days a week. We have no good prospects in sight. It usually takes at least 6 mo. sometimes a year to fill a position. Because of this I can’t seek employment outside the home. Even when I have help I am always on call. Somebody asking me questions, training new staff, juggling everybody’s schedule, the schedule changes several times a month. Also a CAP worker who can work with one of my sons usually isn’t qualified or won’t work with one of the others. There are times if I can get a neighbor or family member to help me a few hours I have paid them out of my own pocket. WE CAN’T LEAVE THEM WITH JUST ANYONE. One of my sons was RAPED, the other 2 SEXUALLY MOLESTED by another CAP worker. My sons have been HIT, VERBALLY & EMOTIONALLY ABUSED, LEFT IN THE CARE OF SOMEONE NOT EMPLOYED BY AGENCY, LEFT IN PARKED CAR WITH MOTOR RUNNING, & LEFT UNATTENDED WHILE HAB TECH TOOK A NAP. “Other parents, grandparents can tell you HORRORS like these also. “ That is why we family members started providing services so our adult children could be taken care of . WE DESPERATELY NEED TO BE PERMITTED TO PROVIDE EVER HOW MANY HOURS OF SERVICES THAT IS NECESSARY TO MEET THEIR MEDICALLY NECESSARY NEEDS ACCORDING TO EACH ONES POC. Other CAP workers are not limited to 40 hrs. per week and it isn’t going to add cost to their POC. Why would any one object to parents/relatives providing "excellent” services over 40 hrs.per week when we can’t find qualified, dependable outside CAP workers to do so? “ Which in our case is every week.” OUR SONS VERY MUCH WANT TO LIVE AT HOME WITH US. IT ISN’T THE EASIEST ROAD FOR US TO TRAVEL. HOWEVER, WE WANT THEM TO BE CARED FOR IN THE LEAST RESTRICTIVE ENVIRONMENT POSSIBLE AND FOR THEIR RIGHT TO MAKE A CHOICE FOR THEIR CARE NOT BE VIOLATED.Here we are devoting our whole lives to our adult children, who have been violated by CAP workers and it seems like you expect us to volunteer more and more of our time. There are parents who have put their adult children in state care 24/7 who are able to keep them at home. If you expect all this volunteer time from us then you should send those adult children back home for their parents to take care of them also. What about AFL Homes they are paid 24/7. Our 3 sons are going to be in danger of being put into state care 24/7 if I am cut to 40 hrs. per week. PLEASE BAN THIS 40 HR. LIMIT ON FAMILY CAP WORKERS OR PLEASE MAKE AN EXCEPTION FOR FAMILIES LIKE OURS WHO HAVE EXTENUATING CIRCUMSTANCES. Even when I have to provide 84 hrs. per wk. of CAP services among 3 adult sons. I & their Dad are still volunteering dozens of hrs. per wk. I can provide letters from others about the quality of care I provide and the endless effort I make to keep them included in the community. I travel 500 + hrs. per month to make sure their POC is met. Both you and I don’t want them to be socially isolated. I don’t provide care so I can profit. Everything I do & everything I have is for them. However, if I am restricted to 40 hrs. per week there is going to be a lot of social isolation here because of lack of qualified, dependable, outside of family, CAP workers available to provide services. Even now there are times when we have 2 CAP workers besides me I am the one who has to provide the transportation for everybody. I cannot continue to do this if I am limited to 40 hrs. per week.
The 8M-CAP-I-DD waiver section H d. states that the PERSON CENTERED PLAN shall outline measures that ENSURES THE PARTICIPANT’S CHOICE and CONTROL OVER HIS DAILY LIFE and PROMOTE COMMUNITY INTEGRATION. In our case when I, the mother am the only qualified CAP worker available to provide services (this happens every week) and if 8M-CAP-I-DD won’t let me provide paid services (over 40 hrs. per wk.) then my 3 SONS CHOICE & CONTROL OVER THEIR DAILY LIVES WILL BE VIOLATED & THEY WILL BE SOCIALLY ISOLATED.
The issue of CAP workers not providing respite services if they accompany family on out of state on vacation because , family caregiver, is present. In our case we desperately need staff to accompany us. We have 3 sons who need one on one attention therefore, we are technically not really there for the son who has a CAP worker with him. We are there for the other 2 sons. Words cannot articulate how extremely important it is for the boys to get to go on vacation. How much it helps them emotionally . It is getting more difficult for us to handle it. Especially if we have an emergency. For our SONS’ SAFETY & WELLBEING Will you PLEASE! PLEASE! reconsider this policy especially for families with multiple CAP recipients and make an exception
PLEASE DON’T VIOLATE OUR ADULT CHILDREN’S RIGHT TO HAVE CHOICE & CONTROL OVER THEIR DAILY LIVES, NOR IMPOSE REGULATIONS (like limit family members to 40 hrs. per week) THAT WILL CAUSE SOCIAL ISOLATION, BECAUSE THEY CHOOSE TO LIVE AT HOME WITH THEIR PARENTS AND CHOOSE FAMILY MEMBERS TO PROVIDE “EXCELLENT” CAP SERVICES TO MEET THEIR MEDICALLY NECESSARY NEEDS ACCORDING TO THEIR PLAN OF CARE. PLEASE REMEMBER THE DECISIONS YOU MAKE EFFECT VENERABLE PEOPLE’S LIVES WHO CAN’T HELP THEMSELVES
YOUR DECISIONS CAN GIVE THEM GOOD QUALITY OF LIFE OR MAKE THEM MISERABLE. MAY GOD HELP US ALL !!!
I know I have rambled a bit. I hope you can understand our unique situation. If you have any questions Please Contact Me.
Margaret H.
Mount Airy, N.C.
P.S. What if I mother/legal guardian move out of family home or into apartment B. Would I still be limited to 40 hrs. per week? Do you think this will help the CAP recipients in our home?
DMA 8M Public Comment on CAP-I/DD 294
Note: Below is a Public Comment submitted to DMA regarding the 8M Clinical Coverage Policy proposal for CAP-I/DD during the 15 day comment period from July 28 - August 11, 2011. This exert was pulled from it's original source, a public record, and is posted exactly as it appeared save the removal of the submitter's personal contact information and abbreviation of last name.
[ More on DMA Public Comments. ]
Comment 294
To: Webmedpolicy, Dma
Subject: 8M-CAP-I-DD
Importance: High
Sent: Thursday, August 11, 2011 10:01 PM
Attached, please find a document detailing my concerns regarding the new 8M-CAP-I-DD policy.
The new proposed 8M CAP Policy to take effect in November 2011 is a devastating blow to families affected by a developmental and/or physical challenge. It is incomprehensible how my daughter, Chelley, age 12, diagnosed with Autism, will escape being institutionalized. How is it that this great government of ours will rush to the aid of other countries in need, but cannot recognize the great need in THIS country? I have an enormous amount of concern about how inhumane this new policy will be towards those not classified as “typical”. It’s almost as if we are living in a Hitler regime, where those not deemed to fit a certain class or characteristic should be punished is some way, because they are looked upon as degrading the race or inferior to what they call “normal”. What kind of world have we become when compassion and humanity can only be expressed in the public eye to impress other nations, and not an actionable standard at home? I am ashamed to say that this country’s standards/motives reflect nothing that our forefathers fought for.
Below, I have outlined how this new policy will negatively impact my child, my family, my life (if that’s what one would even call it).
Concerns with the proposed 8M CAP Policy:
Marie P.
[ More on DMA Public Comments. ]
Comment 294
To: Webmedpolicy, Dma
Subject: 8M-CAP-I-DD
Importance: High
Sent: Thursday, August 11, 2011 10:01 PM
Attached, please find a document detailing my concerns regarding the new 8M-CAP-I-DD policy.
The new proposed 8M CAP Policy to take effect in November 2011 is a devastating blow to families affected by a developmental and/or physical challenge. It is incomprehensible how my daughter, Chelley, age 12, diagnosed with Autism, will escape being institutionalized. How is it that this great government of ours will rush to the aid of other countries in need, but cannot recognize the great need in THIS country? I have an enormous amount of concern about how inhumane this new policy will be towards those not classified as “typical”. It’s almost as if we are living in a Hitler regime, where those not deemed to fit a certain class or characteristic should be punished is some way, because they are looked upon as degrading the race or inferior to what they call “normal”. What kind of world have we become when compassion and humanity can only be expressed in the public eye to impress other nations, and not an actionable standard at home? I am ashamed to say that this country’s standards/motives reflect nothing that our forefathers fought for.
Below, I have outlined how this new policy will negatively impact my child, my family, my life (if that’s what one would even call it).
Concerns with the proposed 8M CAP Policy:
- Enhanced Care: In 2010, Chelley had 100+ appointments. She was in the ER a few times and was hospitalized 6 times during the latter part of 2010. As a result of battling with an array of illnesses, she was only able to attend school SIXTEEN (16) days this past academic year. I am twice divorced to 2 cowardly men. I work two steady jobs, and during tax season, that goes up to 3 steady jobs. I am the primary caretaker of my 87 year old widowed father, and my 23 year old daughter, Christine, still in college, who we recently informed me, is expecting a child in October! (This just means another dependent to care for in the very near future). Because of my busy schedule and family responsibilities (both physically and financially), I am dependent of professional care for my daughter Chelley. Her health is very fragile, and the need for quality care is essential. Without the right enhanced services in place, I would have to quit all my jobs and stay home and care for her myself. And that would only lead me to be dependent on public assistance, which in turn would not be able to pay for her care, our home, basic standard of living...so that’s not an option. So the only alternative would be to institutionalize Chelley, which would NOT provide her with quality of life, and where she feels most acclimated and safe. This option is also against Chelley’s wishes and the family’s wishes. And that would be a tremendous cost to the government in the end. Eliminating Enhanced Care would have a tremendous NEGATIVE impact!
- Home Supports: The change back to coupled services is the best thing going in this new waiver!
- Habilitation Limitation: The maximum habilitative limit coupled with maximum personal care limit is clearly not enough for me to work my 2-3 jobs. The purpose of my working these additional jobs is to be able to supplement for Chelley’s care....which to me...is doing the government a favor. Because if she is institutionalized, that financial burden will fall in the good old US government’s lap. (Reminder: an institution is against Chelley’s and the family’s wishes) A typical family working member is required to work a 40 hr week outside of the home and come home from work and provide another 80 hrs a week to care for a disabled loved one. Because I don’t have a typical work week, my number of hours is substantially greater. Chelley is in need of consistent long-term person centered care!! Children with disabilities learn at a slower rate than the average person but yet the highest need individual can only receive 129 hrs per month? And I understand that there will be no exceptions? Whatever happened to the person centered approach??? These limitations surely support my belief of us living in a Hitler society. How can anyone deem that one set amount of time is suitable to everyone....regardless of their limitations, their dependencies, their abilities, etc.? Our children, both adults and minors, need additional care for a lifetime and it needs to be person centered so they can become productive in their community! Our children’s needs are great!!! Many individuals, specifically my daughter, will lose their freedom and possibility their life if this new waiver should take effect!
- Personal Care Limitation: Please refer to my notes in Habilitation Limitation. Just to reiterate....The UR limits will cause many to be institutionalized!!!! My daughter will be one of them! This negative impact will be the detriment of not only my daughter, but my family....society will miss out of gaining a wonderful viable member; the government will be greatly impacted financially, etc. But more importantly, an institution is against Chelley’s and the family’s wishes.
- Family Member: If it were not for the love of family, I think that my daughter would be a forgotten person in our society. We are quick to sweep problems under the rug so to speak and ignore people who are truly in need. But thank God that Chelley is loved by her family, and we are willing to stand up for her and protect her and provide her with the individual care that she needs. The BEST care that Chelley receives is from her family, because we have the patience, and the knowledge of her individual care, and always make the decisions which best fits her individual requirements. But this new policy seeks to limit the individual care provided by family members. This is not even logical!! What external staff will be willing to stay up hours upon hours each and every night when a child’s sleep patterns is only 3-5 hours? What external staff will be willing to sacrifice their time to fill out endless paperwork, attend grueling appointments/meetings, sacrifice not ever taking a vacation, etc.? External staff will not endure the pain and heartache that family members endure for the sake of caring for a loved one? And what about when qualified staff cannot be found, or are in transition? Who picks up the slack? How in anyone’s right mind would it be a good idea to punish the work and time that families put in for the care of their loved one?
- Home Modifications: How is the 15,000 factored into the budget? Does it go toward the total cost of the current budget year? For example, participant current budget is 125000 without home modifications. Home modification is 13,000. This puts current budget 138000 but less than 15000 in 5 years. Would this case a denial in Home Modifications/Services? Although this does not personally apply to my daughter, it is still concerning. For example a specialized bathroom for a person who truly needs it, is not a luxury item and but rather is needed for health and safety. Adding an assessable bathroom into an existing bedroom should be added to the inclusive list. This would not be needed or provided for another child in an average home. Without this it would jeopardize the health and safety of the individual and put an individual at risk of institutionalization.
- Respite: Restricting how Respite is to be used is purely inhumane! I work 2-3 jobs, work countless additional hours in the home caring for my daughter, don’t have options for vacation because of my unique family situation, have daily interruption of sleep, etc....and yet the state dares to think that I should not be entitled to some occasional respite to get some relief at my discretion???? Currently there is no other service that would be appropriate....and the reason why I and other families cherish every moment that can be had from respite care. And if I may add, those respite hours are not always spent resting...which is a novel idea....but I use those hours to give me time to grocery shop, to clean my house, to fill out paperwork, to cook, to do laundry, to care for other family members in my home, etc. It is impossible to accomplish all that I do for my daughter without having some occasional free time (if I can even call it that). With the past waiver, how many “typical” families can say they could survive on just 576 hrs per year of down time? It would be unfathomable!!!! I’d like to meet the person or committee who agreed to enforce this restriction. I would love to have them visit me and stay for a while to truly evaluate whether their decision was conscionable!!!
- 2.0 Eligible Participants: for the CAP waiver notes “Waiver-Specific Requirements” A person with mental retardation, developmental disabilities, or both may be considered for CAP-I/DD funding if s/he fulfills all of the following criteria: Can maintain his or her health, safety, and well-being in the community with the program”. Please clarify! If I am reading this correctly it states that individuals with great need will no longer be eligible for wavier services and will have no choice but to live in an institution. What does this mean for current participants that have high needs? Is there specific criteria that drives this statement? Who and or what makes that determinations; an individual; a committee; a dollar amount?
Marie P.
24 June 2012
DMA 8M Public Comment on CAP-I/DD 227
Note: Below is a Public Comment submitted to DMA regarding the 8M Clinical Coverage Policy proposal for CAP-I/DD during the 15 day comment period from July 28 - August 11, 2011. This exert was pulled from it's original source, a public record, and is posted exactly as it appeared save the removal of the submitter's personal contact information and abbreviation of last name.
Comment 227
To: Webmedpolicy, Dma
Subject: Proposed Changes
Sent: Wednesday, August 10, 2011 2:52 PM
I certainly understand the challenges of continuing to provide a full array of appropriate and necessary services via the CAP-MR/DD waiver in this most difficult economic climate. But, a number of the proposed changes to the CAP waiver need to be reconsidered due to the potential, and likely, negative impact they will have on consumers of service, and their families.
First, the removal of Home Supports seems to be antithetical to one of the primary intents of the waiver (i.e., assist individuals in continuing to reside in their community). For many families, this service is the only thing that prevents them from having to place their child in a more restrictive setting (e.g., Group Home). Ironically, in order to be placed in a group home, the CAP consumer would need to receive Residential Supports. Given that Residential Supports is almost identical to Home Supports, it seems illogical that the proposed waiver change would force an individual to move to a group home in order to receive essentially the same service they used to receive at home. Moreover, given that most individuals receiving Home Supports receive more hours per week than parents would be allowed to work (40 hours), per proposed changes to the waiver, additional staffing would be needed to meet the previously determined medical needs of the individual. On the surface, it makes no sense to force families to have outside staff come into their home to work with their family member due to an arbitrary determination that family members can work no more than 40 hours per week (providing a combination of HCS and Personal Care). The reality, which is known to all of us, is that parents already work many more hours with their family member than is required by the various Home Supports levels. Thus, the 40 hour limit seems rather arbitraty and solely designed to reduce costs.
Second, the removal of enhanced serviceswill almost certainly lead to increased rates of out-of-home placements. I understand that the State wishes to decrease costs by eliminating this service, but the higher rate of pay for enhanced services helps to ensure agencies can afford to provide families/staff with consultation/supervision by the professionals (e.g., nurses, psychologists) required by this service. Without the enhanced rate, agencies will not be able to provide the additional consultation and training required to ensure staff are competent to provide needed supports, and thus individuals' needs will go unment. As needs go unmet, consumers of CAP services will experience increased behavioral and medical challenges. And these challenges will result in increased rates of institutional/emergency/out-of-home placement. I understand the Innovations waiver does not include enhanced services, but I do not feel that the desire to have the CAP waiver closely match the Innovations waiver is sufficient reason to simply discontinue a service that is critical in helping many individuals to continue to reside in their communities.
On onother topic, the State has done a woeful job of informing families and consumers of proposed changes. Most families and consumers of service have no idea that the State is even proposing changes to the CAP waiver. Because of this, the vast majority of consumers and families will have had no opportunity to provide input regarding the State's proposed changes. To implement any changes without ensuring all vested parties have been directly contacted by the State regarding proposed changes, and thus have had the opportunity to provide comment, is unfair and certainly poor practice.
Finally, the new waiver makes reference to Behavioral Analysts as professionals who can provide CAP services. As has been communicated on numerous occassions by various parties, the practice of behavioral analysis, per the NC Psychology Practice Act, considered the practice of psychology. As such, it is illegal for anyone not licensed as a psychologist, or not supervised by a psycyhologist, to provide behavior analytic services. The only caveate is that other professionals certified/licensed by a regulatory board would be exempt from the authority of the Psychology Practice Act. If, of course, behavior analysis was within their scope of practice. Behavior Analysts, however, are not covered by any NC regulatory board. Thus, it is my understanding that it would be inappropriate to include them in the list of professionals who are eligible to bill for CAP services.
Edward H.
09 May 2012
Federal Government changes re Long Term Care
May 9, 2012
From: Mary K. Short [MaryKShort@aol.com]
Subject: Federal Government changes re Long Term Care
I would like you all to read the information below. I have been following the changes that are talked about. I have been sending you all some information about what is happening at the federal level ... even The Arc put the information about the new Administration on Community Living (ACL) in their Action Alert. On April 17th I sent an email with the press release about the new ACL to Rep. Dollar and Rep. Avila asking them to use that information as a basis for stopping the further implementation of this move to Managed Care! I asked for them to consider the idea of moving IDD to Dept. of Aging or Dept. of Long Term Care because that is the direction the feds are taking. (http://www.hhs.gov/news/press/2012pres/04/20120416a.html.)
The information is from Steve Gold, an ADA attorney in PA, http://www.stevegoldada.com, is clear. Please use this information when you contact your Legislators! This is about NOT moving us to a capitated managed care system.
828-632-5888 or 704-451-4144 (cell)
From: ncadvocacy@yahoogroups.com
Reply-to: notify-dg-ncadvocacy@yahoogroups.com
To: ncadvocacy@yahoogroups.com
Sent: 5/9/2012 6:22:25 A.M. Eastern Daylight Time
Subj: [ncadvocacy] Digest Number 2011
Messages
________________________________________________________________________
1. Fw: [NYAPRS Enews] Gold Urges States to Adopt Community First Choice
Posted by: "lauriecoker"
Date: Tue May 8, 2012 7:18 am ((PDT))
The Centers for Medicare and Medicaid announced this funding program, the "Community First Choice" option, just last week. It is a funding option that would specifically impact our citizens who could live independently with some services rather than being housed in large facility settings such as many of our adult care homes or "assisted living" facilities. It aims to impact states like ours, New York, and others that have become dependent on the convenience of placing people in "homes" -- some of which have 100 plus beds!
New York, which has had a similar ruling by the DOJ to ours about the institutional bias and limiting rightful choices for citizens, is planning to use this to change their behavior.
We could use this to help us in the very near future, but we have to advocate for it!
See some of Steve Gold's strategy suggestions re: this opportunity, below. It may be time to build a cross-disability coalition to bring change.
Please talk to decision-makers about using dollars for services in real community settings so that individuals can envision personal lives with goals and hopes. It costs less to the taxpayer, and surely less to the person who wishes to live differently than in a facility based setting.
Laurie Coker
Director, NC CANSO
North Carolina Consumer Advocacy, Networking, and Support Organization
Citizen self-advocacy and empowerment - State-wide from Winston-Salem
There is no more blessed bondage than to be a prisoner of hope. --R .Z. Kemp
----- Forwarded Message ----
Sent: Tue, May 8, 2012 7:50:39 AM
Subject: [NYAPRS Enews] Gold Urges States to Adopt Community First Choice Programs
NYAPRS Note: New York State officials have already committed to adopting the CFC program, which will also apply to those at risk for residing in what’s called an IMD (institute for mental disease) that includes facilities over 16 beds.
Community First Choice Regulations Published.
Steve Gold May 2012 Information Bulletin # 357
Let's hear the trumpets and the Halleluiahs chorus.
Finally, the Department of Health and Human Services / Centers for Medicare & Medicaid Services issued the final regulations for the Community First Choice option. The regulations state that CFC's scope is designed to make available home and community-based attendant services and supports to eligible individuals, as needed, to assist in accomplishing activities of daily living, instrumental activities of daily living, and health-related tasks through hands-on assistance, supervision, or cueing.
CMS listed CFC's Total Benefits as providing States with additional flexibility to finance home and community-based services and attendant services and supports. The regulations state that CFC will increase State and local accessibility to services that augment the quality of life for individuals through a person-centered plan of services and various quality assurances. CMS further noted that CFC reduces the financial strain on States and Medicaid participants.
CFC is a win-win for States to save money and for people who need community-based and attendant services to stay in their homes and apartments.
For many years, the Community First Choice was strongly supported and initiated by ADAPT, a national grass roots organization of people with disabilities of all ages and all disabilities. ADAPT organized large numbers of supporters, testified before Congressional committees, and last week demonstrated in front of HHS's Washington offices demanding CMS release CFC's regulations.
Now that the federal regulations have been released, the struggle shifts to you disability and aging advocates in each State - to make sure this program is implemented in your State. Nothing happens automatically. Unless advocates demand CFC state-by-state, it will not happen. Yes, another local effort but quire worth the effort.
Here's why your State should amend its Medicaid Plan to include the CFC the federal government will pay an additional 6 percentages to your State's Federal Medical Assistance percentages. (Go to http://aspe.hhs.gov/health/fmap.htm to see what the FMAP is now WITHOUT the additional six points.) That translates into a LOT of federal money!
Another reason: yes, your State can save a lot of State funds while at the same time complying with the ADA/Olmstead requirements to prevent unnecessary isolation and institutionalization of people with disabilities.
Here's a brief summary of the final regulations:
- CFC provides home and community-based attendant care services and supports to persons with disabilities.
- Such services must assist the individual with activities of daily living, instrumental activities of daily living (e.g., shopping cleaning) and health-related tasks.
- States can provide, at the State's option, transition costs (rent and utility deposits, first months rent/utilities, basic kitchen/bedding needs).
- Individual eligibility requires that the person with a disability meets your State's institutional level of care criteria. The person need not be in the institution nor packing their bags or at risk of being imminently institutionalized. If the person meets the level of care for the institution, the CFC services can be provided.
- Individual financial eligibility is the same as what your State has established for the institution.
- Under the CFC, States must use a person-centered service plan and the services must be self-directed, either with a self-directed service budget or an agency-provider model.
- This plan must be in writing and agreed to by the individual and must be based on a functional needs assessment. The regulations state that the person-centered service plan must reflect the services and supports that are important for the individual to meet the needs identified through an assessment of functional need.
- These plans must be reviewed, and revised upon reassessment of functional needs, at least every 12 months, when the individual's circumstances or needs change significantly, and at the request of the individual.
What advocates must do:
- Your State Medicaid Plan must be amended to include the CFC. Advocates should be at the table to ensure the services meet your needs.
- You need a statewide, multi-disability coalition and strategy to ensure your State amends its Medicaid plan to include the CFC. If your State does not already have such a coalition, the CFC presents an opportunity to develop one.
- If your State has such a coalition, convene it!
- You need to show your Governor why s/he should amend your State's Medicaid plan to provide CFC services. This will require real live people who want and need CFC services. They must be ready to speak out. CFC is a critical opportunity to end waiting lists.
- You should get to your media and explain how this program will save your State money, while bringing into your State additional Federal funds.
Steve Gold, The Disability Odyssey continues
Back issues of other Information Bulletins are available online at http://www.stevegoldada.com.
FYI: This is the link to the actual regulation (45 pages!) It is still open for public comment and if you click on the link, there is a section that explains how to make public comment. This is about multiple populations ... elderly, other adult disabled, and IDD. This relates with the federal move to an "Administration on Community Living" department that was created.
FYI: This is the link to the actual regulation (45 pages!) It is still open for public comment and if you click on the link, there is a section that explains how to make public comment. This is about multiple populations ... elderly, other adult disabled, and IDD. This relates with the federal move to an "Administration on Community Living" department that was created.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
42 CFR Parts 430, 431, 435, 436, 440,
441, and 447
[CMS–2249–P2]
RIN 0938–AO53
Medicaid Program; State Plan Home
and Community-Based Services,
5-Year Period for Waivers, Provider
Payment Reassignment, and Setting
Requirements for Community First
Choice
AGENCY: Centers for Medicare &
Medicaid Services (CMS), HHS.
ACTION: Proposed rule.
08 May 2012
Parent Perspective: Parent Letter from K.Feller
A couple of months back, I received a heartfelt letter from a local special mom of two boys with Autism to deliver and share with Dr. Pat Porter in one of my meetings. I am posting with her permission. Thank you Kimberly!
RE: Concerns with NC HB 916
My name is Kim Feller and I live in Wake County. I am writing to you because I have two sons who both have autism and are covered by the Medicaid CAP Waiver program. Nick is 14 years old and James is 11 years old. I am concerned about the NC HB 916 which will greatly affect services. Both of my boys participate in several different therapies including occupational, speech, and social skills therapies. Also, they both take different medications for the treatment of aggressive behaviors, anxiety, and seizures. My youngest son who is 11 years old recently had a temporary residential placement at the Murdoch Developmental Center in Butner, NC where he stayed for three months. He was placed there due to aggressive behaviors which we were unable to handle at home. He is living back home again only because we have home staff provided through the Medicaid CAP Waiver program. We feel very fortunate that both our sons are currently covered by the Medicaid CAP Waiver program. The CAP Waiver program has been critical in providing our boys Home and Community services as well as funding for the aforementioned therapies, medicines, and residential services. These services support individuals in their home and community and avoid more costly institutional settings. Provider agencies just took an almost 3% rate cut on November 1, 2011, in addition to a 5% cut a few years ago. We are concerned that the cut to Home & Community service hours will make it difficult to retain the quality service providers we need to care for our boys. Working with children who have autism requires a certain level of commitment, sensitivity, and resilience which must be compensated accordingly. Also, the DHHS has recently implemented new limits on the number of hours our sons can receive. This concerns us a great deal because our youngest son needs constant supervision. If we don’t have enough home support hours the chances of our son reverting back to his prior aggressive behaviors will be greatly increased. It is much more economical to pay home staff than it is to pay for a residential placement!
The 1915 (b)(c) managed care waiver proposes that a single entity with a financial interest to keep funding low will determine eligibility for services, control who can provide services, develop the Person Centered Plan, and decide the level of funding. This is of concern to us because the decision makers would work for the Local Management Entity (LME) which has a financial interest to contain costs. There needs to be a decision maker representing solely the interests of the person with the disability as is currently happening with the Case Managers. The new plan should recognize the integrity of the Developmental Disability model by excluding Case Management from the Managed Care Entity and separating Developmental Disability from Mental Health and Substance Abuse. Developmental Disability is not an illness, and therefore should not be combined with Mental Health and Substance Abuse.
We appreciate any efforts you can make toward avoiding cuts in Home & Community Service hours as well as excluding Case Management services from the Managed Care Entity.
Thank you for your time and efforts.
Sincerely,
Kimberly H. Feller
contact info...
Parent Perspective
March 1, 2012RE: Concerns with NC HB 916
My name is Kim Feller and I live in Wake County. I am writing to you because I have two sons who both have autism and are covered by the Medicaid CAP Waiver program. Nick is 14 years old and James is 11 years old. I am concerned about the NC HB 916 which will greatly affect services. Both of my boys participate in several different therapies including occupational, speech, and social skills therapies. Also, they both take different medications for the treatment of aggressive behaviors, anxiety, and seizures. My youngest son who is 11 years old recently had a temporary residential placement at the Murdoch Developmental Center in Butner, NC where he stayed for three months. He was placed there due to aggressive behaviors which we were unable to handle at home. He is living back home again only because we have home staff provided through the Medicaid CAP Waiver program. We feel very fortunate that both our sons are currently covered by the Medicaid CAP Waiver program. The CAP Waiver program has been critical in providing our boys Home and Community services as well as funding for the aforementioned therapies, medicines, and residential services. These services support individuals in their home and community and avoid more costly institutional settings. Provider agencies just took an almost 3% rate cut on November 1, 2011, in addition to a 5% cut a few years ago. We are concerned that the cut to Home & Community service hours will make it difficult to retain the quality service providers we need to care for our boys. Working with children who have autism requires a certain level of commitment, sensitivity, and resilience which must be compensated accordingly. Also, the DHHS has recently implemented new limits on the number of hours our sons can receive. This concerns us a great deal because our youngest son needs constant supervision. If we don’t have enough home support hours the chances of our son reverting back to his prior aggressive behaviors will be greatly increased. It is much more economical to pay home staff than it is to pay for a residential placement!
The 1915 (b)(c) managed care waiver proposes that a single entity with a financial interest to keep funding low will determine eligibility for services, control who can provide services, develop the Person Centered Plan, and decide the level of funding. This is of concern to us because the decision makers would work for the Local Management Entity (LME) which has a financial interest to contain costs. There needs to be a decision maker representing solely the interests of the person with the disability as is currently happening with the Case Managers. The new plan should recognize the integrity of the Developmental Disability model by excluding Case Management from the Managed Care Entity and separating Developmental Disability from Mental Health and Substance Abuse. Developmental Disability is not an illness, and therefore should not be combined with Mental Health and Substance Abuse.
We appreciate any efforts you can make toward avoiding cuts in Home & Community Service hours as well as excluding Case Management services from the Managed Care Entity.
Thank you for your time and efforts.
Sincerely,
Kimberly H. Feller
contact info...
* If you are a parent or caregiver with a story to contribute, have correspondence exchanges with legislative members you would like to share, please contact me at no2nchb916@gmail.com.
09 April 2012
email from Dr. Pat Porter
09 April 2012
Received via email from Dr. Pat Porter, DHHS consultant to the NC General Assembly:
Hello
Crystal, I followed up on your question regarding the rates of pay for
direct care workers per the changes in approved service definitions.
While this seems to be resolved for now, there were a couple of issues
that caused some confusion with the transition of ECBH to the B-C
Innovations Waiver.
The
CAP IDD waiver is not a perfect crosswalk to the Innovations waiver.
In the CAP Waiver, recipients have had access to Home and Community
Support (HCS), which is primarily a habilitative service with a very
small amount of personal care (PCS) blended in. (CAP IDD also has the
basic PCS). So, HCS in CAP cross-walks to In-home Skill Building and
PCS in the Innovations waiver. In-Home Skill Building (a hab service)
pays more than PCS.
As ECBH was cross-walking the services during transition, they cross-walked much of the HCS to PCS, rather than In-Home Skill Bldg. Again, HCS/In-Home Skill Bldg. pays a higher rate than PCS. But, there was a reason for this. ECBH could find very few habilitation goals on the plans being reviewed and, unfortunately, they found little or no evidence of assessments supporting the recipient's ability to benefit from habilitation. Based on the assessment information they found, it appeared that most recipients were actually receiving more PCS than hab. As you know, the Managed Care sites must pay for the actual services needed and rendered.
With further review and technical assistance from the Division of Medical Assistance, ECBH elected that the wisest course of action on behalf of their consumers would be to cross-walk HCS directly to In-Home Skill Bldg for ease of transition. I am told that these cross-walked plans will last for the remainder of the plan year. This is the action that had already been taken by Western Highlands and PBH as they made these transitions. I am told that ECBH alerted the providers in a March 22 Communication and in a town-hall meeting in Greenville but, apparently, not everyone has gotten the word yet.
As ECBH was cross-walking the services during transition, they cross-walked much of the HCS to PCS, rather than In-Home Skill Bldg. Again, HCS/In-Home Skill Bldg. pays a higher rate than PCS. But, there was a reason for this. ECBH could find very few habilitation goals on the plans being reviewed and, unfortunately, they found little or no evidence of assessments supporting the recipient's ability to benefit from habilitation. Based on the assessment information they found, it appeared that most recipients were actually receiving more PCS than hab. As you know, the Managed Care sites must pay for the actual services needed and rendered.
With further review and technical assistance from the Division of Medical Assistance, ECBH elected that the wisest course of action on behalf of their consumers would be to cross-walk HCS directly to In-Home Skill Bldg for ease of transition. I am told that these cross-walked plans will last for the remainder of the plan year. This is the action that had already been taken by Western Highlands and PBH as they made these transitions. I am told that ECBH alerted the providers in a March 22 Communication and in a town-hall meeting in Greenville but, apparently, not everyone has gotten the word yet.
At
some point soon, ECBH will be compelled to address the
habilitation/PCS issue. Perhaps this will occur in Annual Revisions.
Care Coordinators have been alerted to pay attention to additional
assessments that may be needed to support habilitation goals. Be
assured that the Care Coordinators will develop plans based on what the
recipient needs and wants ( that’s the rule). Utilization Management
may, however, deny a habilitation service if there is not demonstrated
medical necessity per CMS rules. Certainly, if that should occur, ECBH
will offer review and appeal rights. The DHHS will be monitoring the
process to assure due process.
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