ABCD’s
Comments on Amendments to the Community Care Waiver
The Alliance for the Betterment of Citizens with
Disabilities (ABCD) appreciates the opportunity to comment on the draft
proposal for amendments to the Community Care Waiver (CCW). ABCD has raised concerns in the past that New
Jersey may not be maximizing its federal revenues under the current CCW. Upon review of the proposed changes to the
CCW, we do believe that the Division of Developmental Disabilities (DDD) is
moving forward to ensure that we maximize federal revenues from the CCW. Specifically, we are pleased that DDD is
putting in amendments that will allow Real Life Choices to be funded through
the waiver. In addition, ABCD is pleased that DDD plans to use an ABCD proposal
to allow family members residing in the home to render services to an
individual. We believe that these and
other amendments will support people with developmental disabilities who live
at home with their families.
We do have some additional comments/amendments that
we would like to propose for DDD’s review and consideration prior to sending in
amendments to the Centers for Medicare and Medicaid Services (CMS). Below are a series of issues that we believe
should be included in the CCW. We have
provided you with references to other States that provide these services, if available. Even though we do understand that each
Medicaid Waiver is different, we believe that it is important for New Jersey to
explore these options to allow for the greatest maximization of federal
revenues and to provide for the broadest service array for people with
developmental disabilities and their families.
Caregiver
Training and Education:
This can be offered as a distinct service under the CCW. The service could include: 1) underwriting
the costs of trainers coming into the home to teach skills and techniques for
addressing the individual’s needs (training can be customized for the
individual and their caregiver); 2) underwriting the registration and material
costs for caregivers to attend special trainings and educational classes; and 3)
paying the expenses associated with caregivers attending workshops or
conferences.
This caregiver training could be used for
nutritional services and behavioral services if DDD included these specific
services in the CCW. Below is a brief
description of these services.
Consultative Services
Professionals in psychology, nutrition,
counseling, and behavior management provide consultation activities. The
service may include the development of a home treatment/support plan, training
to carry out the plan and monitoring of the individual and the provider in the
implementation of the plan.
Nutritional
Services: This service
has many aspects that could potentially be paid for through the CCW including
home delivered meals, nutrition counseling, and nutrition risk reduction. For example, Iowa
and Maryland provide medical nutrition therapy (nutrition care planning,
nutrition assessment and dietetic instruction).
Illinois provides training and counseling in nutrition services for
unpaid caregivers.
Behavioral
Services: The
proposed amendments to the waiver makes not provision for behavioral or social
deficits in determining either need or scope of services. This prevents individuals with secondary
psychiatric disorders as well as many individuals diagnosed with autism
spectrum disorders from receiving services under the waiver as their needs
cannot be properly diagnosed nor served.
Behavioral services could be included, in addition to the Medicaid State Plan mental
health services, and could include consultative therapies and family and
individual training such as psychology, counseling and behavior management. States
are permitted to use the extended state plan provision to cover the same
services in the waiver as the State Plan but in greater amount scope and
duration of coverage. DDD should work
with Medicaid and the Division of Mental Health Services to ensure the best
coverage for people with developmental disabilities.
Environmental/Vehicle
Modifications in Combination with Assistive Technology Devices
DDD requested comments on the proposal to limit
expenditures to $11,000 every three years, with the possibility of exceptions
being made for issues of health and safety.
ABCD believes that the cap on expenditures is too limited and requests
$5,000 per year for each of the three modifications/devices, totaling $15,000
per year. The Division could include prior
authorization if there is a concern about cost containment.
During our research, ABCD found that Connecticut’s
waiver included vehicle modifications up to $10,000 over a three year period;
specialized medical equipment and supplies at $750 a year with up to $3,000
over three years (with prior approval); and environmental modifications up to
$10,000 a year over three years. Based
on a review of Connecticut’s waiver manual, that State does not limit the total
utilization of all three services together.
In 2005, Virginia proposed changes to its waiver which would allow a
$5,000 limit per year for environmental modifications and a $5,000 per year
limit for assistive technology. It is
unclear from our research if Virginia received its waiver. According to a report by ASPE, in the US
Department of Health and Human Services, Illinois has a $15,000 cap over five
years for all services. We do understand
that some states have life time caps on environmental modifications and/or
assistive technology (including a life time cap of $10,000 for assistive
technology in Pennsylvania). However, we
do not believe that a lifetime cap is reasonable, but instead believe that a
prior authorization may be in order.
Transition
Services
ABCD is pleased that DDD is including Transition
Services in the CCW. We agree that it is
important to ensure that non-recurring expenses, for individuals transitioning
from Developmental Centers, which are eligible for FFP are maximized. We do believe that additional changes could
be added to allow for transition into any community residence including group
homes. ABCD is including a description
of these additions in a subsection of our comments under CMS Policy
Clarifications on Olmstead.
Support
Coordination
ABCD is pleased that DDD is including Support
Coordination for Real Life Choices and Self Determination into the CCW. ABCD has been advocating for a number of
years that New Jersey is not maximizing its federal dollars under Real Life
Choices. ABCD does believe that the
section on Support Coordination in the CCW should be expanded to include
Support Coordination for moving people out of the Developmental Centers. ABCD is including a description of these
additions in a subsection of our comments under CMS Policy Clarifications on
Olmstead.
CMS
Policy Clarifications on Olmstead
ABCD has raised to DDD and the Department of Human
Services since 2000 that the State utilize the policy changes and
clarifications provided under State Medicaid Directors Letters associated with
Olmstead. ABCD is unclear whether the entire
costs of Support Coordination and other expenses associated with Case
Management, Assessment for Accessibility and Environmental Modifications for
people leaving the Developmental Centers is being reimbursed by the federal
government. ABCD recommends that the
options afforded by the federal government to reimburse states for these
services, including for group homes, be used to fully maximize federal revenues,
if the options are not already in use.
If they are in use, we recommend that the State inform the community of
its use.
In the year 2000, the then Health Care Financing
Administration (HCFA) and renamed CMS, issued several State Medicaid Director
Letters regarding Olmstead. On July 25,
2000, Olmstead Update Number 3 was issued that included policy changes and
clarifications giving States more flexibility to expand services. ABCD suggests that DDD uses these policy
changes and clarifications to ensure that New Jersey is maximizing all of its
federal revenue.
Specifically, we suggest that DDD use Attachment 3-B
related to Home and Community-Based Services (HCBS) Case Management as a way to
assist paying for transition services for an individual leaving a Developmental
Center. We understand that the
Division’s sister agency, the Division on Aging and Community Services in the
Department of Health and Senior Services began to use this option approximately
a year or so ago to assist in transitioning individuals from nursing homes.
The HCBS Case Management allows a person served
under the waiver to receive case management services while they are still
institutionalized, for up to 180 consecutive days prior to discharge. Federal Financial Participation is available
on the date the person leaves the institution and is enrolled in the
waiver. “The case management service begun
while the person was institutionalized is not considered complete until the
person leaves the institution…” The
amount of paid services is claimed as a special single unit of transition case
management. The cost of case management
furnished as a HCBS waiver service must be estimated in factor D of the
waiver’s cost neutrality formula.
In addition, the Administrative Case Management may
be furnished as an administrative activity.
Case management furnished as an administrative expense may be eligible
for FFP even if the person is not eventually served in the community due to death,
the individual’s choice not to receive waiver services or loss of Medicaid
eligibility. According to the Olmstead
Update 3-b “the State must have a policy on file with HCFA that clearly
delineates the circumstances under which case management is billed either as an
administrative or a service expense.
This information must be included in the supporting documentation that
the State forwards with its State plan or waiver request”. ABCD recommends that DDD include this
documentation in its waiver amendments so as to ensure full maximization of
federal revenues.
Other policy changes and clarifications in Update
3-b that could potentially be used by DDD to assist with moving people out of
the Developmental Centers include Assessments for Accessibility and
Environmental Modifications. A State may
assess the accessibility and need for modification in a home or vehicle and FFP
may be available. In the area of
environmental modifications, a State may claim FFP for home modifications
(including the actual construction costs) furnished as a waiver service up to
180 days prior to discharge.
Rates
for Services
ABCD and its member agencies are concerned about the
rates that are included in the proposed CCW amendments for respite, day
habilitation, and individual supports.
We understand that the rates are based upon usual and customary rates
for Personal Care Assistance services in the State Medicaid program. However, we believe that these services for
people with developmental disabilities are different than for personal care and
request that the rates be revised. People with developmental disabilities need
services provided during respite and not just pure respite. The State could accommodate this by adding
habilitation services to be provided in the home to the array of services
included in the waiver. The need for
specific programs which require follow-up would justify and enhanced rate for
in-home services.
In addition, we feel it is especially important to
change the rate for Individual Supports related to Real Life Choices. Several years ago when Real Life Choices was
developed DDD set the rate without any input from providers. Providers determined that the staffing ratio
and supervisory issues for Real Life Choices were different than other services
provided and suggested a higher rate.
DDD promised that as soon as 150 individuals were in Real Life Choices
that the Division would enter into discussions with providers about a different
rate. Now, a number of years later, with
many more than 150 individuals using these services and there has been no
discussion of a different rate. ABCD
strongly recommends that DDD meet with providers to discuss a change in the
rates for Real Life Choices and the other services in the CCW.
ABCD is not including rates from other states for
this analysis due to the fact that each state has a different definition for
services. We did not believe it useful
to provide a review of rates for this reason.
Family
Support
ABCD is pleased that DDD has included several options
under Family Support for inclusion in the Community Care Waiver. ABCD believes that there are a number of
services under Family Support that could be included in the Waiver. We have testified to the Legislature and
discussed with the Administration over the years that we are one of only about
14 States that do not receive federal reimbursement for family support. We understand that there will be additional
discussions about expanding federal reimbursement for Family Support. ABCD requests inclusion in any discussions
related to Family Support and amendments to the Waiver.