1915(k) State plan option and Waiver Case Management

1. 1915(k) State plan option and Waiver Case Management

2. 1915 (k) Community-First Choice Option • Section 1915(k) of the Social Security Act (42 CFR 441.500 - 441.590) • Community First Choice 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 (ADLs), instrumental activities of daily living (IADLs), and health-related tasks through hands-on assistance, supervision, or cueing. • ADL means basic personal everyday activities including, but not limited to, tasks such as eating, toileting, grooming, dressing, bathing, and transferring. (§ 441.505) • IADL means activities related to living independently in the community, including but not limited to, meal planning and preparation, managing finances, shopping for food, clothing, and other essential items, performing essential household chores, communicating by phone or other media, and traveling around and participating in the community. (§ 441.505) • Health-related tasks means specific tasks related to the needs of an individual, which can be delegated or assigned by licensed health-care professionals under State law to be performed by an attendant. (§ 441.505)

3. 1915 (k) Community-First Choice Option Eligibility (§441.510) • Eligible for medical assistance under the State plan -and- • As determined Annually- • Be in an eligibility group under the State plan that includes nursing facility services • Receive a determination, at least annually, that in the absence of the home and community-based attendant services and supports provided under this subpart, the individual would otherwise require the level of care furnished in a hospital, a nursing facility, an intermediate care facility for the intellectually disabled, an institution providing psychiatric services for individuals under age 21, or an institution for mental diseases for individuals age 65 or over, if the cost could be reimbursed under the State plan. States must provide 1915(k) services to individuals in a manner that provides such services in the most integrated setting appropriate to the individual’s needs, and without regard to the individual’s age, type or nature of disability, severity of disability or the form of home and community-based attendant services and supports that the individual requires to lead an independent life. (§441.515)

4. 1915 (k) Community-First Choice Option States cannot waive: • Statewideness; • Comparability; • Freedom of choice of services or qualified providers. Included Services (§441.520) Mandatory Services • Assistance with ADLs, IADLs, and health-related tasks through hands-on assistance, supervision, and/or cueing • Acquisition, maintenance, and enhancement of skills necessary for the individual to accomplish ADLs, IADLs and health-related tasks • Backup systems or mechanisms to ensure continuity of services and supports • Voluntary training on how to select, manage and dismiss attendants

5. 1915 (k) Community-First Choice Option Included Services (§441.520) Optional Services • Expenditures for transition costs such as rent and utility deposits, first month's rent and utilities, bedding, basic kitchen supplies, and other necessities linked to an assessed need for an individual to transition from a nursing facility, institution for mental diseases, or intermediate care facility for the mentally retarded to a home and community-based setting where the individual resides • Expenditures relating to a need identified in an individual's person-centered service plan that increases an individual's independence or substitutes for human assistance, to the extent that expenditures would otherwise be made for the human assistance Excluded Services (§441.525) • Room and Board costs, except for allowable transition services • Special education and related services provided under IDEA and vocational rehabilitation services provided under the Rehabilitation Act of 1973

6. 1915 (k) Community-First Choice Option Assessment of Functional Need (§441.535) • Must conduct face-to-face assessment of the individual’s needs, strengths, preferences and goals for the services and supports provided under 1915(k) • Assessment supports the determination that individual requires 1915(k) and supports the development of the person-centered service plan • Functional Needs Assessment must be conducted at least every 12 months, as needed when the individual’s support needs or circumstances change significantly requiring revisions to the person-centered service plan, and at the request of the individual

7. 1915 (k) Community-First Choice Option Person-Centered Service Plan Process (§441.540) • Person-centered planning process is driven by the individual. • Includes people chosen by the individual • Provides information and support to ensure that the individual directs the process and is enabled to make informed choices and decisions • Is timely and occurs at times and locations of convenience to the individual • Reflects cultural considerations of the individual • Includes strategies for solving conflict or disagreement within the process, including clear conflict-of-interest guidelines for all planning participants • Offers choices to the individual regarding the services and supports they needs and from whom • Includes a method for the individual to request updates to the plan • Records the alternative home and community-based settings that were considered by the individual

8. 1915 (k) Community-First Choice Option Person-Centered Service Plan (§441.540) • 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, as well as what is important to the individual with regard to preferences for the delivery of such services and supports. Commensurate with the level of need of the individual, and the scope of services and supports available under 1915(k), the plan must: • Reflect that the setting in which the individual resides is chosen by the individual • Reflect the individual’s strengths and preferences • Reflect clinical and support needs as identified through an assessment of functional need • Include individually identified goals and desired outcomes • Reflect the services and supports (paid and unpaid) that will assist the individual to achieve identified goals, and the providers of those services and supports, including natural supports. Natural supports cannot supplant needed paid services unless the natural supports are unpaid supports that are provided voluntarily to the individual in lieu of an attendant

9. 1915 (k) Community-First Choice Option • Reflect risk factors and measures in place to minimize them, including individualized backup plans • Be understandable to the individual receiving services and supports, and the individuals important in supporting him or her • Identify the individual and/or entity responsible for monitoring the plan • Be finalized and agreed to in writing by the individual and signed by all individuals and providers responsible for its implementation • Be distributed to the individual and other people involved in the plan • Prevent the provision of unnecessary or inappropriate care • The person-centered service plan must be reviewed, and revised upon reassessment of functional need, at least every 12 months, when the individual’s circumstances or needs change significantly, and at the request of the individual

10. 1915 (k) Community-First Choice Option Support System (§441.555) State must provide, or arrange for the provision of, a support system that meets all of the following conditions: • Appropriately assesses and counsels an individual before enrollment • Provides appropriate information, counseling, training, and asssistance to ensure that an individual is able to manage the services • Information must be communicated to the individual in a manner and language understandable by the individual Support Activities Support activities include the following: • Person-centered planning and how it is applied • Range and scope of individual choices and options • Process for changing the person-centered service plan • Grievance process • Information on the risks and responsibilities of self-direction

11. 1915 (k) Community-First Choice Option • The ability to freely choose from available home and community-based attendant providers and available service delivery models • Individual rights, including appeal rights • Reassessment and review schedules • Defining goals, needs and preferences of 1915(k) services and supports • Identifying and accessing services, supports and resources • Development of risk management agreements • Development of a personalized backup plan • Recognizing and reporting critical events • Information about an advocate or advocacy systems available in the State and how an individual can access the advocate or advocacy systems • Establishes conflict of interest standards for the assessment of functional need and the person-centered service plan development process that apply to all individuals and entities, public or private

12. 1915 (k) Community-First Choice Option Conflict of Interest Standards (§441.555) At a minimum, conflict of interest standards must ensure that the individuals or entities conducting the assessment of functional need and person-centered service plan development process are not: • Related by blood or marriage to the individual, or to any paid caregiver of the individual. • Financially responsible for the individual. • Empowered to make financial or health-related decisions on behalf of the individual. • Individuals who would benefit financially from the provision of assessed needs and services. • Providers of State plan HCBS for the individual, or those who have an interest in or are employed by a provider of State plan HCBS for the individual, except when the State demonstrates that the only willing and qualified entity/entities to perform assessments of functional need and develop person-centered service plans in a geographic area also provides HCBS, and the State devises conflict of interest protections including separation of assessment/planning and HCBS provider functions within provider entities, which are described in the State plan, and individuals are provided with a clear and accessible alternative dispute resolution process.

13. Waiver Case Management • Waiver Case Management is services furnished to assist individuals in gaining access to needed medical, social, educational and other services. Waiver Case Management includes the following assistance: Assessment and periodic reassessment of individual needs: These annual assessment (more frequent with significant change in condition) activities include: • Taking client history; • Evaluation of the extent and nature of recipient’s needs (medical, social, educational, and other services) and completing related documentation; • Gathering information from other sources such as family members, medical providers, social workers, and educators (if necessary), to form a complete assessment of the individual. Development (and periodic revision) of a specific care plan that: • is based on the information collected through the assessment; • specifies the goals and actions to address the medical, social, educational, and other services needed by the individual;

14. Waiver Case Management • includes activities such as ensuring the active participation of the eligible individual, and working with the individual (or the individual’s authorized health care decision maker) and others to develop those goals; and • identifies a course of action to respond to the assessed needs of the eligible individual.

15. Waiver Case Management Referral and related activities: • To help an eligible individual obtain needed services including activities that help link an individual with: • Medical, social, educational providers; or • Other programs and services capable of providing needed services to address identified needs and achieve goals specified in the care plan such as making referrals to providers for needed services, and scheduling appointments for the individual. Monitoring and follow-up activities: • Activities, and contact, necessary to ensure the care plan is implemented and adequately addressing the individual's needs. The activities, and contact, may be with the individual, his or her family members, providers, other entities or individuals and may be conducted as frequently as necessary; including at least one annual monitoring to assure following conditions are met:

16. Waiver Case Management • Services are being furnished in accordance with the individual's care plan; • Services in the care plan are adequate; and • If there are changes in the needs or status of the individual, necessary adjustments are made to the care plan and to service arrangements with providers. • Waiver case management may include contact with non-eligible individuals, that are directly related to identifying the eligible individual’s needs and care, for the purposes of helping the eligible individual access services; identifying needs and supports to assist the eligible individual in obtaining services; providing case managers with useful feedback, and alerting case managers to changes in the eligible individual’s needs. (42 CFR 440.169(e)) • Providers maintain case records that document for all individuals receiving case management as follows: • (i) The name of the individual; • (ii) The dates of the case management services; • (iii) The name of the provider agency (if relevant) and the person providing the case management service; • (iv) The nature, content, units of the case management services received and whether goals specified in the care plan have been achieved; • (v) Whether the individual has declined services in the care plan;

17. Waiver Case Management • (vi) The need for, and occurrences of, coordination with other case managers; • (vii) A timeline for obtaining needed services; • (viii) A timeline for reevaluation of the plan. • Providers of Waiver Case Management services are limited to employees of a Community Developmental Disabilities Program (CDDP), or other public or private agency contracted by a local community mental health authority or the Office of Developmental Disability Services (ODDS) Division. • Case management does not include, and Federal Financial Participation (FFP) is not available in expenditures for, services defined in §441.169 when the case management activities are an integral and inseparable component of another covered Medicaid service (State Medicaid Manual (SMM) 4302.F). • Case management does not include, and Federal Financial Participation (FFP) is not available in expenditures for, services defined in §441.169 when the case management activities constitute the direct delivery of underlying medical, educational, social, or other services to which an eligible individual has been referred, including for foster care programs, services such as, but not limited to, the following: research gathering and completion of documentation required by the foster care program; assessing adoption placements; recruiting or interviewing potential foster care parents; serving legal papers; home investigations; providing transportation; administering foster care subsidies; making placement arrangements. (42 CFR 441.18(c))

18. Waiver Case Management • FFP only is available for case management services if there are no other third parties liable to pay for such services, including as reimbursement under a medical, social, educational, or other program except for case management that is included in an individualized education program or individualized family service plan consistent with §1903(c) of the Act. (§§1902(a)(25) and 1905(c)).

19. Waiver and State Plan Unit Contacts • Dana Hittle- 503-945-5810, dana.hittle@state.or.us • Darlene O’Keeffe- 503-945-9817, darlene.b.okeeffe@state.or.us • Chris Pascual- 503-945-7035, chris.pascual@state.or.us