Habilitation Supports Waiver

1. Habilitation Supports Waiver The Basics You Need To Know References: Medicaid Provider Manual, version 01/2010 AAM HSW verification checklist – created by KAC AAM HSW policy & procedure – authored by MSN Title 42 Code of Federal Regulations --Public Health 441.301-441.303 Title 42 Code of Federal Regulations --Public Health 435.1009 Title 42 Code of Federal Regulations --Public Health 483.430 Title 42 Code of Federal Regulations --Public Health 483.440 Draft 03/2009 msn; Updated 07/2009 msn; Updated 03/2010 msn,; Updated 04/26/2010 msn/dz input; Updated 08/04/2010 msn/kac

2. What is the Habilitation Supports Waiver (HSW)? • The HSW provides additional funding for specialized mental health services to eligible adults and children with developmental disabilities that are receiving Medicaid and typically have higher behavioral, medical, and/or personal care needs.

3. Background Of HSW • The Intermediate Care Facility for People with Mental Retardation (ICF/MR) program was established in 1971 as an optional service under states’ Medicaid programs. This amendment to the Social Security Act permitted states to receive federal matching funds for institutional programs serving only individuals with mental retardation for the first time. The ICF/MR program reached its peak spending and utilization in the early 1990s and has been in relative decline ever since. The Habilitation Supports Waiver has contributed to this reduction because people were able to receive additional supports within their communities. In the state of Michigan there are no ICF/MR beds.

4. Background Of HSW • The Medicaid waiver program was authorized in 1981 under Section 1915(c) of the Social Security Act to provide states with a way of providing home and community-based alternatives to institutionalization in ICFs/MR, nursing facilities and hospitals. The program authorizes the federal government to waive certain Medicaid statutory provisions to permit states to offer home and community-based services (HCBS) to individuals who would otherwise qualify for institutional services, and are able to receive community supports at a cost that on average does not exceed the average cost of institutional care. For persons with mental retardation and related conditions, the waived provisions allowed states to implement community-based services that might deter the need for institutionalization in ICFs/MR.

5. Background Of HSW • The KEY to remember is: HSW is always evolving , always pushing to allow people to live more inclusive, self-determined and empowered lives. What is considered state of the art in 2010 may be old news in 2015.

6. Background of HSW • What is a waiver according to Medicaid? • The Habilitation Supports Waiver is Michigan’s title for the Federal Home and Community Based Waiver which WAIVES specific requirements of the Social Security Act under the authority of Section 1915(c). Without the waiver, all people enrolled in Medicaid would have to be offered the same set of services. With the Habilitation Supports Waiver, people with highly specialized needs are able to have highly specialized services. • This waiver allows for additional supports to be provided to those people enrolled in the Habilitation Supports Waiver in order to help prepare them for independence within their home and their community.

7. Background of HSW • People enrolled in the Habilitation Supports Waiver if not for the additional supports and services would most likely require ICF/MR services. Therefore, with these services in place the HSW enrollees are living their lives within their communities as opposed to living their lives in institutions. • It also provides help for HSW beneficiaries to be able create meaningful lives and develop community connections and natural supports so they can live a life like anyone else.

8. HSW Eligibility Criteria • The individual must: 1) Have a developmental disability 2) Be Medicaid-eligible 3) Reside in a community setting (A community setting is: own apartment or home; with family or friends; adult foster care or specialized residential. A community setting is NOT: jail, hospital, state hospital, nursing home, or institution.) 4) If not for HSW services, would require ICF/MR level of care services

9. HSW Eligibility Criteria 5) Choose to participate in the HSW in lieu of ICF/MR services (Which is evidenced by the legally responsible party signing the certification and “accepting” the services. Section 3 of the certification form.) 6) Receive at least one HSW service per month in order to retain eligibility. (Only requiring support coordination services on a monthly basis is not consistent with the expected needs of a person requiring ICF/MR level of care services. So it is expected that the person would need additional services on a monthly basis.)

10. Definition of a Developmental Disability Developmental disability means either of the following: • If applied to an individual older than 5 years, a severe, chronic condition that meets all of the following requirements: • Is attributable to a mental or physical impairment or a combination of mental and physical impairments. • Is manifested before the individual is 22 years old. • Is likely to continue indefinitely. • Results in substantial functional limitations in 3 or more of the following areas of major life activity: 1) Self-care. • 2) Receptive and expressive language. • 3) Learning. (IQ alone does not mean that a person is developmentally disabled. IQ is a measurement of the learning domain.)

11. Definition Of A Developmental Disability • 4) Mobility. • 5) Self-direction. • 6) Capacity for independent living. • 7) Economic self-sufficiency. • And, reflects the individual's need for a combination and sequence of special, interdisciplinary, or generic care, treatment, or other services that are of lifelong or extended duration and are individually planned and coordinated. • If applied to a minor from birth to age 9 (according to Federal law), a substantial developmental delay or a specific congenital or acquired condition with a high probability of resulting in developmental disability as defined in subdivision (a) if services are not provided.

12. Habilitation vs. Rehabilitation “Habilitate” : to make fit or capable (as for functioning in society). Also: to prepare for position or to qualify for employment or a formal office. “Rehabilitate” : to restore to a former capacity or to restore or bring to a condition of health or useful and constructive activity. MDCH’s Definition of “Habilitation” – the process of providing an individual assistance with the acquisition, retention or improvement in self-help, socialization, and adaptive skills which facilitate independence and promote integration into the community.

13. Habilitation vs. Rehabilitation • The main difference between habilitate and rehabilitate is that to habilitate is to teach someone skills that he/she does not presently have and to rehabilitate is to help someone relearn/regain a skill and/or ability that has been lost.

14. HSW Service Array • Community Living Supports • Enhanced Medical Equipment And Supplies • Enhanced Pharmacy • Environmental Modifications • Family Training • Goods & Services (Self-Determination only) • Out-Of-Home Non-Vocational Habilitation • Personal Emergency Response System • Prevocational Services • Private Duty Nursing • Respite Care • Supports Coordination • Supported Employment In addition, all HSW beneficiaries are entitled to all of the B3 Services. This list of services may change at any time to better serve those enrolled to live lives like anyone else.

15. What Does ICF/MR Mean? • Remember that if a person decides to participate in HSW then they are choosing community-based services in lieu of ICF/MR. Had they chosen ICF/MR they would have been able to have: • ICF/MR: (Intermediate Care Facility/Mental Retardation 42 CFR 435.1009) Institution for the mentally retarded or persons with related conditions means an institution (or distinct part of an institution) that: • (a) Is primarily for the diagnosis, treatment, or rehabilitation of the mentally retarded or persons with related conditions; and

16. What Does ICF/MR Mean? • (b) Provides, in a protected residential setting, ongoing evaluation, planning, 24-hour supervision, coordination, and integration of health or rehabilitative services to help each individual function at his greatest ability. The Medicaid Provider Manual refers to this same definition • Food for thought: ICF/MRs were originally set up to be a training facility where individuals with developmental disabilities were sent to develop social, adaptive, and daily living skills. A person need not have major behavioral issues in order to be eligible for ICF/MR level of care services.

17. What Does Active Treatment Mean? • Active Treatment: (42 CFR 483.440(a)) refers to aggressive and consistent implementation of a program of specialized and generic training, treatment and health services. Active treatment does not include services to maintain generally independent clients who are able to function with little supervision or in the absence of a continuous active treatment program. • Food for thought: Active treatment is not a term used in HSW services but it is the level of services they would be entitled to in ICF/MR. Remember that Active Treatment is not once a week or once a month trainings. It is training that is throughout the day, everyday based on what the individual’s needs are and barriers to an independent life. A life like anyone else.

18. Service Array (cont) Community Living Supports (CLS) facilitate an individual’s independence and promote integration into the community. The supports can be provided in the enrollee’s residence (licensed facility, family home, own home or apartment) and in community settings, and may not supplant other waiver or state plan covered services – such as chore provider/home help services through DHS. HSW is the payor of last resort and other resources must be exhausted prior to the utilization of HSW services. CLS staff will be able to help teach beneficiaries many skills within the home and community. Skills ranging from cooking and cleaning to social skills as well as being able to order a meal at a restaurant. The acquisition of these skills by the enrollee will be able to help increase the person’s independence within many areas of his or her life. These areas include: communication of basic needs, employment, independent living, building relationships, community connections, staff assistance in order for the person to take vacations, and exerting control over his/her own life.

19. Service Array (cont) • Enhanced Medical Equipment And Supplies Include devices, supplies, controls, or appliances that are not available under regular Medicaid coverage or through other insurances. All enhanced medical equipment and supplies must be specified in the plan of service, and must enable the person to increase his abilities to perform activities of daily living; or to perceive, control, or communicate with the environment. The plan must document that, as a result of the treatment and its associated equipment or adaptation, institutionalization of the person will be prevented. There must be documented evidence that the item is the most cost-effective alternative to meet the person’s need. All items must be by the physician.

20. Service Array (cont) • Enhanced Pharmacy - Includes physician-ordered, nonprescription "medicine chest" items as specified in the person’s support plan. Only the following items are allowable: Cough, cold, pain, headache, allergy, and/or gastrointestinal distress remedies; Vitamins and minerals; Special dietary juices and foods that augment a regular diet; Thickening agents for safe swallowing when the person has a diagnosis of dysphagia and either: A history of aspiration pneumonia, or Documentation that the person is at risk of insertion of a feeding tube without thickening agents for safe swallowing; First aid supplies (e.g., band-aids, iodine, rubbing alcohol, cotton swabs, gauze, antiseptic cleansing pads); Special oral care products to treat specific oral conditions beyond routine mouth care (e.g., special toothpaste, toothbrushes, anti-plaque rinses, antiseptic mouthwashes); and Special items (i.e., accommodating common disabilities—longer, wider handles), tweezers and nail clippers. This benefit only includes items on this list. It can never be co-pays or items not on this list. Gluten-Free diets cannot be funded either.

21. Service Array (cont) • Environmental Modifications - Physical adaptations to the home and/or workplace required by the person’s support plan that are necessary to ensure the health, safety, and welfare of the person, or enable him to function with greater independence within the environment(s) and without which the person would require institutionalization. Adaptations include: ramps and grab bars; Widening of doorways; Modification of bathroom facilities; and Installation of specialized electric and plumbing systems that are necessary to accommodate the medical equipment and supplies necessary for the welfare of the person. Adaptations or improvements to the home that are not of direct medical or remedial benefit to the person (e.g., carpeting, roof repair) are not included. This must always be the most cost-effective option. Sometimes it may mean repurposing a room in order to make the option less costly.

22. Service Array (cont) • Family Training - Training and counseling services for the families of beneficiaries served on the waiver. For purposes of this service, "family" is defined as the family members who live with or provide care to the person enrolled in the HSW, and may include parent, spouse, children, relatives, foster family, unpaid caregivers, or in-laws. Training includes instructions about treatment regimens and use of equipment specified in the individual plan of services, and includes updates as needed to safely maintain the person at home. Family training goals, and the content, frequency, and duration of the training and/or counseling, should be identified in the person’s individual plan of services. Not included are individuals who are employed to provide waiver services for the person.

23. Service Array (cont) • Goods & Services - Goods and services must increase independence, facilitate productivity, or promote community inclusion and substitute for human assistance (such as personal care in the Medicaid State Plan and community living supports and other one-to-one support as described in the HSW or §1915(b)(3) Additional Service definitions) to the extent that individual budget expenditures would otherwise be made for the human assistance. A Goods and Services item must be identified using a person-centered planning process, meet medical necessity criteria, and be documented in the IPOS. Purchase of a warranty may be included when it is available for the item and is financially reasonable. • Goods and Services are available only to individuals participating in arrangements of self-determination whose individual budget is lodged with a fiscal intermediary.

24. Service Array (cont) • Out-Of-Home Non-Vocational Habilitation - Assistance with acquisition, retention, or improvement in self-help, adaptive, and socialization skills; and the supports services, including transportation to and from, incidental to the provision of that assistance that takes place in a non-residential setting, separate from the home in which the person resides. Services must be furnished four or more hours per day on a regularly scheduled basis for one or more days per week unless provided as an adjunct to other day activities included in the person’s plan of service. These supports focus on enabling the person to attain or maintain his maximum functioning level, and should be coordinated with any PT, OT, or speech therapies listed in the plan of services. Services may serve to reinforce skills or lessons taught in school, therapy, or other settings.

25. Service Array (cont) • Personal Emergency Response System Electronic devices that enable beneficiaries to secure help in the event of an emergency. The person may also wear a portable "help" button to allow for mobility. The system is connected to the person’s phone and programmed to signal a response center once the button is activated. PERS coverage should be limited to beneficiaries living alone (or living with a roommate who does not provide supports), or who are alone for significant parts of the day; who have no regular support or service provider for those parts of the day; and who would otherwise require extensive routine support and guidance.

26. Service Array (cont) • Prevocational Services Services aimed at preparing a person for paid or unpaid employment, but that are not job task-oriented. They include teaching such concepts as compliance, attendance, task completion, problem solving, and safety. Prevocational services are provided to people not expected to be able to join the general workforce, or to participate in a transitional sheltered workshop within one year (excluding supported employment programs).

27. Service Array (cont) • Private Duty Nursing(PDN) services are provided to individuals age 21 and older up to a maximum of 16 hours per day and consist of nursing procedures to meet an individual’s health needs directly related to his developmental disability. PDN includes the provision of nursing treatments and observation provided by licensed nurses within the scope of the State’s Nurse Practice Act. The individual receiving PDN must also require at least one of the following rehabilitative services, whether being provided by natural supports or through the waiver: Community living supports; Out-of-home non-vocational habilitation; Prevocational or supported employment.

28. Service Array (cont.) When there is a person enrolled in the Children’s Waiver Program and they are aging out it is imperative to plan for this event. It is best to apply for HSW at least 3 months prior to the day they turn 18. If the person must transition from one PDN provider to another this takes time and planning at the state and local level. This prevents gaps in services.

29. Service Array (cont) • Respite Care - for beneficiaries whose primary caregivers typically are the same people day after day (e.g., family members and/or adult family foster care providers), and is provided during those portions of the day when the caregivers are not being paid to provide care. Relief needs of hourly or shift staff workers should be accommodated by staffing substitutions, plan adjustments, or location changes, and not by respite care. Services must only be provided on a short-term basis because of the need for relief of those persons normally providing the care of a waiver person during times when they are not being paid to provide care.

30. Service Array (cont) Food for thought: CLS = Predictable /Routine Respite = temporary/intermittent break for the unpaid caregiver. So, if mother/father gets paid by DHS for Home Help services then they can’t get respite during that time.

31. Service Array (cont) • Supports coordination Involves working with the waiver person and others that are identified by the person, such as family member(s), in developing a written individual plan of services (IPOS) through the person-centered planning process. Functions performed by a supports coordinator: Planning using person-centered principle; Developing an IPOS using the person-centered planning process; Linking to, coordinating with, follow-up of, advocacy with, and/or monitoring of HSW, other mental health services and community services/ supports; Brokering of providers of services/supports; Assistance with access to entitlements and/or legal representation; Coordination with the Medicaid Health Plan, Medicaid fee-for-service, or other healthcare providers.

32. Service Array (cont) • Supported employment is community-based, taking place in integrated work settings where workers with disabilities work alongside people who do not have disabilities; For beneficiaries with severe disabilities who require ongoing intensive supports such as job coach, employment specialist, or personal assistant; For beneficiaries who require intermittent or diminishing amounts of supports from a job coach, employment specialist or personal assistant; Supported employment includes activities needed to sustain paid work by individuals receiving waiver services, including supervision and training, job coach, employment specialist services, personal assistance and consumer-run businesses.

33. HSW / B3 Services Crosswalk ***Link to HSW/B3 Services Crosswalk***

34. Enrollment In The HSW • How to initially enroll a person into the Habilitation Supports Waiver program: • Identify an individual with a developmental disability, who is Medicaid eligible and might benefit from HSW services. Or assist an individual with a developmental disability who is Medicaid eligible and seeks out the HSW services through the local affiliate or the AAM. • Consult with the AAM HSW Coordinator regarding any questions about the application process; the applicant’s eligibility; the plan and assessment verbiage, etc.

35. Enrollment in the HSW • Explore with the individual and the legally responsible party what HSW services are available: community living supports, enhanced medical equipment and supplies, enhanced pharmacy, environmental modifications, family training, goods & services, out-of-home non-vocational habilitation, personal emergency response system, prevocational services, private duty nursing, respite care, supports coordination, and supported employment. • The local affiliate completes the initial screening for eligibility and then sends the completed application packet to the AAM for review. (Or the affiliate could send a copy of the assessment and PCP for review and suggestions.) The AAM HSW Coordinator reviews the HSW application packet prior to submission to MDCH for reviewing and processing.

36. Enrollment In The HSW • Included in the HSW application packet, at a minimum is: 1) Initial certification form which is completely filled out, signed and dated (The SC attests to the fact that the person has Medicaid and a current assessment and PCP in Section One. The QMRP attests that the person meets ICF/MR level of need in Section Two. The legally responsible party agrees/accepts the HSW services in Section Three. In Section IV, MDCH gives the final approval for enrollment and the effective date of the enrollment.) ***Link to HSW Initial Certification Form*** 2) MDCH PHI Consent signed by legally responsible party (This allows MDCH to review the application packet.) ***Link to DCH-1183 (E) RELEASE FOR HSW PROGRAM ***

37. Enrollment in the HSW 3) Current PCP which is signed by the legally responsible party. 4) Current assessments and any other documentation which supports the need for HSW services 5) HSW Level of Care form ***Link to HSW Level of Care form***

38. HSW Application Determination • The Michigan Department of Community Health receives the documents then thoroughly reviews them and determines eligibility. They will either approve, pend or reject the application. • If MDCH approves the application they will determine the enrollment date and notify the PIHP. The PIHP will notify the CMHSP and the CMHSP will notify the individual whom applied. • If MDCH pends the application they will notify the PIHP. The PIHP will then notify the CMHSP why the application was pended and will work with the CMHSP and MDCH in order to get the additional information needed to help MDCH make the final determination.

39. HSW Application Determination • If MDCH rejects the application then MDCH will notify the applicant, the legally responsible party and the PIHP of the rejection and the appeal rights of the individual.

40. HSW Services And The Person-Centered Plan (PCP) • An HSW enrollee must receive at least one HSW service per month in order to retain eligibility. Medical necessity criteria should be used in determining the amount, duration, and scope of services and supports to be used. The person's services and supports that are to be provided under the auspices of the PIHP must be specified in his individual plan of services developed through the person-centered planning process which is to be specific with regards to amount, scope, and duration. • Medical necessity: Determination that a specific service is medically (clinically) appropriate, necessary to meet needs, consistent with the person’s diagnosis, symptomatology and functional impairments, is the most cost-effective option in the least restrictive environment, and is consistent with clinical standards of care. Medical necessity of a service shall be documented in the individual plan of services.

41. HSW Services And The PCP • Amount: The number of units (e.g., 25 15-minute units of community living supports) of service identified in the individual plan of service or treatment plan to be provided. • Scope: The parameters within which the service will be provided, including Who (e.g., professional, paraprofessional, aide supervised by a professional); How (e.g., face-to-face, telephone, taxi or bus, group or individual); and Where (e.g., community setting, office, person’s home). • Duration: The length of time (e.g., three weeks, six months) it is expected that a service identified in the individual plan of service or treatment plan will be provided.

42. HSW Services And The PCP • Food for thought: Think of the PCP as a contract where the CMHSP is agreeing to providing services to the person. If you were the person receiving the services wouldn’t you want to know exactly what services you will receive, how you will receive them and when the services will begin and end?

43. HSW Services And The PCP • Example goal: I want to decide where I go, what I do and whom I spend my time with. I need to learn to exert control over my life by making my choices known. • Objective #1 By 10/31/2011, I will start by learning to decide between two snack choices. I will show my choice by grasping at my preferred snack. I will progress on to other choices once I have mastered this choice. (I will then immediately be able to eat my snack of choice in order to help me make the connection between me grasping at what I want and receiving what I want!) • Step#1: By 02/28/2011, I will grasp at the snack item of my choice 3/5 times for one month. • Step#2: By 04/30/2011, I will grasp at the snack item of my choice 5/5 times for one month.

44. HSW Services And The PCP • That example goal can then be broadened to include activities of choice, staff whom provide care or take the person to the activity he/she chooses as well as who helps the person with personal care needs, etc. Remember to start wherever the person is and build upon skills and abilities he/she already has. Whenever possible, teach the person in the environment that the activity would normally take place.

45. HSW Services And The PCP • Goal: I want to learn to safely take a taxi/bus by myself into my community. • Objective: By 10/2011, I will learn and be able demonstrate that I am a safe passenger by wearing a seatbelt so I can be safe within my community when I take a taxi to the mall. • Steps: I will, with staff instruction/modeling/ oversight, learn the following skills while in the community with staff within my home and community: While riding in a car staff are to teach me to: a) Stay in my seat by 02/28/2011. b) Speak in a calm voice so I don’t distract the driver by 04/31/2011. c) Latch my safety belt and keep it on until the vehicle is parked at my destination by 06/30/2011. d) Keep the doors locked while the car is moving by 08/31/2011.  

46. HSW Services And The PCP • Goal: I want a boyfriend. • Objective: By 10/2011, I will improve my social skills (personal space, taking turns, not interrupting, etc.) in order to be able to have a boyfriend and go on dates, like everyone else. • Steps: I will, with staff instruction/modeling/oversight, learn the following skills while in my home and community: A) Appropriate greetings 1. Making eye contact 2. Smiling in response to a smile 3. Reacting appropriately to touch 4. Appropriate physical interaction such as a handshake 5. Saying hello or goodbye • 6. Introducing myself

47. HSW Services And The PCP • B) Appropriate socialization 1. Speaking with a clear voice 2. Speaking with appropriate volume 3. Sharing with others 4. Taking turns 5. Staying on the topic of conversation 6. Following directions 7. Responding to criticism

48. HSW Services And The PCP • C) Appropriate waiting 1. Learning to wait without interrupting 2. Responding appropriately to a request to wait 3. Waiting for interaction with staff near 4. Waiting for turn without staff near 5. Waiting for turn in a group

49. HSW Payments And Recoupments • HSW payments are paid prospectively and can be withheld/recouped due to the following reasons: • The person does not have active Medicaid. • The person did not receive at least one HSW service within in the month. • HSW payment rates are based on the county in which the person resides, the region serving the person and the Residential Living Arrangement (RLA). • There are several reasons for the difference in HSW payments from PIHP to PIHP: • Cost of living is different from region to region, city compared to country, etc.

50. HSW Payments And Recoupments • Rate of funding from the state/intensity factor is different from PIHP to PIHP • The cost of care is different for each RLA. • For example, if someone lives with their parents the cost associated with their care is less due to the amount of care provided by the family. • If someone lives in their own apartment or home then they will have more cost associated with their care as there are less natural supports in the home.