12VAC30-120 Waivered Services

REGULATIONS

Vol. 32 Iss. 6 - November 16, 2015

TITLE 12. HEALTH

DEPARTMENT OF MEDICAL ASSISTANCE SERVICES

Chapter 120

Fast-Track Regulation

Title of Regulation: 12VAC30-120. Waivered Services (amending 12VAC30-120-2000, 12VAC30-120-2010).

Statutory Authority: § 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.).

Public Hearing Information: No public hearings are scheduled.

Public Comment Deadline: December 16, 2015.

Effective Date: January 1, 2016.

Agency Contact: Emily McClellan, Regulatory Supervisor, Policy Division, Department of Medical Assistance Services, 600 East Broad Street, Suite 1300, Richmond, VA 23219, telephone [phone], FAX (804) 786-1680, or email [e-mail].

Basis: Section 32.1-325 of the Code of Virginia grants to the Board of Medical Assistance Services the authority to administer and amend the State Plan for Medical Assistance. Section 32.1-324 of the Code of Virginia authorizes the Director of the Department of Medical Assistance Services (DMAS) to administer and amend the State Plan for Medical Assistance according to the board's requirements. The Medicaid authority, as established by § 1902(a) of the Social Security Act (42 USC § 1396a), provides governing authority for payments for services.

An amendment to the Social Security Act (42 USC § 1396n(k)(1)(D)) and Item FFFF of Chapter 2 of the 2014 Acts of Assembly, Special Session I, gives DMAS the authority to modify its Transition Services, in the Money Follows the Person waiver, to provide coverage of the first month's rent for qualified housing as an allowable cost.

Purpose: The Money Follows the Person demonstration program is intended to facilitate individuals moving into their communities from institutional settings such as nursing facilities or residential care facilities.

Enabling individuals to move into community settings is both an economic strategy and one of welfare for the individual. Community living provides the individuals more autonomy and control over their personal care and life experiences. Individuals responding to quality of life surveys during institutional residence and then during their first and second years of community living tend to report higher satisfaction with life and increased happiness. Cost-savings are realized when individuals successfully live in a community setting versus institutional residence. The amount of cost savings varies depending on what Medicaid services an individual needs but can range from as low as $14,262 to $109,578 or higher.

For some individuals, payment of their first month's rent is the only barrier to living in a community setting. This barrier exists largely due to the timing of the receipt of Social Security income and other supports arriving after the initial move into the community.

Other permissible services and supports for which expenditures can be made in this program include, but are not limited to, rent and utility deposits, bedding, and basic kitchen supplies.

Rationale for Using Fast-Track Process: This regulatory action is noncontroversial because the Centers for Medicare and Medicaid Services (CMS) revised its national policy so that both stakeholders and consumers in the Commonwealth have advocated for this change. Since the stakeholders have advocated for this change, it is not likely that they would object to DMAS using of the fast-track rulemaking process. The affected provider community is not expected to object because the coverage of the first month's rent will enable a small number of additional individuals to transition from institutions into their communities.

Furthermore, it is highly desirable to enable institutionalized individuals who wish to transition into their communities to do so as expeditiously as possible. Community living fosters individual independence and control, self-direction, and person-centered planning, thereby creating a higher level of happiness and greater sense of well-being.

Substance: The Money Follows the Person demonstration program is intended to facilitate individuals moving into their communities from institutions, typically nursing facilities or residential care facilities. "Transition services" means "set-up expenses for individuals who are transitioning from an institution to a living arrangement in a private residence." Transition Services has paid for security deposits that are required to obtain a lease on an apartment or home.

For some individuals, payment of their first month's rent is the only barrier to living in a community setting. This barrier exists largely due to the timing of the receipt of Social Security income and other supports arriving after the initial move into the community.

The CMS now allows for the payment of both security deposit and the first month's rent from funds allocated for transition services.

The amendments revise Transition Services, 12VAC30-120-2010, to include language that allows for the payment of the first month's rent for persons who cannot meet this expense and make technical corrections to outdated acronyms (changing "ICF/MR" to "ICF/IID," for example) and update internal citations to the Virginia Administrative Code.

Issues: The primary advantage is to enable individuals to live in a community setting versus institutional setting. In addition, property owners are able to rent to individuals who are using home and community-based waivers since they now have the ability to pay their first month's rent. Systems already exist to provide approval and reimbursement for payments of first month's rent. There are no known disadvantages to the public or the Commonwealth.

Department of Planning and Budget's Economic Impact Analysis:

Summary of the Proposed Amendments to Regulation. The proposed amendments 1) provide coverage for the first month's rent for individuals in the Money Follows the Person (MFP) program who are transitioning from an institution to a community based living and 2) update references and acronyms used in the regulations.

Result of Analysis. The benefits likely exceed the costs for all proposed changes.

Estimated Economic Impact. The MFP program facilitates individuals moving into communities from institutions, typically nursing or residential care facilities. Under this program, Medicaid pays for transition services which are set-up expenses involved in such transition. These expenses include security deposits to obtain a lease, utility deposits, moving expenses, pest eradication and cleaning services, and essential household furnishings to occupy and use a private residence. These expenditures are currently covered. However, according to Department of Medical Assistance Services (DMAS), payment of the first month's rent is a barrier to moving into a community setting for some individuals. This barrier exists largely due to the timing of the receipt of Social Security income and/or other supports arriving after the initial move into the community.

In 2010, an amendment to the Social Security Act, 42 USC 1396n(k)(1)(D), authorized states to pay for the first month's rent as a transition service. Following the federal authorization, Item 301 FFFF of the 2014 Acts of the Assembly authorized DMAS to provide for the coverage of the first month's rent for qualified housing as an allowable cost. The proposed change implements the authority to cover the first month's rent for individuals in the MFP program.

Based on data from last two fiscal years, DMAS estimates that approximately 40 individuals will receive the first month's rent per year at a total cost of $33,706. Since MFP program expenditures are subject to enhanced federal match, the Commonwealth will pay $8,427 of this amount while $25,279 will be paid by the federal government. On the other hand, providing health care coverage in community settings is cheaper than providing care in institutional settings. The amount of cost savings varies depending on what Medicaid services an individual needs but can range from as low as $14,262 to as high as $109,578 or higher per person per year. Thus, cost savings from this change would probably exceed the additional costs it will create. Since the federal match for long term care costs is 50%, the Commonwealth will accrue half of any savings from this change.

Additionally, community living provides the individuals more autonomy and control over their personal care and life experiences. According to DMAS, individuals responding to quality of life surveys during institutional residence and then during their first and second years of community living tend to report higher satisfaction with life and increased happiness. Community living fosters individual independence and control, self-direction and person-centered planning, thereby creating a higher level of happiness and greater sense of well-being.

Furthermore, businesses that offer rental properties will have an increased demand for their services and likely benefit from the proposed coverage of the first month's rent for about 40 individuals.

Finally, the proposed changes update references and acronyms used in the regulations. These changes are not expected to create any significant economic effects other than improving the clarity of the regulations.

Businesses and Entities Affected. The proposed amendments will primarily affect individuals in MFP program who cannot currently pay for the first month's rent to transition into a community based living. DMAS estimates that there are approximately 40 such individuals. In addition, some of approximately 2,500 providers offering medical/pharmacy services to individuals in the MFP program will serve 40 more individuals. On the other hand, some of the 271 long term care providers will serve 40 less individuals.

Localities Particularly Affected. The proposed changes apply throughout the Commonwealth.

Projected Impact on Employment. The proposed amendments are anticipated to increase demand for rental properties and have a positive impact on employment in that sector. The proposed amendments will increase demand for services offered by the providers to individuals in the MFP program. A positive impact on employment in that sector may be expected. However, the proposed amendments are also anticipated to reduce demand for services offered by institutions such as nursing homes and residential care facilities. A negative impact on employment in that sector may be expected.

Effects on the Use and Value of Private Property. Due to increased demand for their services, businesses that offer rental properties may see an increase in their asset values. Similarly, the providers serving MFP program population may see an increase in their asset values due to increase in demand for their services. On the other hand, institutions such as nursing homes and residential care facilities may see a decrease in their asset values due to likely reduction in demand for their services.

Small Businesses: Costs and Other Effects. Most of the businesses that offer rental properties and the providers serving MFP program population are believed to be small businesses. About 25% of the long term care facilities are believed to be small businesses. The costs and other effects on affected small businesses are the same as discussed above.

Small Businesses: Alternative Method that Minimizes Adverse Impact. There is no alternative method that minimizes adverse impact on nursing homes and residential care facilities while accomplishing the same goals.

Real Estate Development Costs. The proposed amendments are unlikely to affect real estate development costs.

Agency's Response to Economic Impact Analysis: The agency has reviewed the economic impact analysis prepared by the Department of Planning and Budget. The agency concurs with this analysis.

Summary:

Pursuant to an amendment to the Social Security Act (42 USC § 1396n(k)(1)(D)) and Item 301 FFFF of Chapter 2 of the 2014 Acts of the Assembly, Special Session I, the amendments (i) provide coverage of the first month's rent for qualified housing as an allowable cost for persons moving from institutional settings to community settings and (ii) update and correct acronyms and a citation to Virginia Administrative Code.

Part XX
Money Follows the Person

12VAC30-120-2000. Transition coordinator.

A. Service description.

1. Transition coordination means the DMAS-enrolled provider who is responsible for supporting the individual and family/caregiver, as appropriate, with the activities associated with transitioning from an institution to the community pursuant to the Elderly or Disabled with Consumer Direction waiver.

2. Transition coordination services include, but are not limited to, the development of a transition plan; the provision of information about services that may be needed, in accordance with the timeframe specified by federal law, prior to the discharge date, during and after transition; the coordination of community-based services with the case manager if case management is available; linkage to services needed prior to transition such as housing, peer counseling, budget management training, and transportation; and the provision of ongoing support for up to 12 months after discharge date.

B. Criteria.

1. In order to qualify for these services, the individual shall have a demonstrated need for transition coordination of any of these services. Documented need shall indicate that the service plan cannot be implemented effectively and efficiently without such coordination from this service. Transition coordination services must be prior authorized by DMAS or its designated agent.

2. The individual's service plan shall clearly reflect the individual's needs for transition coordination provided to the individual, family/caregivers, and providers in order to implement the service plan effectively. The service plan includes, at a minimum: (i) a summary or reference to the assessment; (ii) goals and measurable objectives for addressing each identified need; (iii) the services, supports, and frequency of service to accomplish the goals and objectives; (iv) target dates for accomplishment of goals and objectives; (v) estimated duration of service; (vi) the role of other agencies if the plan is a shared responsibility; and (vii) the staff responsible for coordination and integration of services, including the staff of other agencies if the plan is a shared responsibility.

C. Service units and limitations. The unit of service shall be specified by the DMAS fee schedule. The services shall be explicitly detailed in the supporting documentation. Travel time is an in-kind expense within this service and is not billable as a separate item. Transition coordination may not be billed solely for purposes of monitoring. Transition coordination shall be available to individuals who are transitioning from institutional care to the community. Transition coordination service providers shall be reimbursed according to the amount and type of service authorized in the service plan based on a monthly fee for service.

D. Provider requirements. In addition to meeting the general conditions and requirements for home and community-based care participating providers as specified in 12VAC30-120-217 and 12VAC30-120-219 12VAC30-120-730 and 12VAC30-120-740, transition coordinators shall meet the following qualifications:

1. Transition coordinators shall be employed by one of the following: a local government agency; a private, nonprofit organization qualified under 26 USC § 501(c)(3); or a fiscal management service with experience in providing this service.

2. A qualified transition coordinator shall possess, at a minimum, a bachelor's degree in human services or health care and relevant experience that indicates the individual possesses the following knowledge, skills, and abilities. These shall be documented on the transition coordinator's job application form or supporting documentation, or observable in the job or promotion interview. The transition coordinator shall be at least 21 years of age.

3. Transition coordinators shall have knowledge of (i) aging, independent living, the impact of disabilities, and transition planning; (ii) individual assessments (including, including psychosocial, health, and functional factors) factors, and their uses in service planning, (iii) interviewing techniques, (iv) individuals' rights, (v) local human and health service delivery systems, including support services and public benefits eligibility requirements, (vi) principles of human behavior and interpersonal relationships, (vii) interpersonal communication principles and techniques, (viii) general principles of file documentation, and (ix) the service planning process and the major components of a service plan.

4. Transition coordinators shall have skills in negotiating with individuals and service providers; observing, and reporting behaviors; identifying and documenting an individual's needs for resources, services and other assistance; identifying services within the established services system to meet the individual's needs; coordinating the provision of services by diverse public and private providers; analyzing and planning for the service needs of the individual; and assessing individuals using DMAS' authorized assessment forms.

5. Transition coordinators shall have the ability to demonstrate a positive regard for individuals and their families or designated guardian; be persistent and remain objective; work as a team member, maintaining effective interagency and intraagency working relationships; work independently, performing position duties under general supervision; communicate effectively, both verbally and in writing; develop a rapport; communicate with different types of persons from diverse cultural backgrounds; and interview.

12VAC30-120-2010. Transition services.

A. Service description. "Transition services" means set-up expenses for individuals who are transitioning from an institution or licensed or certified provider-operated living arrangement to a living arrangement in a private residence, which may include an adult foster home, where the person is directly responsible for his own living expenses. 12VAC30-120-2010 12VAC30-120-2000 provides the service description, criteria, service units and limitations, and provider requirements for this service.

The individual's transition from an institution to the community shall have a transition coordinator in order to receive EDCD Waiver services or a case manager or health care coordinator if he shall be receiving services through either the HIV/AIDS, IFDDS, MR ID, or Technology Assisted Waivers.

B. Criteria for receipt of services. In order to be provided, transition services shall be prior authorized by DMAS or its designated agent. These services include rent or utility deposits, basic furniture and appliances, health and safety assurances, and other reasonable expenses incurred as part of a transition. For the purposes of transition services, an institution means an ICF/MR ICF/IID, a nursing facility, or a specialized care facility/hospital as defined at 42 CFR 435.1009. Transition services do not apply to an acute care admission to a hospital.

C. Service units and limitations.

1. Services are available for one transition per individual and must be expended within nine months from the date of authorization. The total cost of these services shall not exceed $5,000, per person lifetime limit coverage of transition costs to residents of nursing facilities, specialized care facility/hospitals, or ICF/MR ICF/IID, who are Medicaid recipients and are able to return to the community. The $5,000 maximum allowance must be expended within nine months from the date of authorization for transition services. It shall not be available to the individual after that period of time. The DMAS designated fiscal agent shall manage the accounting of the transition service. The transition coordinator for the EDCD Waiver or the case manager or health care coordinator, as appropriate to the waiver, shall ensure that the funding spent is reasonable and does not exceed the $5,000 maximum limit.

2. Allowable costs include, but are not limited to:

a. Security deposits and the first month's rent that are required to obtain a lease on an apartment or home;

b. Essential household furnishings required to occupy and use a community domicile, including furniture, window coverings, food preparation items, and bed/bath linens;

c. Set-up fees or deposits for utility or services access, including telephone, electricity, heating and water;

d. Services necessary for the individual's health, safety, and welfare such as pest eradication and one-time cleaning prior to occupancy;

e. Moving expenses;

f. Fees to obtain a copy of a birth certificate or an identification card or driver's license; and

g. Activities to assess need, arrange for, and procure needed resources.

3. The services are furnished only to the extent that they are reasonable and necessary as determined through the service plan development process, are clearly identified in the service plan and the person is unable to meet such expense, or when the services cannot be obtained from another source.

4. The expenses do shall not include ongoing monthly rental or mortgage expenses, food, regular utility charges, or household items that are intended for purely diversional/recreational purposes. This service does shall not include services or items that are covered under other waiver services such as chore, homemaker, environmental modifications and adaptations, or specialized supplies and equipment.

D. Provider requirements. Providers must be enrolled as a Medicaid Provider for Transition Coordination or Case Management and work with the DMAS designated agent to receive reimbursement for the purchase of appropriate transition goods or services on behalf of the individual.

VA.R. Doc. No. R16-4145; Filed October 23, 2015, 2:06 p.m.