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Proposed Amendment to the Home and Community-Based Services Waiver for People with Intellectual and Developmental Disabilities

The draft proposed waiver amendment posted on June 12, 2020, included a technical error that created an inconsistency with the summary that DDS shared. DDS has uploaded an updated version of the draft amendment that correctly removes the reference to "the person has an emergency or urgent need" for residential supports on pages 84, 85, 88, and 89 of the attachment. The language included in error is redlined in the pdf below and will be corrected ahead of final submission.

The Director of the Department of Health Care Finance (DHCF) and the Director of the Department on Disability Services (DDS), pursuant to the authority set forth in the Department of Health Care Finance Establishment Act of 2007 and the Department on Disability Services Establishment Act of 2006, hereby give notice of the intent to submit an amendment to the District of Columbia Medicaid’s Home and Community-Based Services for People with Intellectual and Developmental Disabilities (IDD) Waiver program to the U.S. Department of Health and Human Services’ Centers for Medicare and Medicaid Services (CMS) for review and approval. 

The amendment application for the IDD Waiver contains three types of changes to be effective November 1, 2020, as follows: 

(1) changes to the amount, duration and scope of several services;

(2) systemic changes that relate to systems improvements, including the new DDS Developmental Disabilities Administration (DDA) Formal Complaint System; and

(3) reimbursement rate changes to comply with the District Universal Paid Leave Act and the Living Wage Act.

Each of these types of changes is described in greater detail in the sections below.

Service Changes:

Based on review of IDD waiver service utilization, the District is proposing changes to eight (8) IDD waiver services to align their scope with actual need and encourage the use of natural supports in lieu of paid services. These changes are necessary to ensure the continued sustainability of the waiver program, promote community integration, and better tailor IDD waiver services to support people with diverse needs.

The District believes there is sufficient capacity of facility-based providers to meet the needs of people enrolled in IDD waiver for the services outlined above and wants to discourage reliance on facility-based placements for people who are able to receive services in less restrictive, more integrated settings.

To support the goals of improved community integration for people with intellectual and/or developmental disabilities and ensure appropriate utilization of facility-based services, the District is proposing service limitations to the following six (6) services:

(1) Day Habilitation: Adding the restriction that there will be no authorized increase in the number of facility-based settings for current or new providers. (Except for small group day habilitation)

(2) Employment Readiness: Adding the restriction that there will no authorized increase in the number of facility-based settings for current or new providers.

(3) Host Home: Modifying requirements to limit this service to be only for people who have limited informal supports.

(4) Supported Living: Adding restriction that there will be no additional supported living homes approved unless determined essential by the DDA Deputy Director.

(5) Residential Habilitation: Adding restriction that there will be no new residential habilitation homes approved unless determined essential by the DDA Deputy Director.

(6) Respite: Modifying requirements to state that respite cannot be offered in an ICF; and cannot be offered in a residential habilitation setting, if that would cause the setting to be greater than four (4) people in the home.

The District is also seeking to ensure two additional IDD Waiver services are sufficiently flexible and target benefits to those with the greatest level of need by proposing the following changes:

  1. Assistive Technology Service: To ensure flexibility for people using the service and to allow residential providers to assist with purchasing needed equipment, the District is proposing changes to the Assistive Technology Service to amend provider qualifications by adding all Residential providers to automatically be enrolled as Assistive Tech providers.
  1. Wellness Services: The District is proposing the following changes to Wellness services to promote the use of natural supports and ensure appropriate service utilization/delivery:

(1) Massage: Limiting this benefit to 52 hours per year (reduced from 100 hours per year) with option to extend benefit to 100 hours per year with approval by DDA Deputy Director based upon assessed medical or clinical need. 

(2) Sexual Education: Limiting maximum service hours to 52 hours  per year, down from 100 hours per year.

(3) Fitness: Limiting maximum service hours to 52 hours per year for people who use Host Home, Supported Living, Supported Living with Transportation, Residential Habilitation, or In-Home Supports, or who otherwise have natural supports available that can help the person practice the skills they learn in fitness and achieve their fitness goals. The District will authorize up to 104 hours per year for people who live in natural homes, without In-Home Supports, and who do not have such natural supports available (for example, people who live with aging parents). 

(4) Nutrition: Limiting maximum service hours to 26 hours per year with extension up to 104 hours per year with approval by DDA Deputy Director based upon assessed medical or clinical need. The District is also adding a requirement that the person have natural or paid supports who can help them implement the learning and nutrition goals outside of the time with the nutritionist.

Systemic Changes:

To comply with statutory requirements, increase opportunity for people to communicate grievances, and clarify roles and responsibilities with regard to the reporting and review of unmet needs, allegations of abuse or neglect, and findings of deficiency, the District is also proposing changes and systems improvements in the following IDD Waiver sections:

(1) Appendix F: Adding a new DDA Formal Complaint System, which will provide a grievance system where people receiving DDA supports or services may file a formal complaint.

(2) Appendix G: Proposing two changes:

- Updating language to offer other means of communication (telephone and email in addition to an on-site visit) by an IDD Waiver Service Coordinator for follow-up on serious reportable incidents (SRI). The Service Coordinator is responsible for follow-up regarding health and safety or unmet needs by telephone or email within two (2) business days of acceptance by the Incident Review Committee of an SRI (not including a death). 

- Changing the seventy-two (72) hour reporting requirement to three (3) business days for SRIs involving an allegation of abuse or neglect or a serious physical injury. Under the proposed new requirements, the Incident Management Enforcement Unit investigator would conduct an in-person visit within three business days of assignment or by 5 p.m. the day following a weekend or holiday, unless waived by the supervisory investigator. 

(3) Appendix H: In the “Systems Improvements” section, changing language from “issues” identified to “findings,” identified in the discussion of quality reviews, to implement changes to the proposed process for DDS action based on reports. Under the proposed change, DDS would continue to review and analyze the reports and data from DC Health, but will not assign issues/sanctions unless a person is in immediate jeopardy. 

Reimbursement Changes:

Proposing updates to the reimbursement and rate methodology to include reference  to the District of Columbia Universal Paid Leave Act language (UPLA) and the new living wage rate. The District is not proposing other changes to the overall the rate methodology.

Public Comment:

There are two opportunities for the public to provide comments or other input on the proposed HCBS IDD Waiver amendments:

  1. Written Comments: Written Comments on the proposed IDD Waiver amendment shall be submitted to:  Ieisha Gray, Director, Long Term Care Administration, Department of Health Care Finance, 441 4th Street, NW, Suite 900S, Washington, D.C. 20001, or via email at [email protected] during the thirty (30) calendar day public comment period,  beginning June 12, 2020 and ending July 13, 2020.
  2. Public Forum: DHCF and DDS will hold a virtual public forum during which written and oral comments on the proposed waiver amendment will be accepted, at the date and time below:

Date: Thursday, June 25, 2020

Time: 10:00am to 11:30am

By Phone: 1-650-479-3208 (Access Code: 479 487 709)

Web conference: https://dcnet.webex.com/dcnet/j.php

Accommodations for the public forum are available upon request.  Please provide your name, address, telephone number, organizational affiliation and accommodation request, if needed, by June 19, 2020, to Cynthia Scott at (202) 910-0148 or [email protected].