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Medicaid State Plan, Waivers & Quality
AssurancePresented by:
Dana Hittle, Darlene O’Keeffe and Chris Pascual
Department of Human Services
Aging and People with Disabilities
Waiver and State Plan Unit
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What is Medicaid?
Joint Federal and state program to assist states in furnishing medical assistance to eligible needy persons.
Federal law concerning the Medicaid program is located in Title XIX of the Social Security Act.
Within broad national guidelines established by Federal statutes, regulations, and policies, each state: establishes its own eligibility standards; determines the type, amount, duration, and scope
of services; sets the rate of payment for services; and administers its own program.
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Federal and State Funding
Centers for Medicare and Medicaid
Services (CMS)
>60% of Oregon’s Total Medicaid Budget
State of Oregon, Oregon Health Authority and
Department of Human Services <40% of Total Medicaid Budget
CDDP Brokerage
Consumer’s Service Provider Consumer/Provider
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* Worker Guides; * Policy Transmittals; * Action Requests; * Information Memoranda
FEDERAL REGULATIONS Social Security Act (SSA), U.S. Code, Code of Federal
Regulations, State Medicaid Directors’ Letters
Title XIX of SSA: * Medicaid State Plan; * Medicaid State Plan HCBS Options; * Medicaid Waivers
* Oregon Revised Statutes; * Oregon Administrative Rules; * Contracts; * Medicaid Provider Agreements
Regulations Hierarchy
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Medicaid State Plan
Details requirements established by the State.
Historically referred to as an individual’s “Medical Card”.
Oregon Health Authority, Division of Medical Assistance Programs (DMAP) manages Oregon’s State Plan.
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Who May Be Eligible for Oregon’s Medicaid State Plan?
The Categorically Needy and the Categorically Eligible: Families who meet states’ Aid to Families with Dependent
Children eligibility requirements in effect on 07/16/96. Pregnant women & kids under age 6 whose family income is at
or below 133 % of the Federal Poverty Level (FPL) Kids aged 6 to 19 with family income up to 100% of the FPL. Caretakers (relatives or legal guardians who care for children
under age 18 (or 19 if still in high school)). Supplemental Security Income (SSI) recipients. Aged, Blind, Disabled (per Social Security Administration’s
definition). Individuals and couples who are living in medical institutions
(Hospital, NF, ICF/IDD) and have monthly income up to 300% of the SSI income standard (Federal benefit rate).
Other Identified Special Groups.
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Oregon’s Medicaid State Plan Services Options:
Federally Mandated Services:o Inpatient Hospital (non-Institutions for Mental Disease)o Outpatient Hospitalo Federally Qualified Health Centerso Laboratory and X-Rayo Nursing Facility for adults over 21o *Early and Periodic Screening, Diagnosis, and Treatment
(EPSDT) for children under 21o Family planning services and supplieso Physician’s Serviceso Home Health Serviceso Pregnancy-related serviceso Nurse Midwife/Practitioner Services
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Oregon’s Medicaid State Plan Services Options:
Optional Services:o Med/Remedial - Licensed Practitionerso Private Duty Nursingo Clinico Dentalo Physical Therapy, Occupational Therapy, and Speech/Hearing/
Languageo Drugs, Dentures, Prostheses, Glasseso Rehabilitative Serviceso Services for adults >65 in Institutions for Mental Disease (IMD)
(ex: OSH Gero, EOPC)o ICF/IDD Services o Other NFo IMD <21 (ex: OSH Children’s Program)o *Personal Careo Primary Care Case Management (OHP)o Respiratory Care: Ventilator-Dependent
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State Plan Personal Careotherwise known as “PC20”
Developmentally-appropriate assistance provided to individuals with disabilities and chronic conditions of all ages which enables them to accomplish certain tasks.
Assistance may be in the form of hands-on assistance or cueing.
Needs assessments are performed on all clients prior to receiving personal care services.
Available to all qualifying Medicaid-eligible individuals. Need for institutional level of care is not required. Must be provided by a qualified provider as identified in
the State Plan.
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Activities of Daily Living (ADL)
Personal Care assistance with:• Eating• Bathing• Dressing• Toileting• Transferring • Maintaining continence
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Instrumental Activities of Daily Living (IADL)
Personal Care assistance with:• Personal Hygiene• Light Housework• Laundry• Meal Preparation• Transportation• Grocery Shopping• Using the Telephone• Medication Management• Money Management
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Delegated Nursing Tasks
Dressing Changes Oxygen Administration Pulse Oximeter Placement and Monitoring Apnea Monitoring Tracheotomy Care Oral Suctioning Ventilator Care Continuous Positive Airway Pressure (CPAP) Injections (subcutaneous) Blood Glucose Testing
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Oregon’s CMS-Approved State Plan HCBS Options
1915(i) HCBS State Plan Option- Targets individuals with chronic mental illness(CMI) receiving assistance through OHA, Addictions and Mental Health Division. Provides home-based habilitation, HCBS behavioral habilitation, HCBS psycho-
social rehabilitation for persons with CMI. Individuals require daily assistance of at least 1 hour per day to perform at least
two personal care services. Individuals do not meet criteria established for 1915(c) waivers. Services are provided in independent living situations, supported housing, adult
foster homes, residential treatment facilities or the individual’s own home. Home Based Habilitation is based individual assessment and an individual to
deliver a combination of the following services: Assistance with ADL/IADL needs Staff as needed to support the individual’s recovery Assistance in obtaining Non-Medical Transportation Skill development (ADLs, cooking, home maintenance, recreation,
community mobility, money management, shopping, community survival skills, educational support)
Services may be delivered in the community, adult foster home, residential treatmenthome or residential treatment facilities that are not considered secured.
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Oregon’s CMS-Approved State Plan HCBS Options
1915(j) Self-Directed Personal Assistance Services-Targets individuals who are aged or physically disabled. Provides ADL/IADL services to individuals who reside in
their own home and who are eligible for the Aged and Physically Disabled Waiver #0185.
Individuals receive a monthly cash benefit to purchase services and supports.
Individuals self-direct their personal assistance services and are responsible for hiring, directing, paying and dismissing providers, and purchasing other goods and services.
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Oregon’s Proposed State Plan HCBS Option – 1915(k) Community First Choice
Allows states to provide attendant services and supports in any home and community-based setting to all Medicaid-eligible individuals who meet an institutional level of
care. States receive a 6% increase in federal match for the provision of CFC services and supports.
Services:Participating states must: Cover assistance and maintenance with ADL/IADL needs and health-
related tasks; Ensure continuity of services and supports; Provide voluntary training on how to select, manage and dismiss staff.
Services can be provided through an agency or self-directed model.
Participating states may choose to cover: Transition costs; Expenditures related to participant’s independence and services, or
supports linked to an assessed need or goal.
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Oregon’s Proposed State Plan HCBS Option – 1915(k) Community First Choice
Additional requirements: CFC services must be provided 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 the individual requires to lead an independent life.
Individuals must be determined to need an institutional level of care to be eligible for CFC services.
CFC does not create a new Medicaid Eligibility Group.
States cannot waive: Statewideness; Comparability; Freedom of choice of services or qualified providers.
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Title XIX (TXIX) Waivers
TXIX of the Social Security Act allows
states to use Medicaid funds to provide
home and community-based services
(HCBS) to individuals who would require
the level of care in an institution if not for
the provision of HCBS.
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Waiver Eligibility
Must meet the need for institutional level of care during initial application and annually thereafter.
Must meet initial and ongoing financial eligibility requirements.
Meet other waiver requirements, if applicable (e.g.: DD eligible).
Must be enrolled in and receiving a waivered service at least monthly.
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Institutions
Intermediate Care Facilities for individuals with Intellectual & Developmental Disabilities (ICF/IDD), formerly known as ICF/MR
Nursing Facilities Hospitals (Non-IMD)
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Oregon’s Waivers, Populations, and Institutional LOC:
Comprehensive Residential Waiver #0117 – ID/DD; ICF/IDD
Support Services Waiver #0375 – ID/DD; ICF/IDD Behavioral Model Waiver #40194– ID/DD; ICF/IDD Hospital Model Waiver (Medically Fragile Children)
#40193– Physically Disabled; Hospital Medically Involved Children’s Waiver #0565 – Physically
Disabled; Nursing Facility Aged and Physically Disabled Waiver #0185– Aged and
Physically Disabled; Nursing Facility
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Waiver Assurances
The commitment by a state to operate a
HCBS waiver program in accordance
with statutory requirements (42 CFR
§441.302).
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Level of Care (LOC) Determination
The specification of the minimum amount of assistance that an individual must require in order to receive services in an institutional setting under the State plan.
Sub-assurances: An evaluation for LOC is provided to all applicants for whom
there is reasonable indication that services may be needed in the future.
The LOC of enrolled participants are reevaluated at least annually or as specified in the approved waiver.
The processes and instruments described in the approved waiver are applied appropriately and according to the approved description to determine participant LOC.
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Service Plan
Written document that specifies the waiver and other services (regardless of funding source) along with any informal supportsthat are furnished to meet the needs of and to assist a waiver participant to remain in the community.
The service plan must contain, at a minimum: the types of services to be furnished; the amount, the frequency and duration of each service; and the type of provider to furnish each service.
Federal Financial Participation (FFP) may only be claimed for the waiver services that are furnished to a waiver participant when they have been authorized in the service plan.
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Service Plan
Sub-assurances: Service plans address all participants’ assessed needs
(including health and safety risk factors) and personal goals, either by waiver services or through other means.
The state monitors service plan development in accordance with its policies and procedures.
Service plans are updated/revised at least annually or when warranted by changes in the waiver participant’s needs.
Services are delivered in accordance with the service plan, including in the type, scope, amount, duration, and frequency specified in the service plan.
Participants are afforded choice: Between waiver services and institutional care; and Between/among waiver services and providers.
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Qualified Providers
Standards established by the state that specify the education, training, skills, competencies and attributes that an individual or provider agency must possess in order to furnish services to waiver participants.
Sub-assurances: The state verifies that providers initially and continually meet
required licensure and/or certification standards and adhere to other standards prior to their furnishing waiver services.
The state monitors non-licensed/non-certified providers to assure adherence to waiver requirements.
The state implements its policies and procedures for verifying that provider training is conducted in accordance with state requirements and the approved waiver.
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Health and Welfare
A waiver’s design must provide for continuously
and effectively assuring the health and welfare of
waiver participants.
Sub-assurance: The state, on an on-going basis, identifies, addresses, and
seeks to prevent the occurrence of abuse, neglect and exploitation.
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Administrative Authority
The Medicaid Agency (Oregon Health
Authority) retains ultimate administrative
authority and responsibility for the operation of
the waiver program by exercising oversight of
the performance of waiver functions by other
state and local/regional non-state agencies (if
appropriate) and contracted entities.
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Financial Accountability
The assurance by a state that its claims for Federal financial participation in the costs of waiver services are: based on state payments for waiver services that have
been rendered to waiver participants; authorized in the service plan; and properly billed by qualified waiver providers in
accordance with the approved waiver.
Sub-assurance: State financial oversight exists to assure that claims are coded
and paid for in accordance with the reimbursement methodology specified in the approved waiver.
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Oregon’s Tools for AssuringQuality
Well-trained and empowered Services Coordinators and Personal Agents
HCBS Waiver Review Checklist CDDP Site Reviews Brokerage Site Reviews Consumer Satisfaction Surveys Contract Reviews and Renewal Licensing Reviews and Actions SERT, County Reviews and Abuse
Investigations
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Questions?
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Waiver, State Plan and Quality Assurance Unit Contacts
Dana Hittle, 503-945-5810, [email protected]
Darlene O’Keeffe, 503-945-9817, [email protected]
Chris Pascual, 503-945-7035, [email protected]
