Updates & Current Expansion Overview Community Integration Advisory Commission March 26, 2019

1. Updates & Current Expansion Overview Community Integration Advisory Commission March 26, 2019

2. Today’s Outline • Introduction • General Assembly • Legislation • Medicaid Expansion • Population Served • What Services are Covered • How to Apply • Current Enrollment Figures • HCBS Settings Overview & Updates

3. Donna Boyce • Sr. Program Advisor – Developmental Disabilities & Behavioral Health teams • With DMAS since August, 2018 • Previously an I/DD Director for one of the Community Services Boards

4. General Assembly & Legislative Updates • The 2019 General Assembly session saw some changes to Medicaid DD Services: • HB1812(Hope); allows dependent of a foreign service member added to the DD waivers waiting list while he/she was a resident of the Commonwealth to maintain his/her position on waiting list following transfer to assignment outside the Commonwealth, so long as the foreign service member maintains the Commonwealth as legal residence to return to following completion of his/her assignment; • SB1135 (Favola); the local department of social services shall notify the appropriate community services board as soon as it is known that a child in the foster care system has a developmental disability so that the community services board may screen the child for placement on the statewide developmental disability waiver waiting list.

5. Legislation (cont’d) • SB1195(Dance); directs the Children’s Cabinet to establish task force to evaluate and improve MH services in public schools; • Assess current landscape of school-based services and MH screening, evaluation, treatment in school settings; • Coordinate with ongoing behavioral health transformation efforts of DMAS and DBHDS, developing best practice recommendations for trauma-informed school-based health centers as vehicle for provision of both medical and behavioral health delivered in school settings; • Evaluate options for billing public and private insurance for school-based health services; and • Develop plan for establishing a Virginia affiliate member org., recognized by National School-Based Health Alliance, for the purposes of providing technical assistance and guidance for localities.

6. Item 303 #6c requires DHBDS to recognize CESP, ACRE, and CARF in lieu of competency requirements. It’s unclear how many providers this would affect. • These requirements were created to improve qualify of the DSPs and address numerous health, safety and person-centered complaints from individuals, families and advocates.

7. Item 307 #11c eliminates $1 million for training of CD Attendants. • The DMAS Office of Community Living created an “orientation to CD services” type training to improve the quality of CD services. The Governor’s office had included these funds to allow DMAS to train CD attendants. Without the money, DMAS will do its best to conduct the training with other resources at hand. • Session to reconvene April 3, 2019

8. Medicaid Expansion Overview & Updates • Population Served (100-138% FPL) not in or eligible for Medicare • Childless Adults (prior to January, 2019 – not eligible) • As of January, eligible with annual income at or below $16,754 • Parent family of 3 (prior to January, 2019 – annual income at or below $6,900 • As of January, eligible with annual income at or below $28,677 • Person with Disability (prior to January – annual income at or below $9,700 • As of January, eligible with annual income at or below $16,754

9. Some of the Covered Services • Doctor, hospital, and emergency services • Prescription drugs • Laboratory and X-ray services • Maternity and newborn care • Long-term care and support services • Home health services

10. Covered Services (cont’d) • Behavioral health services including addiction & recovery treatment • Rehabilitative services including physical, occupational & speech therapies • Family planning services • Medical equipment and supplies • Preventive and wellness services and chronic disease management services

11. Enrollment Update • Enrollment Pathways: • Auto Enroll • GAP Adults 21-64 with SMI • Plan First – Family planning services for men and women • Express Application (shortened version) • SNAP Beneficiaries - Parents of children enrolled in Medicaid • Transition to VA Medicaid • Individual who were or are currently enrolled in a qualified health plan (QHP) from the Federally-facilitated Exchanged (Marketplace or Healthcare.gov)

12. Enrollment Pathways, (cont’d) • General Public – newly eligible adults not captured in streamlined enrollment groups • Priority Populations – uninsured individuals served through other systems of care

13. For Those Not Captured in Streamlined Process • Ways to Apply • Phone: Cover Virginia Call Center 1-855-221-1590 VDSS Enterprise Call Center 1-855-635-4370 • Online: Common Help commonhelp.Virginia.gov Marketplace healthcare.gov • Paper: Local Dept. of Social Services

14. Enrollment Update By February 28, enrollment was at 233,179newly enrolled individuals

15. Just the Facts - Home & Community Based Services (HCBS) • Virginia’s Statewide Transition Plan (STP) • Received initial approval from CMS on December 9, 2016 • Describes activities the state will take to assess and ensure compliance with the HCBS settings rule (42 CFR Part 430, 431 et al)1.

16. Facts • Federal matching dollars for reimbursement of Medicaid-funded HCBS waiver services provided in settings that do not comply with the HCBS rule will not be allowable by CMS • The HCBS rule was implemented to ensure delivery of Medicaid-funded HCBS services comply with the community integration mandate of the ADA. The requirements of the rule also comply with the Commonwealth’s Settlement Agreement with the DOJ for people with developmental disabilities

17. Dispelling misinformation about HCBS • Individuals who live in their own home/family home who live on the same street with others receiving waiver services are at risk of losing their waiver. • FACT: The HCBS regulations allow states to presume an individual’s own home/family home meet the requirements of HCBS settings; therefore, individuals are not at riskof losing their waiver. Their homes are considered home and community based settings (STP p.22)

18. Individuals who live in a group home with 5 or more people who receive waiver services are at risk of losing their waiver. • FACT: Individuals are not at riskof losing their waiver based on size of the group home. The HCBS regulations do not include requirements for size of a provider-owned or operated residential setting, and there is not a limit on the number of individuals who live in a group home. However, all provider-operated HCBS settings must be integrated into the community, provide access to the greater community, and cannot isolate individuals from broader community opportunities (STP p. 46)

19. If an individual receives waiver services and chooses to live in a disability specific gated/campus style community, he or she will lose their waiver. • FACT: Disability specific gated/campus style communities are considered “presumed institutional” settings because they may have the effect of isolating individuals receiving Medicaid HCBS from the broader community. These settings may be compliant if the setting(s) demonstrates the characteristics of an HCBS setting. If a presume institutional setting overcomes this presumption, as determined by CMS, Medicaid-funded waiver services can be provided in the setting (STP.p45).

20. HCBS Final Rule • Revised Statewide Transition Plan (STP) for Virginia’s four 1915(c) HCBS Waivers: CL, FIS, BI & CCC+ - posted for public comment. STP must demonstrate compliance by March, 2022. • Intent of STP – to demonstrate how the state will bring waiver services and settings into compliance. • The following slides address required elements by CMS for final approval

21. Site Specific Assessment, (cont’d) • Process for communicating with beneficiaries currently receiving services in settings that the state may determine cannot or will not come into compliance with the HCBS settings rule by March 2022; • Ongoing monitoring and quality assurance processes to ensure all settings providing HCSB continue to remain fully compliance with the rule in the future.

22. Site-Specific Assessments • Comprehensive site-specific assessments of all HCB settings, implementation of necessary strategies for validating assessment results, and include activity outcomes within the STP; • Remediation strategies and corresponding timeline to resolve site-specific issues identified; • Detailed plan for identifying settings ‘presumed’ to have institutional characteristics, including qualities that isolate HCBS beneficiaries, and proposed process for evaluating these settings; preparing for submission to CMS for review under Heightened Scrutiny;

23. Public Comment Period • Thirty day public comment period began on February 27, 2019 and closes March 29, 3019 at 5:00 p.m. (EST). For more information on the Statewide Transition Plan (STP) please visit: • http://www.dmas.Virginia.gov/#/hcbs (scroll to the bottom of the page). Comments may be sent within the body of an email or placed in a Microsoft Word document and submitted as an email attachment to: hcbscomments@dmas.Virginia.gov • Provider has updated their self-assessment in RedCap– a database platform DMAS is using for the detailed Provider Self-Assessments. DMAS has granted extensions on case-by-case to many providers.