Nursing Home Transition and Diversion (NHTD) Waiver

Approved Application Overview

  • Changes also available in Portable Document Format (PDF)

NYSDOH Presentation

September 13, 2018

Today´s Discussion

  • The Nursing Home Transition and Diversion (NHTD) 1915c Medicaid Waiver application, approved effective July 1, 2018, highlights:
    • Service Plan Development
    • Serious Reportable Incidents/Recordable Incidents
    • Modifications to Service Definitions
    • Modifications to Provider Qualifications
  • The approved application can be found here.

Eligibility

  • Applicant must be Medicaid eligible with Medicaid coverage that supports community based long term care at the time of application.
  • The individual must be assessed to need nursing facility level of care (LOC), which is a LOC score of 5, as established by the currently approved patient assessment instrument, the Uniform Assessment System for New York (UAS–NY).
    • If an individual is transitioning from a facility, the PRI/SCREEN may be used to assess LOC.
      • A UAS–NY must be completed within 90 days of enrollment onto the waiver.
    • If an individual should require a second assessment, this must be completed by the Regional Resource Development Center (RRDC) Nurse Evaluator (NE).
  • The individual must choose to participate in the waiver.
  • The individual must be able to identify a residence in which he/she will be residing when receiving waiver services.
    • Residential settings of 4 or more unrelated individuals are excluded from the NHTD waiver.
    • Assistive living is considered a congregate care living arrangement and is not an eligible residential setting for the NHTD waiver.
    • Waiver participants residing in the situations above prior to the approval of the waiver application can continue to receive these services until they move. However, applicants to the waiver will be considered ineligible if they reside in a congregate care living arrangement and participants will be considered ineligible for the NHTD waiver if they move into a congregate care living arrangement.

Notice of Decision (NOD)

  • The NOD format has changed with specific examples provided in the context of the document, depending on the reason for the action.
    • For example: “on xx date you indicated in a letter to the RRDC you are no longer interested in receiving NHTD waiver services.”
  • See Appendix F–1 of the approved NHTD application for reasons of denial/discontinuation.
  • The summary of a case conference is to be included in the Fair Hearing packet.
  • When a Fair Hearing decision is reached, a letter must be sent to the applicant/participant explaining the decision, when aid continuing ends, and the transition plan that is put in place, if applicable.

Complaint Protocols

  • Appendix F–3 of the NHTD waiver application addresses the complaint protocol.
  • The complaint protocols are posted on the DOH website.
  • Participants should be provided a copy of the complaint protocols at the time of enrollment, and at other times, as appropriate.
  • Phone numbers should be readily available to the participant in the home.
  • All participants will receive a close–out letter for all filed complaints.

Service Plan Development

  • The program continues to use both:
    • Initial Service Plan (ISP) and
    • Revised Service Plan (RSP)
  • Service Coordinator (SC) is responsible for the completion of the plans.
  • RRDC reviews and approves the plan.
  • Assessments are completed by the service providers.
    • Additional outside assessments may be procured on behalf of the individual.
  • Individual Service Reports (ISRs) are required by every provider.
    • SCs must also complete an ISR.
  • Team meetings are conducted every 6 months. Each service provider is responsible for providing feedback to the participant.
    • Currently, it is at the discretion of the RRDC to decide whether they would like to request a copy of the ISR with the Service Plan or team meeting minutes. As a result of issues presented by the Office of the Inspector General (OIG) audit, effective 10/1/2018, it will be mandatory that ISRs be included in Service Plan information submitted to the RRDC.
  • The SC is responsible for ensuring all waiver providers receive a copy of the approved service plan.

Service Plan Review

  • The RSP is reviewed:
    • Every 6 months at a Team Meeting,
    • When there is a significant change in the participant’s needs for support and services or their life situation,
    • When requested by a waiver participant.
  • The RSP is due to the RRDC at least 60 days prior to the last day of the current service plan. The RSP must include ISRs.
  • The RRDS reviews the Team Meeting summaries and informs the SC of required changes in the Service Plan.
  • If a LOC score is not completed by the time the service plan is submitted, then the RRDC cannot approve the Service Plan.

Serious Reportable Incidents

  • A Serious Reportable Incident (SRI) is:
    • Any situation in which someone has knowledge that the safety and well–being of the waiver participant is compromised.
    • A significant event or situation endangering a person´s well–being.
    • Because of the severity or sensitivity of the situation, an SRI must be reported.
  • The definitions of SRIs have been amended to include:
    • Abuse: subcategories include physical, sexual, psychological, seclusion, restraint, mistreatment and/or adverse conditioning;
    • Neglect;
    • Violation of a person´s civil rights;
    • Missing person;
    • Death of a waiver participant due to circumstances that were not of natural cause;
    • Unplanned hospitalization which results in admission/observation for greater than 24 hours;
    • Possible Criminal Action; and
    • Medication error/refusal (previously separate SRIs; now combined).
  • Exploitation has been removed as a SRI definition.
    • This is because it is now considered to be a mistreatment, violation of a person´s rights and/or possible criminal action.
  • Deaths due to natural causes, such as death of an individual in hospice, would not be considered an SRI.
    • However, all deaths should be reported to the RRDC within 24 hours and the RRDC will determine if it will be categorized as an SRI or a Recordable Incident.

Recordable Incidents

  • Recordable incidents have been amended to include:
    • Injury accidental in nature: must be reported to the RRDC within 24 hours and the RRDC will determine if it will be categorized as an SRI;
    • Death due to natural causes when in a treatment facility or hospice environment: must be reported to the RRDC within 24 hours and the RRDC will determine if it will be categorized as an SRI; and
    • Sensitive situation.
  • Recordable incidents are maintained by the NHTD waiver provider and are reported quarterly to the RRDC. The records must be maintained for a period of 6 years following termination of waiver services.

Modifications to Service Definitions

  • Service definitions are amended to enhance qualifications of providers, address staff supervision requirements and improve service delivery.
  • Any currently approved provider who met 2010 waiver application qualifications on the date of approval of this application will continue to be approved for employment until his/her employment ends with the current provider.
  • All new provider applications received by NYSDOH after July 1, 2018 must meet the new provider qualifications.

Service Coordination (SC)

There are four types of Service Coordination provided to the participant:

  1. Initial SC, Transition–Short Term Nursing Home Stay: Provided to individuals who are newly enrolled in the waiver and have been residing in a nursing home for less than 6 months. Encompasses those activities involved in assisting individuals seeking application for waiver services and developing the documentation included in the Application Packet. Providers may only bill for this service upon the person´s enrollment into the waiver. This will occur only once per waiver enrollment.
  2. Initial SC, Transition–Long Term Nursing Home Stay: Provided to individuals who are newly enrolled in the waiver and have been residing in a nursing home for 6 months or more. Encompasses those activities involved in assisting individuals seeking application for waiver services and developing the documentation included in the Application Packet. Providers may only bill for this service upon the person´s enrollment into the waiver. This will occur only once per waiver enrollment.
  3. Initial SC, Diversion: Provided to individuals who are newly enrolled in the waiver and reside in the community. Encompasses those activities involved in assisting individuals seeking application for waiver services and developing the documentation included in the Application Packet. Providers may only bill for this service upon the person´s entry into the waiver. This will occur only once per waiver enrollment.
  4. Ongoing Sc: Ongoing SC begins as soon as the individual is determined eligible for waiver services. The SC is responsible for the timely and effective implementation of the approved service plan. The SC is responsible for assuring that there is adequate coordination, effective communication, and maximum cooperation between all sources of support and services for the participant. This is provided on an ongoing, monthly basis.
  5. A SC´s maximum caseload has increased from 20 to 25 NHTD participants.
    • The SC must complete a monthly face–to–face meeting with each NHTD participant on their caseload.
    • The SC must meet with the participant in their home at least quarterly.
  6. Independent proprietors are now included as a category for SC.

Service Coordination Supervisor

  • Any agency that employs 2 or more SCs must employ an SC supervisor who fully meets the qualifications of a SC.
    • The supervisor must meet with each of the waiver participants served by the SC staff before approving the RSP, at least annually.
    • SC supervisors must meet with their staff monthly.
    • SC supervisors must review and sign all service plans.
    • A supervisor may maintain an active caseload not to exceed 25 waiver participants.

Assistive Technology (AT)

  • The service definition for AT has been expanded to include:
    • The costs associated with the acquisition of the AT;
    • Evaluation of the AT needs of the participant;
    • Implementation and oversight of the AT; and
    • Training/technical assistance for the participant or others involved with the care of the participant.
  • Increased from $15,000 per 12–month period to $35,000 per 24 month period.
    • 24–month period begins at the time of the next request.
    • This amount may be exceeded if approved by NYSDOH.
  • AT costing up to $2,000 only requires 1 bid.
  • AT costing $2,000 or more requires 3 bids.

Community Integration Counseling (CIC)

  • The participant must be present for any billable service.
  • The service does not duplicate services available through state plan; once counseling is no longer specific to community integration and becomes general counseling the service will terminate.
  • The assessment time is limited to 5 hours of direct service with the participant present.
  • The service is limited to 2 years. The 2–year period begins with the approval of the next annual service plan.
  • Goals must be reasonable and attainable.
  • Services may not exceed 220 hours annually, 4 hours weekly.
  • Services may be extended in extraordinary cases with sufficient medical justification and upon review and approval of the RRDC.

Community Transitional Services (CTS)

  • This service includes:
    • The cost of moving furniture and belongings,
    • Security deposit,
    • Broker´s fees,
    • Health and safety assurances (e.g. pest removal, allergen control, cleaning),
    • Landlord application fees.
  • Security deposits funded through CTS and returned upon vacating the residence must be returned to the CTS provider. Upon return of funds, the CTS provider must submit a paid claim void to eMedNY.
  • Amount is increased from $5,000 per waiver enrollment to $8,000 for any enrollment occurring after July 1, 2018.
  • Waiver CTS and CFCO CTS cannot be provided at the same time; it will be provided as a waiver service.
  • Language in the service definition of CTS is amended to reflect that housing security deposits must be credited through eMedNY.
    • If a security deposit is provided through CTS and the participant later receives the security deposit back, it should be returned to the CTS provider who will then complete a payment adjustment (credit) in eMedNY.
  • In an attempt to develop more providers:
    • Licensed pharmacies were added as providers.
    • Not–for–profit housing agencies or Local Housing Authorities were added as providers.

Environmental (E–Mods)/Vehicle Modifications

  • The service includes the performance of necessary assessments and project management to ensure that the modification has been completed according to the required specifications.
    • These costs must be included in the bid and must be itemized by the provider.
  • For modifications with an estimated cost of $5,000 or more, a home evaluation is required. The evaluation is now completed in three phases:
    • Initial;
    • Mid Project; and
    • Final
  • Payments may be made in 3 increments with the approval of the RRDC.
  • Environmental modifications and vehicle modifications must be less than $45,000 per 36 month period unless approved by NYSDOH.
  • Driver Rehabilitation Specialist services may not exceed 10% of the total cost of the project.
  • Any request for a modification with a total cost of $15,000 or more requires prior approval from NYSDOH.
  • E–mod and Vehicle modifications costing up to $2,000 only require 1 bid.
  • E–mod and Vehicle modifications costing $2,000 or more require 3 bids.

Independent Living Skills Training Services (ILST)

  • The Uniform Assessment System for New York (UAS–NY) is used to develop the detailed plan and service goals for ILST.
    • A separate ILST assessment has been eliminated.
    • In the absence of a UAS–NY, other resources available in the participant´s plan, such as medical records, PRI/SCREEN, and case history may be used to develop the detailed plan until a UAS–NY can be completed.
    • The goals must be reasonable and attainable. It is used for training purposes and is cost–effective and necessary to avoid institutionalization.
  • The participant must be present at the time of service delivery, including training.
  • A group setting may be approved by the RRDC in extraordinary circumstances.
  • ILST cannot be provided in a structured day program setting.
  • Training time provided to informal supports or waiver or non–waiver service providers must be designated in the service plan in order to be reimbursed.
  • Services are limited to 220 hours annually, not to exceed 4 hours per day. No additional hours are allowed to complete initial and re–assessments.
  • Service limits may be exceeded due to medical necessity upon RRDC approval.
  • Justification to provide or continue this service must be clearly stated in the service plan and approved by the RRDS.
  • All agencies that employ 2 or more ILSTs must provide supervision by an individual who fully meets the qualifications of an ILST provider.
    • ILST supervisors may maintain an active caseload.
  • ILST providers must participate in Team Meetings and are reimbursed at the hourly rate for their time at the Team Meeting. Meeting time is included in the service plan.

Positive Behavioral Interventions and Support Services (PBIS)

  • A comprehensive assessment of an individual´s behavior in the context of their medical diagnosis, abilities, disabilities, and the environment which precipitates the behaviors is necessary.
    • Hours to complete behavioral assessments must be included in the service plan – limited to 10 hours per Service Plan period.
    • Training hours are included in the total annual hours of service.
    • The participant must be present when the training occurs.
  • Information in the assessment must be consistent with information contained in the UAS–NY.
  • PBIS staff must attend Team Meetings as needed.
  • Hours are not included to write the behavior plan.
  • All agencies that employ 2 or more Behavior Specialists must provide supervision by an individual who fully meets the qualifications of a Program Director.
  • The Program Director is expected to meet any waiver participants prior to approving the behavior plan by a Behavior Specialist under their supervision, have supervisory meetings with staff on at a monthly basis, and review and sign– off on all behavior plans.
    • A supervisor may maintain an active caseload of waiver participants.
  • The service is limited to 240 hours annually, not to exceed 8 hours per day.
  • Service limits begin with the next approved service plan.
  • Service limits may be exceeded due to medical necessity with RRDC approval.

Structured Day Program (SDP)

  • Structured Day Program Services cannot be provided in the participant´s home.
  • The RRDS and/or NYSDOH staff determine the appropriateness of the physical space for NHTD waiver participants through site visits. The SDP site must also meet HCBS settings requirements.
  • The SDP is responsible for providing adequate physical space:
    • Must meet functional needs of participants;
    • Must protect participants´ safety;
    • Must adhere to all provisions of NYS Uniform Fire Prevention/Building Codes;
    • Must adhere to requirements of the Americans with Disabilities Act.
  • Each SDP must provide a site for participants to meet when arriving and departing for the day.
    • Site must be available should a participant choose not to attend a community outing.
  • There must be a location for participants to meet in the morning and afternoon prior to and at the end of the day´s activities.
  • Verification needs to be made by the SDP to confirm that the participant is on site.
    • When a participant goes in and out of the site during the day, this must be identified and the reason for this must be stated in the Service Plan.
    • We are currently reviewing provider polices regarding this topic (e.g. participant sign–in and sign–out forms).
  • SDPs will be subject to heightened scrutiny review for HCBS settings.
  • The SDP must be available to provide hands–on assistance to participants.
    • Required to have at least 1 employee with previous training as a Personal Care Assistant (PCA) or Certified Nursing Assistant (CNA) available to participants during program hours.
  • This service is reimbursed on an hourly basis, not to exceed 10 hours per day.
    • SDP staff must attend team meetings as needed.
    • Participation in team meetings is reimbursed at the hourly rate and included in the total number of approved annual hours of service.

Transportation Services

  • A new service added to the waiver.
  • A direct service to waiver participants in order to enable individuals to gain access to identified community resources, other community services, and activities as specified in their service plan.
  • Provider Type: common carrier & specialized transportation
  • Protocols for transportation are forthcoming.
  • Transportation services will be consistent with the Traumatic Brain Injury (TBI) waiver program.
  • Transportation services must be supported by goals within the Service Plan.
  • Transportation services must be provided within the common market area.
  • In order to receive transportation services, the transportation grid must be completed and submitted to the RRDC.
  • MAS and Logisticare are the transportation contractors.
  • Transportation services should be utilized only when there are no other community resources available, such as mass transit.

Respite

  • Respite cannot be billed when other services that include care and supervision (such as HCSS) are provided at the same time.
  • The primary location for the provision of respite services is in the waiver participant´s home. If services must be provided outside of the participant´s home, the location must be a non–congregate care setting and the location must be acceptable by the participant.

Cost Reporting

  • The Certified Cost Report (CCR) is used by all providers to communicate annual costs incurred as a result of operating NHTD waiver services, along with related participant utilization and staffing statistics.
  • A standard reporting tool and process will be implemented on January 1, 2018.
  • Providers will not be required to secure an independent financial audit.
  • CCRs will be used to reconcile the Medicaid Payments for waivers and will demonstrate that NYS´ costs are economic and efficient.
  • Improperly paid claims will be reimbursed to the state and Firm–Fixed–Price (FFP) will be returned to the Centers for Medicare and Medicaid Services (CMS).
  • To ensure that claims meet the essential test that billed services have been properly provided to waiver participants, the Office of Medicaid Inspector General (OMIG) conducts waiver provider audits to verify Medicaid claims.
  • CCR for non–profit waiver services will be subject to review. The CCR will be submitted to CMS within 16 months after the close of the reporting period.
  • If total payments for any waiver service, subject to the annual reconciliation, exceed the final allowable Medicaid reimbursement for such rate period, the State will treat any overage as an overpayment of the federal share and it shall be returned to CMS on the next calendar quarter.
  • The rates unit will be conducting a training on Cost Reporting in the near future.

NHTD Waiver Program

Contact us:

nhtdwaiver@health.ny.gov
518–474–5271

NYS Department of Health

Division of Long Term Care, Bureau of Community Integration and Alzheimer´s Disease

Home and Community Based Services Medicaid Waivers/NHTD Program

One Commerce Plaza Suite 1620 Albany, NY 12260

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