person family directed support waiver renewal changes...

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CMS Informal Comments

05/16/2017

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CMS INFORMAL REQUEST FOR ADDITIONAL INFORMATION Major Changes in the Renewal

1. Please note all proposed future effective dates throughout the waiver application will need to be deleted/revised with next amendment(s) to the waiver as appropriate. ODP Response: Future amendments will delete effective dates that are no longer applicable. CMS – no additional comments

2. For CMS’ understanding, please explain why changes identified in the waiver will not go into effect until 1/1/18, e.g. rates, etc.

ODP Response: There are no references in this waiver to changes that will take effect on January 1, 2018. CMS – the service definitions for In-Home and Community Support, Companion have effective date changes for staff levels. No additional comments

Attachment #1 Transition 3. Please describe the similarities and differences between the services covered in

the approved waiver and the proposed limitations (Education Support, In-Home and Community Support, Companion, Community Participation Support).

ODP Response: In the current approved waivers the service definition for Education Support is very general and includes general adult educational services, classes, tutoring to receive a General Education Development (GED) degree and support to participate in an apprenticeship program. There are no limits on the current Education Support service. In the renewal, ODP modified the service definition to remove apprenticeship programs and GED programs because analysis of Education Support authorizations indicated no participants use this service for these purposes. The service definition was revised to clearly enumerate expectations for college classes (including integration standards with the general student population). The following were added to the service definition: payment of general fees, on campus peer support, classes to teach deaf participants how to communicate and adult education or tutoring programs for reading or math instruction. Limits were added based on public comment received. ODP based the limits on current

PERSON/FAMILY DIRECTED SUPPORT WAIVER RENEWAL – CHANGES MADE SINCE APRIL 2017

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authorizations, publicly posted tuition fees for Comprehensive Transition Programs in the Commonwealth, and discussions with colleges. There are very few changes in the service definition for the current Home and Community Habilitation services and the proposed In-Home and Community Support services in the renewal. The proposed service definition decreases the allowable staff to individual ratio from 1:6 to 1:3. There are very few changes in the service definition for the current Companion services and the proposed Companion services in the renewal. The proposed service definition decreases the allowable staff to individual ratio from 1:6 to 1:3. Community Participation Support replaces the current approved Licensed Day Habilitation and Prevocational services. The primary distinction in the service definition is broadening the type of support available to provide opportunities for these activities to occur in non-facility settings and establishing a target for the frequency that activities are provided in non-facility settings. Licensed Day Habilitation, Prevocational services and employment services in the approved waiver has a limit of 40 hours per week for any combination of services. To incentivize employment, in the waiver application, for people who use a Supported or Advanced Supported Employment service, the limit is 50 hours per week. CMS – no additional comments

4. Please provide additional specific details of a transition plan for individuals impacted by the reduction of hours per day for In-Home and Community Support, Companion, and Community Participants Supports. The state has identified the need for transition, but is missing details of the plan. CMS recommends including the details that individuals have from 7/01/17 to 1/01/18 to meet, discuss, and identify other services and/or support that will meet the needs of the participants. The state should include appeal rights as applicable.

ODP Response: There is no reduction of hours per day of In-Home and Community Support, Companion and Community Participation Support that a participant can receive in this waiver. There was an error made in the Major Changes section of this waiver that stated we were implementing a limit. This error will be corrected. This section of the waiver will be revised to state, “Participants impacted by new limitations on Education Support will have from 7/01/17 through 12/31/17 to meet with the Individual Support Plan team, discuss and identify other services and/or support that will meet the needs of the participants.”

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ODP bulletin 00-08-05 entitled Due Process and Fair Hearing Procedures for Individuals with Mental Retardation states, “The Department’s fair hearing and appeals process does not apply to the following actions: Changes solely established by a Waiver amendment approved by the Centers for Medicare and Medicaid Services.” In accordance with this policy, participants will not be informed of the opportunity to request a fair hearing for any changes made solely because of a change in the Waiver approved by CMS. Appendix F describes in detail appealable actions and how participants are informed of the opportunity to request a fair hearing for these appealable actions. CMS – no additional comments

5. The State’s transition plan regarding behavior therapy (IDT to meet up to six months after 7/01/17) is not a person-centered approach and doesn’t enable an individual to access needed services timely. By 7/01/17, behavior therapy is no longer an option as a waiver service so alternatives should be in place prior to its elimination. ODP Response: This section of the waiver will be revised to say, “Behavior Therapy is the only service being removed from the waiver. Behavior Therapy was an option under the Therapy service. There are no participants currently authorized to use Behavior Therapy in this waiver. As a result, no transition is needed to implement this change.” CMS – Please make the revisions noted. No additional comments. ODP Response: Revisions have been made.

6. Please explain if behavior therapy is provided under the state’s Medicaid State Plan and/or other options. Please explain if individuals utilizing this service have other options or replacements for this service.

ODP Response: Two participants who were previously authorized for this service have already transition from Behavior Therapy to either the Behavioral Support service in the waiver or to therapy through insurance. There are no individuals enrolled in the P/FDS waiver that are authorized for Behavior Therapy. CMS – No additional comments.

7. According to 42 CFR 441.301(a), the State must include a plan on how

participants are informed of the opportunity to request a fair hearing. With the

elimination of Behavior therapy as a waiver service, please identify and include

language to describe how participants are informed of the opportunity to request

a fair hearing and/or appeals based upon these changes that are effective for

July 1, 2017. If applicable, please add language that explains why participants

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are not entitled to an opportunity to a fair hearing based upon the proposed

changes.

ODP Response: ODP bulletin 00-08-05 entitled Due Process and Fair

Hearing Procedures for Individuals with Mental Retardation states, “The

Department’s fair hearing and appeals process does not apply to the

following actions: Changes solely established by a Waiver amendment

approved by the Centers for Medicare and Medicaid Services.” In

accordance with this policy, participants will not be informed of the

opportunity to request a fair hearing for any changes made solely because

of a change in the Waiver approved by CMS. Appendix F describes in

detail appealable actions and how participants are informed of the

opportunity to request a fair hearing for these appealable actions.

CMS – No additional comments

Main – Attachment #2 Home and Community-Based Settings Waiver Transition Plan

8. The State must include the following language under this section: The State assures that the settings transition plan included with this waiver renewal will be subject to any provisions or requirements included in the State's approved Statewide Transition Plan. The State will implement any required changes upon approval of the Statewide Transition Plan and will make conforming changes to its waiver when it submits the next amendment or renewal.

ODP Response: This language will be added to the waiver. CMS – Please make the revisions noted. No additional comments. ODP Response: Revisions have been made.

9. CMS recommends the State to include details that the Statewide Transition Plan received initial approval on 8/30/2016. ODP Response: This information will be added to the waiver. CMS – Please make the revisions noted. No additional comments. ODP Response: Revisions have been made.

Appendix A Waiver Administration and Operation

10. For Appendix A, one of the functions of the Administrative Entities (AEs) is participant waiver enrollment – receive/review applications, ensure initial and annual completion of PUNS or its successor and refer applicants for eligibility decisions. Back in December 18, 2015, CMS recommended disapproval of the proposed claiming plan for enrollment fees for the Aging Waiver and move the responsibility from the Area Agency on Aging (AAAs) to Independent Enrollment

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Broker (IEBs) because we believed them to be duplicative of what the enrollment broker was performing and being paid to do.

ODP Response: This waiver does not use IEBs for enrollment of participants or for any other function. CMS – No additional comments.

a. How would the responsibility of AEs in the Person/Family Directed Support waiver defer from the responsibilities of IEBs? ODP Response: This would not be applicable to this waiver. The AEs would be the only entity responsible for enrolling participants in the waiver. CMS – No additional comments.

b. Is this the same concept? ODP Response: The concept of the Aging Waiver using the IEBs is not the same for this waiver. CMS – No additional comments.

c. What is the rate to do this? ODP Response: There is no rate since ODP does not use IEBs. CMS – Please make the revisions noted. No additional comments. ODP Response: ODP did not propose any revisions. We are unclear as to what CMS wants us to add to the waiver.

d. Will the AEs have the sole responsibility of enrolling individuals or will they share in the responsibility with the enrollment broker? ODP Response: The AEs are the only entity responsible for participant waiver enrollment for this waiver. This waiver does not utilize IEBs. CMS – No additional comments.

11. Please provide a copy of the Interagency agreement or memorandum of understanding between the State and these agencies that sets forth responsibilities and performance requirements for Local/Regional non-state public agencies and/or contract between the Medicaid agency and/or the operating agency (when authorized by the Medicaid agency) and each local/regional non-state entity that sets forth the responsibilities and performance requirements of the local/regional entity for local/Regional non-governmental non-state entities.

ODP Response: A copy of the AE Operating Agreement is attached to the email with this response.

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Appendix A-3 Contracted Entity 12. The State has marked that contracted entities do not perform waiver operational

and administrative functions on behalf of the Medicaid agency and/or the operating agency (if applicable). Please verify if Administrative Entities (AE) and Independent Enrollment Brokers (IEB) perform administrative function on behalf of the Medicaid Agency.

ODP Response: The AEs are the sole entities performing waiver operations and administrative functions on behalf of the Medicaid agency and the operating agency. This waiver does not use IEBs.

CMS – Please make the revisions noted. No additional comments.

ODP Response: The waiver already states that the AEs are the sole entities performing waiver operations and administrative functions on behalf of the Medicaid agency. We are unsure what CMS want us to add to the waiver.

Appendix A-6 Assessment Methods and Frequency:

13. Please indicate if the conduct of ODP assessments are subject to review by the

Medicaid agency to ensure that the operating agency is exercising its

responsibilities and that there are procedures that provide for the reporting of

assessment results to the Medicaid agency.

ODP Response: The Office of Medical Assistance Programs reviews ODP

actions taken to remedy AE noncompliance with the agreement and OMAP

reviews the evidence reports submitted to CMS. Further, upon annual

finalization of the statewide assessment report, a copy will be provided to

the Deputy Secretary of Office of Medical Assistance Programs.


14. ODP monitors AEs on a three year cycle. During that period, ODP gathers AE

performance data annually on one-third of AEs. During the cycle the AE must

complete a self-assessment in accordance with the ODP Oversight Process. The

AE self-assessment is reviewed and validated by ODP. Please explain how

ODP is making sure the self-assessments are accurate. Please explain when

during the three-year cycle the self-assessment is required to be completed,

reviewed, and validated by ODP, i.e. the beginning of the cycle, mid-point, end,

etc.

ODP Response: Following the onsite review, ODP’s Quality Assurance and Improvement (QA&I) team will compile a written QA&I Comprehensive Report for each AE within 30 calendar days of the onsite review completion. The report will compile findings from desk review and onsite review, face-to-face interviews, and self-assessments, as applicable. For each AE, the QA&I Comprehensive Report will:

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Highlight those areas where the AE is doing well related to person-centered services delivery and best practices;

Analyze performance in ODP’s quality focus areas for the current QA&I cycle;

Compare results of the desk and onsite reviews with the entity’s self-assessment;

Summarize those instances of non-compliance that were remediated during the onsite review;

Outline issues of non-compliance expected to be remediated within 30 calendar days of report receipt;

Recommend plans of improvement where compliance is below established thresholds of 86%; and

Recommend improvement activities to be addressed during the remainder of the QA&I cycle, including systemic quality improvement projects to incorporate into Quality Management Plans.

AEs will have 30 calendar days to review and respond to the QA&I Comprehensive Report. The response will include the entity’s plans and timelines to address instances of non-compliance requiring remediation within 30 days, and Plans to Prevent Recurrence. The response also may address points of disagreement with the report findings including appropriate evidence justifying the disagreement. Entities are responsible for submitting evidence of remediation along with the submission of the QA&I Comprehensive Report response to the ODP QA&I Coordinator. The ODP QA&I Coordinator will review and approve all remediation and Plans to Prevent Recurrence (PPR) activities in order to close the QA&I Comprehensive Report. Additionally, entities will submit evidence to demonstrate that the PPR activities are successfully completed as they occur. Each year in the self-assessment process, entities are expected to address the impact of PPR activities completed within the past year. If necessary, follow-up site visits may also be conducted to adequately assure that all remediation and PPR actions have been completed as documented in the QA&I Comprehensive Report and for ODP or the AE, as appropriate, to provide technical assistance. All documentation used to complete the self-assessment must be maintained and made available to ODP upon request. AEs that do not submit a self-assessment to ODP by the due date will be considered in non-compliance with the QA&I process requirements and will be scheduled for an onsite review regardless of the distribution assigned by ODP.

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Annually, at the completion of the self-assessment process for all entities, ODP will issue an aggregate report of self-assessment results and analysis statewide. This report will be used to inform the QA&I process throughout the year and technical assistance targeted to AEs, SCOs and providers. CMS – No additional comments.

Appendix A – Quality Improvement Systems:

15. Performance Measure AA2 - Number and percent of eligible applicants having an

emergency need or who have been identified as being in reserved capacity

status who receive preference in waiver enrollment. Percent = number of eligible

applicants having an emergency need or who have been identified as being in

reserved capacity status who receive preference in waiver enrollment/number of

eligible applicants. Please clearly identify what the numerator and denominator

are for this PM.

ODP Response: Performance Measure AA2 will be revised to state the

following, “Number and percent of eligible applicants having an emergency

need or who have been identified as being in reserved capacity status who

receive preference in waiver enrollment. Numerator = number of eligible

applicants having an emergency need or who have been identified as being

in reserved capacity status who receive preference in waiver enrollment.

Denominator = number of eligible applicants.

CMS – Please make the revisions noted. No additional comments.

ODP Response: Revisions have been made.

16. Performance Measure AA5 states a gathering of 100% review data annually but

under Appendix A-6 the “narrative” there indicates a 3 year cycle review. Please

explain

ODP Response: Each year of the 3-year cycle, one-third of Administrative

Entities, distributed geographically to represent the state, are selected for

review. 100% of the data collected each year is aggregated for review and

analysis annually.


Appendix B-3-c Reserved Waiver Capacity 17. Please define in the waiver application unanticipated emergencies and the

criteria.

ODP Response: There is no reserved capacity for unanticipated emergencies in this waiver. CMS – No additional comments

Appendix B-3-f Selection of Entrants to the Waiver

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18. Please provide more details of the selection of entrants to the waiver after reserved capacity has been met. CMS is unclear how selection is made for individuals who do not meet reserved capacity criteria, e.g. who is next in line and why (application date).

ODP Response: ODP works closely with AEs to manage waiver capacity. This includes tracking both the number of individuals utilizing each type of reserved capacity and the unduplicated number of individuals enrolled in the waiver throughout each year. When there is available capacity the AE enrolls an individual who will not be utilizing reserved capacity, they must enroll a person who meets emergency need status in the Prioritization of Urgency of Need for Services (PUNS). The PUNS was developed to gather information in order to categorize the needs of people with an intellectual disability, developmental disability or autism who have requested services from the County MH/ID Program or AE. CMS – No additional comments.

Appendix C-1-a Participant Services Based on a review of the service descriptions in the waivers, CMS has the following questions and comments: General: CMS has updated its policy for how services from 1915(c) waivers are

reviewed for inclusion in the Medicaid state plan. This updated policy affords more

flexibility to States, and asks States to share with CMS why services should remain in

the 1915(c) waiver and do not meet the requirements for coverage set forth in 1905(a)

of the Social Security Act. In order to better assist the state, CMS has provided the

recent Autism and Early and Periodic Screening, Diagnostic and Treatment (EPSDT)

CMS Informational Bulletins to help aid the state in determining why services do not

comport with 1905(a) authorities:

i. The EPSDT Informational Bulletin issued 1/5/2017 -

https://www.medicaid.gov/federal-policy-

guidance/downloads/cib010517.pdf

ii. The ASD treatment services Informational Bulletin issued 7/14/2014 -

http://www.medicaid.gov/Federal-Policy-Guidance/Downloads/CIB-07-07-

14.pdf

iii. The ASD FAQs issued on 9/24/2014 - http://www.medicaid.gov/Federal-

Policy-Guidance/downloads/FAQ-09-24-2014.pdf

General: CMS also wanted to remind the State of their EPSDT obligations since many

of the 1915(c) waiver services are targeted to children. EPSDT entitles enrolled infants,

children and adolescents under 21 years of age to any medically necessary treatment

or procedure that fits within any of the categories of Medicaid-covered services listed in

Section 1905(a) of the Social Security Act if that treatment or service is necessary to

https://www.medicaid.gov/federal-policy-guidance/downloads/cib010517.pdf

https://www.medicaid.gov/federal-policy-guidance/downloads/cib010517.pdf

http://www.medicaid.gov/Federal-Policy-Guidance/Downloads/CIB-07-07-14.pdf

http://www.medicaid.gov/Federal-Policy-Guidance/Downloads/CIB-07-07-14.pdf

http://www.medicaid.gov/Federal-Policy-Guidance/downloads/FAQ-09-24-2014.pdf

http://www.medicaid.gov/Federal-Policy-Guidance/downloads/FAQ-09-24-2014.pdf

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“correct or ameliorate” defects and physical and mental illnesses or conditions. The

EPSDT benefit prohibits the targeting of services based on the age of a child or by a

specific diagnosis. States have an affirmative obligation to make sure that Medicaid-

eligible children and their families are aware of EPSDT and have access to required

screenings and necessary treatment services. States must arrange (directly or through

delegations or contracts) for children to receive the physical, mental, vision, hearing,

and dental services they need to treat health problems and conditions. If the state keeps

the services in the 1915(c) waivers the EPSDT state obligations will still be in effect and

the CMS expectation will be that the state is meeting all the EPSDT requirements set

forth in 1905(r) of the Social Security Act.

Behavioral Support Services

19. Please review the CMS policy guidance provided regarding EPSDT. Please

describe why services should remain in the 1915(c) waiver for individuals 21 and

under and do not meet the requirements for coverage set forth in 1905(a) of the

Social Security Act.

ODP Response: The Behavioral Support service definition will be revised

to state, “Behavioral Support services can only be provided to adult

participants. All necessary Behavioral Support services for children under

age 21 are covered in the state plan pursuant to the EPSDT benefit.”

CMS: Please make the revisions as noted above. Also, please add the following

statement under the limits section of the service definition OR right after the

statement regarding individuals under 21. “To the extent that any listed services

are covered under the state plan, the services under the waiver would be limited

to additional services not otherwise covered under the state plan, but consistent

with waiver objectives of avoiding institutionalization”.


Consultative Nutritional Services

20. Please review the CMS policy guidance provided regarding EPSDT. Please

describe why services should remain in the 1915(c) waiver for individuals 21 and

under and do not meet the requirements for coverage set forth in 1905(a) of the

Social Security Act.

ODP Response: The Consultative Nutritional Services definition currently

has language that states this service is only available to individuals age 21

and older. The service definition will be revised as follows to make this

point clearer, “Consultative Nutritional Services can only be provided to

adult participants. All medically necessary Consultative Nutritional

Services for children under age 21 are covered in the state plan pursuant to

the EPSDT benefit. Consultative Nutritional Services may only be funded

for adult participants through the Waiver if documentation is secured by

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the Supports Coordinator that shows the service is medically necessary

and either not covered by the participant’s insurance or insurance limits

have been reached. A participant’s insurance includes Medical Assistance

(MA), Medicare and/or private insurance.”

CMS: Please make the revisions as noted above. Also, please add the following

statement under the limits section of the service definition OR right after the

statement regarding individuals under 21. “To the extent that any listed services

are covered under the state plan, the services under the waiver would be limited

to additional services not otherwise covered under the state plan, but consistent

with waiver objectives of avoiding institutionalization”.


Community Participation Support 21. Please revise the service definition to eliminate language “included, but not

limited to”. The State must be specific in the activities allowed but can provide a broad scope for activities included.

ODP Response: The Community Participation Support service definition will be revised as follows to remove the language, “This service is expected to result in the participant developing and sustaining a range of valued social roles and relationships; building natural supports; increasing independence; increasing potential for employment; and experiencing meaningful community participation and inclusion. Activities include the following supports for:” CMS: Please make the revisions as noted above. No additional comments.


22. Please explain the information described regarding Older Adult Living Centers

(individuals 60+ years, individuals w/dementia, and individuals under 60 years) may receive services at these types of facilities. Please explain who is not allowed to receive services at these types of settings and why.

ODP Response: In Pennsylvania, Adult Training Facilities (subject to licensure under 55 Pa. Code Chapter 2380) and Older Adult Daily Living Centers (subject to licensure under 6 Pa. Code Chapter 11) have distinct eligibility criteria for admissions. The distinctions in eligible populations for these two types of facilities are based on age and presence of dementia or dementia-related diagnosis.

In Adult Training Facilities (subject to licensure under 55 Pa. Code Chapter 2380) services are provided to four or more individuals, who are 59 years of

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age or younger and who do not have a dementia-related disease as a primary diagnosis. Older Adult Daily Living Centers (subject to licensure under 6 Pa. Code Chapter 11) serve individuals with functional impairment who are 60 years of age or older, or who are 18 years of age or older and have post-stroke dementia, Parkinsonism or a dementia-related disease such as Alzheimer’s. Community Participation Supports services may be provided in both types of facilities but, given the needs of the populations served, the expectations for activities provided outside of the facility differ. CMS: Please make the revisions as noted above. No additional comments.

ODP Response: This information was already included in the waivers

submitted to CMS.

23. Please note the 9/01/18 effective date of change for the phasing for Adult training

facilities or Vocational facilities should be included under the settings transition plan along with the details of the transition in attachment #2.

ODP Response: We would like to take this opportunity to extend the effective date for this provision to July 1, 2019 in accordance with the CMCS Informational Bulletin regarding Extension of Transition Period for Compliance with Home and Community-Based Settings Criteria. This will give providers two years to ensure that each participant is provided with opportunities for community integration consistent with his or her preferences, choices and interests. Attachment #2: Home and Community-Based Settings Waiver Transition Plan will be revised with the following information, “Description: Provider Service Alignment with Waiver. Time for providers to analyze services rendered and make changes to comply with waiver. This includes compliance with the Community Participation Support requirement that beginning July 1, 2019, participants may not receive services in a licensed facility for more than 75% of his or her support time, on average, per month. This also includes compliance with the requirement in Community Participation Support that starting January 1, 2022, services may not be provided in any facility required to hold a 2380 or 2390 license that serves more than 150 individuals at any one time. Start Date: March 2017 Target End Date: March 2020. Deliverable: No Deliverable For This Item Description: Revise Provider Monitoring Tool.

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Revise provider monitoring tool to capture new requirements in waiver renewals and regulations. This includes compliance with the Community Participation Support requirement that beginning July 1, 2019, participants may not receive services in a licensed facility for more than 75% of his or her support time, on average, per month. This also includes compliance with the requirement in Community Participation Support that starting January 1, 2022, services may not be provided in any facility required to hold a 2380 or 2390 license that serves more than 150 individuals at any one time. Start Date: March 2017 Target End Date: July 2022 Deliverable: Provider Monitoring Tool Description: Provider Self-Assessment All waiver providers will complete a self-assessment of their compliance with current applicable waivers, regulations and policies. This includes compliance with the Community Participation Support requirement that beginning July 1, 2019, participants may not receive services in a licensed facility for more than 75% of his or her support time, on average, per month. This also includes compliance with the requirement in Community Participation Support that starting January 1, 2022, services may not be provided in any facility required to hold a 2380 or 2390 license that serves more than 150 individuals at any one time. Start Date: September 2017 Target End Date: November 2022 Deliverable: Provider Tracking Tool” CMS: Please make the revisions as noted above. No additional comments.


24. Please note the 3/17/19 effective date of prohibiting Adult Training and

Vocational facilities as allowable settings for CPS should be included under the settings transition plan along with details of the transition in attachment #2.

ODP Response: The waiver renewal does not prohibit Adult Training Facilities and Vocational Facilities as allowable settings for Community Participation Support. We would like to take this opportunity to extend the effective date for this provision to January 1, 2022 in accordance with the CMCS Informational Bulletin regarding Extension of Transition Period for Compliance with Home and Community-Based Settings Criteria. The Attachment #2: Home and Community-Based Settings Waiver Transition Plan will be revised as written in the question above to reflect that starting January 1, 2022, services may not be provided in any facility required to

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hold a 2380 or 2390 license that serves more than 150 individuals at any one time. CMS: Please make the revisions as noted above. No additional comments.


25. Please provide additional details regarding the reduced maximum 24 hour per

day to 14 hours for In-Home Support, Community Support, Companion, and Community Participation Support under the attachment #1 section of the renewal.

ODP Response: There is no limit on the number of hours of In-Home and Community Support, Companion and Community Participation Support a participant may receive in this waiver. CMS: No additional comments.

Education

26. The State has established limits on who can receive sign language instruction. Please explain and/or add more details to explain why the limit is established. Can individuals who don’t receive sign language as a waiver service receive it elsewhere?

ODP Response: The lifetime limit of $35,000 for Education Support services was established based on the estimated cost of college certificate programs in Pennsylvania. Adult participants may also receive sign language instruction through In-Home and Community Support and/or through Speech and Language Therapy. CMS: No additional comments.

In-Home and Community Support

27. Specific employment-related activities should not be included under residential habilitation service and should be provided/reimbursed under prevocational, supported employment, advanced supported employment, or small group employment. Please explain and identify how these activities are general or specific and do not duplicate other services under the waiver. The service definition may need revision.

ODP Response: The In-Home and Community Support service definition will be revised to remove number 17 (which includes employment activities) from the list of assistance, support and guidance that can be provided to participants as part of this service. CMS: Please make the revisions as noted above. No additional comments.


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28. Please note the change implementing multiple staffing levels will need to be reflected fully in appendix I-2-a and appendix J tables.

ODP Response: The tables in appendix J will be revised to reflect this information. The CMS Technical Guide does not require this level of detail be captured in section I-2-a and ODP is very close to exceeding the character limit for this section of the waiver. ODP requests that it be sufficient for this level of detail to be included in the service definitions and Appendix J tables. CMS: Please make the revisions as noted above. No additional comments.


29. Please provide additional details for transition regarding the reduced maximum

24 hour per day to 14 hours for In-Home Support, Community Support, Companion, and Community Participation Support under the attachment #1 section of the renewal.

ODP Response: There is no limit on the number of hours of In-Home and Community Support, Companion and Community Participation Support a participant may receive in this waiver. CMS: No additional comments.

Music Therapy, Art Therapy and Equine Assisted Therapy

30. The State has categorized this service as Day Treatment. Within the service definition the State has indicated individuals with/without mental illness may be eligible to receive this service. Since the category day treatment is defined as services necessary for the diagnosis or treatment of person’ mental illness provided in a fixed site facility (generally day services), CMS recommends the State categorize the service under “Other” (other health and therapeutic services).

ODP Response: The service definition will be revised to reflect the “other” categorization. CMS: Please make the revisions as noted above. No additional comments.


31. Please explain why equine therapy is not provided to individuals under 21 years

through the waiver service.

ODP Response: The service definition submitted to CMS allows participants under 21 years of age to receive Equine Assistance Therapy as it is not covered by Medical Assistance. CMS: No additional comments.

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32. Please explain why individuals who receive residential habilitation, life sharing or

supported living may not receive these services.

ODP Response: This provision is not contained in this waiver because

residential habilitation, life sharing and supported living are not offered in

this waiver.

CMS: No additional comments.

33. The service description provided in the waiver may comport with the Therapy

benefit requirements at 42 CFR 440.110. Please review the guidance provided

and share if the state will be relocating this service to the Medicaid state plan. If

relocating the service under the Medicaid state plan, please specify under which

1905(a) benefit.

ODP Response: Music Therapy, Art Therapy and Equine Assisted Therapy

are not covered therapies for adults under Pennsylvania’s Medicaid state

plan and Pennsylvania has no plans to relocate this service to the Medicaid

state plan.

CMS: No additional comments.

34. In the waiver description please add the following attestation language in the

Limits box: “To the extent that any listed services are covered under the state

plan, the services under the waiver would be limited to additional services not

otherwise covered under the state plan, but consistent with waiver objectives of

avoiding institutionalization.”

ODP Response: The service definition submitted to CMS contains similar

language, “Music Therapy and Art Therapy may only be funded for adult

participants through the Waiver if documentation is secured by the

Supports Coordinator that shows the service is medically necessary and

either not covered by the participant's insurance, insurance limitations

have been reached, or the service is not covered by Medical Assistance or

Medicare or limitations for Medical Assistance or Medicare have been

reached… Equine Assisted Therapy can be provided to participants of any

age as it is not covered by Medical Assistance. For school age participants,

Supports Coordinators must document that Equine Assisted therapy is not

covered through the participant’s individualized education plan (IEP) or

through the participant's insurance.” This information can be moved to the

limits box if CMS prefers.

CMS: Please make the revisions as noted above. No additional comments.


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35. The State has opted to include and bundle three service components under this service (music, art, equine). Please note since the service is bundled, each service component will need to be broken out under the appendix J tables. ODP Response: The tables in appendix J will be revised to reflect this information. CMS: Please make the revisions as noted above. No additional comments.


Respite

36. Please identify which type of settings would be considered “non-waiver funded licensed residential settings” in addition to hotels. The State needs to be as specific as possible identifying the approved settings for this service.

ODP Response: Settings considered non-waiver funded licensed residential settings would include residential settings located on a campus or that are contiguous to other ODP-funded residential settings (settings that share one common party wall are not considered contiguous). This will also include settings enrolled on or after the effective date of the Chapter 6100 regulations that are located in any development or building where more than 25% of the apartments, condominiums or townhouses have waiver funded Residential Habilitation, Life Sharing or Supported Living being provided. CMS: Please add these details to this section. No additional comments.


Supported Employment

37. Career Assessment – Expanded day habilitation services, Supported employment services may not be provided in residential settings. Please revise the service and definition.

ODP Response: ODP requests a citation of where it is stated that Supported Employment services may not be provided in residential settings. The Waiver Technical Guide states the following for Supported Employment, “Supported employment individual employment supports may also include support to establish or maintain self-employment, including home-based self-employment.” Does your assertion mean that Supported Employment may only be used for support to establish or maintain home-based self-employment when the individual’s home is somewhere other than a residential setting? Does your assertion mean that the Supported Employment provider cannot go to the residential setting to conduct informational interviews with staff who work at the residential setting as part of the career assessment?

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CMS: After additional consideration, CMS supports individuals’ needs to complete career assessments within their residential settings; however, the state must include additional language for clarification and assurances of non-duplication. The supported employment service definition identifies this service may be provided in a variety of settings and specifically identifies career assessment may be provided in a residential settings. Please revise the service definition to indicate this service component (career assessment) may be provided within a variety of settings such as the residential setting when identified as a need and must be time limited. CMS recommends adding language specifying the end result would be a completed assessment and/or identified as no longer a need. Language that defines “time limited”. ODP Response: Revisions have been made.

38. Job finding or development activities may not be provided in residential habilitation settings. Please revise the service and definition.

ODP Response: ODP requests a citation of where it is stated that Supported Employment services may not be provided in residential settings. Does this mean that the Supported Employment provider cannot go to the residential setting to review available job opportunities, practice interview skills, and fill out job applications with the participant when the participant is most comfortable in his or her home environment? CMS: After additional consideration, CMS individuals’ needs to complete job finding or development within their residential setting; however, the state must provide include additional language for clarification and assurances of non-duplication. The supported employment service definition identifies this service may be provided in a variety of settings and specifically identifies job finding or job development may be provided in a residential settings. Please revise the service definition to indicate this service component may be provided within a variety of settings such as residential settings when identified as a need. Please include the restriction/prohibition that any component of supported employment may not be provided/billed at the same time as any residential habilitation service aside from companion services which identifies the component of personal assistance. ODP Response: Revisions were made to indicate that the service can be provided within a variety of settings. Residential Habilitation services are billed as a day unit which means that supported employment would be billed at the same time as the residential habilitation service. Further, companion services are encompassed in the residential habilitation service rate.

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39. Supported Employment and components of this service furnished under the waiver may not include services available under a program funded under section 110 of the Rehabilitation Act of 1973 or section 602(16) and (17) of the Individuals with Disabilities Education Act (20 U.S.C. 1401(16 and 17). Please revise the service definition to include this statement.

ODP Response: The Supported Employment service definition submitted to CMS states, “Supported Employment services may not be rendered under the Waiver until it has been verified that:

The services are not available in the student’s (if applicable) complete and approved Individualized Education Program (IEP) developed pursuant to IDEA;

OVR has closed the participant’s case or has stopped providing services to the participant;

The participant is determined ineligible for OVR services; or

It has been determined that OVR services are not available. If OVR has not made an eligibility determination within 120 days of the referral being sent, then OVR services are considered to not be available to the participant.”

Supports Broker

40. Please describe within the service definition what protections are in place for legally responsible, relatives, and legal guardians serving as support brokers for waiver participants.

ODP Response: The CMS Waiver Technical Guide reads that additional protections must be in place when legally-responsible individuals are permitted to provide personal care or similar services (such as home health aide, homemaker, chore and companion services). The Supports Broker service has no personal care or similar component, and involves a degree of programmatic knowledge and expertise exceeding that of legally responsible individuals, relatives, and legal guardians who are not Supports Brokers. There is no prohibition against legally responsible individuals, relatives, and legal guardians serving as their support broker. However, Managing Employers and Common-Law Employers, including surrogates, are prohibited from enrolling as Support Service Professionals and rendering Supports Broker services, and Supports Brokers may not perform duties for which Managing Employers and Common-Law Employers are responsible. Legally responsible individuals, relatives, and legal guardians may not serve in both capacities. All Supports Brokers must successfully complete a Supports Broker Certification Program, one element of which includes establishing role boundaries between natural supports, Managing Employers and Common-Law Employers, Supports Coordinators, and Supports Brokers. The standard protection for all services provided by legally responsible individuals, relatives, and legal

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guardians is monitoring to assure that services provided are in compliance with the individual plan. CMS: CMS’s intent was not to insinuate legally responsible, relatives, or legal

guardians for individuals could not be support brokers. It is a paid position that

can create potential conflicts for individuals. CMS made the inquiry to learn if the

state had implemented additional protections to ensure the individual’s best

interests are preserved.

Advanced Supported Employment 41. The State has proposed paying for outcomes specifically successful retention of

a job as evidenced by a participant working a minimum of 5 hours per week for at least four months. Please explain the state’s rationale of how this criteria is evidence of a successful competitive employment.

ODP Response: Advanced Supported Employment is only available to participants who have little or no job skills training or development or any work related experience including volunteering. Participants must have either been found ineligible for OVR services in the past or have not had a successful outcome there. Participants would not be able to complete a traditional vocational assessment, which is why we chose to use Discovery and Customized Employment provided by a nationally certified consultant. ODP believes that given the participant’s lack of employment history and the significance of their disability if they qualify for this services, five hours per week of successful employment and job retention are indications of success for the person. This determination was made in consultation with providers of supported employment and Discovery and Customized Employment services.

42. Advanced Supported Employment services furnished under the waiver may not include services available under a program funded under section 110 of the Rehabilitation Act of 1973 or section 602(16) and (17) of the Individuals with Disabilities Education Act (20 U.S.C. 1401(16 and 17). Please revise the service definition to include this statement.

ODP Response: The service definition submitted to CMS states, Eligibility for Advanced Supported Employment is limited to participants whose preferences, skills, and employment potential cannot be best determined through traditional, standardized means due to the impact of their disability. Specifically, the participant: 1. Has been found ineligible for or has a closed case with Office of Vocational Rehabilitation (OVR) services and chooses not to be re-referred or it has been determined that OVR services are not available. If OVR has not made an eligibility determination within 120 days of the referral being sent, then OVR services are considered to not be available to the participant;”

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The service definition will be revised to state, “Advanced Supported Employment services furnished under the waiver may not include services available under section 602(16) and (17) of the Individuals with Disabilities Education Act (20 U.S.C. 1401 (16 and 17).” CMS: Please make the revisions as noted above as well as the additional

information requested under supported employment.


Assistive Technology 43. In February 2016, Medicaid published the home health face-to-face final rule

which went into effect July 1, 2016. The regulation provides a federal framework

for defining medical equipment and appliances. Based on this definition, there

will be items currently coverable under 1915(c) waivers that must now be

covered under the mandatory home health benefit.

As indicated in the final rule, CMS is allowing a delay in compliance based on legislative timeframes. If the state needs to seek legislative approval to implement the new definitions, the state has up to one year to come into compliance, if their legislature has met in that year (i.e., July 2017) or 2 years to come into compliance (i.e., July 2018). At that time items and services that meet the criteria for coverage under the home health benefit must be covered according to home health coverage parameters. To ensure full coverage for medical equipment and appliances, to the extent that there is overlap in coverage with another benefit, states must nevertheless provide for the coverage of these items under the mandatory home health benefit. Please advise CMS of the state’s timeframe for implementation of the home health final rule as outlined above and revise the waiver to include the following assurance: “To the extent that any listed services are covered under the state plan, the services under the waiver would be limited to additional services not otherwise covered under the state plan, but consistent with waiver objectives of avoiding institutionalization.” ODP Response: Pennsylvania’s currently approved MA state plan complies with the home health final rule. The Assistive Technology service definition submitted to CMS states, “Items reimbursed with Waiver funds shall be in addition to any equipment or supplies provided under the MA State Plan… When Assistive Technology is utilized to meet a medical need, documentation must be obtained stating that the service is medically necessary and not covered through the MA State Plan which includes EPSDT, Medicare and/or private insurance. When Assistive Technology is covered by the MA State Plan, Medicare and/or private insurance, documentation must be obtained by the SC showing that limitations have been reached before the Assistive Technology can be covered through the Waiver. CMS: No additional comments.

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44. Please revise the service definition to eliminate language “included, but not limited to”. The State must be specific in the activities allowed but can provide a broad scope for activities included.

ODP Response: The Assistive Technology service definition will be revised to remove this language. “Examples of electronic devices include: tablets, computers and electronic communication aids… Examples of equipment and services covered as independent living technology include: medication dispensers, door sensors, window sensors, stove sensors, water sensors, pressure pads, GPS Tracking Watches, panic pendants and the remote monitoring equipment necessary to operate the independent living technology.” CMS: Please make the revisions as noted above. No additional comments. ODP Response: Revisions have been made.

45. Please note any modification of the additional conditions under 442.301(c)(4)(vi)(A) through (D), which would include devices identified under independent living technology, must follow the requirements outlined under this section of the regulation.

ODP Response: ODP will add the following to the Assistive Technology service definition “Assistive Technology provided to individuals living in provider owned, leased or operated settings must comply with 442.301(c)(4)(vi)(A) through (D) related to privacy, control of schedule and activities and access to visitors.” ODP will add to the residential habilitation service, life sharing and supported living service definitions: “Any use of Independent Living Technology must comply with 442.301(c)(4)(vi)(A) through (D) related to privacy, control of schedule and activities and access to visitors. ” CMS: Please make the revisions as noted above. No additional comments. ODP Response: We made an error when providing the original response. This waiver does not include provider owned, leased or operated settings so this revision was not made to this waiver.

46. The State has identified “items reimbursed with waiver funds shall be in addition to any equipment or supplies provided under the MA State Plan” along with limitations language regarding the State plan. With this statement, this service appears to be an extended state plan waiver service. Please categorize the service as an Extended State Plan since items under this service may be reimbursed under the Medicaid State plan.

ODP Response: The Assistive Technology service definition covers items that are not available through Pennsylvania’s MA State Plan such as

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generators and tablets such as iPads. Further, the Independent Living Technology provider qualifications are different from provider qualifications in the MA State Plan. It is our understanding from the guidance provided in the CMS Waiver Technical Guide that this meets the criteria for categorization as “other”. CMS: No additional comments.

47. Please describe what protections are in place for individuals who chose to have legally responsible, relatives, and legal guardians serving as their support broker.

ODP Response: The CMS Waiver Technical Guide reads that additional protections must be in place when legally-responsible individuals are permitted to provide personal care or similar services (such as home health aide, homemaker, chore and companion services). The Supports Broker service has no personal care or similar component, and involves a degree of programmatic knowledge and expertise exceeding that of legally responsible individuals, relatives, and legal guardians who are not Supports Brokers. There is no prohibition against legally responsible individuals, relatives, and legal guardians serving as their support broker. However, Managing Employers and Common-Law Employers, including surrogates, are prohibited from enrolling as Support Service Professionals and rendering Supports Broker services, and Supports Brokers may not perform duties for which Managing Employers and Common-Law Employers are responsible. Legally responsible individuals, relatives, and legal guardians may not serve in both capacities. All Supports Brokers must successfully complete a Supports Broker Certification Program, one element of which includes establishing role boundaries between natural supports, Managing Employers and Common-Law Employers, Supports Coordinators, and Supports Brokers. The standard protection for all services provided by legally responsible individuals, relatives, and legal guardians is monitoring to assure that services provided are in compliance with the individual plan. CMS: No additional comments

Behavior Support

48. The State has structured this service to deliver two levels of service which would indicate two levels or rate reimbursement. Please breakout the two levels of support under the appendix J table.

ODP Response: The tables in appendix J will be revised to reflect this information. The CMS Technical Guide does not require this level of detail be captured in section I-2-a and ODP has already exceeded the character limit for this section of the waiver. ODP requests that it be sufficient for this level of detail to be included in the service definitions and Appendix J tables. CMS: Please make the revisions as noted above. No additional comments.

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Companion Services

49. Please revise the service definition to eliminate language “included, but not limited to”. The State must be specific in the activities allowed but can provide a broad scope for activities included.

ODP Response: The Companion service definition will be revised to remove this language. “Companions may supervise, assist or even perform activities for a participant that include: grooming, household care, meal preparation and planning, ambulating, medication administration in accordance with regulatory guidance and socialization.” CMS: Please make the revisions as noted above. No additional comments. ODP Response: Revisions have been made.

50. Please note the change implementing multiple staffing levels will need to be reflected fully in appendix I-2-a and appendix J tables.

ODP Response: The tables in appendix J will be revised to reflect this information. The CMS Technical Guide does not require this level of detail be captured in section I-2-a and ODP is close to exceeding the character limit for this section of the waiver. ODP requests that it be sufficient for this level of detail to be included in the service definitions and Appendix J tables. CMS: Please make the revisions as noted above. No additional comments. ODP Response: Revisions have been made.

51. Please provide additional details regarding the reduced maximum 24 hour per day to 14 hours for In-Home Support, Community Support, Companion, and Community Participation Support under the attachment #1 section of the renewal.

ODP Response: There is no limit on the number of hours of In-Home and Community Support, Companion and Community Participation Support a participant may receive in this waiver. CMS: No additional comments

Housing Transition & Tenancy Sustaining Services

52. Assistance with establishing a relationship with a housemate is beyond a coverable, reimbursable service. Please revise the service definition.

ODP Response: The CMS Waiver Technical Guide states, “A state may propose to cover services beyond those that are included here. When

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coverage of another service is proposed, CMS will review the proposed coverage to ensure that the service is necessary in order to avoid institutionalization and addresses participant needs that stem from their disability or condition.” The Housing Transition and Tenancy Sustaining Services is ODP’s proposal to cover a service beyond what is included in the CMS Waiver Technical Guide. As such, ODP requests a citation that states this assistance is beyond a coverable, reimbursable service. The Department of Human Services (DHS) has assembled a Permanent Supportive Housing Analysis Workgroup composed of policy and operations staff from each DHS Program Office representing children and families, physical disabilities, intellectual and developmental disabilities, autism, and serious mental illness as well as staff from the Technical Assistance Collaborative (TAC). This group is developing a Permanent Supportive Housing Needs Analysis which identifies the services necessary for individuals to access PSH units and function successfully as a tenant. The Housing Transition and Tenancy Sustaining Services definition was developed as a result of this workgroup and needs analysis. For participants served through the ODP, sharing costs with a roommate may be the only way that renting a home/apartment is affordable. Further, ODP encourages the sharing of supports in private homes and has purposely written service definitions to allow for this (for example, In-Home and Community Support and Supported Living). The service addresses a gap in our current service array will enable more people who can no longer live with their family to live independently in their own home (with the assistance of the new supported living service) and as such will reduce overall costs to the waiver program through reduced reliance on and utilization of 24 hour staffed residential services. CMS: Please include the requested added language provided in the CMS email dated 6/13/2017. No additional comments. ODP Response: Revisions have been made.

53. Please explain if assistance with obtaining financial education is an activity with the individual with budgeting for house/living expenses. Please revise to include more details to describe the activities included.

ODP Response: The service definition will be revised to state, “Assistance with obtaining and identifying resources to assist the participant with financial education. Activities include assistance with budgeting for house and living expenses. Assistance with completing applications for subsidies or other entitlements such as energy assistance, or public assistance. Assistance with identifying resources to assist with financial planning for the individual and family including special needs trusts and ABLE accounts.”

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CMS: Please make the revisions as noted above. No additional comments. ODP Response: Revisions have been made.

54. Individuals who need assistance with financial planning should be referred to a financial planner and this would not be covered and reimbursable under housing services. Please revise.

ODP Response: The service definition will be revised to state, “Assistance with obtaining and identifying resources to assist the participant with financial education and planning for housing. Activities include assistance with budgeting for house and living expenses. Assistance with completing applications for subsidies or other entitlements such as energy assistance, or public assistance. Assistance with identifying financial resources to assist with housing for the participant including special needs trusts and ABLE accounts.” CMS: Please make the revisions as noted above. No additional comments. ODP Response: Revisions have been made.

55. At this time, assistance with community housing is offered only to individuals who are moving from an institutional setting to a community-based setting. Please revise.

ODP Response: The CMS Waiver Technical Guide states, “A state may propose to cover services beyond those that are included here. When coverage of another service is proposed, CMS will review the proposed coverage to ensure that the service is necessary in order to avoid institutionalization and addresses participant needs that stem from their disability or condition.” The Housing Transition and Tenancy Sustaining Services is ODP’s proposal to cover a service beyond what is included in the CMS Waiver Technical Guide. The Department of Human Services (DHS) assembled a Permanent Supportive Housing Analysis Workgroup composed of policy and operations staff from each DHS Program Office representing children and families, physical disabilities, intellectual and developmental disabilities, autism, and serious mental illness as well as staff from the Technical Assistance Collaborative (TAC). This group is developing a Permanent Supportive Housing Needs Analysis which identifies the services necessary for individuals to access PSH units and function successfully as a tenant. The Housing Transition and Tenancy Sustaining Services definition was developed as a result of this workgroup and needs analysis. The service addresses a gap in our current service array will enable more people who can no longer live with their family to live independently in

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their own home (with the assistance of the new supported living service) and as such will reduce overall costs to the waiver program through reduced reliance on and utilization of 24 hour staffed residential services. This service will provide crucial assistance to participants who want to transition from residential settings and homes of relatives to homes that the participant owns, rents or leases. ODP will not limit this service to individuals who are moving from an institutional setting to a community-based setting and will remove the service from the waivers if CMS stipulates that this is the only population who can receive Housing Transition and Tenancy Sustaining services.

56. Please provide additional details to identify if activities to provide assistance with utility assistance is for deposits for utilities.

ODP Response: The service definition will be revised to state, “Assistance with identifying resources to secure household furnishings and utility assistance. Activities will include identifying and coordinating resources that may assist with obtaining a security deposit, first month rent, or any other costs associated with the transition.” CMS: Please make the revisions as noted above. No additional comments. ODP Response: Revisions have been made.

57. Please provide additional details describing the activities included with assistance in resolving disputes with landlords…CMS will approve supports to assist the individual in communicating with the landlord and/or property manager and assistance to support the individual in understanding and meeting the obligations of tenancy.

ODP Response: The CMCS Informational Bulletin regarding Coverage of Housing- Related Activities and Services for Individuals with Disabilities lists “assistance in resolving disputes with landlords and/or neighbors to reduce risk of eviction or other adverse action” as a tenancy support service. The service definition will be revised to state, “Assistance with activities such as supporting the participant in communicating with the landlord and/or property manager; developing or restoring interpersonal skills in order to develop relationships with landlords, neighbors and others to avoid eviction or other adverse lease actions; and supporting the participant in understanding the terms of a lease or mortgage agreement.” CMS: Please make the revisions as noted above. No additional comments. ODP Response: Revisions have been made.

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58. Please provide more details describing advocacy with community resources to prevent eviction. This activity appears to be duplicated under other services and goes beyond the types of activities covered under this service.

ODP Response: The service provider would access services and resources which are specific to housing resources to ensure stability in the individual's home. CMS: No additional comments.

Small Group Employment 59. Guidance provided in the HCBS Technical Guide identifies small group

supported employment does not include services provided in facility based work settings or other similar types of vocational services furnished in specialize facilities that are not part of general community workplaces. Please provide additional details to indicate how Work Station in Industry aligns with this guidance.

ODP Response: A “work station in industry" is an employment station arranged and supported by a provider within a community business or industry site, not within a licensed facility site. An example would be three seats on an assembly line within a computer chip assembly factory. The provider has a contract with the business to ensure that those three seats are filled by adults with disabilities that they support. As per the proposed service definition, small group employment must occur in a location other than a facility subject to 55 Pa. Code Chapter 2380 or Chapter 2390 regulations. CMS: Please add these details from the response above. This information is very helpful and useful to describe these activities and settings under this service. No additional comments. ODP Response: Revisions have been made.

60. Please include the following language: Documentation is maintained in the file of each individual receiving this service that the service is not available under a program funded under section 110 of the Rehabilitation Act of 1973 or the IDEA (20 U.S.C. 1401 et seq.). Federal financial participation is not claimed for incentive payments, subsidies, or unrelated vocational training expenses such as the following: 1. Incentive payments made to an employer to encourage or subsidize the employer's participation in supported employment services; or 2. Payments that are passed through to users of supported employment services.

ODP Response: The service definition submitted to CMS states, “Small Group Employment services may not be rendered under the Waiver until it has been verified that the service is not available in the student’s (if applicable) complete and approved Individualized Education Program (IEP) developed pursuant to IDEA. Documentation must be maintained in the file

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of each participant receiving Small Group Employment services to satisfy this state assurance. Small Group Employment services may be provided without referring a participant to OVR unless the participant is under the age of 25. When a participant is under the age of 25, Small Group Employment services may only be authorized as a new service in the service plan when documentation has been obtained that OVR has closed the participant's case or that the participant has been determined ineligible for OVR services.” The service definition will be revised to add the following information, “Federal financial participation is not claimed for incentive payments, subsidies, or unrelated vocational training expenses such as the following: 1. Incentive payments made to an employer to encourage or subsidize the employer's participation in supported employment services; or 2. Payments that are passed through to users of supported employment services.” CMS: Please make the revisions as noted above. No additional comments.


Supported Living 61. The State has identified this service includes reimbursement for periods of

indirect support. Please provide explanation of what is included and reimbursed as indirect support.

ODP Response: Supported Living is not a service in this waiver. CMS: No additional comments

62. Please explain how the supported living specialist does not duplicate activities performed by the service coordinator.


63. Please describe in detail Supplemental Habilitation and its reimbursement structure in appendix I-2-a if applicable.


64. Please explain whether Supplemental Habilitation is included in the rate and does not need to be broken out for reimbursement or coding.


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Therapy Services 65. The State has opted to include and bundle three service components under this

service (OT, PT, speech). Please note since the service is bundled, each service component will need to be broken out under the appendix J tables.

ODP Response: The tables in appendix J will be revised to reflect this information. CMS: Please make the revisions as noted above. No additional comments. ODP Response: Revisions have been made.

66. Please change “Therapy Services” from “Other Services” to “Extended State

Plan Services.”

ODP Response: Therapy services will be revised from Other Services to

Extended State Plan Services.

CMS: Please make the revisions as noted above. No additional comments. ODP Response: Revisions have been made.

Appendix C-5 HCB Settings 67. At this time, CMS requests all information pertaining to the waiver settings be

contained in Attachment #2 until the transition period has ended for the STP. The State can have under this section the STP received initial approval. ODP Response: The information in Appendix C-5 will be relocated to Attachment #2 of the waiver. CMS: Please make the revisions as noted above. No additional comments. ODP Response: Revisions have been made.

Appendix G-1-b State Critical Event or Incident Reporting Requirements 68. Please add details to define the state’s definition of abuse, neglect, and

exploitation.

ODP Response:

o Abuse is defined as an allegation or actual occurrence of the infliction of injury, unreasonable confinement, intimidation, punishment, mental anguish, sexual abuse or exploitation. Abuse is reported on from the victim’s perspective, not on the person committing the abuse.

Physical abuse. An intentional physical act by staff or other person which causes or may cause physical injury to an

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individual, such as striking or kicking, applying noxious or potentially harmful substances or conditions to an individual.

Psychological abuse. An act, other than verbal, which may inflict emotional harm, invoke fear or humiliate, intimidate, degrade or demean an individual.

Sexual abuse. An act or attempted acts such as rape, incest, sexual molestation, sexual exploitation or sexual harassment and inappropriate or unwanted touching of an individual by another. Any sexual contact between a staff person and an individual is abuse.

Verbal abuse. A verbalization that inflicts or may inflict emotional harm, invoke fear or humiliate, intimidate, degrade or demean an individual.

Improper or unauthorized use of restraint. A restraint not approved in the individual support plan or one that is not a part of an agency’s emergency restraint procedure is considered unauthorized. A restraint that is intentionally applied incorrectly is considered an improper use of restraint.

o Neglect. The failure to obtain or provide the needed services and supports defined as necessary or otherwise required by law or regulation. This includes the failure to provide needed care such as shelter, food, clothing, personal hygiene, medical care, protection from health and safety hazards, attention and supervision, including leaving individuals unattended and other basic treatment and necessities needed for development of physical, intellectual and emotional capacity and well-being. This includes acts that are intentional or unintentional regardless of the obvious occurrence of harm.

o Exploitation is defined as Misuse of funds and Rights violation.

Misuse of funds. An intentional act or course of conduct, which results in the loss or misuse of an individual’s money or personal property. Requiring an individual to pay for an item or service that is normally provided as part of the individual support plan is considered financial exploitation and is reportable as a misuse of funds. Requiring an individual to pay for items that are intended for use by several individuals is also considered financial exploitation. Individuals may voluntarily make joint purchases with other individuals of items that benefit the household.

Rights violation. An act which is intended to improperly restrict or deny the human or civil rights of an individual including those rights which are specifically mandated under applicable regulations. Examples include the unauthorized removal of personal property, refusal of access to the telephone, privacy violations and breach of confidentiality.

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This does not include restrictions that are imposed by court order or consistent with a waiver of licensing regulations.

CMS: Please make the revisions as noted above. No additional comments. ODP Response: Revisions have been made. Appendix I- 1 Financial Integrity

69. Please demonstrate how the state ensure the financial integrity and

accountability for participant-directed providers and other provider(s) that fall

below the $750,000 threshold.

ODP Response: Both traditional and AWC FMS providers are reviewed by

the Department (ODP or AEs) through the Quality Assessment and

Improvement (QA&I) Process on a 3-year cycle. During ODP’s QA&I

process, claims submitted by the traditional and AWC FMS are reviewed by

the AE for accuracy and to ensure that there is documentation to

substantiate the claim and that the service was actually rendered. This

includes individuals that fall below the $750,000 threshold. The Department

monitors the VF/EA FMS to ensure that the contract deliverables are met

and participants are in receipt of VF/EA FMS services in accordance with

their service plan. The statewide VF/EA FMS is monitored by agents of the

Department. The contract includes a set of minimum standards which the

VF/EA must meet or exceed in order to ensure that claims are processed

corrected. Additionally, the financial integrity and accountability of the

Common-Law Employer is monitored through submission of overtime and

utilization reports. The overtime report is used to ensure that Support

Service Professional overtime is scheduled in accordance with ODP’s

policies. The utilization report is used to ensure that the participant is not

over-utilizing the service. Overutilization usually includes services

rendered above the authorized amount in the service plan, but unusually

high utilizations may also be investigated. This also includes participants

with service authorizations in their service plans that fall below the

$750,000 threshold.

CMS: Please add the abovementioned. No additional comments.


70. Please provide documentation that providers are required to secure an

independent audit of their financial statements.

ODP Response: The document entitled “Audit Requirements for Fiscal

Year 2015-2016 Reporting Period” is attached to the email with this

response. This document is reviewed and updated at least annually (more

frequently if necessary) to reflect any audit requirement changes. The

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document is released to the provider via the listserv and posted to the

MyODP website.

CMS: No additional questions.

71. Please explain how the State ensures that services billed were actually

rendered. Please detail the states post payment review methods.

ODP Response: On a quarterly basis, ODP pulls a random, representative

sample of claims using a 95% confidence level and 5% margin of error and

reviews claims for accuracy and to assure that documentation adequately

supports the claim.

CMS: Please add the abovementioned. No additional questions.


72. Please explain how the State accounts for fraudulent and/or inaccurate billings.

Describe the state’s recoupment process for inappropriate billings.

ODP Response: Fraudulent and/or inaccurate billings discovered during

the monitoring process will trigger an expanded review by ODP or referral

to the Bureau of Financial Operations or the Bureau of Program Integrity

depending on the nature and extent of the finding. Inappropriate billings

are required to be refunded by the provider and further remediation up to

termination may occur.



73. Please document what period of claims are monitored by the Office of

Improvement and Integrity.

ODP Response: Claims are monitored on a quarterly basis for the most

recent 3 months.



74. Detail the process for selecting a post-payment review sample. Explain how the

sample is selected and what methods are used.

ODP Response: A statistically valid sample with 95% confidence level is

randomly drawn from the statewide universe of claims for the preceding 3

month period.


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75. Please provide how frequently post-payment review activities are conducted.

ODP Response: Post-payment review activities are conducted quarterly. CMS: Please add the abovementioned. No additional questions. ODP Response: Revisions have been made.

Appendix I-2-a Rates, Billings & Claims 76. Please submit a copy of the MA fee schedule, AWC fee schedule, non-

participant directed fee schedule and other rates related to the applicable to the

renewal period or provide a web link.

ODP Response: The document entitled “Fee Schedule Public Notice” is

attached. The fee schedule in this document applies to services in both the

Consolidated and P/FDS waiver. This document includes the MA fee

schedule for traditional providers (non-participant directed) and AWC

services.


77. Provide a sample copy of a cost report including a cross walk on how a cost-

based rate is calculated and the items with descriptions that are included in the

calculation. Please describe the rate assignment process.

ODP Response for the P/FDS Waiver – The only service that has a cost-

based rate in this waiver is Transportation Trip. The documents entitled

“Year 9 Transportation Cost Report Template,” and “Year 9 Transportation

Cost Report Instructions” are attached.

A description of the cost-based rate assignment process is described in

Section I-2-a of the waiver submitted as follows, “ODP assigns rates in the

following manner:

-A provider is assigned the average of the provider's cost-based rates for

an existing service at a new service location if the provider has an

approved cost-based rate at another service location. A provider shall be

assigned the area adjusted average of all provider approved cost-based

rates for new HCBS if:

(1) The cost report of the provider did not contain the new HCBS because

the HCBS was not delivered during the reporting period.

(2) A provider is a new provider who was not delivering HCBS during the

reporting period of the cost report.

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-A provider shall be assigned the lowest rate calculated Statewide based

on all provider cost reports for HCBS if a provider was required and failed

to submit a cost report.

-A provider who is required to submit an audit & then fails to do so shall

receive the lowest rate calculated statewide.

-A provider who submits an audit which indicates the information in the

cost report requires adjustment & the provider does not submit a revised

cost report, shall be assigned the lowest rate calculated statewide.

-A provider that chooses to not submit a cost report or the cost report is

not approved will be assigned the lowest rate calculated statewide for each

cost-based service.


ODP Response: This information was included in the waiver so no

revisions were made.

78. Please provide supporting documentation on how the cost of new services are

calculated such as:

o Advanced Supported Employment. o Music Therapy, Art Therapy and Equine Assisted Therapy. o Supported Living. o Benefits Counseling. o Communication Specialist. o Consultative Nutritional Services. o Family/Caregiver Training and Support. o Housing Transition and Tenancy Sustaining Services o Participant Directed Goods and Services. o Community Participation Support o 14 hours per day of In-Home and Community Support, o Companion and Community Participation Support o Transitional Work to Small Group Employment o Education Support services

ODP Response: The P/FDS waiver does not include Supported Living or Life Sharing services. Further, there is no limit on the number of hours of In-Home and Community Support, Companion and Community Participation Support a participant may receive in this waiver. The rates for new services are calculated in accordance with the methodologies enumerated in Section I-2-a of the waiver. Rate assumption logs for non-residential services can be accessed under the Draft Fee Schedule Documents header at http://dhs.pa.gov/provider/developmentalprograms/2017waiverrenewals/Appendies/index.htm.

http://dhs.pa.gov/provider/developmentalprograms/2017waiverrenewals/Appendies/index.htm


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CMS: The type of providers include agency and individual. The unit cost include employee related expenses. Why do believe paying the same amount for individual provider is reasonable since employee related employees do not apply? Why do you believe 10% administration percentage is reasonable?

ODP Response: Individual providers still incur both administrative and employee-related expenses and do not benefit from any economy of scale purchasing of such things as software, training or insurances. Based on provider financial reports and CMS guidance, we believe 10% is an appropriate administration percentage.

Fee Schedule/Agency with Choice Methodology

79. Provide the rate model used to set the fee schedule rates.

ODP Response: The rate assumption logs for residential services and non-

residential services can be accessed under the Draft Fee Schedule

Documents header at

http://dhs.pa.gov/provider/developmentalprograms/2017waiverrenewals/Ap

pendies/index.htm.


80. Describe the exception process noted when the needs of the participant require

higher staffing. How is the additional payment amount determined? What is the

process for an individual to receive additional support?

ODP Response: The exception process is for participants who need

enhanced levels of staffing (staff to participant ratio of 2:1 or staffing by a

person who has a certification or bachelor’s degree). This applies to

Community Participation Support, In-Home and Community Support and

Respite services. When a participant has a need for enhanced levels of

staffing for any of these services, the ISP team will complete a variance

form describing why a participant needs this level of service. The

completed variance form will be submitted to the AE for review and

approval. There is a fee schedule rate developed and in accordance with

the fee schedule rate setting methodology.


ODP Response: Revisions were made.

81. Please provide what the specific compensation studies and cost reports were

used as a guide to set payment rates. How did the State decide that these

sources were appropriate to estimate costs?

ODP Response - ODP utilized the most recent Bureau of Labor Statistics

wages specific to Pennsylvania. Cost reports were not utilized to develop



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fee schedule rates in this waiver since residential habilitation, life sharing

and supported living are not available in this waiver.


82. The State references additional services are in consideration to be transitioned to

fee schedule each year. What prompts the State to consider transitioning a

service to the fee schedule?

ODP Response: ODP will determine when and if we could transition

transportation trip when staff review the service definitions and make a

determination of the allowable cost components which reflect costs that

are reasonable, necessary and related to the delivery of the service, as

defined in Uniform Administrative Requirements, Cost Principles, and

Audit Requirements for Federal Awards (OMB Circular Uniform Guidance,

12/26/14). We will only transition if the Department can establish the fee

schedule rates to fund services at a level sufficient to ensure access,

encourage provider participation and promote provider choice, while at the

same time ensuring cost effectiveness and fiscal accountability.


Cost-Based Rates 83. Please describe how the retention factor is calculated.

ODP Response: The retention factor only applies to residential services which are not covered by the P/FDS waiver. There is no reference to a retention factor in this waiver and one is not applied to any rates in this waiver. CMS: No additional questions.

84. What is the value of the COLA applied?

ODP Response: As stated in the waiver submitted to CMS, “a COLA is

applied as appropriated by the General Assembly”. It is anticipated that no

COLA will be appropriated by the General Assembly for Fiscal Year 17/18

(waiver year 1). Cost-based services are, however, adjusted annually

based on cost-reports submitted by providers of the applicable services.


Appendix I-3-d Payments to State or Local Government Providers 85. Please describe what type of entity are the Supports Coordination Organizations.

Can they perform other services aside from supports coordination and/or administration functions delegated by the State? ODP Response: Supports Coordination Organizations (SCOs) are either private businesses or businesses run by a county. SCO cannot perform other services aside from supports coordination. The provider

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qualification requirements submitted to CMS for SCOs states that the organization must “Function as a conflict free entity. A conflict-free SCO, for purposes of this service definition, is an independent, separate, or self-contained agency that does not have a fiduciary relationship with an agency providing direct services and is not part of a larger corporation. To be conflict free, an SCO may not provide direct or indirect services to participants. The following are considered direct and indirect services: Direct Services:

All intellectual disability services provided to base-funded individuals and waiver participants with the exception of Waiver Supports Coordination, Targeted Service Management and State-funded Case Management as well as transportation and ICF/ID services where the SCO shares a Federal Employer Identification Number (FEIN) with the provider.

Indirect Services:

All services related to Health Care Quality Units, Independent Monitoring Teams, Organized Health Delivery System Providers, Financial Management Service Providers/Organizations for Waiver participants, and the Statewide Needs Assessment with the exception of Family Driven Support Service funds and the administration of Money Follows the Person (MFP) as approved by CMS.

CMS: Please add the abovementioned. No additional questions. ODP Response: Revisions were made.

Appendix I-3-e Amount of Payment

86. Please provide the definitions and descriptions of the following providers, what

type of providers and what type of services are they providing. Provide a sample

copy of their agreements with the State (scope of work). If the State is using

same agreement, forward only one copy.

a. AEs

b. FMS Organizations

c. OHCDS

d. SCOs

e. VF/E

f. AWC

ODP Response: Currently all AEs are County MH/ID programs that have signed an AE Operating Agreement that stipulates the administrative functions they will perform. When a County MH/ID program is unwilling or unable to perform AE functions, ODP will select a nongovernmental entity to perform delegated functions. ODP may select a multi-county MH/ID

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program or non-profit entity. The AE Operating Agreement is included as an attachment. AEs perform the following delegated waiver administration functions:

1. Participant waiver enrollment – Receive/review applications, ensure initial and annual completion of PUNS or its successor and refer applicants for an eligibility decision.

2. Level of care (LOC) determination – Compile necessary documentation for a LOC determination, review documentation and make a determination regarding whether the applicant/participant meets LOC criteria.

3. Review of service plans – Includes review, clarification and approval of service plans.

4. Qualified provider enrollment – Provider recruitment. 5. Quality assurance and improvement activities – Conduct qualified

provider reviews, oversee provider corrective action plans, refer providers to ODP for sanctions and/or disqualification.

As specified in Appendix E-1-a of the waiver, participants who wish to self-direct services through the utilization of a Financial Management Service (FMS) Organization may do so though one of two FMS models: Agency with Choice (AWC) or Vendor Fiscal/Employer Agent (VF/EA). The AWC FMS model is provided by provider agencies enrolled with ODP. AWC FMS providers are responsible for activities that include, but are not limited to:

Hiring qualified Support Service Professionals (SSP) referred by participants or surrogates;

Processing employment documents;

Verifying that qualified SSPs meet the qualification standards outlined in Appendix C-3;

Obtaining criminal background checks and child abuse checks, if applicable, on prospective SSPs;

Submitting claims to the Department for services authorized and rendered;

Preparing and disbursing payroll checks;

Providing workers compensation for SSPs;

Providing Managing Employer skills training;

Conducting SSP training, and

Fulfilling any responsibilities established by ODP bulletins.

The waiver services available through the AWC FMS model are listed at Appendix E-1-g of the waiver. Provider agencies who render AWC FMS services are required to complete an ODP Waiver Provider Agreement, available at https://www.hcsis.state.pa.us/hcsis-ssd/custom/OMR_MAProviderAgreement.pdf.

https://www.hcsis.state.pa.us/hcsis-ssd/custom/OMR_MAProviderAgreement.pdf


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The VF/EA FMS model is provided by an entity under contract with the Department to serve as the FMS Agent. Under the VF/EA model, the FMS is responsible for functions such as but not limited to:

Functioning as the employer agent on behalf of the participant or surrogate;

Withholding, filing, and paying Federal employment taxes, State income taxes, and workers compensation for SSPs on behalf of the participant or surrogate;

Paying SSPs and vendors for services rendered as per the participant’s authorized service plan;

Verifying that SSPs meet established qualification criteria for the service(s) they provide;

Conducting criminal background checks and child abuse checks, if applicable, on prospective SSPs;

Providing Common-Law Employers with informational materials relating to the VF/EA FMS model; and

Fulfilling any responsibilities established by the Department’s contract with the VF/EA FMS and ODP bulletins.

The waiver services available through the VF/EA FMS model are listed at Appendix E-1-g of the waiver. As of this writing, the VF/EA FMS Agent under contract with the Department is Public Partnerships, LLC. A copy of the contract, including statements of work and contract addendums, may be viewed by visiting http://contracts.patreasury.gov/search.aspx, entering Contract Number 4100061881 in the “Contract Number” box, and clicking the “search” button. The contracted VF/EA FMS Agent is also required to complete an ODP Waiver Provider Agreement, available at https://www.hcsis.state.pa.us/hcsis-ssd/custom/OMR_MAProviderAgreement.pdf. Organized Health Care Delivery Systems (OHCDS) are businesses that provide at least one direct waiver service. This can be any direct waiver service with the exception of Supports Coordination. In their function as an OHCDS, the business must ensure that the vendor meets the qualification standards for the service being rendered, ensure that the service is delivered in accordance with the service definition, ensure that the amount charged by the vendor is the same as what the public pays and maintain documentation on the service delivered by the vendor. OHCDS sign a ODP Waiver Provider Agreement which can be accessed at https://www.hcsis.state.pa.us/hcsis-ssd/custom/OMR_MAProviderAgreement.pdf.

http://contracts.patreasury.gov/search.aspx





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Supports Coordination Organizations (SCOs) provide Supports Coordination services and performs administrative functions delegated by the AE in accordance with the AE Operating Agreement. SCOs are either private businesses or businesses run by a county. When an SCO performs administrative functions delegated by the AE, these functions are prohibited from being billed as an SC service. ODP looks at documentation of services rendered when monitoring SCOs to ensure that claims submitted as an SC service are appropriate. To provide Supports Coordination services, the SCO signs a ODP Waiver Provider Agreement which can be accessed at https://www.hcsis.state.pa.us/hcsis-ssd/custom/OMR_MAProviderAgreement.pdf. CMS: Please add the abovementioned. No additional questions.

ODP Response: The system does not allow us to enter information in

Appendix I-3-e.

87. Describe the process to ensure that billing is not duplicative amongst these providers.

ODP Response: There are separate procedures codes for billing AE administrative costs, FMS administrative fees, OHCDS administrative fees and the supports coordination waiver service. Further, claims are reviewed as part of monitoring and post-payment review. CMS: Please provide the procedure code(s) and add. ODP Response: The system does not allow us to enter information in

Appendix I-3-e.

Appendix I- Quality Improvement Systems 88. Please add a new performance measure, or modify the existing performance

measure, that specifies how the State ensures that claims are coded and paid for in accordance with the reimbursement methodology specified in the approved waiver.

ODP Response: The following revisions (indicated in red italicized font) will be made: Performance Measure Number and percent of claims coded and paid for in accordance with the reimbursement methodology specified in the approved waiver. Numerator = number of claims coded and paid for in accordance with the reimbursement methodology specified in the approved waiver. Denominator = number of claims paid.



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b. Methods for Remediation/Fixing Individual Problems i. Performance Measure FA3. Number and percent of claims coded and paid for in accordance with the reimbursement methodology specified in the approved waiver. CMS: Please add the abovementioned. No additional questions. ODP Response: Revisions were made.

Appendix J-2-c Derivation of Estimates

89. Provide the FY 17-18 rates, the FY 16-17 user counts and the 15-16 paid waiver claims data used to project Factor D and corresponding waiver service estimates for WY 1-5. ODP Response: The document entitled “Fee Schedule Public Notice” is

attached and includes the FY 17-18 rates. The document entitled “User

Counts” is attached and contains the FY16-17 user counts, the document

entitled “Claims Paid” is also attached and contains FY 15-16 paid waiver

claims data.


90. The State projects that there will be no waiver service growth WY 1-5. We recommend that the State incorporate a growth factor for its waiver service estimates WY 1-5. These growth factors can include an inflation factor, historical trends or some other factor that the State feels is appropriate to project waiver service cost growth.

ODP Response: There is no waiver service growth projected because

Pennsylvania’s legislature approves funding on an annual basis. ODP

develops a budget request on an annual basis and operates within the

approved budget. The Factor G estimates will be updated via amendment

as funding is approved.


91. Per the 372 reports Factor D’ has increased each year but the State estimates that Factor D’ will remain stagnant over a 5-year waiver period. Why does the State estimate Factor D’ to remain stagnant for 5 years?

ODP Response: Pennsylvania’s legislature approves funding on an annual basis. ODP develops a budget request on an annual basis and operates within the approved budget. The Factor D’ estimates will be updated via amendment as funding is approved. CMS: No additional questions.

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92. How did the State use the 2014-15 372 report Factor G (189,554) to estimate Factor G (217,159)?

ODP Response: The 2014-2015 372 report information was the most

current and accurate information available at the time that Factor G was

developed for the waiver renewal. Current year cost data was compared to

the 372 for consistency and annualized to arrive at a Year 1 estimate.


93. Factor G is projected to remain stagnant all 5 years, but the State references a projection factor in the application. How did the State apply a projection factor to Factor G estimates?

ODP Response: As noted in the response above, the projection factor

referenced is to annualize best available information at the time of

submission.


94. Why does the State estimate that Factor G will remain stagnant all 5 years?

ODP Response: Pennsylvania’s legislature approves funding on an annual

basis. ODP develops a budget request on an annual basis and operates

within the approved budget. The Factor G estimates will be updated via

amendment as funding is approved.


95. How did the State use the 2014-15 372 report Factor G’ (6,347) to estimate Factor G’ (5,442)? ODP Response: The 2014-2015 372 report information was the most

current and accurate information available at the time that Factor G’ was

developed for the waiver renewal. Current year cost data was compared to

the 372 for consistency and annualized to arrive at a Year 1 estimate.


96. Factor G’ is projected to remain stagnant all 5 years, but the State references a projection factor in the application. In addition, Factor G’ is estimated to be lower than the referenced 372 report Factor G’. What projection factor was used and how was it applied?

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ODP Response: The referenced projection factor means that we

annualized current year costs to arrive at the most realistic estimate of

Year 1 Factor G’.


97. Why does the State estimate that Factor G’ will remain stagnant all 5 years?

ODP Response: Pennsylvania’s legislature approves funding on an annual basis. ODP develops a budget request on an annual basis and operates within the approved budget. The Factor G’ estimates will be updated via amendment as funding is approved. CMS: No additional questions.

Appendix J-2-d Estimate of Factor D

98. Please explain why Factor C in Year 1 of 14,720 is 1,785 or 14% higher than the

most recent 372 report of 12,935.

ODP Response: The unduplicated number of individuals to be served in

this waiver is 14,720. The 372 report referenced is from Fiscal Year 2014-

2015. ODP requested a waiver amendment effective June 30, 2016 that

increased the unduplicated number of participants served to reflect the 600

young adults who are graduating from the special education system to

continue to live independently in the community through enrollment in the

Person/Family Directed Support (P/FDS) Waiver. This submitted waiver

renewal also anticipates funding to serve 820 additional young adults who

are graduating from the special education system.



99. Please explain why Factor D in Year 1 of 22,910 is 5,309 or 30% higher than the

most recent 372 report of 17,601.

ODP Response: This increase is due to two factors: 1) The fee schedule

rates were rebased for FY17/18 to current market levels which has resulted

in an increase in the majority of the rates; and 2) Data indicates that

participants who are newly enrolling into the waivers have higher acuity

levels and higher service authorizations on their service plans.



100. Please explain why Factor G in Year 1 of 217,159 is 27,606 or 15% higher than

the most recent 372 report of 189,553.

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ODP Response: The number of individuals in Intermediate Care Facilities

continues to decrease each year, however, the costs to serve those

individuals that remain in these facilities do not decline with the census.

This is due to the fact that 1) many of the costs are fixed regardless of the

census in the facility; 2) the individuals in the facilities are aging and

require increased care; and 3) the few individuals who are admitted each

year have higher acuity levels and need intensive staffing.

CMS: Please add the abovementioned. No additional questions. ODP Response: Revisions were made.

CORRECTIONS MADE

Main module – Major changes – The following bullet was removed, “Add a limit of 14 hours per day of In-Home and Community Support, Companion and Community Participation Support with a process to request a variance to this limit.” This change only applies to the Consolidated Waiver and was erroneously added to the list of changes made to the P/FDS waiver.

Main Module – Home and Community-Based Settings Waiver Transition Plan – Revisions were made to reflect the actions that have been completed to date.

Appendix C - In-Home and Community Support and Companion Service Definitions - The staffing ratios will take effect on 7/1/17, not 1/1/18. The waiver originally stated “Effective 1/1/18, this service may be provided at the following levels:” This date has been corrected to say “This service may be provided at the following levels:”

Appendix C – References to “exceptions” were replaced with “variances” in the Respite, Assistive Technology and Home Accessibility Adaptations service definitions.

Appendix C – Community Participation Support service definition and provider qualifications – Level 2 enhanced staff requirements have been updated to align with enhanced qualifications in the In-Home and Community Support service. These qualification requirements will go into effect January 1, 2018.

Appendix C – QP3 refers to qualification on a biennial cycle. This information has been updated to reflect the three year cycle that ODP will be using to qualify all providers and Support Service Professionals.

Appendix G-1-b - The following types of incidents require a formalized investigations to be completed by a Department-certified incident investigator: (1) Death that occurs during the provision of an HCBS.

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Appendix I-2-a – Revisions were made to the fee schedule methodology to reflect that there is now one statewide rate for each service.

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