Tuesday, January 16, 2018

Documents from the Michigan Home and Community-Based Medicaid Waiver Conference, 10/2017

The Michigan Association of Community Mental Health Boards (now called the Community Mental Health Association of Michigan) sponsored the 2017 Annual Home and Community-Based Waiver Conference last October. The written materials from the conference are available on the Community Mental Health Association (CMHA) Website.

NAME CHANGE: The Michigan Association of Community Mental Health Boards is changing its name - “…The Association’s new name will be the Community Mental Health Association of Michigan. This new name retains the words ‘community mental health’ to represent the association’s link to the community mental health movement that, fifty years since its genesis, is in robust and continual development. However, you will notice that the name no longer contains the word ‘Boards’. While the Association is still led by the members of the Boards of Directors of the state’s public Community Mental Health centers (CMHs) and public Prepaid Inpatient Health Plans (PIHPs) – with Board members making up 2/3 of the Association’s Member Assembly – the Michigan Mental Health Code (the state law under which the public BHIDD [Behavioral Healthcare and Intellectual/Developmental Disability services] system in Michigan is governed has not, for years, used the term ‘Board’ to describe the local and regional organizations that make up the public BHIDD system. Additionally, none of the Association’s members use the word 'Board' in their names.”

Local CMH agencies serve people with mental illness and developmental disabilities, as well as other populations needing public social, health, and behavioral services. Along with representing the Michigan Community Mental Health agencies, the CMHA represents the PIHP’s (Prepaid Inpatient Health Plans)
, the regional administrative agencies that, among other things, distribute Medicaid funds to local agencies.

I attended one day of the HCB Waiver conference in October and did not come close to covering all the topics offered. The CMHA has made available all the written materials for the conference sessions. In my experience, families usually find that topics that provide information on the services available in Michigan and how to access them are the most helpful to begin with. I recommend for starters the  written materials on the following topics:
I sometimes disagree with the interpretation of policies that are part of the discussion on Medicaid Waivers, but at least the written documents from the conference give families enough information to explore these topics further as well as providing state and local contacts that may be helpful in obtaining services for a DD family member.


A quick reference to acronyms and their meanings:
HSW - the Habilitation Supports Waiver, the Michigan Medicaid Waiver for people with developmental disabilites

CWP - the Michigan Children's Medicaid Waiver Program

HCBS - Home and Community-Based Services

Behavioral Healthcare and Intellectual/Developmental Disability services system

CMH - Community Mental Health

PIHP - Prepaid Inpatient Health Plans; regional administrative agencies that distribute Medicaid funds to local agencies

Friday, January 12, 2018

U.S. Representatives raise concerns about restrictions on group settings for people with disabilities

Three U.S. Representatives wrote a letter to the Centers for Medicare and Medicaid Services (CMS) on 11/27/17 to ask for changes in guidelines for the federal 2014 Home and Community-Based Settings rule. John Faso (R-NY), Jackie Rosen (D-NV), and Raja Krishnamoorthi (D-IL) expressed their concern that the “Guidance on settings that have the effect of isolating individuals receiving HCBS from the broader community” unfairly discriminates against “disability-specific, congregate, farmstead, and lifesharing communities” and that the guidance "reflects a fundamental misunderstanding of how [such settings] operate,"

Many innovative housing projects and planned communities for people with disabilities have been developed in recent years, only to be threatened by a loss of Medicaid funding to pay for services in settings that are deemed by CMS too much like institutions. Such settings may be acceptable to CMS only after going through a process of “heightened scrutiny” to assure that they are integrated into the broader community. Individuals and organizations supporting these housing options have questioned the CMS requirement, saying that CMS lacks the authority to limit the choices of people with disabilities in determining where they want to live. [see the Legal Vulnerabilities of the HCBS settings rule]

The letter from the U.S. Representatives goes on to say,

“We are particularly concerned that the guidance may have the unintended impact of discouraging and ultimately phasing out congregate and lifesharing models which promote individual independence, community integration, and enhanced quality of life for all served by these communities. …In subjecting these communities to a heightened scrutiny standard, CMS has introduced significant uncertainty to the future of these communities.

“By painting all congregate and farmstead communities with a broad brush, CMS threatens to remove a critical choice from individuals looking for a setting that provides individuals with a community that supports inclusion, not seclusion. We applaud CMS’ intent in the 2014 final rule to protect patient choice and dignity, but urge CMS to revise its subsequent guidance to clarify that congregate and farmstead communities based on the lifesharing model are not subject to the heightened scrutiny standard. We understand that these communities would welcome third party certification (such as the Center for Quality and Leadership) as an alternative to the current broad brush policy.”


More resources: The Coalition for Community Choice ; Together for ChoiceMadison House Autism Foundation 

Tuesday, December 5, 2017

Michigan: Proposed changes to the Medicaid Manual based on the federal settings rule

From the ARC Michigan Governmental Affairs Update, December, 2017:

"The Medical Services Administration (Medicaid) has published proposed policy creating a new Medicaid Provider Manual chapter for Home and Community Based Services in compliance with the final federal HCBS rule. 
Public comment will be accepted until January 1; the policy has a proposed effective date of January 1, 2018."

Here are the proposed changes - read carefully and comment.

Mail comments [due January 1, 2018] to:

Heather Hill
Bureau of Medicaid Policy and Health System Innovation
Medical Services Administration
P.O. Box 30479
Lansing, Michigan 48909-7979

Phone: 517-241-9397

Policy Subject: New Medicaid Provider Manual Chapter for Home and Community Based Services (HCBS)

Affected Programs: MI Health Link HCBS Waiver, MI Choice Waiver, Managed Specialty Services & Supports Waiver, Habilitation Supports Waiver

Policy Summary: The Michigan Department of Health and Human Services (MDHHS) has developed a new Medicaid Provider Manual chapter for HCBS that describes the requirements under the HCBS Final Rule. These requirements aim to improve the quality of the lives of beneficiaries and allow them to live and receive services in the least restrictive setting possible and be fully integrated in the community.

Purpose: To ensure compliance with federal HCBS requirements. 


Wednesday, November 22, 2017

Update on Medicaid Home and Community-Based Services

The final implementation of the controversial 2014 Federal Home and Community-Based Settings rule has been delayed by the Centers of Medicare and Medicaid Services (CMS) until 2022, but that has done nothing too allay the fears of many people with disabilities and their families that it may be used as an excuse to discontinue funding for needed services and programs.

State Transition Plans (STP) are important for protecting the rights of people with disabilities to appropriate services in settings of their choice that assure integration into the larger community appropriate to the needs of the individual.

Michigan has identified settings that will undergo “heightened scrutiny” to assure that they meet the conditions of the settings rule before they are finally approved or rejected for HCBS funding. There are also grounds for legal challenges to the rule and commentary that explains why the Federal rule has been so controversial.

The following are links to resources and information to better understand what is at stake in the implementation of the federal settings rule:


HCBS Advocacy

This is a Website supported by the Association of University Centers on Disabilities (AUCD).

From here you can find information regarding your state, including State Transition Plans that have received initial or final approval from CMS. So far only five states - Tennessee, Washington, Oklahoma, Kentucky, Arkansas - and the District of Columbia have final approval for their STPs.

According to HCBS Advocacy, although implementation of the rule has been extended to 2022, the deadline for final statewide transition plan approval is still March 2019.


The Michigan Health and Human Services Website on the “Home and Community-Based Services Program Transition”

“As the Department develops new opportunities for stakeholders to provide feedback on this project, information about these events and opportunities will be published on this webpage. If you have any questions about this project, please send an email to HCBSTransition@michigan.gov.”

“Heightened Scrutiny”:

from CMSHome and Community-based Setting Requirements” - Heightened Scrutiny:

“Importantly, any setting regardless of location that has the effect of isolating individuals receiving Medicaid home and community-based services (HCBS) from the broader community of individuals not receiving HCBS is also presumed to be institutional, and therefore requires information from the state to overcome that presumption and describe how the HCBS settings requirements are met. States have an obligation to identify settings that are presumed institutional. …[The] final regulation …describes the process of “heightened scrutiny” that states can use to rebut or overcome this presumption. In particular, the regulations indicate that a settings described above “will be presumed to be a setting that has the qualities of an institution unless the Secretary determines through heightened scrutiny, based on information presented by the state or other parties, that the setting does not have the qualities of an institution and that the setting does have the qualities of home and community-based settings.”

Heightened Scrutiny in Michigan: 

In Michigan: Providers have been notified if they are subject to heightened scrutiny. Family members are encouraged to ask their provider about their status with regard to state implementation of the federal rule. 

from the HHS HCBS Transition Program:

“For those providers whom the department may submit for further review by the Centers for Medicare and Medicaid (CMS) there will be a public comment period. During this time all members of the public, including family members, will have an opportunity to share their opinions about whether the setting is home and community based. These comments will be taken into consideration before the department makes the final decision regarding submission to CMS.”


May 9, 2017 letter from CMS extending the deadline for full implementation of the settings rule:

Extension of Transition Period for Compliance with Home and CommunityBased Settings Criteria”

“In recognition of the significance of the reform efforts underway, CMS intends to continue to work with states on their transition plans for settings that were operating before March 17, 2014 to enable states to achieve compliance with the settings criteria beyond 2019. Consistent with the preamble language, states should continue progress in assessing existing operations and identifying milestones for compliance that result in final Statewide Transition Plan approval by March 17, 2019. However, in light of the difficult and complex nature of this task, we will extend the transition period for states to demonstrate compliance with the home and community-based settings criteria until March 17, 2022 for settings in which a transition period applies. We anticipate that this additional three years will be helpful to states to ensure compliance activities are collaborative, transparent and timely.”


From Together For Choice Blog, 11/14/17

Together for Choice Meets with CMS Administrator Seema Verma

"Together for Choice was invited to meet with Seema Verma, CMS Administrator, on November 1, to discuss the future of Medicaid. Approximately twenty other organizations participated in this invitation only meeting. The focus of the discussion was CMS’s Settings Rule which defines what constitutes a “community” setting and is therefore eligible for Medicaid waiver funding. I was the only person at the meeting who advocated for choice. I argued that the Settings Rule should be changed to honor the choices of individuals and their families regarding where to live and spend their days and to expand residential and day programming options. All of the other participants said that they did not want any changes to the Settings Rule or the CMS guidance under the Rule.

"Administrator Verma stated that she wanted Medicaid to be beneficiary focused and to put people first. She also said that she wanted to provide the states with more flexibility on administering Medicaid programs. In fact, she said that she wanted to give states an 'unprecedented level of flexibility.' She also acknowledged that individuals with disabilities receiving Medicaid should be viewed differently from non-disabled individuals receiving Medicaid. She wants the states to be creative and innovative in developing Medicaid programs and she repeatedly said that she wants less process and more focus on outcomes. In that connection, she said that CMS will be developing a Medicaid scorecard for states…

"Brian Neale, the head of Medicaid services at CMS also spoke. He indicated a preference for revising the CMS guidance to address the unintended consequences of the Rule rather than amend the Rule.

..."We will continue to advocate for choice by following up with Administrator Verma and Director Neale. Please join our voices to preserve choice and expand quality options by joining Together for Choice. Click HERE to join."

Scott Mendel
Chairman, Together for Choice


Misericordia’s Developmental Training Program No Longer Subject to “Heightened Scrutiny”


...“In early November, Illinois issued for public comment a draft of its transition plan. The plan listed all the facilities in the state that it believed should be subject to 'heightened scrutiny.' Misericordia’s DT program was one of the facilities on the list. The reason the state gave for subjecting Misericordia’s DT program to 'heightened scrutiny' was that it was located on a campus and was close to Misericordia’s ICF/DDs. We immediately asked all of our families with a family member living in a Misericordia CILA [Community Integrated Living Arrangement] (these are the individuals receiving “waiver” funding) to submit a public comment to HFS explaining how Misericordia’s DT program does not isolate their family member from the broader community.
  • We asked each family to include in its comment: all of the activities their family member engages in both on and off campus to show how full and integrated their life is. 
  • We asked the families to explain that their family member was engaging in the employment opportunities and other activities they choose. 
  • We also had the families point out that the state was applying the wrong standard in deciding that DT should be subject to heightened scrutiny. 
"We explained that the rule (quoted above) does not require heightened scrutiny just because a setting is located on a campus and is close to an ICF/DD. In fact, the CMS rule says nothing about location. Instead, heightened scrutiny is limited to settings that isolate individuals. By having each family explain how their family member is not isolated, we were able to show that DT did not come within the settings that required heightened scrutiny.”…


Legal Vulnerabilities of CMS’s Regulation of Home and Community-Based Settings 

from Covington and Burling, LLP, 1/17/17

“We believe that both the regulations and subsequent CMS guidance can be challenged as exceeding CMS’s authority. The effect of the regulations is to limit the choices of living situations for individuals with disabilities, and to replace the preferences of individuals, families and guardians with the preferences of CMS as to which setting best suits the needs of a particular individual.” 


The Federal Government’s Quiet War on Adults with Autism 

by Jill Escher, 4/19/16


The Coalition for Community Choice and the Madison House Autism Foundation have been following the implementation of the Federal settings rule since 2014. They have extensive knowledge of State Transition Plans and the effort to preserve innovative housing solutions for people with autism and other developmental disabilities. For questions, see contact information here.


Another threat to replacing the preferences of individuals and their families and guardians with the preferences of CMS and federally-funded advocacy organizations, is the promotion of Supported Decision-Making (SDM). SDM is based on the belief that all people with disabilities can make and communicate decisions for themselves regardless of the nature or severity of their disabilities. Many SDM advocates refuse to acknowledge that disability can impair an individual's capacity to make decisions and they support the total elimination of guardianship. 

See Guardianship vs. Supported Decision-Making


"The idea that one residential model is appropriate for the entire spectrum of intellectual ​and developmental disability — from college-educated self-advocates to profoundly impaired individuals at risk of detaching their own retinas or bolting into traffic — is patently absurd."

by Amy Lutz in "Myth - Truth", an article on Pennsylvania's proposed bill to close all Intermediate Care Facilities for Individuals with Intellectual Disabilities


The Americans with Disabilities Act and the 1999 Supreme Court Olmstead decision protect people with disabilities from discrimination in their choice of residential settings, but they do not exclude the choice of institutional settings necessary for individuals to receive the services they need, nor do they ban congregate settings of more than 4 individuals with disabilities receiving services in a group setting.

See also, 


“The Olmstead Decision has been Misinterpreted”


HCBS Update as a Word Document

Friday, November 17, 2017

Michigan Family Connections Fall 2017 News

Michigan Family Connections Fall 2017 newsletter is a publication of the Michigan Family to Family Health Information Center and the Family Center for Children and Youth with Special Health Care Needs Family [phone Line 800-359-3722]. Here are two items that will help families seeking medical and other benefits for their special needs children:


With so much uncertainty around the Affordable Care Act, some individuals and families are waiting to see what happens. But it is important to note that there are important deadlines to meet if you need to purchase coverage. Don’t wait and take a chance on missing out on enrollment.

The Kaiser Foundation recently did an analysis on individuals eligible for Marketplace insurance. The results show that 54% or 5.9 million people who are uninsured and eligible to purchase coverage on the Marketplace would pay less in premiums than they would owe as a penalty for lacking coverage.

Within that, about 4.5 million (or 42%) could obtain a bronze level plan at no cost in 2018, after taking income-related premium tax credits into account. For more information on the results of this analysis, go to the Kaiser Foundation website here

For more information, or for assistance in finding help with enrollment, please visit: www.healthcare.gov .

December 15, 2017—Enrollment closes

For individuals who enroll during this open enrollment period, coverage will begin on Jan 1, 2018.


The Michigan Military Family Special Needs Coalition was recently formed as a partnership between the State Family Program Office, and Michigan military families with special needs. The purpose of the Coalition is to improve support and gather resources for all military and veteran families in Michigan requiring medical or educational consideration for family members. A family member with special needs is defined as a:

  • Spouse, child or incapacitated adult, who, regardless of age, has special medical needs and requires medical care for a chronic condition, receives ongoing services from a medical specialist or has significant behavioral health concerns. 
  • Child (birth through age 21) with special education needs who is eligible for, or receives, either early intervention services through an individualized family service plan, or special education services through an Individualized Education Program. 
The Coalition is seeking any Michigan military service members, veterans, or family members who want to assist in improving support and resources for our Michigan military and veteran families with special needs.

Please share this information with any military or veteran family with special needs that may be interested in participating. Any service members or family members interested may contact Jess Ulrey at (517) 481-8301. You can also visit their Facebook page at: https://www.facebook.com/mmfsncoalition/  .

Wednesday, November 8, 2017

2017 Election results: Washtenaw County millages supporting special ed and Community Mental Health win and other news

Both Washtenaw County millages won by a wide margin in yesterday’s election.

In other news, the Michigan legislature seems to be losing its mind depending on how you feel about guns in schools and protecting wildlife.

According to a Detroit Free Press article, “Michigan bills would allow concealed guns in schools, churches” by Kathleen Gray, 11/7/17:

“In the wake of mass shootings in Las Vegas and Texas that left dozens of people dead or injured, a Michigan Senate committee approved bills Tuesday that will allow gun owners to carry concealed weapons in gun-free zones such as schools, churches, day care centers, bars, dorms and stadiums.”

…”The bills taken up in the Senate Government Operations Committee passed on a party-line vote with Republicans supporting the three-bill package and Democrats opposing it. The bills would also close the open-carry loophole, effectively barring gun owners from openly carrying their weapons in gun-free zones.” This was a concession to school districts that claim that seeing people carrying weapons in school upsets students, parents, and staff to the point where they sometimes have to shut down.

Emily Durbin, Michigan chapter president of Moms Demand Action, responded:

”Two days after the latest shooting, we’re here not having a conversation about keeping guns away from domestic abusers, increasing background checks or banning bump stocks," she said. "Instead, we're urgently discussing what the gun lobby wants and that's a desire to have more guns in more places, no questions asked."

Governor Rick Snyder vetoed a similar bill in 2012, four days after a gunman slaughtered 20 children in an elementary school in Newtown, Connecticut.

“SB 584-586 — could come up for a vote in the Senate on Wednesday, and will likely pass the chamber, where Republicans hold a 27-11 majority.” 

In addition,..."The state House of Representatives, in a voice vote and without debate, …passed a resolution urging the state Natural Resources Commission to establish a sandhill crane hunting season in Michigan." ---“‘Ribeye of the sky?' House recommends sandhill crane hunt in Michigan”, by Keith Matheny, Detroit Free Press, 10/18/17.

This has little to do with developmental disabilities, but a lot to do with how government fails to address important issues and sometimes seems to just want to aggravate the opposition for no particular reason. I doubt there has been a groundswell of support from hungry citizens who can’t wait to sample sandhill crane breast meat.

The Phyllis Haehnle Memorial Audubon Sanctuary near Jackson, Michigan has documented the successful repopulation of Sandhill Cranes in Michigan from near extinction to abundance throughout the Mississippi flyway. Since 2009, however, the fall population count has leveled off in Michigan and the birds reproduce in low numbers. The birds are protected under the federal Migratory Bird Treaty Act, but farmers can apply to the U.S. Fish and Wildlife Service for special permits to eradicate birds damaging their crops.

Is a Sandhill Crane hunt necessary, or could we all show a little restraint in the protection of native bird species?