Thursday, October 23, 2014

Frequently Asked Questions on HCBS settings

These FAQs on the Home and Community Based Services (HCBS) settings rule are from ACCSES, a national organization representing disability service providers. They are helpful in understanding the HCBS rule:

September 2014

Frequently Asked Questions Regarding the Home and Community-Based Services (HCBS) Setting Requirement and the Full Array of HCBS Services  

1. Does the rule regarding home and community-based services settings continue to permit the full array of home and community-based services, as defined in the Medicaid HCBS statute and regulations and included in the individual’s person-centered plan? 

Yes. As we indicated in the section-by-section analysis accompanying the final rule “the final rule will continue to convey this flexibility for states.” [79 FR 2954 (January 16, 2014)] Consistent with the Americans with Disabilities Act and the Olmstead decision, the state must administer the full array of home and community-based services in the most integrated setting appropriate to the needs of qualified individuals with disabilities. In addition, the state, in providing these services, directly or through contract or other arrangement, may not provide different or separate services unless such action is necessary to provide qualified individuals with disabilities with services that are as effective as those provided to others. [28 CFR 35.130(b)(1)(iv) and 35.130(d)]

2. Does the full array of home and community-based services defined in the Medicaid HCBS statute and regulations include prevocational services?

Yes. Prevocational services are defined in the regulations [42 CFR 440.180] to mean habilitation services that prepare an individual for paid or unpaid employment and that are not job-task oriented but are instead aimed at a generalized result, for example, teaching an individual such concepts as compliance, attendance, task completion, problem solving and safety.

As specified in the regulations, prevocational services are distinguishable from noncovered vocational services by the following criteria [42 CFR 440.180]:
  • The services are provided to persons who are not expected to be able to join the general workforce; 
  • If the beneficiaries are compensated, they are compensated at less than 50 percent of the minimum wage; 
  • The services include activities which are not primarily directed at teaching specific job skills but at underlying habilitation goals (for example attention span, motor skills); and 
  • The services are reflected in a plan of care directed to habilitation rather than explicit employment objectives.
Prevocational services, as a form of habilitation services, are designed to assist individuals acquire, retain, and improve self-help, socialization and adaptive skills. [42 U.S.C. 1396n(c)(5)] 

Prevocational services are time limited and the time limitations are determined based on the individual’s needs, including the need to retain skills, as identified in his or her person-centered plan. [September 16, 2011 Information Bulletin at page 7]

 3. May prevocational services be provided in a variety of locations in the community, including fixed site facilities?

Yes. Consistent with an individual’s person-centered plan, prevocational services may be furnished in a variety of locations in the community, including fixed site facilities but prevocational services are not limited to fixed site facilities. [September 16, 2011 Information Bulletin at page 8]

4. Must prevocational services provided in fixed-site facilities satisfy the home and community-based setting requirement?

Yes. The final HCBS setting rule establishes affirmative outcome-based criteria rather than criteria based solely on a setting’s location, geography, or physical characteristics. [79 FR 3011 (January 16, 2014)] Thus, prevocational services and other home and community-based services that are provided in fixed-site facilities must meet the HCBS setting requirements set forth in the rule [79 FR 3013 January 16, 2014)], including the requirement that the setting is integrated in and supports full access of individuals receiving Medicaid HCBS to the greater community, including opportunities to seek employment and work in competitive integrated settings, engage in community life, control personal resources, and receive services in the community, to the same degree of access as individuals not receiving Medicaid HCBS [42 CFR 440.301(c)(4)(i)-(vi)].

5. What practices illustrate the qualities of a home and community-based setting in a fixed-site facility providing prevocational services?

Example of appropriate practices regarding the provision of prevocational services in fixed site facilities that illustrate the qualities of a home and community-based setting include:

  • The program is in a facility that resembles any other business of its size and scope; Individuals are working on production of goods and services for the greater business community, similar to other businesses; 
  • The program may serve populations other than HCBS participants with disabilities, including
    Veterans, individuals who are poor and under-privileged and need assistance; 
  • Participants are provided an overview of employment options, including discussions about and referrals to state vocational rehabilitation and other programs for competitive integrated
  • Community competitive integrated employment is discussed, encouraged, and promoted at every review, and the person is directly involved in making an informed choices, as well as during the delivery of prevocational services; and 
  • Prevocational services include opportunities to gain greater exposure to the greater community and to teach individuals how to access the greater community, including trial work experiences, and internships, and tours of local businesses.

6. If a program provided in a fixed-site facility satisfies the home and community-based services setting outcome-based criteria set out in 42 CFR 440.301(c)(4)(i)-(vi), does the program qualify for HCBS funding?

Yes. The program conforms to the HCBS setting characteristics and thus may receive HCBS funding.

Wednesday, October 22, 2014

Unintended Consequences of Closing Sheltered Workshops

Parents have their say on closing sheltered workshops for their adult children:

Michigan 2014 Medicaid Waiver Conference Update

The Michigan Department of Community Health & The Michigan Association of CMH Boards Present: 

ANNUAL HOME AND COMMUNITY BASED WAIVER CONFERENCE on November 18 & 19, 2014 at the Kellogg Hotel & Conference Center - 55 South Harrison Road, East Lansing 48823.

We have three easy ways to register: 1. Online here; 2. Fax (517) 374-1053 or 3. Mail at MACMHB 426 S. Walnut, Lansing, MI 48933

Topics Covered: Michigan Medicaid Waivers including the Children’s Waiver Program (CWP) and the Habilitation Supports Waiver (HSW). Also, training in ASD (Autism Spectrum Disorder) and implementation of the Medicaid/MIChild Autism Benefit.

The regular fee for this Conference is $140 but it is only $20 for individuals receiving waiver services and their family members.

Continuing Education Credits available for Licensed Social Workers.

Overnight Accommodations/Directions:   The Kellogg Hotel & Conference Center is located in East Lansing adjacent to Michigan State University.  Our special guestroom rate is $75+ fees and taxes per night based on availability.   For specific directions or to reserve a room, please call 517/432-4000 and mention that you are attending the C-Waiver Conference.

Conference Brochure & Registration Materials:  Conference details and registration will be available on our website, or if you have any questions, please call (517) 374-6848.

MACMHB Contact info:

Anne Wilson, Training & Meeting Planner
Michigan Association of Community Mental Health Boards
426 S. Walnut Street, Lansing, MI  48933
(517) 374-6848 phone
(517) 374-1053 fax

Tuesday, October 21, 2014

Bringing Home the Bacon

Is there such a thing as a multi-Billion dollar NONprofit? Yes, there is, and one of them is The ARC, the country's largest advocacy organization for people with developmental disabilities. 

An article in Fusion, a newsletter from the national ARC for September 29, 2014, covers a recent report from the National Center on Charitable Statistics of the Urban Institute. Based on a year's worth of data compiled from IRS 990 forms (the forms that most nonprofit organizations file annually with the IRS),  The ARC and its chapters throughout the United States have brought in $4.02 Billion in Gross Receipts, "…including $3.83 Billion in Total Revenue, $2.76 Billion in Program Service Revenue, $989 Million in Contributions & Grants (includes Government Grants) and $20 Million in Investment Income."

"Of the Total Contributions, Gifts and Grants, $145 Million is from individuals, foundations and corporations while $847 Million is from government…"

That's a lot of money! Of The ARC's total revenues of $3.83 Billion, $847 Million or 22% came from government, and  $145 Million or 3.8% from individual donations.

One can learn a lot about an organization from its IRS 990 forms, including its revenues, expenditures, and how much it pays its highest paid employees. Guidestar is a good place to start looking for information on nonprofit organizations. Registration is free. Here is Guidestar's Frequently Asked Questions about form 990.

Read the full article on The ARC's finances here.

Friday, October 17, 2014

The Revolving Door between Advocacy Organizations and Government

I found this in an email newsletter from ACCSES, a national disability provider organization. 

Careful! You might get dizzy. Ms. Barkoff has gone from staff attorney at the Bazelon Center for Mental Health Law, to the US Department of Justice, with forays into the Centers for Medicare and Medicaid Services and the Department of Labor, and back again to the Bazelon Center:

Alison Barkoff Returns to Bazelon as Advocacy Director

Ms. Barkoff was a staff attorney with the Bazelon Center [for Mental Health Law] from 2005 to 2010, before joining the U.S. Department of Justice (DOJ), where she served for four years as Special Counsel for Olmstead Enforcement in the Civil Rights Division. As Director of Advocacy, Ms. Barkoff will help lead the Bazelon Center's policy and litigation work, as well as work on organizational activities such as fundraising. While at the DOJ, Ms. Barkoff led the Civil Right Division's efforts to enforce the rights of individuals with disabilities to live, work, and receive services in the community. Under her leadership, the Division issued its first guidance based on the U.S. Supreme Court's landmark Olmstead disability-rights ruling and was actively involved in Olmstead litigation across the country, including several cases culminating in statewide system reform settlement agreements. She also worked with Centers for Medicare and Medicaid Services [CMS, the federal agency that regulates Medicare and Medicaid] on finalizing rules governing Medicaid-funded community-based services and with the Department of Labor on implementation of its new home care rule in Medicaid-funded disability service systems.

Wednesday, October 15, 2014

New Jersey: Autistic man brought "home" from PA; ends up in jail with no other options

This is from the VOR Weekly News Update for 10/10/14:

Tyler Loftus, 23, has been sitting in New Jersey’s Hunterdon County Jail since September 18. “Every day he calls and says, ‘Mom, come get me, I don’t want to stay here,'” his mother, Rita O’Grady, told me.

Diagnosed with autism and intellectual disability, Tyler has the cognitive capacity of a 5-year-old. He can’t understand why he’s not allowed to leave.

“I never consented to this placement,” O’Grady said. “I specifically withdrew consent, because I knew what would happen. But the Arc [the agency that operated the group home] moved him anyway.”

And there are facilities that specialize in the treatment of individuals with developmental delay and dangerous behaviors: the Woods School in Pennsylvania, for instance, where Tyler lived from the ages of 15 to 21. Closer to home there are state-run developmental centers, such as the one in Hunterdon, where Tyler has previously been admitted.

But these are no longer options. Governor Chris Christie’s Return Home New Jersey program has put a moratorium on all out-of-state placements and “Christie is closing [developmental centers],” O’Grady told me. “And he’s put a stop order on all new admissions. Ideally, Tyler would be at Hunterdon while a permanent placement is found, but they can’t take him.”

The problem, O’Grady explained, is that the community-based supports that Christie promised have not yet materialized...

Read the full article here : "No End in Sight for Autistic Man Jailed in New Jersey" by Amy Lutz, 10/3/14.

Here is an updated article about the case: "Christie plan to return disabled to N.J. leads one man to hospitals, jail" by Susan Livio, 10/10/14 at .

VOR is a national organization that advocates for the right of individuals with intellectual and developmental disabilities and their families to choose from a full array of high quality residential and other support options including own home, community-based, and large settings such as Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICFs/IDD). See also VOR Weekly News Updates and Olmstead Resources.

Wednesday, October 8, 2014

...and you thought you were having a bad year!

When more costs less: more RN's in nursing facilities equals better and less costly outcomes for patients

Some of the most severely developmentally disabled people have medical needs that go beyond what most community settings and group homes can provide and may only be adequately met in Intermediate Care Facilities for people with intellectual and developmental disabilities. But what is the cost of not meeting those needs through the availability of competent nursing services?

Here is a clue from an article in the New York Times, "Where are the Nurses?" by Paula Span, 8/13/14. It looks at the effects of too few registered nurses in nursing homes:

"The 1987 federal law intended to reform the country’s nursing homes required a registered nurse on-site only eight hours a day, regardless of the size of the facility. Supporters at the time understood that in a building full of sick and disabled elders, health crises could occur at any hour. But getting the legislation passed required substantial compromises, including in regulations allowing reduced nurse staffing.

"'It’s something advocates have wanted to return to ever since,' said Robyn Grant, director of public policy and advocacy for the National Consumer Voice for Quality Long-Term Care. 'I think most people will be both shocked and appalled that there’s not an R.N. on duty around the clock.'"

Representative Jan Schakowsky, Democrat of Illinois, wants to fix this through proposed legislation, HB 5373:

"Adding registered nurses will hardly solve all the quality problems at nursing homes, which need more staff of other varieties, too. But it’s important unfinished business.

"'Otherwise, we probably should refer to these facilities as something besides nursing homes: 'pre-hospitalization holding facilities,' perhaps, or 'well-intended residences for the incurably underattended to.' You can probably come up with a few even-less-flattering names yourselves.'"

Studies cited in the article support the idea that providing adequate nursing care in nursing facilities will save money in the long term: 

"Studies have repeatedly pointed to the importance of registered nurses. With higher registered-nurse staffing, patients have fewer pressure ulcers (aka bedsores) and urinary tract infections and catheterizations. They stay out of hospitals longer. Their homes get fewer serious deficiencies from state inspectors. Their care improves, but it costs less."

Perhaps we could learn something from this for people with DD.

Friday, October 3, 2014

Michigan Medical Necessity Criteria for all Medicaid DD services

This if from the Michigan Medicaid Provider Manual and applies to all Medicaid services for people with developmental and other disabilities. PIHPs (Prepaid Inpatient Health Plans) are the regional mental health agencies in MichiganTake note of the last paragraph:

 "A PIHP may not solely deny services based solely on present limits of the cost, amount, scope, and duration of services. Instead, determination of the need of services shall be conducted on an individualized basis."

The following medical necessity criteria apply to Medicaid mental health, developmental disabilities, and substance abuse supports and services

Medical Necessity Criteria
Mental health, developmental disabilities, and substance abuse services and treatment:

  • Necessary for screening and assessing the presence of a mental illness, developmental disability or substance use disorder; and/or 
  • Required to identify and evaluate a mental illness, developmental disability or substance use disorder; and /or
  • Intended to treat, ameliorate, diminish, or stabilize the symptoms of mental illness, developmental disability or substance use disorder; and/ or
  • Expected to arrest or delay to progression of a mental illness, developmental disability or substance use disorder; and/ or
  • Designed to assist the beneficiary to attain or maintain a sufficient level of functioning in order to achieve his goals of community inclusion and participation, independence, recovery, or productivity.

The determination of a medically necessary support, service or treatment must be:
  • Based on information provided by the beneficiary, beneficiary’s family, and/ or other individual’s (e.g., friends, personal assistants/ aides) who know the beneficiary; 
  • Based on clinical information from the beneficiary’s primary care physician or health care professionals with relevant qualifications who have evaluated the beneficiary; 
  • For beneficiaries with mental illness or developmental disabilities, based on person-centered planning, and for beneficiaries with substance use disorders, individualized treatment planning; 
  • Made by appropriately trained mental health, developmental disabilities, or substance abuse professional with sufficient clinical experience; 
  • Made within federal and state standards for timeliness; 
  • Sufficient in amount, scope and duration of service(s) to reasonably achieve its/ their purpose; and
  • Documented in the individual plan of service.
Supports, Services, and Treatment Authorized by the PIHP must be:
  • Delivered in accordance with federal and state standards for timeliness in a location that is accessible to the beneficiary; 
  • Responsive to particular needs of multi-cultural populations and furnished in a culturally relevant manner;
  • Responsive to the particular needs of beneficiaries with sensory or mobility impairments and provided with the necessary accommodations; 
  • Provided in the least restrictive, most intergrated setting. Inpatient, licensed residential or other segregated settings shall be used only when less restrictive levels of treatment, service or support have been, for that beneficiary, unsuccessful or cannot be safely provided; and
  • Delivered consistent with, where they exist, available research findings, health care practice guidelines, best practices and standards of practice issued by professionally recognized organizations or government agencies.
PIHP Decisions:

Using criteria for medical necessity, a PIHP may:

Deny services that are:
  • Deemed ineffective for a given condition based upon professionally and scientifically recognized and accepted standards of care; 
  • Experimental or investigational in nature; or
  • For which there exists another appropriate, efficacious, less -restrictive and cost-effective service, setting or support that otherwise satisfies the standards for medically-necessary services; and/ or
  • Employ various methods to determine amount, scope and duration of services, including prior authorization for certain services, concurrent utilization reviews, centralized assessment and referral, gate-keeping arrangements, protocols, and guidelines.
A PIHP may not solely deny services based solely on present limits of the cost, amount, scope, and duration of services. Instead, determination of the need of services shall be conducted on an individualized basis.

Wednesday, October 1, 2014

FYI: Michigan State Plan and Medicaid Waiver Services

Services currently available under Michigan's state plan and Medicaid waivers for adults and children with disabilities and mental illness:

HAB = Habilitation Supports Waiver for people with developmental disabilities
SED = Children with Serious Emotional Disturbances Waiver
State Plan = Michigan's Medicaid State Plan Services
B3 = Michigan's Managed Speciality Supports and Services Plan
CWP = Children's Waiver Program

These waivers and state plan services may be used in combination in some cases. Although there are a limited number of  HAB Waivers (Habilitation Supports Waivers) for people with DD, State Plan Services cover almost all the services in the HAB waiver and availability is not limited.

As these Medicaid Waivers and other services come up for renewal, they may be changed. Vigilance is important to keep track of changes that are proposed.

Do not assume that just because these services are listed on a chart, that everyone gets everything they need. It is an impressive array of services, but only if you know how to ask for them. Here is more information on the Habilitation Supports Waiver.

Covered services from the Michigan Medicaid Provider Manual:

 Covered Services Medicaid – Provider Manual – 4/1/14

State Plan

Access, Assessment, & Referral (SA)

Applied Behavior Analysis


Assertive Community Treatment




Assistive Technology


Behavior Treatment Review


Child Therapeutic Foster Care

Child Therapy


Chore Services

Clubhouse Psychosocial Rehabilitation


Community Living Supports “Licensed Setting”



Community Living Supports “Unlicensed Setting”


Crisis Interventions


Crisis Observation Care

Crisis Residential Services


Drop-In Centers


Enhanced Medical Equipment and Supplies


Enhanced Pharmacy



Enhanced Transportation


Enhanced Accessibility Adaptations


Environmental Modifications



Family Home Care Training

Family Therapy


Family Training


Non-Family Training


Family Support and Training




Fiscal Intermediary Services


Goods and Services


Health Services


Home-Based Services


Home Care Training, Non-Family

Housing Assistance


Individual/Group Therapy


Inpatient Psychiatric Hospital Admissions


Intensive Crisis Stabilization Services


Intensive Outpatient Program (IOP) (SA)

Intermediate Care Facility Individuals with Mental Retardation (ICF/MR)


Medication Administration


Medication Review


Methadone & LAAM Treatment (SA)

Nursing Facility Mental Health Monitoring


Occupational Therapy


Out-of-Home-Non-Vocational Habilitation


Outpatient Care (SA)

Outpatient Partial Hospitalization Services


Peer Specialist Services


Personal Care in a Specialized Residential


Personal Emergency Response System (PERS)


Prevocational Services


Private Duty Nursing


Physical Therapy


Residential Treatment (SA)




Skill-Building Assistance


Specialized Medical Equipment and Supplies


Speech, Hearing, and Language


Specialty Services


Sub-Acute Detoxification (SA)


Supports Coordination


Support and Service Coordination


Supported Employment


Supported Employment/Integrated Employment


Targeted Case Management




Therapeutic Activities

Therapeutic Overnight Camp

Transitional Services



Treatment Approved Services (DBPT/CSAT) Pharmacological Supports (SA)


Treatment Planning


Wraparound Services
paround Services for Children and Adolescents