Substantive Changes Made to the Consolidated and P/FDS Waiver Renewals Effective July 1, 2017
This document is intended to be used as a tool to help understand where substantive changes were made to the Consolidated and Person/Family Directed Support (P/FDS) waiver renewals as a result of public comment. This document does not contain every change made to the waiver renewals. Please read the Consolidated and P/FDS waiver renewal documents for all changes made.
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Waiver(s) Impacted / Appendix/Service Definition / Proposed Language Released For Public Comment on December 3, 2016 / Final Language Submitted to CMS / Reason for ChangeAppendix A
Consolidated and P/FDS / Appendix A-4:Role of Local/Regional Non-State Entities / The Office of Developmental Programs (ODP) has an agreement with County Mental Health/Intellectual Disability (MH/ID) programs under the control of local elected officials to perform delegated waiver and operational administrative functions. The 55 Pa. Code Chapter 51 regulations authorize Department Designees, Administrative Entities (AEs), to perform waiver administrative functions. Each of these public agencies are delegated functions through an AE Operating Agreement. The AE implements these responsibilities and meets the requirements specified in the AE Operating Agreement.
AEs perform the following delegated waiver administration functions:
1. Participant waiver enrollment – Receive/review applications, ensure initial and annual completion of a waiting list assessment of need and refer applicants for an eligibility decision. / The Office of Developmental Programs (ODP) has an agreement with County Mental Health/Intellectual Disability (MH/ID) programs under the control of local elected officials to perform delegated waiver and operational administrative functions. The 55 Pa. Code Chapter 51 regulationsor its regulatory successor authorize Department Designees, Administrative Entities (AEs), to perform waiver administrative functions. Each of these public agencies are delegated functions through an AE Operating Agreement. The AE implements these responsibilities and meets the requirements specified in the AE Operating Agreement.
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 a waiting list assessment of need and refer applicants for an eligibility decision. / Public comment recommended that we reference Chapter 6100 regulations which will not be promulgated by July 1, 2017. For this reason, we have inserted “or its regulatory successor” and will replace references to Chapter 51 when we amend the waivers after July 1, 2017.
Public comment recommended that we provide the name of the waiting list assessment of need. ODP may be revising the Prioritization of Urgency of Need for Services (PUNS) in future years so we have inserted “PUNS or its successor.”
Both of these changes were made throughout the waiver document. Each instance of this change is not reflected in this side-by-side.
Waiver(s) Impacted / Appendix/Service Definition / Proposed Language Released For Public Comment on December 3, 2016 / Final Language Submitted to CMS / Reason for Change
Appendix B
Consolidated and P/FDS / Appendix B-1-a: Target Groups / Developmental Disability
Minimum Age 0
Maximum Age 7 / Developmental Disability
Minimum Age 0
Maximum Age 78 / Public comment recommended the maximum age for developmental disability be increased from age seven to age eight when IQ testing and diagnosis become more stable and reliable.
Consolidated and P/FDS / Appendix B-1-c: Transition of Individuals Affected by Maximum Age Limitation / Individuals who are enrolled with a developmental disability will be reevaluated using the ICF/ID or ICF/ORC criteria prior to their 8th birthday. If they are eligible, they will continue to receive waiver services. If the individual is not eligible, they will be referred to other resources. Individuals will be referred to the Office of Medical Assistance Programs for EPSDT services; Office of Long Term Living; Office of Children, Youth and Families as applicable and Office of Mental Health and Substance Abuse Services. / IndividualsParticipants who are enrolled with a developmental disability will be reevaluated using the ICF/ID or ICF/ORC criteria during their 8th year (prior to their 8th9thbirthday). If they are eligible, they will continue to receive waiver services. If the individualparticipant is not eligible, theyhe or she will be referred to other resources. Individuals will be referred to the Office of Medical Assistance Programs for EPSDT services;Office of Long Term Living; Office of Children, Youth and Families as applicable and Office of Mental Health and Substance Abuse Services. / Public comment recommended the maximum age for developmental disability be increased from age seven to age eight when IQ testing and diagnosis become more stable and reliable.
Office of Long Term Living waivers do not serve individuals under the age of 18. As such, references to Office of Long-Term Living were removed as a referral resource for individuals under the age of nine. To be eligible for the waivers, children must be enrolled in the EPSDT benefit through Medical Assistance and receiving medically necessary services so that reference has been removed as well.
Consolidated / Appendix B-3-a: Unduplicated Number of Participants / Year 1 – 18097
Year 2 – 18097
Year 3 – 18097
Year 4 – 18097
Year 5 – 18097 / Year 1 – 18097 18209
Year 2 – 1809718209
Year 3 – 1809718209
Year 4 – 1809718209
Year 5 – 1809718209 / The governor’s proposed budget for Fiscal Year 2017-2018 includes funding to serve an additional 112 people in the Consolidated Waiver.
P/FDS / Appendix B-3-a: Unduplicated Number of Participants / Year 1 – 13900
Year 2 – 13900
Year 3 – 13900
Year 4 – 13900
Year 5 – 13900 / Year 1 – 13900 14720
Year 2 – 13900 14720
Year 3 – 1390014720
Year 4 – 1390014720
Year 5 – 1390014720 / The governor’s proposed budget for Fiscal Year 2017-2018 includes funding to serve 820 students age 21 who are graduating from special education.
P/FDS / Appendix B-3-c: Reserved Waiver Capacity / Nothing written in proposal / Title: Graduate Waiting List Initiative
Purpose: ODP has reserved capacity in Year 1 for the waiting list initiative to serve approximately 820 students graduating from special education in May or June of 2017 who are not eligible to continue their education through the next year. In accordance with ODP policy as enumerated in Appendix A, any new individual identified for enrollment must be identified as having an emergency need. The students identified for the waiting list initiative may not meet this requirement which makes it necessary to reserve capacity for them to ensure they have access to the waiver.
All participants enrolled in the Waiver have comparable access to all services offered in the Waiver regardless of whether he or she is enrolled due to meeting reserved capacity criteria or the criteria for emergency status in PUNS or its successor. This is evidenced by the service plan process that is required for all participants and requires that service options be promoted and fully explored with every participant.
Describe how the amount of reserved capacity was determined: ODP is proposing to fund approximately 820 individuals in Year 1. The capacity is reserved to the extent that resources have been identified to support it.
The capacity that the State reserves in each waiver year is specified in the following table:
Year 1: 820
Year 2: 0
Year 3: 0
Year 4: 0
Year 5: 0 / The governor’s proposed budget for Fiscal Year 17/18 includes funding to serve 820 students age 21 who are graduating from special education.
P/FDS / Appendix B-3-c: Reserved Waiver Capacity / Nothing written in proposal / Title: Competitive Employment Initiative
Purpose: ODP reserves capacity for individuals who are transitioning out of OVR with a competitive integrated job to encourage competitive employment.
In accordance with ODP policy as enumerated in Appendix A, any new individual identified for enrollment must be identified as having an emergency need. The individuals identified for the competitive employment initiative may not meet this criteria which makes it necessary to reserve capacity for them to ensure that they have access to the waiver.
All participants enrolled in the Waiver have comparable access to all services offered in the Waiver regardless of whether he or she is enrolled due to meeting reserved capacity criteria or the criteria for emergency status in PUNS or its successor. This is evidenced by the service plan process that is required for all participants and requires that the service options be promoted and fully explored with every individual.
Describe how the amount of reserved capacity was determined: This initiative allows ODP to support approximately 50 individuals in Year 1 who have or expect to have a successful OVR closure. The capacity is reserved to the extent that resources have been identified to support it.
The capacity that the State reserves in each waiver year is specified in the following table:
Year 1: 50
Year 2: 0
Year 3: 0
Year 4: 0
Year 5: 0 / Public comment recommended that this reserved capacity be restored in the P/FDS waiver to encourage competitive employment by ensuring individuals will have the supports needed after they have transitioned fromservices received fromthe Office of Vocational Rehabilitation (OVR).
Consolidated and P/FDS / B-3-e: Allocation of Waiver Capacity / The Department calculates and distributes waiver openings to the AEs based on the current enrollment in the AE and expected need for access based on a review of the waiting list needs assessment across the state. The distribution method is reviewed annually.
AEs are responsible to ensure waiting list needs assessment information is current. In accordance with the AE Operating Agreement, if unused capacity exists with an AE, the capacity may be held and authorized at the state level and/or the state may commit the unused capacity to another AE based on need. Additionally, ODP may commit additional capacity to an AE based on unanticipated emergencies as defined in ODP policy.
The AE is responsible to evaluate the waiting list needs assessment categorization of a Waiver applicant when making enrollment decisions. Waiver applicants assessed by the AE must meet the criteria for emergency status in the waiting list assessment of need or be in reserved capacity status to be enrolled in the Waiver. ODP retains ultimate authority to select individuals for Waiver enrollment based on an individual's unique emergency circumstances. The Department reserves the right to adjust the number of participants in the AE’s Waiver Capacity Commitment in either Waiver based on utilization or other considerations. / The Department calculates and distributes waiver openings to the AEs based on the current enrollment in the AE and expected need for access based on a review of the waiting list needs assessmentPUNS or its successor across the state. The distribution method is reviewed annually.
AEs are responsible to ensure waiting list needs assessmentPUNS (or its successor) information is current. In accordance with the AE Operating Agreement, if unused capacity exists with an AE, the capacity may be held and authorized at the state level and/or the state may commit the unused capacity to another AE based on need. Additionally, ODP may commit additional capacity to an AE based on unanticipated emergencies as defined in ODP policy.
The AE is responsible to evaluate the PUNS (or its successor)waiting list needs assessment categorization of a Waiver applicant when making enrollment decisions. Waiver applicants assessed by the AE must meet the criteria for emergency status in the waiting list assessment of needPUNS (or its successor) or be in reserved capacity status to be enrolled in the Waiver. ODP retains ultimate authority to select individuals for Waiver enrollment based on an individual's unique emergency circumstances. The Department reserves the right to adjust the number of participants in the AE’s Waiver Capacity Commitment in either Waiver based on utilization or other considerations. / Public comment recommended that we provide the name of the waiting list assessment of need. ODP may be revising the PUNS in future years so we have inserted “PUNS or its successor.”
Consolidated and P/FDS / B-6-d: Level of Care Criteria / 3. Developmental Disabilities prior to age 8 ICF/ORC
i. There are four fundamental criteria that must be met prior to an individual being determined eligible for an ICF/ORC level of care:
1. Have a diagnosis of developmental disability. Eligibility criteria is defined as the following: developmental disability which is defined as a condition of substantial developmental delay or specific congenital or acquired conditions with a high probability of resulting in an intellectual disability or autism, the disability manifested prior to the age of 8 and the disability is likely to continue indefinitely.
2. Individual is 7 years of age or younger; and
3. Substantial adaptive skills deficits in three or more areas of major life activity: self-care, understanding and
use of language, learning, mobility, self-direction and/or capacity for independent living based on a standardized adaptive functioning; and
4. Be recommended for an ICF/ORC level of care based on a medical evaluation. / 3. Developmental Disabilities prior to age 89 ICF/ORC
i. There are four fundamental criteria that must be met prior to an individual being determined eligible for an ICF/ORC level of care:
1. Have a diagnosis of developmental disability. Eligibility criteria is defined as the following: developmental disability which is defined as a condition of substantial developmental delay or specific congenital or acquired conditions with a high probability of resulting in an intellectual disability or autism, the disability manifested prior to the age of 89 and the disability is likely to continue indefinitely.
2. Individual is 78 years of age or younger; and
3. Substantial adaptive skills deficits in three or more areas of major life activity: self-care, understanding and use of language, learning, mobility, self-direction and/or capacity for independent living based on a standardized adaptive functioning; and
4. Be recommended for an ICF/ORC level of care based on a medical evaluation. / Public comment recommended the maximum age for developmental disability be increased from age seven to age eight when IQ testing and diagnosis become more stable and reliable.
Consolidated and P/FDS / B-6-f: Process for Level of Care Evaluation/Reevaluation / The following four criteria must be met to document a diagnosis of developmental disability and determine eligibility upon initial certification:
1. A licensed psychologist, certified school psychologist, psychiatrist, or licensed physician who practices psychiatry certifies that the individual has a diagnosis of developmental disability with a high probability of resulting in an intellectual disability or autism which is documented by the results of a standardized diagnostic tool.
2. A QDDP certifies that the individual has impairments in adaptive behavior based on the results of a standardized
assessment of adaptive functioning which shows that the individual has both of the following:
a. Substantial adaptive skill deficits in three or more areas of major life activity: self-care, understanding and use of language, learning, mobility, self-direction and/or capacity for independent living based on a standardized adaptive functioning test.
3. The individual is 7 years old or younger.
4. The results of a medical evaluation completed within the previous 365 days that reflects the individual’s current medical condition. The medical evaluation may be the medical evaluation approved by the Department (Form MA 51), or an examination that is completed by a licensed physician, physician’s assistant, or nurse practitioner that states the individual is recommended for an ICF/ORC level of care. / The following four criteria must be met to document a diagnosis of developmental disability and determine eligibility upon initial certification:
1. A licensed psychologist, certified school psychologist, psychiatrist, developmental pediatrician or licensed physician who practices psychiatry certifies that the individual has a diagnosis of developmental disability with a high probability of resulting in an intellectual disability or autism which is documented by the results of a standardized diagnostic tool.
2. A QDDP certifies that the individual has impairments in adaptive behavior based on the results of a standardized assessment of adaptive functioning which shows that the individual has both of the following:
a. Substantial adaptive skill deficits in three or more areas of major life activity: self-care, understanding and use of language, learning, mobility, self-direction and/or capacity for independent living based on a standardized adaptive functioning test.
3. The individual is 78 years of ageold or younger.
4. The results of a medical evaluation completed within the previous 365 days that reflects the individual’s current medical condition. The medical evaluation may be the medical evaluation approved by the Department (Form MA 51), or an examination that is completed by a licensed physician, physician’s assistant, or nurse practitioner that states the individual is recommended for an ICF/ORC level of care. / Public comment recommended that we add developmental pediatricians to the list of professionals that can diagnose a developmental disability.
Waiver(s) Impacted / Proposed Language Released For Public Comment on December 3, 2016 / Final Language Submitted to CMS / Reason For Change
Appendix C – Advanced Supported Employment
Consolidated and P/FDS / Advanced Supported Employment, an indirect and direct service, is an enhanced version of supported employment services provided by qualified providers. The service includes discovery, job development, systematic instruction to learn the key tasks and responsibilities of the position and intensive job coaching and supports that lead to job stabilization and retention. / Advanced Supported Employment, an indirect and direct service, is an enhanced version of supported employment services provided by qualified providers. The service includes discovery, job development, systematic instruction to learn the key tasks and responsibilities of the position and intensive job coaching and supports that lead to job stabilization and retention. / Advanced Supported Employment is paid when the outcome is achieved. The rate developed for each outcome assumed that the provider would engage in some indirect activities. For this reason, it is not necessary to say that Advanced Supported Employment is an indirect and direct service.
Consolidated and P/FDS / Eligibility for discovery under 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; and
2. In the past 2 years, with the use of Supported Employment services, has not been able to secure a competitive integrated job or has not been able to keep a competitive integrated job for more than 6 months; and