CMS Meeting Minutes 11.12.13 – Location: Arc of Mercer
Executive Committee Members in Attendance: Bonnie Brien, Dan Keating, Cheryl Resnick and Veronica Trathen
Guest Speakers: Dominique Mathurin, John Montalto and Rick Holligan – Region 2 Office, Center for Medicare/Medicaid Services (CMS)
General Information: The Central Office for Medicare/Medicaid Services (CMS) in located in Baltimore. There are 10 Regional Offices. The representatives present oversee NY, NJ, Puerto Rico and the Virgin Islands. CMS has (2) main roles: Regulator/Partner with the state and stakeholders; and Help with funding operations.
A brief overview was provided on how CMS interacts with each the state. Criteria for Medicaid services is set at the Federal level. All states have a State Plan that meets minimum criteria based on Federal requirements. Each state can prepare waivers under the State Plan that allows them to meet the criteria while administering services differently outside of the State Plan. Regional offices work with each state in their regions to oversee the State Plan and waivers. CMS review waivers and requests feedback from the state on questions about the waiver. Once all issues have been addressed and resolved between CMS and the state, CMS approves the final waiver. CMS contracts with the state to operate and fund the Sate Plan and waivers through Medicaid. New Jersey currently has two approved waivers that serve individuals with I/DD: the Supports Program (SP) which is under the umbrella of the Comprehensive Waiver and the Community Care Waiver (CCW). The SP waiver is an 1115c waiver and the CCW a 1915 waiver, often referred to as a Home and Community-based waiver (HCBS). HCBS waivers are designed to provide specialized services to support Medicaid eligible individuals with I/DD to live in their communities and avoid an institutional placement.
The brief overview was followed by a questions and answer period. Questions were gathered from members of the Family Support Coalition of NJ along with other interested family members and providers.
Question:
NJ’s Division of Developmental Disabilities/Department of Human Services submitted a CCW renewal in June, 2013, as the current CCW was set to expire on 9/30/13. CMS has given DDD questions about the renewal and extended the current CCW for 90 days while the Division prepares its responses to the questions. As stakeholders we requested a copy of the renewal at various points in the process. DDD has told stakeholders that the renewal could not be given to us. Is this correct, or can stakeholders have the opportunity to review the CCW renewal application prior to submission to CMS by DDD?If CMS has questions/comments about the renewal application, can we as stakeholders also review the comments/revisions made by CMS?
· Community input should be requested of the Public by the State through a Public Notice and it is CMS’s expectation that this type of feedback would happen before, during and after all submissions from the stakeholders. Major changes are expected to be shared by the State with all Stakeholders.
· The Renewal of the Community Care Waiver has been extended for 90 days while the state addresses all questions from CMS. Stakeholders have been asking the State to see the submission with no results. CMS indicated it is not their policy to release a waiver under review, however, there is nothing stopping the State from sharing what they submitted to Stakeholders. Stakeholder input is requested by CMS in the process. They are interested in feedback at any time and it can be directly provided to CMS if the stakeholder feels any input has been left out. Stakeholders do not have to go through the State to have their input considered.
· Waivers are approved for a 5 year period. Once a waiver is approved it should be available for viewing by stakeholders during the 5-year period. Stakeholders can comment directly to CMS at any time during the 5-year lifespan. Renewals are required every 5 years. During the renewal process, CMS and the state may exchange questions and answers over the course of several months, sometimes resulting in extensions to the existing waiver when needed. Waivers such as the 1915 HCBS Waivers such as the CCW cannot be shared by CMS while in process; but the state can share the waiver with Stakeholders.
· The State is obligated to notify the public of any changes to a waiver. “Any major changes to a waiver CMS expects that stakeholders have had the opportunity to review and comment on.”
Question:
Many Medicaid regulations and policies have their roots in the "institutional" model. How is CMS working to make sure that definitions used (habilitative, rehabilitative, etc.) are used properly when applied to those with IDD living in the family home for many years. Example, a day program may have elements of both habilitative and rehabilitative supports, or an individual may need training, or re-training depending on their need and situation at various times throughout their life. Person-centered planning over the lifespan would require sensitivity to those needs. How is CMS currently working to ensure that this happens?
· CMS definitions of Habilitation/Rehabilitation are based on Institutional care and there is great concern about how this applies to people living at home with their families. The State needs to make recommendations and CMS will react to those recommendations where definitions should be well defined.
· Based on definition of rehabilitative services by CMS Central office in Baltimore MD, Medicaid will not pay for Sheltered Workshops. This was a CMS Central Office decision and had been done nationwide. Services related to job placement and community integration will be paid for. CMS’s objective is to create programs that will benefit all individuals across the range of level of support needs. Waiver service definitions by the state should be driving support measures related to this issue.
· States are required to publish a report on performance measures in the first three years of a new waiver or annually that is available to the public are public information and posted on the State website.
· There has been a nationwide reaction to the new definitions of day programs and the loss of “sheltered workshops/extended day programs.
Question:
Direct Medical care: Individuals with I/DD were forced to move into a Medicaid HMO in NJ 2 years ago. This has resulted in negative consequences. In addition to the State Medicaid office, where can families file a complaint about their family member’s Medicaid HMO? What happens when the HMO cancels a contract with a specialized medical group and does not inform the individuals they serve? How can the HMO cancel a contract that leaves thousands of individuals with complex health needs that often require specialists and whom they have been seeing for 10, 20 30 or more years? A number of these individuals are now at risk for life-threatening emergencies.
· HMO are required to notify all consumers before a change in contracts with current providers and assist the consumers in finding alternatives. State should be reviewing each physician network with the HMOs to ensure there are no gaps in the medical professionals needed by their customers. They are required to have access to an adequate number of medical professionals within a maximum of 99 miles of their home including specialists.
· Stakeholders can request this information and “watch dog” the provider list. Individuals and families can contact their state Medicaid office to report problems and file a complaint with the State. It’s the unique needs of families and the established relationships with Providers that is more the issue for families.
· A Medicaid Assistance Committee exists in NJ and should be informed and involved of these types of issues/concerns.
Question:
Providers are hearing that CMS will require case notes for billing purposes. If that is correct, can you elaborate on the format of the case notes? How detailed and at what increments will they need to be written? It has been said that notes may need to be written as frequently as in 15 minute increments. Is this required in all states?
· Other states are already moving away from Fee for Service. New Jersey is just entering. It was noted that New Jersey must go to Fee for Service before jumping to Managed Care. A base rate needs to be established first.
· Provider agencies will need to adhere to fiscal intermediary requirements for case note the format.
· CMS team recommended that NJ look at the methodology and waivers used by other states as all adults with I/DD are moved to a Medicaid-driven system.
Question:
What is the role of CMS in rate setting?
· Rates for ALL services need to be set before anyone can be enrolled on and receive services under the Support Program waiver.
· Those individuals that are not Medicaid eligible may need to come from State dollars but this is not a concern of CMS.
· Assessment Tools are determined State by State. It is believed that the State did amend the Assessment Tool. It is important to CMS if an Assessment Tool is changed that it meets the same criteria. Assessments will drive budgets.
The CMS team recognize the major system changes in how adults with I/DD will receive services in NJ. They offered their expertise and availability to Stakeholders to answer further questions as N continues to finalize CCW amendments and begins implementation of the SP waiver.
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