Nursing Facility | Acute Hospital Transition & Diversion Waiver Renewal

CDCAN Capital Updates

Public Stakeholder Meeting In Sacramento Thursday July 7 & Four More Throughout State This Month –

Written Public Comment Period Ends July 10  At 5 PM But Department of Health Care Services Says It Will Accept Comments Up To July 29 – Date of Last Public Stakeholder Meeting (In Redding) 

 SACRAMENTO, CA – A July 10th deadline for public comments is fast approaching regarding the State’s proposed revision and renewal of an existing Medicaid funded program – known as the “Nursing Facility/Acute Hospital Transition and Diversion Waiver” – that provides community-based services and supports for persons with disabilities – including developmental – and seniors who otherwise would be receiving institutional models of care.

In addition, the first of five public statewide stakeholder meetings on the draft proposal by the California Department of Health Care Services is scheduled for July 7th, Thursday from 10:00 AM to 1:00 PM in Sacramento. A conference call line for that meeting – and for the other four statewide meetings for those unable to attend in person – will be available (see details below).   

The current existing Nursing Facility/;Acute Hospital Transition and Diversion Waiver is set to expire December 31, 2016.

The State intends to submit in September a revised proposal that would renew and extend the waiver, and if approved by the federal government, would go into effect January 1, 2017. 

That July 10th deadline is the end of the official and formal public comment period as required by federal law, but the State, according to the California Department of Health Care Services,  will continue to accept comments, until July 29, 2016 – the date of the fifth and last public stakeholder meeting it will hold in July on this issue.

The current Nursing Facility/Acute Hospital Transition and Diversion Waiver serves just under 3,000 people with disabilities and seniors across the State. That waiver, which has a current enrollment cap of 3,964 persons, had an enrollment in 2014 of 2,878 persons, according to the California Department of Health Care Services.  The State is proposing to increase that cap to 5,000 people over five years.

There is an estimated 100,000 people with disabilities and seniors and others who, at any one time, are receiving long term services in an institutional type setting in California, including skilled nursing facilities.  The Nursing Facility/Acute Hospital Waiver is meant to provide an individualized and person centered alternative to eligible persons in those institutional settings, that also would further the State’s compliance of the landmark 1999 US Supreme Court ruling – known as the “Olmstead Decision” – that requires the states to take steps to avoid the unjustified or unnecessary institutionalization of people with disabilities, mental health needs and seniors. 

[CDCAN Note: “Olmstead” is the name of the former head of the State of Georgia’s health and human services agency – Tommy Olmstead – who was sued by two women with developmental disabilities and mental health needs – Lois Curtis and Elaine Wilson, who were, at the time, resided in institutions in that state and who wanted to live in the community in their own homes and with their own individualized services and supports.] 

Formal Public Comment Period For Nursing Facility/Acute Hospital Waiver Renewal Proposal

Any interested person or his or her authorized representative may submit written comments to the California Department of Health Care Services regarding the draft Nursing Facility/Acute Hospital Transition and Diversion Waiver renewal proposal, as posted on the department’s website on June 10, 2016.

The full NF/AH (Nursing Facility/Acute Hospital) Waiver application is also available upon request.

The written comment period closes at 5:00 p.m. on July 10, 2016; any written comments regardless of the method of transmittal must be received electronically by 5:00 PM or postmarked on this date, for consideration.  The department however also indicated that it would accept comments – including those written – up to July 29th – the date of the fifth and final public stakeholder meeting (in Redding). 

A summary of comments received and the department’s response(s) will be made available on the California Department of Health Care Services Nursing Facility/Acute Hospital ( NF/AH) Waiver Renewal webpage (see “For More Information” below) by July 30, 2016 (hard copies will be mailed to persons receiving Nursing Facility/Acute Hospiual Waiver services or providers upon request).
 
WHERE TO SEND WRITTEN COMMENTS
 
BY US MAIL DELIVERY:
ATTN: Gopinath Vijayalakshmi
Department of Health Care Services
Long-Term Care Division
1501 Capitol Avenue, MS 4502
P.O. Box 997437
Sacramento, CA 95899-7437
 
 BY EMAIl:
 nfahwaiverrenewal@nulldhcs.ca.gov
 
IN PERSON:

As mentioned, the California Department of Health Care Services (DHCS) will hold five stakeholder meetings throughout the state to discuss the comments received on the waiver renewal during 30-day public comment period, and to inform the public of changes made to the waiver as a result of public input. The first meeting is scheduled for July 7th at 10 AM to 1:00 PM in Sacramento; July 14th in Fresno; July 18th in Los Angeles; July 19th in San Diego and July 29th in Redding (see below for specific locations and other information)
 
BY PHONE:

A toll-free phone number will be made available for each of the five public stakeholder meetings in July organized and conducted by the California Department of Health Care Services, for people who cannot attend in person.  Comments and questions can be made using this phone line:
    Toll-Free Phone Number: 888-469-1335
    Passcode: 6997523
 
REASONABLE ACCOMMODATIONS:

For individuals with disabilities, the California Department of Health Care Services indicated that it will provide assistive devices such as reading or writing assistance, and conversion of materials into Braille, large print, audio, or computer disk.
    To request such services or copies in an alternate format or language, write or email by June 29, 2016:
    ATTN: Jonathan Alspektor
    Department of Health Care Services
    Long-Term Care Division
    1501 Capitol Avenue, MS 4502
    P.O. Box 997437
    Sacramento, CA 95899-7437
    Email: nfahwaiverrenewal@nulldhcs.ca.gov
 
FIVE PUBLIC STAKEHOLDER MEETINGS IN JULY ON NURSING FACILITY/ACUTE HOSPITAL WAIVER RENEWAL – FIRST MEETING JULY 7TH IN SACRAMENTO

In addition to the written public comment process, the California Department of Health Care Services – the state agency that oversees the State’s federally funded Medicaid programs – called “Medi-Cal” in California – is also conducting a series of public stakeholder meetings and conference calls this month on the revision and renewal Nursing Facility/Acute Hospital Transition and Diversion Waiver proposal.

The California Department of Health Care Services said it will review all comments received through the written public comment period and from the stakeholder meetings, and will consider them when working to finalize the Nursing Facility/Acute Hospital Waiver renewal proposal for submission to the federal Centers on Medicare and Medicaid Services no sooner than August 31, 2016, and is targeting sometime in September 2016.
   
SCHEDULE OF PUBLIC MEETINGS AND CONFERENCE CALLS ON PROPOSED NURSING FACILITY/ACUTE HOSPITAL WAIVER RENEWAL

The following is the current schedule (see below for link) for the five public stakeholder meetings (which will include a conference call-in number for those not able to attend in person):
 
    JULY 07 2016 (THU) 10:00 AM – 01:00 PM – SACRAMENTO AREA
    California Department of Health Care Services Building (EEC – East End Complex)
    1500 Capitol Avenue
    Sacramento, CA 95814
    Toll-Free Conference Call Phone Number: 888-469-1335 [same for all July meetings]
    Passcode: 6997523 [same for all July meetings]
 
    JULY 14 2016 (THU) 10:00 AM – 01:00 PM – FRESNO AREA
    State Office Building
    2550 Mariposa Mall – Room 1036
    Fresno, CA 93721
    Toll-Free Conference Call Phone Number: 888-469-1335 [same for all July meetings]
    Passcode: 6997523 [same for all July meetings]
 
    JULY 18 2016 (MON) 10:00 AM – 01:00 PM – LOS ANGELES AREA
    Ronald Reagan State Office Building
    300 South Spring Street – Suite 1726
    Los Angeles, CA 90013
    Toll-Free Conference Call Phone Number: 888-469-1335 [same for all July meetings]
    Passcode: 6997523 [same for all July meetings]
 
    JULY 19 2016 (TUE) 10:00 AM – 01:00 PM – SAN DIEGO AREA
    State Office Building – Eshleman Auditorium
    1350 Front Street – Suite 6034
    San Diego, CA 92101
    Toll-Free Conference Call Phone Number: 888-469-1335 [same for all July meetings]
    Passcode: 6997523 [same for all July meetings]
 
    JULY 29 2016 (FRI) 10:00 AM – 01:00 PM – REDDING AREA
    Oxford Suites Hotel
    1967 Hilltop Drive
    Redding, CA 96002
    Toll-Free Conference Call Phone Number: 888-469-1335 [same for all July meetings]
    Passcode: 6997523 [same for all July meetings]
 
WHAT IS NEW IN THE DRAFT NURSING FACILITY/ACUTE HOSPITAL RENEWAL WAIVER PROPOSAL – AND WHAT IS NOT CHANGED

The California Department of Health Care Services said it was “…committed to ongoing stakeholder dialogue throughout the [Nursing Facility/Acute Hospital Transition and Diversion] Waiver Renewal process with the ultimate goal of identifying the strongest Waiver structure to provide the highest level of quality of care, community integration, independent living, quality of life and availability of providers and services…” for all persons participating in the program.

The main challenges with the existing Nursing Facility/Acute Hospital Transition and Diversion Waiver that were identified during by stakeholders in October 2015, as part of a larger on-going stakeholder process organized by the California Department of Health Care Services included: 1) Participant health and life experiences, 2) inability to access Nursing Facility/Acute Hospital Waiver services due to being on the wait list, 3) decreases in authorized services (absent a change in health status of a person receiving services under this waiver) due to annual individual cost limits in the existing Nursing Facility/Acute Hospital Waiver; and 4) a lack of diverse Waiver providers.

The California Department of Health Care Services indicated that it considered those concerns in the draft renewal proposal, by including the following changes:

  • Implementing local comprehensive care management;
  • Moving to an aggregate (over-all) cost limit and cost neutrality;
  • Additional requirements pertaining to ensuring safety of persons receiving Nursing Facility/Acute Hospital Waiver services and safety of the provider
  • Modifying the Nursing Facility/Acute Hospital Waiver’s financial model;
  • Increasing the availability of Nursing Facility/Acute Hospital Waiver providers and services;
  • Combining the Nursing Facility/Acute Hospital Transition and Diversion Waiver with the existing In-Home Operations (IHO) Waiver; and
  • Incorporating the federal Home and Community-Based Services (HCBS) rules – including those impacting settings, as required by the federal Centers on Medicare and Medicaid Services (CMS).
  • During 2018 calendar year, the State, according to the draft renewal waiver proposal,  will conduct an “interim review of the effectiveness of the these proposed changes to determine if additional slots should continue to be added…” after 2018, and any modifications should be made.

The department also, after stakeholder meetings and comments last year and in recent months, proposed n changes to the following components of the existing Nursing Facility/Acute Hospital Transition and Diversion Waiver structure:

  • Eligibility Criteria;
  • Currently Available Services and Provider Types;
  • Participant Rights and Safeguards;
  • Quality Improvement; and
  • Financial Accountability and Model.

ADVOCATES PRAISE NURSING FACILITY/ACUTE HOSPITAL WAIVER – BUT URGE ADDITIONAL CHANGES

Advocates, who have praised the Nursing Facility/Acute Hospital Waiver general goals and outcomes including changes proposed in the renewal proposal – have strongly been critical of the existing enrollment cap and the increase in that cap that the State proposes in the draft renewal waiver proposal.

While the State does propose an increase – advocates, including Disability Rights California (DRC), have argued for a much larger increase in the cap to eliminate what they contend are long waiting lists that results in limiting a person’s choice for long term services to only an institutional model of care such as a skilled nursing facility.

Disability Rights California contends that the existing Nursing Facility/Acute Hospital Transition and Diversion Waiver “…is supposed to provide real choice to people who need long term services and supports, but because of decisions the State has made, the [Nursing Facility/Acute Hospital] Waiver has never done that” and that while the existing waiver “helps many people” the inclusion of needed changes would mean help “for many more people.”.

Disability Rights California is urging other advocates, persons with disabilities and families, providers and workers to ask the State to include more changes in the Nursing Facility/Acute Hospital Transition and Diversion Waiver renewal proposal such as: 

  • Speeding up the individual Waiver application process, which now takes six months or more;
  • Increasing the number of people who can get Nursing Facility/Acute Hospital Waiver services. There are, according to Disability Rights California, about 100,000 people in nursing homes at any one time, but the State is proposing to add only 5,000 slots over five years.
  • Eliminating the waiting list for the Nursing Facility/Acute Hospital Waiver: Disability Rights California cites that some people in the community wait two years to get services, and that the draft waiver renewal proposal does not fix this problem.
  • Base the overall (aggregate) cost cap in the draft renewal waiver proposal on the full institutional costs.
  • Outreach: urges a more robust information and outreach effort so that people in the communities are aware of the In-Home Operations Waiver, and the Nursing Facility/Acute Hospital Waiver in particular, including outreach to eligible persons with disabilities and seniors, In-Home Supportive Services (IHSS) social workers, hospital discharge planners and managed health care plans.
  • To view or download Disability Rights California written comments – PDF Document copy (14 pages): http://www.disabilityrightsca.org/Events/Documents/20160630WaiverRenewalCommentsToDHCS.pdf

NURSING FACILITY/ACUTE HOSPITAL WAIVER MUST ALSO COMPLY WITH NEW HOME AND COMMUNITY BASED SERVICES RULES

The Nursing Facility/Acute Hospital renewal waiver proposal also reflects necessary changes to comply with the new sweeping federal Medicaid Home and Community Based Services (HCBS) regulations that all states must be in full compliance with by March 2019 (sooner for new programs such as the Self Determination Program proposed waiver that, when re-submitted to the federal government by the State sometime in the late summer or early fall, must show that the services provided in the Self Determination Program waiver will be in full compliance of the Home and Community Based Services rules that impact settings and other issues). 

Those Home and Community Based Services regulations are also having or will have a dramatic impact on other existing Home and Community Based Services Waivers, including specific community-based services funded through the 21 non-profit regional centers. 
 
BACKGROUND OF NURSING FACILITY/ACUTE HOSPITAL (NF/AH) TRANSITION & DIVERSION WAIVER RENEWAL

The California Department of Health Care Services describes the Nursing Facility/ Acute Hospital (NF/AH) Transition and Diversion Waiver as a program that is intended to allow persons with disabilities who eligible for Medi-Cal, “…who would otherwise be institutionalized and reside in a nursing facility or hospital, an opportunity to remain in their own homes and/or community and be independent.”

It is also an alternative, what the department says is “…more costly nursing facility care”.

Currently there is capacity to serve 3,964 persons eligible for Medi-Cal under the Nursing Facility/Acute Hospital Transition and Diversion Waiver (NF/AH Waiver) who vary “…in acuity and physical and/or mental abilities based on different levels of care (LOC)”.

The current Nursing Facility/Acute Hospital Transition and Diversion Waiver (NF/AH Waiver) will expire December 31, 2016.  The State plans to submit in September this year, a proposal that revises and renews the current waiver, to the Centers for Medicare and Medicaid Services (CMS).

The In-Home Operations Branch, within the California Department of Health Care Services, administers the In-Home Operations Waiver (IHO Waiver) and the Nursing Facility/Acute Hospital Transition and Diversion (NF/AH Waiver). 

Both the In-Home Operations, and Nursing Home/Acute Hospital Transition and Diversion Medicaid Waivers offer services in the home or in the community to persons with disabilities and seniors who receive Medi-Cal and who would otherwise receive care in a skilled nursing facility. 

The “level of care” per waiver participant is determined by the person’s medical need and substantiated by a physician thru a completed Medi-Cal “Plan of Treatment” and a home evaluation. Some of the services offered by the two waivers are private duty nursing, case management, and waiver personal care services (WPCS).  Under current federal law, in order to meet federal approval, the waivers must be “cost neutral” and maintain cost cap.

See “For More Information” for links to the Department of Health Care Services webpages on In-Home Operations and the two waivers. 
 
LINKS FOR MORE INFORMATION

NURSING FACILITY/ACUTE HOSPITAL TRANSITION & DIVERSION WAIVER RENEWAL WEBPAGE – DEPARTMENT OF HEALTH CARE SERVICES:
http://www.dhcs.ca.gov/services/ltc/Pages/Nursing-Family-Acute-Hospital-(NF–AH)-Waiver-Renewal.aspx

NURSING FACILITY/ACUTE HOSPITAL TRANSITION & DIVERSION WAIVER PROPOSAL DATED JUNE 10 2016 – PDF DOCUMENT COPY (15 PAGES):
http://www.dhcs.ca.gov/services/ltc/Documents/Proposal_for_the_NFAH_Public_Comment_Period_060916.pdf

NURSING FACILITY/ACUTE HOSPITAL TRANSITION AND DIVERSION WAIVER (CURRENT APPROVED WAIVER SET TO EXPIRE DECEMBER 31 2016) – PDF DOCUMENT COPY (347 PAGES):
http://www.dhcs.ca.gov/services/ltc/Documents/NF-AH_Transition_and_Diversion_Waiver.pdf

TRANSITION PLAN (INCLUDING HOME AND COMMUNITY BASED SERVICES) FOR NURSING FACILITY/ACUTE HOSPITAL WAIVER PROPOSAL – PDF DOCUMENT COPY (8 PAGES):
http://www.dhcs.ca.gov/services/ltc/Documents/NF_Transition_Plan.pdf

NOTICE OF 30 DAY PUBLIC COMMENT PERIOD (JUNE 10 – JULY 10 2016) – PDF DOCUMENT COPY (PAGES):
http://www.dhcs.ca.gov/services/ltc/Documents/Noticeof30dayPublicComment.pdf

PUBLIC COMMENT TEMPLATE – PDF DOCUMENT COPY (9 PAGES):
http://www.dhcs.ca.gov/services/ltc/Documents/NFAH_PublicCommentTemplate_060716.pdf

SCHEDULE OF JULY 2016 STAKEHOLDER MEETINGS ON NURSING FACILITY/ACUTE HOSPITAL TRANSITION & DIVERSION WAIVER PROPOSAL – PDF DOCUMENT COPY (1 PAGE):
http://www.dhcs.ca.gov/services/ltc/Documents/StakeholderScheduledMeetings.pdf

CALENDAR OF EVENTS – (DEPARTMENT OF HEALTH CARE SERVICES WEBPAGE LISTING NURSING FACILITY WAIVER & OTHER EVENTS) BY MONTH:
http://www.dhcs.ca.gov/services/Pages/CalendarofEvents.aspx

LEGISLATIVE OVERSIGHT: DEPARTMENT OF HEALTH CARE SERVICES RESPONSE TO QUESTIONS FROM LEGISLATURE DATED NOVEMBER 5 2015 – PDF DOCUMENT COPY (2 PAGES):
http://www.dhcs.ca.gov/services/ltc/Documents/November4,2015.pdf

IN-HOME OPERATIONS (IHO) WEBPAGE – DEPARTMENT OF HEALTH CARE SERVICES:
http://www.dhcs.ca.gov/services/ltc/Pages/In-HomeOperations.aspx

DISABILITY RIGHTS CALIFORNIA (DRC) WEBPAGE ON NURSING FACILITY/ACUTE HOSPITAL TRANSITION & DIVERSION WAIVER RENEWAL:
http://www.disabilityrightsca.org/Events/20160630IHSSMeetingsInJulyNotice.htm

07.06.2016

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