Medicaid Program; State Plan Home and Community-Based Services, 5-Year Period for Waivers, Provider Payment Reassignment, and Home and…

Medicaid Program; State Plan Home and Community-Based Services, 5-Year Period for Waivers, Provider Payment Reassignment, and Home and Community-Based Setting Requirements for Community First Choice and Home and Community-Based Services (HCBS) Waivers

SUMMARY: This final rule amends the Medicaid regulations to define and describe state plan section 1915(i) home and community-based services (HCBS) under the Social Security Act (the Act) amended by the Affordable Care Act. This rule offers states new flexibilities in providing necessary and appropriate services to elderly and disabled populations. This rule describes Medicaid coverage of the optional state plan benefit to furnish home and community based-services and draw federal matching funds.

This rule also provides for a 5-year duration for certain demonstration projects or waivers at the discretion of the Secretary, when they provide medical assistance for individuals dually eligible for Medicaid and Medicare benefits, includes payment reassignment provisions because state Medicaid programs often operate as the primary or only payer for the class of practitioners that includes HCBS providers, and amends Medicaid regulations to provide home and community-based setting requirements related to the Affordable Care Act for Community First Choice State plan option. This final rule also makes several important changes to the regulations implementing Medicaid 1915(c) HCBS waivers.

DATES: Effective Date: These regulations are effective on March 17, 2014.

FOR FURTHER INFORMATION CONTACT: Kathy Poisal, (410)786-5940.

SUPPLEMENTARY INFORMATION:

Table of Contents

I. Executive Summary

II. State Plan Home and Community-Based Services, 5-Year Period for Waivers, Provider Payment Reassignment, and Home and Community-Based Setting Requirements for Community First Choice

A. Background

B. Provisions of the Proposed Regulations and Analysis of and Responses to Public Comments

1. 5-Year Period for Certain Demonstration Projects and Waivers (part 430)

2. State Organization and General Administration (part 431)

3. Eligibility in the States, District of Columbia, the Northern Mariana Islands, and American Samoa (part 435) and Eligibility in Guam, Puerto Rico and the Virgin Islands (part 436)

4. Services: General Provisions (part 440)

5. State Plan Home and Community-based Services under section 1915(i)(1) of the Act ( SEC 441.710) and Community First Choice State Plan Option: Home and Community-Based Setting Requirements ( SEC 441.530)

6. Needs-based Criteria and Evaluation ( SEC 441.715)

7. Independent assessment ( SEC 441.720)

8. Person-Centered Service plan ( SEC 441.725)

9. Provider qualifications ( SEC 441.730)

10. Definition of Individual's Representative ( SEC 441.735)

11. Self-directed Services ( SEC 441.740)

12. State Plan HCBS Administration: State Responsibilities and Quality Improvement ( SEC 441.745)

13. Prohibition Against Reassignment of Provider Claims ( SEC 447.10)

III. Home and Community-Based Services (HCBS) Waivers (Section 1915(c) of the Act)

A. Background

B. Provisions of the Proposed Regulations and Analysis of and Responses to Public Comments

1. Contents of request for a waiver ( SEC 441.301)

2. State Assurances ( SEC 441.302)

3. Duration, extension, and amendment of a waiver ( SEC 441.304)

IV. Provisions of the Final Regulations

V. Collection of Information Requirements

VI. Regulatory Impact Analysis

VII. Regulatory Flexibility Act Analysis

VIII. Unfunded Mandates Reform Act Analysis

IX. Federalism Analysis

Regulation Text

Acronyms

Because of the many terms to which we refer by acronym in this final rule, we are listing the acronyms used and their corresponding terms in alphabetical order below.

ADA Americans with Disabilities Act of 1990 (Pub. L. 110-325)

ADLs Activities of daily living

AHRQ Agency for Healthcare Research and Quality

ANPRM Advance Notice of Proposed Rulemaking

CFC Community First Choice (1915(k) State plan Option)

CHIPRA Children's Health Insurance Program Reauthorization of 2009 (Pub. L. 111-3)

CMS Centers for Medicare & Medicaid Services

DRA Deficit Reduction Act of 2005 (Pub. L. 109-171)

EPSDT Early and Periodic Screening, Diagnosis and Treatment

FBR Federal benefit rate

FFP Federal financial participation

FPL Federal poverty line

FY Federal fiscal year

HCB Home and community based

HCBS Home and Community-Based Services

HHS Department of Health and Human Services

IADLs Instrumental activities of daily living

ICF/IID Intermediate care facility for individuals with intellectual disabilities

LOC Level of care

NF Nursing facility

OBRA`81 Omnibus Budget Reconciliation Act of 1981 (Pub. L. 97-35)

OT Occupational therapy

PT Physical therapy

RFA Regulatory Flexibility Act

SPA State Plan Amendments

SSI Supplemental Security Income

SSI/FBR Supplemental Security Income Federal Benefit Rate

UPL Upper payment limit

I. Executive Summary

A. Purpose

This final rule amends Medicaid regulations consistent with the requirements of section 2601 of the Patient Protection and Affordable Care Act of 2010 (Affordable Care Act), which added section 1915(h)(2) to the Act to provide authority for a 5-year duration for certain demonstration projects or waivers under sections 1115, 1915(b), (c), or (d) of the Act, at the discretion of the Secretary, when they provide medical assistance to individuals who are dually eligible for both Medicaid and Medicare benefits.

This final rule also provides additional limited exception to the general requirement that payment for services under a state plan must be made directly to the individual practitioner providing a service when the Medicaid program is the primary source of reimbursement for a class of individual practitioners. This exception will allow payments to be made to other parties to benefit the providers by ensuring workforce stability, health and welfare, and trainings, and provide added flexibility to the state. We are including the payment reassignment provision, because states' Medicaid programs often operate as the primary or only payer for the class of practitioners that includes HCBS providers.

In addition, this final rule also amends Medicaid regulations to provide home and community-based setting requirements related to section 2401 of the Affordable Care Act for section 1915(k) of the Act, the Community First Choice State plan option.

This final rule further amends the Medicaid regulations to define and describe state plan home and community-based services (HCBS). This regulation outlines the optional state plan benefit to furnish home and community-based state plan services and draw federal matching funds. As a result, states will be able to design and tailor Medicaid services to better accommodate individual needs. This may result in improved patient outcomes and satisfaction, while enabling states to effectively manage their Medicaid resources.

This final rule also revises the regulations implementing Medicaid home and community-based services (HCBS) waivers under section 1915(c) of the Social Security Act (the Act) by providing states the option to combine the existing three waiver targeting groups identified in SEC 441.301. In addition, this final rule will include other changes to the HCBS waiver provisions to convey expectations regarding person-centered plans of care, to provide characteristics of settings that are home and community-based as well as settings that may not be home and community-based, to clarify the timing of amendments and public input requirements when states propose modifications to HCBS waiver programs and service rates, and to describe the additional strategies available to CMS to ensure state compliance with the statutory provisions of section 1915(c) of the Act. The final rule also includes requirements for person-centered plans of care that document, among other things, an individual's choice of a HCB setting from among options that meet the individual's needs.

B. Summary of the Major Provisions

1. State Plan Home Community-Based Services (Section 1915(i) of the Act)

--This is a summary of a Federal Register article originally published on the page number listed below--

Final rule.

CFR Part: "42 CFR Parts 430, 431, 435, 436, 440, 441 and 447"

RIN Number: "RIN 0938-AO53; 0938-AP61"

Citation: "79 FR 2948"

Document Number: "CMS-2249-F; CMS-2296-F"

Federal Register Page Number: "2948"

"Rules and Regulations"