[NYAPRS Enews] CMS Issues Proposed Rule to Empower Medicaid to Direct Personal Assistance Services

[Harvey Rosenthal]

NYAPRS Note: On the heels of CMS' recent encouragement to fund Medicaid
peer specialist services and to create the 1915.i home and community
based services option, here's another progressive opportunity to foster
self directed peer supported recovery.

 

CMS Issues Proposed Rule to Empower Medicaid to Direct Personal
Assistance Services

Centers for Medicare & Medicaid Services   January 14, 2008


 

            A proposed rule that would allow more Medicaid beneficiaries
to be in charge of their own personal assistance services, including
personal care services, instead of having those services delivered by an
agency, was announced today by the Centers for Medicare & Medicaid
Services (CMS).  

 

            Through the rule on display today at the Federal Register,
CMS requests public comment on how states could allow Medicaid
beneficiaries who need help with the activities of daily living to hire,
direct, train or fire their own personal care workers rather than
working with personnel employed by an agency. Beneficiaries could even
hire qualified family members who may already be familiar with the
individual's needs to perform personal assistance (not medical)
services.  

 

            "This proposal would give Medicaid beneficiaries significant
new freedom to determine how their personal assistance services are
delivered and by whom," said Kerry Weems, CMS acting administrator.  "As
health care is not simply an economic transaction, this proposal
represents a fundamental shift that restores a person's ability to
improve their overall health by taking greater control of his or her own
decisions," Weems said.

 

            If a state adopts a self-directed personal assistance
services state plan option,  beneficiaries could receive a cash
allowance to hire their own workers to help with such activities as
bathing, preparing meals, household chores and other related services
that help a person to live independently.  Allotments could also be used
to purchase items that help foster independence such as a wheelchair
ramp or microwave oven.  The beneficiaries also have the option to have
their cash benefit allotment managed for them.

 

The proposal would put into place a provision of the Deficit Reduction
Act of 2005 that allows states to elect a state plan option to provide
care in ways that previously required "waivers" of previous Medicaid
laws.  Such waivers are subject to certain budgetary requirements and
are temporary in nature.

 

            Before a state could request this change to its state plan,
the state must have an existing personal care services benefit, or be
operating a home or community-based services waiver program. 

 

            Furthermore, enrollment in this new state plan option is
voluntary and the state must also provide traditional agency-delivered
services if the beneficiary wishes to discontinue self-directed care.

 

            States choosing this option must have necessary quality
assurances and other safeguards in place to assure the health and
welfare of participants.  States must also train potential participants
in ways to manage their budgets and assess their personal care needs.

            

            The notice of proposed rulemaking will be published in the
January 18, 2008 issue of the Federal Register.  There is a 30-day
comment period.  Comments are due February 19, 2008.

 

            To view the proposed rule visit:
http://www.cms.hhs.gov/MedicaidGenInfo/Downloads/CMS2229P.PDF.

-------------

 

Deficit Reduction Act Important Facts for State Policymakers

January 14, 2007

Optional Choice of Self-Directed Personal Assistance Services (PAS)
"Cash & Counseling"

 

Section 6087 of the Deficit Reduction Act (DRA) of 2005 amended the
Social Security Act to include a new section 1915(j) that provides
States flexibility to institute self-directed personal assistance
services (PAS) programs using the Medicaid State plan amendment process.
Self-directed PAS is a service delivery model that States may use to
offer beneficiaries an alternative to traditional agency-delivered
services.

 

Background

Beginning January 1, 2007, the new self-directed PAS option is available
to states. The new option is based on the Cash and Counseling
demonstrations carried out in AR, FL and NJ and the Department of Health
& Human Services' Independence Plus initiative that encouraged all
States to institute self-directed care programs. Prior to DRA, the
Independence Plus initiative was accomplished through section 1115
demonstration and section 1915(c) waiver authorities. States could also
elect to cover limited PAS under their Medicaid state plans using the
traditional personal care services option.

 

What Section 1915(j) of the Social Security Act Does

Under this section, States are provided: 

* Flexibility to provide a more comprehensive self-directed PAS program
than under the traditional personal care services option 

* Discretion to determine whether to include traditional state plan
personal care services and/or section 1915(c) home and community based
services (HCBS) in the self-directed PAS. 

* Ability to pay for PAS being self-directed for persons who otherwise
qualify for State plan personal care services or HCBS waiver services. 

* Relief of the administrative burden of submitting a demonstration or
waiver proposal required to provide self-directed PAS under 1915(c) and
1115 demonstrations. 

* Ability to permit eligible individuals to choose to hire, fire,
supervise, and manage employees of their own choosing and to direct a
budget from which they purchase PAS. 

* Ability to limit the population served under the program and the
number of individuals self-directing. The State may offer services to
beneficiaries without regard to the Medicaid requirements of
statewideness1 or comparability to permit operation of these programs
within limited subdivisions of the State and vary services provided
individuals based on assessed needs. (1 Under traditional Medicaid
rules, the State must implement the Medicaid program uniformly
throughout the State. The State cannot vary eligibility requirements or
scope of services based on a geographic subset of the State. 2
Generally, all Medicaid recipients must receive the same scope of
services. The State cannot limit the duration or coverage of a
particular service to a particular eligibility group or any other subset
of the Medicaid-eligible population.)

 

Eligibility

* In States electing this option, individuals are eligible to
participate if they choose to do so. The State must assess the
individual's needs, strengths, and preference for PAS and develop a
service plan that includes supports for such services.

* An individual's election of this service delivery model does not
affect Medicaid eligibility, including any individual whose Medicaid
eligibility is attained through receipt of 1915(c) waiver services.

 

Services

Participating recipients will be provided an individual budget to
purchase an array of services that are designated in a written plan of
care.

* Services available include:

*      personal care and related services, or

*      home and community-based waiver services.

* Any capable individual may be a paid service provider, including
legally responsible relatives such as parents of children with
disabilities or spouses.

 

Unique Features of Section 1915(j) Self-direction PAS Authority

Unlike 1915(c), 1115, or traditional state plan PAS, section 1915(j)
uniquely requires states to:

* Inform individuals determined to meet needs criteria of the option for
self-direction; and

* Prohibit provision of services in a setting that is owned, operated,
or controlled by a provider of services not related by blood or marriage

 

What do states need to do to implement PAS under 1915(j)?

Prior to electing the 1915(j) option, States must have in place:

* Traditional personal care services through the State plan; or

* Have operational a Section 1915(c) home and community based services
waiver that includes the services to be self-directed under section
1915(j). Having these vehicles in place will provide recipients access
to the traditional PAS delivery option in the event the recipient
voluntarily disenrolls from or is involuntarily disenrolled from the
1915(j) State plan option.

 

Important Information

To obtain additional information on the other changes DRA made to HCBS,
please visit the CMS website at http://www.cms.hhs.gov/HCBS/ .

 

 

 

 

 

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