The Office of Long-Term Living (OLTL) amended the 2022 Community HealthChoices (CHC) Agreement, the contract that governs the CHC plans. While the amendments are awaiting final approval by Centers for Medicare & Medicaid Services (CMS), OLTL has indicated it will treat the CHC Plans as bound by the new changes effective January 1, 2022. Below is a summary of some key changes impacting participants:
- New Time Frames for HCBS Decisions: The 2022 CHC Agreement clarifies the time frame for CHC Plans to decide participants’ requests for home and community-based services (HCBS). Under the previous agreement, CHC plans were required to decide and notify a participant within two business days of a decision on prior authorization; however, it was unclear how this applied to HCBS such as personal assistance services (PAS). This ambiguity created uncertainty and delay, particularly for participants new to the waiver or seeking new or additional services. The 2022 CHC Agreement now requires CHC plans to decide and notify participants about their HCBS requests in two days. The 2022 Agreement also clarifies that the two-day timeframe begins the day the person-centered service plan (PCSP) is finalized for services that require an assessment or the date the request is made by the participant, their provider, or service coordinator for services that do not require an assessment.
The 2022 CHC Agreement also establishes new time frames for decisions on requests for home adaptations, vehicle modifications and pest eradication. Under the previous CHC agreements, there was no clear time frame for these requests. Many participants who sought these services waited months without a decision or any update. The 2022 CHC Agreement now requires CHC plans to issue a written decision within 60 days of a request for home adaptations, vehicle modifications or pest eradication, which begins when the need for the service is identified in the participant’s service plan. If the CHC Plan requires additional information, it must send the participant a written request within 15 days, and then allow 30 days for the participant to provide the additional information. If the plan does not receive the requested information by day 60, it must issue a denial notice. This means that participants who have not otherwise received a decision within 60 days will now get a written denial notice that they can appeal, rather than being left in the dark about the status of their request.
- Limits on Comprehensive Needs Assessments: The 2022 CHCH Agreement now limits how often CHC Plans can require a comprehensive needs assessment. CHC Plans are required to do a full assessment once a year or when there is a triggering event, such as a participant’s hospitalization or a request from the participant. However, under previous agreements, CHC plans were not prohibited from assessing more frequently, and in practice, some CHC plans assessed participants every three or six months. This meant some participants were continuously reassessed, and in some cases participants had their in-home services changed without any change in condition. Under the 2022 CHC Agreement, CHC plans can only reassess a participant within 60 calendar days before the annual assessment is due or if there is a triggering event. This change should provide more stability for participants whose medical condition and needs have not changed and who are not seeking new or additional services.
- Clarification on Use of Informal Supports: The 2022 CHC Agreement also provides additional guidance on how CHC Plans may consider “informal supports” in the service planning process. Informal supports, also known as “natural supports” are individuals who voluntarily provide care in lieu of other paid services. Since the implementation of CHC, CHC plans often treated family members, especially those who live with the participant, as informal supports without fully evaluating whether they were capable, able and willing to provide unpaid care. PHLP and other advocate groups have urged OLTL to provide further guidance to ensure plans are properly evaluating informal supports. In response, the 2022 CHC Agreement requires CHC plans to discuss and document whether prospective informal supports are available, willing and able to provide unpaid care. Furthermore, the PCSP must clearly document the individual(s) providing informal support, the days and amount of hours of informal support to be provided, and the type and scope of services provided by informal supports.
- Assistance with Medicaid Renewals: CHC participants must periodically provide the Department of Human Services with updated paperwork to maintain their eligibility for Medicaid and HCBS. Unfortunately, many participants struggle with assembling and submitting the necessary paperwork without assistance, leading to temporary disruptions in their benefits. Under previous CHC agreements, service coordinators were already expected to “coordinate efforts and prompt the Participant to complete activities necessary to maintain LTSS eligibility.” The 2022 CHC Agreement includes additional language that CHC plans “must offer assistance to Participants . . . with completing all paperwork necessary for the participant to maintain MA eligibility.” This reinforces the obligation of CHC plans to assist participants affirmatively and actively with their renewal paperwork. This assistance will be more important than ever in coming months when pandemic-related protection against terminating Medicaid and HCBS are expected end and DHS will resume terminating from Medicaid participants who fail to provide required renewal paperwork.
- Employment Supports: The 2022 CHC Agreement includes additional language specifying that CHC plans are responsible for training their employment staff and service coordinators about employment-related resources covered by the plan. Service coordinators now must engage participants in ongoing education and discussion to assist participants with competitive integrated employment. This change reinforces that CHC plans have an affirmative responsibility to educate their staff and participants about the significant employment-related supports available under the CHC Waiver. These include Career Assessment, Employment Skills Development, Job Coaching, Job Finding, and Benefits Counseling (to understand how employment might impact other benefits).
The complete 2022 CHC Agreement will be published on the CHC website once it is approved by CMS. Readers may recall that the 2021 CHC Agreement was not finalized and published until July 2021.