5547059 Health Care Finance, Department of - Notice of Emergency and Proposed Rulemaking - Governing Conflict-Free Case Management Services

DEPARTMENT OF HEALTH CARE FINANCE

 

NOTICE OF EMERGENCY AND PROPOSED RULEMAKING

 

The Director of the Department of Health Care Finance (DHCF), pursuant to the authority set forth in An Act to enable the District of Columbia to receive federal financial assistance under Title XIX of the Social Security Act for a medical assistance program, and for other purposes, approved December 27, 1967 (81 Stat. 744; D.C. Official Code § 1-307.02 (2014 Repl.)) and Section 6(6) of the Department of Health Care Finance Establishment Act of 2007, effective February 27, 2008 (D.C. Law 17-109; D.C. Official Code § 7-771.05(6) (2012 Repl.)), hereby gives notice of the adoption, on an emergency basis, of an amendment to Section 4216 of Chapter 42 (Home and Community-Based Services Waiver for Persons who are Elderly and Individuals with Physical Disabilities) of Title 29 (Public Welfare) of the District of Columbia Municipal Register (DCMR). 

 

The Centers for Medicare and Medicaid Services (CMS) issued regulations governing conflict-free standards for the delivery of case management services and the person-centered service planning process in its Home and Community-Based regulations, at 42 C.F.R. §§ 441.301(c)(1) – (3). These standards became effective on March 17, 2014.  To bring the District into compliance, these emergency and proposed rules amend the previously published final rules governing the delivery of case management services under the Home and Community-Based Services Waiver for Persons who are Elderly and Individuals with Physical Disabilities (EPD Waiver) by changing the provider qualification criteria for existing case managers.  Each case manager must now self-attest that he or she meets the CMS standards for conflict-free case management services using a form developed by DHCF.  Existing case managers shall have sixty (60) days from the effective date of these rules to complete their self-attestation forms; new case managers will be required to complete their self-attestation forms as a pre-condition for billing EPD Waiver case management services.  EPD Waiver case management service providers shall be required to maintain the self-attestation forms in their personnel files and such files shall be subject to inspection and audit by DHCF or its designated agent.  

 

In addition, these emergency and proposed rules amend the provider qualification criteria to prohibit any new entity from enrolling as a Medicaid reimbursable provider of case management services if that entity is a Medicaid provider of Personal Care Aide (PCA) services or any other direct services under the EPD Waiver, or has a financial relationship, as defined under 42 C.F.R. § 411.354, in a Medicaid provider of PCA or any other direct services under the EPD Waiver.  A new entity is an entity that was not enrolled as an EPD waiver case management service provider on the effective date of these rules.  Existing EPD waiver case management service providers shall have one (1) year from the effective date of these rules to come into compliance with these rules.

 

Finally, EPD waiver case management service providers shall have one (1) year from the effective date of these rules to begin incorporating the requirements of 42 C.F.R. §§ 441.301(c)(1) - (3) requiring that Individual Service Plans developed by case managers incorporate the principles and requirements of person-centered planning. 

 

These changes correlate with the conflict-free case management requirements, 42 C.F.R. § 441.301(c)(1)(vi), and person-centered planning requirements, 42 C.F.R. §§ 441.301(c)(1) – (3) prescribed under CMS’s final rulemaking regarding Home and Community-Based Services published in the Federal Register on January 16, 2014,  79 Fed. Reg. 2948.

 

In order to come into compliance with the new requirements for the delivery of case management services, to preserve the beneficiaries’ health, safety, and welfare, and to avoid any lapse in access to conflict-free case management services, it is necessary that these rules be published on an emergency basis.  These standards ensure that the interests of case managers who arrange for the delivery of services are consistent with the needs and preferences of the beneficiary, and protect the beneficiaries’ health care delivery needs.  Amending the provider enrollment requirements for EPD Waiver case managers is necessary at this time to ensure that the District comes into compliance with CMS’s conflict-free case management standards. 

 

The emergency rulemaking was adopted on July 1, 2015 and shall become effective for services rendered on or after that date.  The emergency rules shall remain in effect for one hundred and twenty (120) days or until October 29, 2015, unless superseded by publication of a Notice of Final Rulemaking in the D.C. Register.  The Director of DHCF also gives notice of the intent to take final rulemaking action to adopt these proposed rules in no less than thirty (30) days after the date of publication of this notice in the D.C. Register.

 

Chapter 42, HOME AND COMMUNITY-BASED SERVICES WAIVER FOR PERSONS WHO ARE ELDERLY AND INDIVIDUALS WITH PHYSICAL DISABILITIES, of Title 29 DCMR, PUBLIC WELFARE, is amended as follows:

 

Section 4216, SPECIFIC PROVIDER REQUIREMENTS: CASE MANAGEMENT AND RELATED WAIVER SERVICES, is amended as follows:

 

4216                SPECIFIC PROVIDER REQUIREMENTS: CASE MANAGEMENT

           

4216.1             Each individual providing case management services shall meet the following requirements:

 

(a)                Be at least eighteen (18) years of age;

 

(b)               Be a United States citizen or alien who is lawfully authorized to work in the United States;

 

(c)                Provide proof of the supporting documents for the Immigration and Naturalization Service’s Form I-9 requirements;

 

(d)               Be able to read and write in English;

 

(e)                Be acceptable to the person using the Waiver service;

 

(f)                Confirm, on an annual basis, that he or she is free of active tuberculosis by undergoing an annual purified protein derivative (PPD) skin test;

 

(g)               Confirm, on an annual basis, that he or she is free of communicable diseases by undergoing an annual physical examination by a physician, and obtaining written and signed documentation from the examining physician that confirms he or she is free of communicable diseases; and

 

(h)               Provide to each case management service provider for whom he or she works:

 

(1)               Evidence of acceptance or declination of the Hepatitis vaccine; and

 

(2)               A completed DHCF Conflict-Free Case Management Self-Attestation Form described under Subsection 4216.2.

 

4216.2             Except as provided in Subsection 4216.3, on or after the effective date of these rules, an individual providing case management services, who is employed or under contract to a Home and Community-Based Services Waiver for Persons who are Elderly and Individuals with Physical Disabilities (EPD Waiver) case management service provider shall self-attest to meeting the CMS conflict-free standards in accordance with 42 C.F.R § 441.301(c)(1)(vi) using the DHCF Conflict-Free Case Management Self-Attestation Form. Under these standards, individual case managers shall not:

 

(a)                Be related by blood or marriage to the person receiving services, or to any paid caregiver of the person;

 

(b)               Be financially responsible for the person, or be empowered to make financial or health decisions on the person’s behalf;

 

(c)                Have a  financial relationship, defined under 42 C.F.R § 411.354, with any entity that is paid to provide care for the person; and

 

(d)               Be employed by any entity that is a provider of a person’s PCA services or any other direct services under the EPD Waiver.

 

 4216.3            An individual providing EPD waiver case management services on the effective date of these rules shall have sixty (60) days from the effective date of these rules to meet the requirements of Subsection 4216.1(h)(ii).

 

4216.4             Within sixty (60) days from the effective date of these rules, EPD Waiver case management service providers shall ensure they have a copy of the DHCF Conflict-Free Case Management Self-Attestation Form on file for each case manager prior to submission of any claims for case management services provided by that case manager.  DHCF Conflict-Free Case Management Self-Attestation Forms are subject to inspection and audit and must be produced upon request. 

 

4216.5             Individuals conducting case management services shall meet one of the following educational requirements:

 

(a)                Have a current appropriate licensure, and have a Master’s degree in social work, psychology, counseling, rehabilitation, nursing, gerontology, or sociology and have at least one (1) year of experience working with the elderly or individuals with physical disabilities;

 

(b)               Have a current appropriate licensure and have a Bachelor’s degree in social work, psychology, counseling, rehabilitation, nursing, gerontology, or sociology and have two (2) years of experience working with the elderly or individuals with physical disabilities; or

 

(c)                Have a current license as a Registered Nurse (RN), and have an Associate degree in nursing, and at least three (3) years of experience working with the elderly and individuals with physical disabilities.

 

4216.6             Case management service providers shall not provide medical, financial, legal, or other service or advice for which they are not qualified or licensed to perform (except for referral to qualified individuals, agencies, or programs).

 

4216.7             Except as provided in Subsection 4216.8, on or after the effective date of these rules, in accordance with 42 C.F.R. § 441.301(c)(1)(vi), the following providers shall not be eligible to provide case management services:

 

(a)                An entity that is a Medicaid provider of personal care aide (PCA) services or any other direct services under the EPD Waiver; or

 

(b)               An entity that has a financial relationship, as defined under 42 C.F.R § 411.354, with a Medicaid provider of PCA services or any other direct services under the EPD Waiver.

 

4216.8             An entity that is enrolled to provide case management services on the effective date of these rules that is also a Medicaid provider of PCA services or any other direct services under the EPD Waiver; or has a financial relationship, as defined under 42 C.F.R § 411.354, with a Medicaid provider of PCA services or any other direct services under the EPD Waiver, shall have one (1) year from the effective date of these rules to come into compliance with Subsection 4216.7.

 

4216.9             An entity described in Subsection 4216.8 shall notify DHCF of its election to continue or discontinue providing case management services within sixty (60) days of the effective date of these rules.  An entity that chooses to discontinue case management services shall submit a transition plan to DHCF within ninety (90) days of the effective date of these rules and shall cooperate with DHCF to effectuate the orderly and timely transition of its enrollees to other case management providers that meet the conflict-free case management standards. 

 

4216.10           Each case management service provider shall conduct a comprehensive intake within forty-eight (48) hours of receiving the waiver referral and prior to the development of the individual service plan (ISP).  All initial ISPs and all renewal ISPs that are initiated on or after the date that is one (1) year from the effective date of these rules shall conform to the person-centered planning requirements under 42 C.F.R §§ 441.301(c)(1) – (3).

 

4216.11           Each case management service provider shall complete the ISP within forty-eight (48) business hours of conducting the comprehensive intake.  

 

4216.12           Each case management service provider shall include the person whose plan is being developed, other contributors chosen and invited by the person, and representatives of the person’s interdisciplinary team, as possible, in the initial assessment and in the development and implementation of the ISP.  The person or authorized representative shall have access to the ISP and shall be involved in the periodic review of the ISP.

 

4216.13           A case management service provider shall submit to the DHCF or its agent a completed ISP for review and approval within seven (7) business days of its receipt.

 

4216.14           It is the responsibility of the case management service provider to ensure that all other professional disciplines, as identified for resolution of identified needs, are incorporated into the ISP.

 

4216.15           Each case management service provider shall maintain, follow, and continually update a training and supervision program to ensure the individual delivering case management services is fully trained and familiar with the waiver policies and procedures, including CMS’s conflict-free case management standards as set forth under this section.

 

4216.16           Each provider of case management services shall ensure that individuals providing case management services are appropriately supervised and that the case management service provided is consistent with the person’s ISP.

 

Comments on the emergency and proposed rules shall be submitted, in writing, to Claudia Schlosberg,  Senior Deputy Director/State Medicaid Director, Department of Health Care Finance, 441 4^th Street, NW, 9^th Floor, Washington, D.C. 20001, via telephone at [phone], via email at [e-mail], or online at www.dcregs.dc.gov, within thirty (30) days after the date of publication of this notice in the D.C. Register.  Copies of the emergency and proposed rules may be obtained from the above address.