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​DHS COVID-19 PROVIDER GUIDANCE // ODP​

ODP Announcement 20-098: Appendix K Update — Waiver Services Provided to Individuals in Hospital Settings and Specialized Supplies

Issued: August 18, 2020 

Audience

All stakeholders

Purpose

To announce guidance for implementing two changes approved in the second Appendix K for the Consolidated, Person/Family Directed Support (P/FDS), Community Living Waivers (ID/A Waivers) and the Adult Autism Waiver (AAW):

    1. Services rendered when an individual is hospitalized for any condition; and
    2. Expansion of items covered under Specialized Supplies.

Discussion

On July 23, 2020, the Centers for Medicare and Medicaid Services (CMS) approved a second Appendix K for the ID/A Waivers and the AAW that addresses additional flexibilities for rendering services during the COVID-19 pandemic. The second Appendix K for the ID/A Waivers and the AAW is in addition to the Appendix K approved by CMS on March 18, 2020. The Office of Developmental Programs (ODP) previously released guidance for implementing many of the changes in the second Appendix K for the ID/A Waivers and the AAW. This communication provides guidance for implementing two new substantive changes in the delivery of waiver services.

Waiver Services Provided to Individuals in Hospital Settings

On March 27, 2020 the Coronavirus Aid, Relief, and Economic Security (CARES) Act was signed into law. This Act allows for Waiver services to be provided in hospital settings  under specific conditions. The initial Appendix K for the ID/A Waivers and the AAW approved on March 18, 2020 only allowed waiver services to be provided in hospital settings when admission was related to COVID-19. ODP has received approval from CMS to allow waiver services to be provided in hospital settings regardless of the reason for hospitalization. ODP will be submitting waiver amendments soon to ensure these  changes remain effective after the COVID-19 pandemic is over.

The following services may be billed starting July 1, 2020, when provided in a hospital setting regardless of the reason for hospitalization:

ID/A Waivers:

    • Supplemental Habilitation for individuals who receive Residential Habilitation, Life Sharing or Supported Living services. The day unit rates for Residential Habilitation, Life Sharing and Supported Living may not be billed when the individual is admitted to a hospital.
    • Supports Coordination
        • Supports Coordination includes locating, coordinating, and monitoring needed services and supports when an individual is hospitalized.
        • Under the current approved waivers, Supports Coordinators (SCs) were only able to bill for services rendered when an individual was admitted to the hospital for fewer than 30 days. This 30-day limit no longer applies.
    • Supports Broker
        • Supports Broker services can be rendered to help managing employers (ME)  and common law employers (CLE) ensure that support service professionals (SSPs) are trained and scheduled to support the individual’s needs when hospitalized and to support a smooth transition of the individual from the hospital to home and community-based settings.
    • In-Home and Community Support
    • Companion
    • Behavioral Support

Adult Autism Waiver:

    • Temporary Supplemental Services
    • Specialized Skill Development
    • Supports Coordination
        • Supports Coordination includes locating, coordinating, and monitoring needed services and supports when an individual is hospitalized.

The services provided may be billed at the same fee schedule rate for services that are rendered in any other allowable setting. Documentation to support a claim must be completed in accordance with Federal and State regulations and guidance.1

In accordance with Section 3715 of the CARES Act, Waiver services provided in a hospital setting must:

    • Be included in the individual’s Individual Support Plan (ISP);
        • The ISP needs to describe what service is being provided in the hospital. If the service is currently authorized in the ISP, the ISP must indicate that the
    • service may be provided in a hospital.
        • The ISP may need to be revised to add a service, such as Supplemental Habilitation, or to address a change in the frequency of service provision.
    • Not duplicate services that the hospital is obligated to provide under Federal or State law, or under another applicable requirement;
        • Waiver services can be billed to assist the individual with communication, intensive personal care, or behavioral support as written in the individual’s ISP.
        • SCs and supports brokers cannot duplicate services that should be provided by the hospital’s case managers or discharge planners.
    • Be provided to meet the needs of the individual that are not met through the provision of hospital services; and
    • Be designed to ensure smooth transitions between acute care settings and home and community-based settings, and to preserve the individual’s functional abilities.

Expansion of Items Covered Under Specialized Supplies

The second Appendix K for the ID/A Waivers and the AAW also authorized revision of the service definition of Specialized Supplies to include personal protective equipment (PPE) and supplies to mitigate the spread of COVID-19. Specialized Supplies now includes the following:

    • PPE:
      • Gloves
      • Respirators
          • Respirators should be requested for the support of an individual who tested positive for COVID-19 or whose health care practitioner directed use of a respirator.
      • Surgical masks
      • Gowns
      • Goggles
      • Alcohol-based hand sanitizer

    • Supplies to mitigate the spread of COVID-19:
      • Cloth masks or clear masks
      • Face shields
      • Pulse oximeters
      • Thermometers
          • The request for thermometers should be no more than one per individual.
          • If an individual is requesting an ear or oral thermometer that requires probe covers, the probe covers are covered through Specialized Supplies.

Specialized Supplies can only be authorized for Waiver participants age 21 and older when a particular medical supply is not available as a home health benefit through Medical Assistance (MA).2 PPE and other supplies to mitigate the spread of COVID-19 is also covered for:

    • Unpaid caregivers who do not render any paid services to the individual and who will use the PPE and supplies to maintain the health and welfare of the individual; and
    • SSPs in the Vendor Fiscal/Employer Agent participant directed services model.

Specialized Supplies are not available to individuals who are receiving Residential Habilitation, Life Sharing or Supported Living services.

Under the approved Appendix K, the new limit on Specialized Supplies is $1,500 per participant per fiscal year (Individual Support Plan year for AAW participants). However,\ in the ID/A Waivers the $1,500 total limit for specialized supplies also includes incontinence supplies, which are limited to $500 per participant per fiscal year. When an individual does not spend the entirety of the $500 towards incontinence supplies, the remaining amount may be used for PPE. It is best practice for SCs to track the amount expended for incontinence supplies, PPE and other COVID-19-related supplies either in the “outcome actions frequency or duration” section or the comment field in the vendor screen of the ISP.

    • Example: Maya is enrolled in an ID/A Waiver. She has used $300 of the $500 available for incontinence supplies ($200 remaining). Maya also needs PPE for  herself and her unpaid caregivers. Since she still has $200 that she did not use for her incontinence supplies, she may use that money towards the cost of PPE, for a total of $1,200 towards PPE.
    • Example: Andres is enrolled in an ID/A Waiver. He works with his SC to add Specialized Supplies on his ISP to obtain PPE. Andres does not use incontinence supplies. Andres can use the total $1,500 to obtain PPE for himself and his unpaid caregivers.
    • Example: James is enrolled in an ID/A Waiver and needs incontinence supplies as well as PPE. He only used $700 towards PPE and already spent $500 on his incontinence supplies. James requested more incontinence supplies. His SC reminded him that he cannot go over his $500 limit for incontinence supplies.

If Specialized Supplies are not already authorized in the participant’s ISP, the individual may contact the SC to discuss if this service can be added. For individuals who already have Specialized Supplies authorized in their ISP, the ISP may need to be revised to include the cost of PPE and other COVID-19-related supplies.

Note to SCS: If the individual is receiving home health services through MA, all PPE for the individual is covered through that service so PPE cannot be covered for the individual through Specialized Supplies. The individual may obtain other covered supplies (as detailed on page 3) to mitigate the spread of COVID-19 through Specialized Supplies. PPE and other covered supplies can be covered for unpaid caregivers who will use the PPE and supplies to maintain the health and welfare of the individual.

There have been no changes to the process for obtaining and documenting eligibility for incontinence supplies as included in the current service definition and ISP manual.

Specialized Supplies must be purchased through one of the following:

    • Organized Health Care Delivery System (OHCDS)
    • Agency with Choice (AWC) organization
    • Vendor Fiscal/Employer Agent (VF/EA) organization

Participants and families cannot purchase supplies and ask for reimbursement.

Documentation to support a claim must be completed in accordance with Federal and State regulations and guidance.3 There must be an invoice that lists the supplies purchased and identification information, such as the MCI number or the name of the individual receiving the service.

Further, as set forth in 55 Pa. Code §§ 6100.803 and 805, the cost of the Specialized Supplies purchased must be the same as or less than the cost charged to the general public. Specialized supplies must be obtained at a rate that is considered reasonable. If it appears that a seller has marked up the price in a manner that would be considered price gouging, specialized supplies should be obtained from another seller if possible. Any instance of price gouging should be reported to pricegouging@attorneygeneral.gov.

Contact

Please contact the appropriate ODP Regional Office with any questions about the information in this communication.