As part of the agency’s ongoing response to the COVID-19 pandemic, the Centers for Medicare and Medicaid Services (CMS) published on March 22 new resources for state Medicaid agencies on home and community-based services (HCBS). These resources were published along with Medicaid-specific guidance on 1135 waivers and follow previous guidance for state Medicaid agencies.

New Resources Available

These new resources include instructions and a template for state Medicaid agencies on filing an Appendix K application for their respective 1915(c) waivers. For context, 1915(c) waivers are the main authority through which states provide Medicaid HCBS, and states can use Appendix K of those waivers to modify their existing 1915(c) waivers in the event of emergencies, including the COVID-19 pandemic.

CMS also announced three states that have approved Appendix K applications. Two of these states, Pennsylvania and West Virginia, include Appendix K provisions for 1915(c) waiver specific to older adults. Key provisions from both states are summarized below. Each of these states may serve as an example for other states considering an Appendix K application. Washington was also approved for Appendix K provisions for waivers serving people with intellectual/developmental disabilities.

The instruction document includes process-oriented items (e.g., allowing electronic signatures, prepopulating certain sections of the application) as well as more substantive examples of flexibilities available through Appendix K. Specifically, CMS cites the following as options states could exercise:

• Expand availability of in-home services, expand who can provide those services and allow family members to deliver in-home services and be paid for those.
• Provide retainer payments to providers when they are forced to close, such as day settings.
• Allow electronic service delivery options for day programs to provide remote monitoring for the people they serve.
• Increase rates across services to bring in more providers and account for potential risk and/or more intensive services.

Implications for Adult Day Services

Each of these could make HCBS more accessible to older adults during the pandemic. In addition, the option for states to provide retainer payments could be a key lifeline for providers such as adult day services that are forced to close by their state agencies and/or who do so voluntarily to limit the spread of COVID-19.

Adult day services are in a particularly precarious position during the COVID-19 pandemic. While aging services across the continuum are under immense pressure, adult day services providers are at particular financial risk due to potential closures.

Unlike providers that are likely to remain operational during the pandemic, such as nursing homes, affordable housing communities and home-based services providers, adult day services providers could be forced to close during the pandemic. In this scenario, adult day services providers could lose the revenue they would otherwise bring in, thereby jeopardizing their long-term financial sustainability. This could have serious implications for the availability of adult day services throughout and beyond the COVID-19 pandemic.

Several states have already mandated that adult day services providers close during the pandemic and it is likely more will follow as the pandemic continues. During closure periods, these providers will likely have no or very limited sources of revenue. Some states are already offering retainer payments to closed providers, including Maryland. States should offer retainer payments for adult day services providers that close during the COVID-19 pandemic and should consider the Appendix K application as a potential option to provide these through.

LeadingAge will continue to monitor for updates on Appendix K applications and work in conjunction with our members and state partners to ensure that aging services providers of all types, including adult day services, are able to continue delivering the services older adults need.

Approved Appendix K Provisions in Pennsylvania and West Virginia

Pennsylvania received approval of an Appendix K application for its Community Health Choices waiver, which serves older adults and people with physical disabilities. Provisions in that application are summarized below.

• Expand nursing services within adult day services and residential habilitation.
• Eliminate cap on certain respite services and do so without a managed care organization's prior authorization.
• Allow certain services (e.g., structured day habilitation, residential habilitation) to be provided in private homes.
• Allow certain services (e.g., cognitive rehabilitation therapy, behavior therapy) to be provided via phone or video conferencing.
• Allow provider staff to work across settings. Per the approved Appendix K, “Staff who are qualified to provide services under any service definition in the 1915(c) waiver may be reassigned to provide Residential Habilitation, Structured Day Habilitation Services, Adult Daily Living, and Personal Assistance Services.”
• To address staffing shortages, allow settings to exceed staffing ratios and limits to individuals served outlined in the 1915(c) waiver.
• Allow assessments and reassessments (e.g., level of care) and service coordination to take place via phone or video conferencing.
• Allow changes to person centered service plans to be approved by email and/or by phone.
• Allow providers to restrict visitors in line with CMS recommendations for nursing homes. Providers do not need to incorporate such restrictions into person centered service plans.
• Provide retainer payments for personal attendant service providers when a service participant is unable to receive care due to COVID-19. Retainer payments may not exceed 15 days.

West Virginia received approval of an Appendix K application for its Aged and Disabled waiver, which serves older adults and people with physical disabilities. Provisions in that application are summarized below.

• Allow service limits outlined in the 1915(c) waiver to be exceeded for personal attendant services if a service recipient’s primary care provider is unable to provide services/supports. Also allow personal attendant services to exceed limits for the purpose of running “essential errands” for service recipients.
• Allow a service recipient’s legal representatives to be paid for personal attendant services if a primary personal attendant is unable to provide services/supports.
• Allow service recipients to receive no services for up to 110 days without being discharged from the waiver.
• Suspend certain staff qualification requirements, including training requirements and background checks. Providers if they choose may deliver trainings via phone or video conferencing instead of in person.
• Suspend provider certification and quality monitoring until the pandemic is over (in Appendix through July 1, subject to extension).
• Allow initial eligibility assessments and reassessments by phone or video conference. Reassessments that cannot be done via these means can be done later and count retroactively. Current service participants may delay reassessment by up to three months.
• Service plans may be revised retroactively to March 12. Expiring service plans can be extended by three months if a new plan cannot be developed due to the pandemic, with monthly telephone monitoring.
• Personal attendant services can be covered when the attendant is delivering support to a hospitalized service recipient.
• Allow enrollment visits, case management visits, periodic (e.g., six month) visits, service planning meetings and provider meetings to take place by phone and/or video conferencing.