1. Implementation of the new Home Care Rule: Requirements for Exceptions Process Alison Barkoff Director of Advocacy Bazelon Center for Mental Health Law alisonb@bazelon.org Presentation to Virginia Stakeholders, May 11, 2016

2. ADA and Olmstead Prohibit Policies that Place People “At Serious Risk” of Institutionalization ADA and Olmstead require public entities to provide services to people in the “most integrated setting” appropriate to their needs ADA and Olmstead do not only apply to individuals in institutions or other segregated settings They also extend to people at serious risk of institutionalization or segregation This includes people with disabilities and seniors who are subject to cuts in critical community-based services

3. “At risk” Olmstead Cases During the recent economic downturn, many states tried to cut optional Medicaid services, particularly personal care services Numerous legal challenges to these proposed cuts, claiming that the “across-the-board” cuts would pace people at risk of institutionalization in violation of the ADA and Olmstead (challenges in Washington, California, and Louisiana) These cases created legal precedent that: People need only show “serious” not “imminent” risk of institutionalization to have a claim; decline in health that could lead to eventual institutionalization Across the board cuts can violate Olmstead States must have in place an individualized process for individuals who are at serious risk of institutionalization to seek an exception from the cut or alternative services

4. ADA and Olmstead and the Home Care Rule If a state enacts a restrictive policy (like a 40 hour worker cap), the state must create a process that allows consumers who would be placed at risk of institutionalization by new policies to be excepted or given alternative services. DOJ and HHS’ Office of Civil Rights “Dear Colleague” Letter says the ADA and Olmstead generally prohibit across-the- board restrictions and caps and that states must have exceptions process People “at risk” include those who may lose services because they cannot find additional workers (eg, they live in areas with worker shortages) or who might be harmed by having multiple workers due to specialized needs.

5. Key Components of Exceptions Processes Robust exceptions criteria  Long-term criteria Lack of providers/unable to find an additional provider Individual’s unique medical or behavioral needs makes them unable to handle multiple providers  Emergency criteria Provider quits, is terminated or no longer meets certification requirements Additional provider is sick or unavailable (like a weather emergency) Emergent medical needs

6. Key Components of Exceptions Processes (cont’d) Exceptions process  Clear and advanced notice to consumers of the exceptions process and criteria  Both consumer and case managers can request exceptions  Appeals process  Collection of data to ensure that the exceptions process is effective and not leading to increased institutionalization or poor health outcomes

7. States Beginning to Develop and Implement Exceptions Processes Oregon Exceptions to 50 hour cap include: lack of providers, provider unable to work, out-of-town situations, relief or substitute care, emergent need, and unique/complex needs Washington state Exceptions to 40 hour cap for new participants (current participants “grandfathered in” to a 65 hour cap): a limited number of providers in the region, complex medical or behavioral needs, language needs, and emergency situations that pose a health or safety risk Illinois Very narrow exceptions to a 40 hour cap and only allows for short-term exceptions Federal government and advocates have raised concerns about Olmstead compliance

8. Additional Resources on the Home Care Rule Department of Labor home care website: http://www.dol.gov/whd/homecare/http://www.dol.gov/whd/homecare/ Center for Medicare & Medicaid Services Guidance: http://www.medicaid.gov/Federal-Policy-Guidance/Downloads/CIB-07-03-2014.pdf DOJ/HHS OCR “Dear Colleague Letter” on ADA/Olmstead and the Home Care Rule: http://www.ada.gov/olmstead/documents/doj_hhs_letter.pdfhttp://www.ada.gov/olmstead/documents/doj_hhs_letter.pdf Bazelon Center Home Care Rule webpage (with advocacy documents): http://www.bazelon.org/Where-We-Stand/Access-to-Services/Home-Care- Rule.aspx http://www.bazelon.org/Where-We-Stand/Access-to-Services/Home-Care- Rule.aspx