1. CHANGES IN THE DD SYSTEM
Lake County Board of DD/Deepwood
Service and Support Administration
6/3/2015

2. Transition TDD Waiver to I.O. Waiver
DODD has submitted a proposed plan for the transition of TDD Waiver to I.O. Waiver to the Centers for Medicare and Medicaid Services (CMS), the federal agency that oversees Medicaid‐funded waivers.
After everyone has transitioned, the TDD Waiver will no longer exist.

3. Why
DODD has heard from individuals and families that the Transitions DD (TDD) Waiver isn’t meeting their needs
TDD has a lack of employment supports
Minimal access to services that help people become more involved in their communities
Limited Providers

4. What
Individuals currently enrolled on the TDD Waiver will be able to enroll on the Individual Options (I.O.) Waiver
Offers a broader array of services than TDD
Includes day and employment options
Designed to help individuals become more involved in community activities
Nursing services will be added to the I.O. Waiver beginning July 1, 2016

5. When
Beginning July 1, 2015, County Boards of DD through SSA will begin transitioning individuals currently enrolled on the TDD Waiver to the Individual Options (I.O.) Waiver.
SSAs will assist you with the enrollment process and in most cases, if not all, will do so at the time of your annual Level of Care (LOC)

6. When
Phase I (July 1, 2015-June 30, 2016) will include those individuals who do not require ongoing nursing services or whose nursing needs can be met under Delegated Nursing and/or Certified Medication Pass as a part of Homemaker Personal Care (HPC).
Phase II (July 1, 2016-June 30, 2017) will include those individuals who require ongoing nursing services or whose nursing needs cannot be met under Delegated Nursing and/or Certified Medication Pass as a part of Homemaker Personal Care (HPC).

7. Do I Have a Choice in Waivers?
If you believe another Waiver administered by DODD would better meet your needs, you can choose to enroll in one of DODD’s other two waivers – the Level One Waiver or the Self-Empowered Life Funding Waiver.
You can discuss these options with your SSA and review information about all three waivers on DODD’s website – visit DODD.Ohio.gov and go to the individuals & families section, then the Waiver Types page.

8. INDIVIDUAL OPTIONS (IO) WAIVER OVERVIEW
Eligibility:
ICF/IID Level of Care
Annualized benefit amount is determined by the completion of the Ohio Developmental Disabilities Profile. Upon completion and submission of the ODDP, a funding range is assigned to the enrollee based on his/her assessed needs and circumstances such as living arrangements and availability of natural supports.
Per Rule, there is a total of 9 funding ranges starting at $5,001.

9. INDIVIDUAL OPTIONS (IO) WAIVER OVERVIEW
Services included in the assigned funding ranges include:
Homemaker/Personal Care (HPC)
Adult Foster Care
Adult Family Living
Remote Monitoring
Remote Monitoring Equipment
Environmental Accessibility Adaptations
Specialized Medical Equipment and Supplies
Transportation
Residential Respite (limited to 90 days in a span year)
Community Respite (limited to 60 days in a span year)
Social Work
Home Delivered Meals
Nutrition
Interpreter Services

10. INDIVIDUAL OPTIONS (IO) WAIVER OVERVIEW
Covered services under IO Waivers for day and/or vocational services that have separate annual budget limitations determined through the completion of an Acuity Assessment Instrument (AAI):
Adult Day Support
Vocational Habilitation
Supported Employment-Enclave
Supported Employment-Community
Non-Medical Transportation with annualized benefit amount of $9,456.00

11. CMS Rule Change and Future Systems Redesign
Effective March 17, 2014, CMS Rule change became effective
Identifies the characteristics of home and community based services (HCBS) settings
Identifies settings that are not home and community based
Outlines timelines for states to submit transition plans to the Centers for Medicare and Medicaid Services (CMS) to ensure compliance

12. HCBS Characteristics
Integrated in and supports full access to the greater community
Selected by the individual among setting options including non-disability specific settings
Ensures the rights of privacy, dignity and respect, and freedom of coercion/restraint
Optimizes, but does not regiment, individual initiative, autonomy, and independence in life choices
Facilitates choice in services and who provides them

13. Settings not HCBS Nursing Facilities Institutions for mental disease
Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IIDs)
Hospitals
Any other setting with the qualities of an institutional setting

14. Institutional Qualities
Located in a building that is also a publicly or privately operated facility that proivdes inpatient institutional treatment
Located in a building on the grounds of or adjacent to a public institution
Any other setting that has the effect of isolation individuals from the broader community UNLESS determined through heightened scrutiny that the setting does not have institutional qualities and does have home and community based qualities

15. Coming into Compliance
Free Choice of Provider Rule Revision – 5/1/2015
Describes the assistance individuals may receive when selecting providers
Ensures county boards help recruit new providers, where needed
New HCBS Waiver Administration Rule – 6/1/2015
Describes settings where services can/cannot be provided
Emphasizes least restrictive services to meet individuals’ needs

16. Coming into Compliance
Ongong compliance:
Develop new HCBS settings evaluation tool – 6/1/2015
Waiver changes:
Phase-out of TDD Waiver – 7/1/2015-6/30/2017
Add nursing to IO Waiver - 7/1/2016
Revised Homemaker/Personal Care definition – 7/1/2016

17. Coming into Compliance
Revised Adult Day Waiver Services – 7/1/2016
Supported Employment – Individual
Integrated Prevocational Services
Integrated Day Supports

18. Common Questions
Does this mean that all current day programs have to close?
No. The Rule requires that all individuals, regardless of where they receive services, must have the opportunity to participate in community-based activities to the greatest extent possible. As a result, existing providers of day services may need to change how services are offered in order to comply with the rule.

19. Common Questions
Does participating in “community-based activities” mean that the existing facilities cannot be used and that everyone must spend the entire day in other community-based places?
No. Each person’s level of participation in community based activities will be determined through the person-centered planning process.

20. Common Questions Does the new rule require everyone to work?
No. The new rule requires everyone to have access to the broader community to the same extent as people without disabilities, including opportunities for employment.
Some people don’t have enough information about working to know if they want to or not
For some, work is not a priority

21. Common Questions
The new services are being designed to give people who want to work the opportunity to do so and also to offer other services they may enjoy when not working.

22. Common Questions
Will people get fewer hours of service than they do today if they don’t want to participate in community-based activities 100% of the time?
No. A fundamental principal of the employment and day service redesign was that individuals will have the same level of service/support available under the new services as they do today.

23. Common Questions Will people be able to keep their current providers?
People who are currently receiving day services from private providers will be able to continue working with those providers, as long as:
the current Provider is also certified to provide adult day array services under the I.O. Waiver
the setting in which the services are provided meets the rule requirements

24. Common Questions Conflict Free Case Management
DODD states that due to a provision in the rule that prevents providers from also being responsible for case management activities, individuals will not be able to receive both SSA (case management) and day services from the county board.
DODD has asked CMS for the ability to transition services from boards to private providers by March 2024.

25. Common Questions
However, County Boards through the Ohio Association of County Boards continues to challenge this provision citing the fact that Free Choice of Provider needs to include all Providers, including County Boards
Conflict Free Case Management is not a new issue and had successfully been addressed in the past with a “firewalls” document that ensures a separation of the case management services (SSA) from the services that are provided under HCBS Waivers.
Work continues on this issue

26. What Will Look Different
Enrollment Process
DODD has developed a simplified process to transfer from the TDD Waiver to the I.O. Waiver
LOC assessments will be submitted on line effective 7/1/2015
Requires the completion of an Ohio Developmental Disabilities Profile (ODDP) to determine funding range for services
Requires the completion of an Acuity Assessment Instrument (AAI) to determine the group size with corresponding rates for day services

27. What Else Will Look Different
Monitoring
Individualized monitoring tailored to current needs
Scope, type and frequency specified in the plan
Increased frequency based on intense behavioral, medical needs, transitions in residential setting or at the request of the individual
Person Centered Planning Process
Focus on gathering information that is important to and for the individual
Risk Management
Keeping the plan relevant and outcome based

28. Person-Centered Planning
The goal is to provide guidance for achieving the individual’s desired outcomes utilizing the requested supports and services
Create a positive picture of who the person is
How to support the individual including challenges
Balance what is important to and important for
Create a shared understanding of effective support between the individual, family and providers
To outline an action plan geared towards meeting the individual’s desired outcomes
Focus is on supporting the person

29. ISP Development Discovery Support planning
Formerly known as assessment
Conversational approach focusing on abilities and existing supports
Identify risks
Focus on relationships and capabilities
Creates a detailed description of the indivdual from the individual’s perspective that outlines how providers can offer support
Support planning
To provide guidance for achieving the indidal’s desired outcomes
Outlines requested supports and services
Balances important to and important for

30. ISP Development Resource management Listening/Learning
To identify, connect and provide methods or funding needed to accomplish desired outcomes
Collaboration of families and community resources to enhance or build on the individual’s skills
Focus is not to have paid supports over –run and individual’s own skills or naturally occurring resources in their lives
Listening/Learning
Formerly known as monitoring
Ongoing formal and informal followup to learn and witness evidence of progress
Outcomes are measured, compared and modified
Learn what is working and not working in a person’s life

31. Waiver Nursing and State Plan Medicaid Services
One thing the TDD Waiver has taught County Boards
Use of state plan Medicaid services to enhance Waiver services
Expectation to continue to utilize state plan Medicaid services while enrolled on IO Waiver

32. Waiver Nursing and State Plan Medicaid Services
Authorization of State Plan Medicaid Services
Process will look similar for those receiving up to 14 hours of Home Health Services
Assessment by a Medicare certified Home Health Agency
Physician sign Plan of Care
SSA include on ISP

33. State Plan Medicaid Services – Private Duty Nursing
The plan for PDN authorization was for CBs to authorize private duty nursing (PDN) for all DD waivers. However, DODD was recently informed by Ohio Department of Medicaid (ODM) that this will not happen. The process will remain as it is currently under the other DD Waivers: SSA refers to ODM who will assess and approve or deny authorizations for PDN

34. What do TDD Waiver Providers need to do to continue providing services?
Option 1: Provisional Certification
DODD will give all TDD providers, who are not already certified under IO, Level One, or SELF, a one‐year provisional certification based upon the attached crosswalk.
Each person enrolled in TDD has a date projected for when he/she will transfer from TDD to IO, Level One, or SELF. This information will be provided to service and support administrators to share with individuals and their teams.
Provisional certification dates for existing TDD providers will follow the schedule below:
Providers for individuals transferring 7/1/15 – 12/31/15 will receive provisional IO, Level One, and SELF certifications that are effective 7/1/15 – 6/30/16. These providers must submit a new application for certification prior to 6/30/16.

35. What do TDD Waiver Providers need to do to continue providing services?
Providers for individuals transferring 1/1/16 – 6/30/16 will receive provisional IO, Level One, and SELF certifications that are effective 1/1/16 – 12/31/16. These providers must submit a new application for certification prior to 12/31/16.
Providers for individuals transferring 7/1/16 – 12/31/16 will receive provisional IO, Level One, and SELF certifications that are effective 7/1/16 – 6/30/17. These providers must submit a new application for certification prior to 6/30/17.
Providers for individuals transferring 1/1/17 – 6/30/17 will receive provisional IO, Level One, and SELF certifications that are effective 1/1/17 – 12/31/17. These providers must submit a new application for certification prior to 12/31/17.

36. What do TDD Waiver Providers need to do to continue providing services?
Option 2: Initial Certification
Existing TDD providers, who are not already certified under IO, Level One, or SELF, may skip the step of provisional certification and submit an initial application to add these services. This application must include verification that the provider meets all the standards for certification as specified in Ohio Administrative Code 5123:2‐2‐01.
Any TDD providers who submit applications between 4/15/15 – 12/31/15 can request a waiver of the initial application fee by submitting an to

37. What do TDD Waiver Providers need to do to continue providing services?
Waiver services – Paid family caregivers that live with the individual will need to be authorized as Adult Family Living (AFL) instead of HPC – there will be no grandfathering. This is indicated on the “crosswalk of services” chart
Waiver Nursing should be available 7/1/16 – TDD nurses will be granted provisional HPC certification. DODD anticipates that most TDD nursing can be covered under HPC.
If Waiver Nursing is needed, the CB will assess locally and submit a recommendation to DODD, who will approve, partially approve, or deny the service once Waiver nursing is available under the I.O. Waiver

38. Other Changes for Providers
Billing Changes:
As individuals transfer to other waivers, the only service for which claims will continue to be submitted through the Medicaid Information Technology System (MITS) is nursing.
Claims for all other waiver services must be submitted through DODD’s Medicaid Billing System (MBS).
In order to access MBS, all providers must create a user account through the Provider Certification Wizard (PCW), as described in the handout.
Information about how to submit claims through MBS and upcoming billing training sessions is available at
DODD will also be conducting billing training sessions specific to TDD providers in May and June. Notice of the trainings will be posted on our website (dodd.ohio.gov).

39. Other Changes for Providers
Medication Administration:
In accordance with chapter 5123:2‐6 of the Ohio Administrative Code, unlicensed direct care workers serving people enrolled in IO, Level One, and SELF are able to administer medications and perform other health‐related activities upon completing required training.
Information about the medication administration requirements is located at

40. Governor’s Proposed Budget and Independent Providers
Governor Kasich had proposed the phase out of Independent Providers as we know them in his proposed state budget. The House of Representatives removed this from the budget prior to the budget's move to the Ohio Senate. A counter proposal is now under discussion which would extend the timelines and allow individuals to continue selecting a qualified providing of their choosing.

41. Governor’s Proposed Budget and Independent Providers
Original proposal - To eliminate or phase out Independent Providers statewide over a three year period beginning July 1, 2016, and go to an Agency only model. 
The only exception to this would be if someone is enrolled on a self-directed waiver and acts as the Employer Authority, then they can choose to hire an Independent Provider, as they are responsible for hiring/training/monitoring, etc. of staff.  The only self-directed waiver that Ohio administers at this time is the Self Empowered Life Funding (SELF) Waiver

42. Governor’s Proposed Budget and Independent Providers
DODD is proposing to add self-directed options under the IO and Level I Waivers in order to allow for individuals on these waivers to have the same opportunity to act as the Employer Authority and be able to hire/train/monitor staff. 
It is anticipated that DODD will continue to move forward with these self directed options in order to preserve the ability for individuals to continue receiving services from Independent Providers.