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Date ArticleType
8/30/2017 INCAL
Medicaid Waiver Heightened Scrutiny Process

The Division of Aging recently participated in a small group call with CMS regarding the heightened scrutiny process that is still quite unclear. A focus of the discussion was how to handle settings (AL and adult day services) that provide memory care services with secured unit/controlled egress. The call was the first of many, the next of which will be at the HCBS conference in Baltimore in two weeks. The takeaway appears to be that CMS may allow a process where CMS approves the state’s heightened scrutiny process, but CMS would not examine each of the heightened scrutiny packets that a state reviews – rather the decision would be at the state level. This is not final at all, but a step in the right direction.

On the specific issue of memory care services with secured unit/controlled egress, the key item is whether the services have the effect of inappropriately isolating the individual. Several states have pushed back at CMS saying that they feel they can make a determination that settings that follow a person-centered approach would not have this effect and therefore would not be presumed intuitional, therefore avoiding heightened scrutiny all together. This is the approach that the DA would like to take – where they can determine at the local level that the community is not subject to heightened scrutiny (at least on this element).

If the DA is able to go down this road, they will be using the CMS guidance on caring for those with unsafe wandering/exit seeking behavior to develop what processes a community has to have in place to avoid heightened scrutiny. INCAL has several concerns about how the DA would fairly implement this guidance, but we will need to work on that together. To that end, INCAL will be convening a meeting of association folks from AL, adult day, and the Alzheimer’s association to review this guidance and provide some comments/insights/questions to the DA on what issues may exist with the guidance depending on the setting, whether the provider is an existing provider or a new provider, and what case management resources are realistically available to fully develop a person-centered plan as called for in the Settings Rule.

If you have questions or insights into this issue, please let Zach Cattell know. If you will be at the HCBS conference in Baltimore, please contact Zach Cattell at zcattell@ihca.org.