Developmental Disabilities Administration Centers for Medicare and Medicaid Services Community Settings Rule

Background:
On January 16, 2014, the federal Center for Medicare and Medicaid Services (CMS) issued new regulations referred to as the “Community Settings Rule.” The intent of the Community Settings Rule was to ensure that individuals receiving long-term services and supports through home and community based service (HCBS) programs under the 1915(c), 1915(i) and 1915(k) Medicaid authorities have full access to benefits of community living and the opportunity to receive services in the most integrated setting appropriate. The DDA’s Community Pathways Waiver and the people served through the waiver are affected by the Community Settings Rule since the waiver operates under the 1915 (c) Medicaid authority. The State receives approximately $500,000,000 yearly in federal matching funds for services provided to participants of the Community Pathways Waiver.

The Community Settings Rule states that services provided in facilities, congregate settings, farmsteads, and/or services that have the effect of isolating individuals from the broader community are considered to have institutional qualities and therefore may not be in compliance. To comply with the Community Settings Rule, individuals being served in these types of settings may need to be transitioned to more integrated community residences if the setting cannot meet the new standards and fully document compliance with the rule. States were required to submit a Statewide Transition Plan (STP) to CMS outlining strategies to come into compliance. Maryland submitted its plan on March 12, 2015. States must be in full compliance with the new rules by March 17, 2019.

Current Status:
Residential Services
The DDA currently supports 8,887 individuals who are receiving some type of residential service (i.e. Residential Habilitation, Shared Living and Personal Supports). Currently 2,939 people reside in group homes, which are defined as homes serving at least 4 but no more than 8 people. Some of these homes are located on the same street or cul-de-sac or in a farmstead type setting, which may fall under the Federal definition of isolating people from the larger community.

Day Services
The DDA currently supports 13,912 individuals receiving some type of day services (e.g. Day Habilitation, Supported Employment, Medical Day Care, etc.). Of those 13,912 individuals, approximately 8,695 are in congregate settings that potentially may not be in compliance with the Community Settings Rule. These 8,695 people are supported by 102 licensed providers. Of the 102 providers, 52 provide services to more than 50 people. One such provider supports 545 people.

Stakeholder Engagement:
The MD Association of Community Services (MACS) is the statewide nonprofit association of over 100 DDA-licensed community providers. In early 2016, MACS sponsored the Moving Maryland Forward Agency Transformation Retreat, an intensive 3-day technical assistance event to assist providers as they work to provide more inclusive employment, day and residential supports.

The Moving MD Forward (MMF) Retreat provided a unique opportunity for community-based agencies to engage a cross-cutting agency team that included the agency CEO, board members, people who receive supports, direct support professionals, and other staff, in a technical assistance event that included personalized access to nationally-recognized experts, and individual facilitators for each agency.

Agencies applied to participate in the MMF retreat, and there were so many applicants that the retreat was offered twice (January and February 2016). Thirteen agencies participated in the retreats, including four agencies from the Eastern Shore, six agencies from Central MD, two agencies from the Southern region, and one agency from Western MD.

Agencies that participated indicated in evaluations that the team-based intensive retreat provided highly valuable resources and experience that is helping them to move forward with efforts to provide more inclusive quality supports. MACS will be providing follow-up support to these agencies.

Next Steps:
The DDA will be conducting provider surveys and on site assessments to confirm the type of setting, the number of people served in these settings, and to determine compliance or non-compliance with the Community Rule. Once the analysis is completed, the DDA will be able to determine which settings need to be transitioned and determine the potential fiscal impact of implementing the Community Settings Rule.

The CMS Community Settings Rule allows states to establish that certain settings currently in use may continue within the waiver, as long as they will be able to meet the minimum standard set in the rule. These standards are referred to as Tiered Standards. The DDA has formed a workgroup to develop Tiered Standards. The workgroup includes individuals in services, families, DDA licensed providers, and DDA staff.

The DDA and Medicaid are conducting public meetings in each of the four regions to provide information about the Community Settings Rule. The first of these meetings was held on February 4th on the Eastern Shore. A meeting will be held in Central Region on February 16th, Western Region on February 29th and Southern Region on March 2, 2016.