ANCOR's Government Relations staff distributes stories in the Washington Insiders Club (WICS) – a weekly round-up of top stories and headlines – to ANCOR Members to keep them up to date on policy and political developments of note to the disability community. The following entries highlight the most significant reports of the last two months.
January 30, 2017 — On January 26 at a GOP policy retreat, Republican Congressional leaders and President Trump said that they plan on repealing the Affordable Care Act (ACA) and overhauling the tax system in the next six months, changing the expectation for an immediate repeal of the ACA. Democrat lawmakers, joined by some prominent Republicans, have said that the ACA should not be repealed unless or until there is a replacement plan in place. Though the sweeping health care law can be repealed without bipartisan support, passing a replacement will require votes from the minority party.
Tax reform plans discussed focused mainly on reducing foreign trade deficits, increasing American exports, and generating revenue from Mexico to offset the costs of constructing a border wall. Last week, Trump's press secretary Sean Spicer said the administration's tax reform place would include a 20 percent tariff on goods imported from Mexico.
These discussions are taking place against the context of the government again needing to address the debt ceiling, which will be reached in March. The current continuing resolution has the government funded into April, at which point legislative action will need to happen to forestall another government shutdown.
January 23, 2017 — On January 20, just hours after his swearing in ceremony, President Donald Trump issued his first executive order. The order directs his agencies to "waive, defer, or grant exemptions to any provision of the ACA [Affordable Care Act] to the maximum extent permitted by law." Though the order does not contain specific or detailed instructions about which provisions of the law should be addressed, it is a strong statement against the law that remained highlighted throughout the presidential campaign. The executive order directs and authorizes agencies to roll back regulations, cease to enforce provisions, and otherwise nullify provisions set through the regulatory, rather than the legislative, process.
Congress acted last week to address portions of the ACA that impact the budget through a budget reconciliation bill. (See WICs article, "Senate Budget Vote Clears Path to ACA Repeal," January 12, 2017.) Trump has said that he supports a fast repeal of the ACA, which must be done by Congress. In the order, Trump wrote, "In the meantime, pending such repeal, it is imperative for the executive branch to ensure that the law is being efficiently implemented, take all actions consistent with law to minimize the unwarranted economic and regulatory burdens of the act, and prepare to afford the states more flexibility and control to create a more free and open healthcare market." Though the repeal of the ACA has been a major talking point by Republicans in Congress for years, they have been cautioned, including by those within their own ranks, against any repeal that does not include a replacement plan.
The Congressional Budget Office (CBO) issued a report last week saying that if the law was repealed without a replacement, it could result in 32 million people losing health insurance, and a doubling of premiums over the next ten years.
January 23, 2017 — On January 18, the Rehabilitation Services Administration issued guidance to address the criteria for an "integrated location" within the Workforce Innovation and Opportunities Act's (WIOA's) definition for "competitive integrated employment". Definitions within the statute were ambiguous, so this guidance seeks to clarify requirements for competitive integrated employment.
The guidance says that there are two criteria to be satisfied for an employment setting to be considered an integrated location: 1) typically found in the community, and 2) the employee with a disability must interact with other employees within the particular work unit and work site other people without disabilities, to the same extent that individuals without disabilities interact with those people.
The guidance then goes on to clarify what "typically found in the community" means, saying that they are "those in the competitive labor market" and do not include settings established by community rehabilitation programs specifically for the purpose of employing individuals with disabilities (e.g. sheltered workshops)". The reason for this is because "these settings are not typically found in the competitive labor market". The next topic in the guidance is around the definition of "work unit". RSA says that if individuals with disabilities are congregated together to perform work under, for example, a Javits-Wagner-O'Day (JWOD) contract, this would not satisfy the criteria for competitive integrated employment because "it is operated for the express purposed of employing individuals with disabilities...and thus is not typically found in the community." Further, "the high percentage of individuals with disabilities employed with these entities most likely would result in little to no opportunities for interaction between individuals with disabilities and non-disabled individuals."
January 23, 2017 — Last week, the Centers for Medicare and Medicaid Services (CMS) added Hawaii and New Mexico to the growing list of states that have received initial approval for their statewide transition plans under the HCBS Rule. Only one state, Tennessee, has received final approval. The states that have received initial approval have been notified of additional steps they must take to receive final approval of their plans. States that have received initial approval are Alaska, Arkansas, Connecticut, Delaware, Hawaii, Idaho, Indiana, Iowa, Kentucky, Montana, New Mexico, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, Virginia, Washington, and West Virginia.
The full list of approved states, with links to their plans and approval letters, is available here.
January 15, 2017 — On January 9, the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) announced a new grant opportunity under the Disability and Rehabilitation Research Projects Program (DRRP) for Using Robotics and Automation to Improve Accessible Transportation Options for Individuals with Disabilities.
The purpose of the DRRP program is to plan and conduct research, demonstration projects, training, and related activities (including international activities) to develop methods, procedures, and rehabilitation technology that maximize the full inclusion and integration into society, employment, independent living, family support, and economic and social self-sufficiency of individuals with disabilities.
This DRRP grant is for advancing the application of automation and robotics to enhance accessible transportation for travelers with disabilities and to improve opportunities for a seamless travel chain that meets the diverse needs of travelers with disabilities (including mobility, vision, hearing, and cognitive disabilities).
Please visit the link above for more details about the grant and application process. This grant opportunity closes on March 21, 2017.
To stay current on NIDILRR grant opportunities, please visit www.grants.gov and search: NIDILRR or 93.433.
Within ACL, NIDILRR works to generate new knowledge and promote its effective use to improve the abilities of individuals with disabilities to perform activities of their choice in the community; and to expand society's capacity to provide full opportunities and accommodations for people with disabilities. NIDILRR conducts its work through grants that support research and development.
January 8, 2017 — On December 30, the Centers for Medicare and Medicaid Services (CMS) issued a guidance package for states regarding the Community First Choice (CFC) State Plan Option that includes three documents: 1) a State Medicaid Director (SMD) letter, 2) a state plan amendment (SPA) pre-print, and 3) a technical guide that provides information to assist states with completing the pre-print. The Community First Choice option was created by the Affordable Care Act (ACA) and is authorized by Section 1915(k) of the Social Security Act.
The SMD outlines specific state activities that are eligible for matching FMAP funds, and what states must do to document those activities. It also includes level of care and financial eligibility requirements, reviews required and optional services and service models under CFC, person-centered planning, and applicable HCB setting exceptions.
In the guidance documents, CMS says that states can use CFC to help reduce the administrative complexity that comes from having multiple authorities providing similar services across different populations. Additionally, they notes that this program allows additional flexibility to states in delivering services. The program may not be capped, which means that any eligible individual under the program is entitled to benefits, which does not permit waiting lists under this authority.
In the guidance, CMS clarified language that discusses natural supports. The section of regulation at issue reads, "Natural supports cannot supplant needed paid services unless the natural supports are unpaid supports that are provided voluntarity to the individual in lieu of the attendant." CMS clarified that this language is "to set forth the requirement that informal caregivers, family members and friends cannot be required to provide unpaid supports as a condition of an individual receiving CFC services, nor can the beneficiary be required to accept such services.” CMS noted, however, that “the identification of natural supports in the assessment is an important aspect in determining an individual’s needs.” The agency further states that this language “does not require that caregivers that were previously unpaid should become paid caregivers under the CFC benefit, nor does this require that caregivers need to be paid beyond the paid hours authorized in the plan.”
Eight states have received approval of or have submitted applications for CFC plans since it became available in 2011 (California, Connecticut, Maryland, Montana, New York, Oregon, Texas, and Washington), and several others are in the process of establishing CFC state plan options.
January 8, 2017 — On December 15, the Centers for Medicare and Medicaid Services (CMS) released a set of FAQs that discuss strategies to ensure the health and welfare of Home and Community Based Services (HCBS) participants who are at risk of wandering. The FAQs focus primarily on how person-centered planning should be used to identify appropriate restrictions while facilitating individualized activities, supports, and access to the community. Other areas of emphasis include adequate staffing to allow for various activities in and outside HCBS settings, proper staff training to identify issues and promote person-centered responses, and the establishment of programs and environments that engage participants, reduce overstimulation, and promote overall beneficiary wellness.
According to the FAQs, “person-centered planning, staff training and care delivery are core components of provider operations to meet HCBS requirements while responding to unsafe wandering and exit-seeking behavior in an individualized manner.” CMS indicates that “provider staff serving beneficiaries who wander or exit-seek should receive education and training about how to communicate with individuals living with conditions that may lead to unsafe wandering or exit-seeking, and recommends “integration of the following promising practices around person-centered planning specifically for people who wander or exit-seek unsafely:”
Assessing the patterns, frequency, and triggers for unsafe wandering or exit-seeking through direct observation and by talking with the person exhibiting such behaviors, and, when appropriate, their families.
Using this baseline information to develop a person-centered plan to address unsafe wandering or exit-seeking, implementing the plan, and measuring its impact.
Using periodic assessments to update information about an individual’s unsafe wandering or exit-seeking, and adjust the person-centered plan as necessary.
Januray 8, 2017 — Recently, the Centers for Medicare & Medicaid Services (CMS) issued a request for information (RFI) seeking public input on potential adaptations of the model of care employed by the Programs of All-Inclusive Care for the Elderly (PACE) for new populations, including individuals with physical disabilities. The PACE Innovation Act of 2015 (PIA) provides authority to test application of PACE-like models for additional populations, including populations under the age of 55 and those who do not qualify for a nursing home level of care, under Section 1115A of the Social Security Act. (See WICs article, "PACE Proposed Rule Released," August 15, 2016.) ANCOR has been very involved in work surrounding expanding the current PACE model, including by bringing national disability organizations together to create an adapted protocol with considerations for CMS to consider when using a PACE model for younger individuals with disabilities.
In the RFI, CMS is specifically seeking information on:
Potential elements of a five-year PACE-like model test, called “Person Centered Community Care” or P3C for individuals ages 21 and older with mobility disabilities that require a nursing home level of care and are dually eligible for Medicare and Medicaid. This potential model is designed to meet the requirements of a model test under Section 1115A of the Social Security Act and to adapt the PACE model of care for one population of focus. Specifically, feedback on the potential elements of the P3C model and on the types of technical assistance that potential P3C organizations and states would require to participate in the model test is requested.
Specific populations whose health outcomes could benefit from enrollment in PACE-like models, and how the PACE model of care could be adapted to better serve the needs of these populations and the currently eligible population.
CMS welcomes feedback from all interested parties, with comments due on February 10, 2017.