Money Follows the Person Demonstration Expansion Notice of Funding Opportunity.pdf

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U.S. Department of Health and Human Services

Centers for Medicare & Medicaid Services

Center for Medicaid and CHIP Services

Money Follows the Person Demonstration Expansion

Notice of Funding Opportunity Type: New

Funding Opportunity Award Type: Cooperative Agreement

Notice of Funding Opportunity Number: CMS1LI-22-001

Federal Assistance Listings Number (CFDA): 93.791

Notice of Funding Opportunity Posting Date: March 31, 2022

Applicable Dates:

Letter of Intent to Apply Due Date: May 2, 2022

Electronic Application Due Date: May 31, 2022

3:00 pm, Eastern Standard Time

Anticipated Issuance Notice of Award: August 15, 2022

Anticipated Period of Performance: September 1, 2022, through September 30, 2022-03-31 Page 2 of 88

Table of Contents Executive Summary

A. Program Description

A1. Purpose

A2. Authority

A3. Background

A4. Program Requirements

A5. Technical Assistance and Information for Prospective Applicants

B. Federal Award Information

B1. Total Funding

B2. Award Amount

B3. Anticipated Award Dates

B4. Period of Performance

B5. Number of Awards

B6. Type of Award

B7. Type of Competition

C. Eligibility Information

C1. Eligible Applicants

C2. Cost Sharing or Matching

C3. Letter of Intent

C4. Ineligibility Criteria

C5. Single Application Requirement

C6. Continued Eligibility

C7. EIN, DUNS, and SAM Regulations

C8. Faith-Based Organizations

C9. Foreign and International Organizations

D. Application and Submission Information

D1. Address to Request Application Package

D2. Content and Form of Application Submission

D3. Unique Entity Identifier and System for Award Management (SAM)

D4. Submission Dates and Times

D5. Intergovernmental Review

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D6. Cost Restrictions

D7. Mandatory Disclosure

E. Application Review Information

E1. Criteria

E2. Review and Selection Process

E3. Federal Awardee Performance Integrity Information System (FAPIIS)

F. Federal Award Administration Information

F1. Federal Award Notices

F2. Administrative and National Policy Requirements

F3. Terms and Conditions

F4. Cooperative Agreement Terms and Conditions of Award

F5. Reporting

G. CMS Contacts

G1. Programmatic Questions

G2. Administrative/Budget Questions

G3. Applicant Webinars

H. Other Information

Appendix I. Guidance for Preparing a Budget Request and Narrative

Appendix II. Application and Submission Information

Appendix III. Medicaid Home and Community-Based Services Eligible for the MFP-Enhanced FMAP

Appendix IV. Business Assessment of Applicant Organization

Appendix V. Accessibility Requirements

Appendix VI. Review and Selection Process

Appendix VII. Application Check-Off List

Appendix VIII. Glossary of Terms

Appendix IX. Letter of Intent to Apply for MFP Demonstration

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Executive Summary

The Money Follows the Person (MFP) Demonstration, originally authorized under section 6071 1 of the Deficit Reduction Act of 2005 (DRA), supports state strategies to rebalance long-term services and supports (LTSS) systems from institutional to community-based care. MFP has played a key role in many states’ LTSS rebalancing efforts under the Medicaid program providing flexible funding opportunities to help states develop and test the necessary processes, tools, and infrastructure to advance LTSS system reform and to support successful transitions from institutional to community-based settings for individuals eligible for Medicaid LTSS.

Under the Consolidated Appropriations Act of 2021 (CAA), Congress authorized an additional $1.253 billion in federal funds for the MFP Demonstration and extended the project through federal fiscal year (FY) 2023. The CAA also provided the Centers for Medicare & Medicaid Services (CMS) with authorization to expand the MFP Demonstration to additional states and territories. Currently, there are thirty-four (34) states, including the District of Columbia, participating in the MFP Demonstration. The MFP Demonstration Expansion focuses on states and territories not currently participating in the MFP Demonstration.2 The MFP Demonstration Expansion (MFP Expansion) citation in this notice of funding opportunity references states and territories eligible to apply. The Money Follows the Person Demonstration (MFP) refers to existing and new participating projects.

This Notice of Funding Opportunity (NOFO) will make funds available for a Planning Phase with an anticipated start date of September 1, 2022. Award recipients will begin with the Planning Phase during which they will work with stakeholders to design and develop an MFP Demonstration that supports the states’ unique LTSS system reform goals. Award recipients will also have the opportunity to implement capacity building initiatives during and after the end of the Planning Phase. Funding requests are available for planning and capacity building for an amount up to $5 million per state; awards are anticipated to range between $4 million and $5 million per state. Funding will be available for the year in which it is awarded and four additional years.

Following the Planning Phase and CMS approval of certain recipient requirements as described further in this NOFO, the state will be awarded funds for the Program Implementation and Home and Community-based Services (HCBS) Transitions Phase to implement the MFP Demonstration in accordance with the MFP Program Terms and Conditions (PTCs). Funding is issued to recipients via a supplemental award no later than September 30, 2023, as dictated by the Consolidated Appropriations Act, 2021 (CAA), Division CC, Title II, Section 204.

1 Link to MFP demonstration in the U.S. Code:

https://uscode.house.gov/search.xhtml?searchString=%22Money+Follows+the+Person%22&pageNumber=1&items PerPage=100&sortField=CODE_ORDER&action=search&q=Ik1vbmV5IEZvbGxvd3MgdGhlIFBlcnNvbiI%3D%7 C%3A%3A%3A%3A%3A%3A%3A%3Afalse%3A%7C%3A%3A%3A%3A%3A%3A%3A%3Afalse%3A%7Cfal se%7C%5B%3A%3A%3A%3A%3A%3A%3A%3Afalse%3A%5D%7C%5B%3A%5D 2 Money Follows the Person Demonstration Expansion (MFP Expansion) citation in this notice of funding opportunity references states and territories eligible to apply, therefore not currently participating, in the project.

Money Follows the Person Demonstration (MFP) refers to existing and new participating projects.

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Under MFP, participating states may receive cooperative agreement funding for qualified HCBS, demonstration services, and supplemental services, as well as for administrative activities, capacity building, and personnel costs:

• States receive an MFP-enhanced federal medical assistance percentage (FMAP) on qualified HCBS and MFP demonstration services during an MFP participant’s 365-day enrollment period. Demonstration services are optional Medicaid reimbursable services that a state currently does not cover under its Medicaid program. CMS expects the recipient to use an equivalent amount of state funds, commensurate with the increase from section 6071(e)(5) of the DRA, for the purposes of providing new or expanded HCBS and for initiatives to strengthen HCBS system infrastructure.

• MFP supplemental services are services to support an MFP participant’s transition that are otherwise not allowable under the Medicaid program, e.g., apartment application fees.

Supplemental services are not expected to be continued after the 365-day enrollment period.

• Capacity building, supplemental services, administrative activities, and personnel costs related to operationalizing the demonstration are fully cooperative agreement-funded.

During this Program Implementation and HCBS Transitions Phase, recipients will receive cooperative agreement funding for qualified HCBS, demonstration services, and supplemental services, as well as for administrative activities and personnel costs. Award recipients will be able to continue implementing capacity building activities that were initiated during the Planning Phase.

Item Money Follows the Person Demonstration

HHS Awarding Agency Centers for Medicare & Medicaid Services (CMS)

CMS Awarding Center Center for Medicaid and CHIP Services (CMCS)

Notice of Funding

Opportunity Title

Money Follows the Person Demonstration Expansion

Authorization Section 6071 of the Deficit Reduction Act of 2005 (P.L. 109-171) (42 U.S.C. 1396a note), as amended by Section 2403 of Patient Protection and Affordable Care Act (P.L. 111-148), Section 2 of the Medicaid Extenders Act of 2019 (P.L. 116-3), Section 5 of the Medicaid Services Investment and Accountability Act of 2019 (P.L. 116-16), Section 4 of the Sustaining Excellence in Medicaid Act of 2019 (P.L 116-39), Section 205 of the Further Consolidated Appropriations Act, 2020 (P.L. 116-94), Section 3811 of the Coronavirus Aid, Relief, and Economic Security Act, 2020 (P.L. 116-136), Section 2301 of the Continuing Appropriations Act, 2021 and Other Extensions Act (P.L. 116- 159), Section 1107 of the Further Continuing Appropriations Act, 2021, and Other Extensions Act (P.L. 116-215), and Section 204 of the Division CC, Title II of the Consolidated Appropriations Act, 2021 (P.L. 116-260)

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Federal Assistance

Listings Number (CFDA)

93.791

Funding Opportunity

Type

New

Funding Opportunity

Number

CMS-1LI-22-001

Type of Award Cooperative Agreement

Type of Competition Competitive

Letter of Intent Applicants are required to submit a non-binding Letter of Intent to Apply (see Appendix IX). Please complete and return Letter of Intent to Apply no later than May 2, 2022. See Section C.3 for instructions.

Application Due Date and

Time

May 31, 2022, 3:00 pm, Eastern Standard Time

Anticipated Issuance

Notice(s) of Award

August 15, 2022

Period of Performance

Start Date

September 1, 2022

Period of Performance

End Date

September 30, 2026

Anticipated Total

Available Funding

Up to an estimated $110 million will be awarded to new applicants for planning and capacity building activities.

Estimated Maximum

Award Amount

Up to $5 million per state for the year in which it was awarded and four additional years for planning and capacity building.

Estimated Maximum

Number of Awardees

22 awardees maximum

A. Program Description

A1. Purpose

The existing MFP Demonstration provides federal cooperative agreement funding to states, which gives individuals who need LTSS more choice and control about where they live and receive care, and to increase the capacity of state LTSS systems to expand and enhance HCBS for individuals who choose to receive services in the community. The MFP Demonstration Expansion will allow states that are not currently participating to apply to participate in MFP.

As authorized under section 6071 of the DRA, MFP is designed to achieve the following objectives:

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(1) Increase the use of HCBS, rather than institutional LTSS, in the Medicaid program;

(2) Eliminate barriers or mechanisms, whether in state law, the state Medicaid plan, the state budget, or otherwise, that prevent or restrict the flexible use of Medicaid funds to enable Medicaid-eligible individuals to receive support for appropriate and necessary LTSS in the settings of their choice;

(3) Increase the ability of state Medicaid programs to assure continued provision of HCBS to eligible individuals who choose to transition from an institutional to a community setting; and

(4) Ensure that procedures are in place (at least comparable to those required under the qualified HCBS program) to provide quality assurance for eligible individuals receiving Medicaid HCBS and to provide for continuous quality improvement in such services.

The existing MFP Demonstration:

• aims to support states with advancing LTSS system reform;

• establishes procedures to provide quality assurance for HCBS;

• expands and enhances HCBS;

• provides flexible funding opportunities for states to strengthen state infrastructure, to increase transitions from institutional settings to community-based settings, and to improve community living for individuals eligible for Medicaid HCBS;

• offers MFP-enhanced FMAP on qualified HCBS and demonstration services for MFP participants;

• provides a supplemental service option for services that are not otherwise covered under the Medicaid program; and

• makes available full cooperative agreement funding for certain administrative, capacity building, supplemental services, and personnel costs.

A2. Authority

The authority for the MFP Demonstration is section 6071 of the Deficit Reduction Act of 2005 (DRA). Section 6071 of the DRA has been amended by: section 2403 of Patient Protection and Affordable Care Act; section 2 of the Medicaid Extenders Act of 2019; section 5 of the Medicaid Services Investment and Accountability Act of 2019; section 4 of the Sustaining Excellence in Medicaid Act of 2019; section 205 of the Further Consolidated Appropriations Act, 2020;

section 3811 of the Coronavirus Aid, Relief, and Economic Security Act, 2020; section 2301 of the Continuing Appropriations Act, 2021 and Other Extensions Act; section 1107 of the Further Continuing Appropriations Act, 2021, and Other Extensions Act; and section 204 of Division II of Title C of the Consolidated Appropriations Act, 2021 (CAA).

The CAA reauthorized the MFP Demonstration and provided funding for the expansion to additional states through federal fiscal year (FY) 20233 and made two statutory amendments to the DRA of 2005 that affect MFP participant eligibility criteria. Specifically, the CAA made the following eligibility changes:

3 All funding must be awarded to recipients by September 30, 2023. MFP funding is available to recipients for the fiscal year in which it is awarded plus four additional fiscal years.

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• Reduced the minimum length of stay in an inpatient facility to qualify for MFP from 90 days to 60 days; and

• Removed language excluding “short-term rehabilitative service” days in a skilled nursing facility that had been used in assessing the length of stay period, to allow states to count the days that an individual receiving skilled nursing services or skilled rehabilitative services in a certified skilled nursing facility, including under Medicare Part A (Hospital Insurance), for the purpose of determining the length of stay period required for MFP eligibility, if the individual is eligible for Medicaid state plan services on those days.

These statutory changes to the length of time required in an inpatient facility to determine MFP eligibility allow recipients to provide community transition services under MFP earlier in an eligible individual’s inpatient stay. Further, identifying individuals interested in transitioning from an inpatient setting earlier in their inpatient stay is expected to be a cost-effective approach that is consistent with many beneficiaries’ preferences for where they would like to receive their care. These changes were effective on January 26, 2021, 30 days after enactment of the CAA.

The CAA also provided CMS with authorization to expand the MFP Demonstration to additional states. In addition, the CAA:

• Established new work plan, evaluation plan, sustainability plan, and Transformed Medicaid Statistical Information System (T-MSIS) reporting requirements for new recipients;

• Required CMS to update the Program Terms and Conditions for current recipients to reflect new requirements included in the CAA for new recipients (due within 1 year of enactment); and

• Made funding available to CMS to support quality assurance and improvement, oversight, technical assistance, and research and evaluation activities.

A3. Background

LTSS enable millions of Americans, including children, individuals with disabilities, and older adults, to have their care needs met in a variety of settings. Medicaid is the single largest payer of LTSS and can cover a continuum of LTSS, ranging from HCBS to institutional care, such as in nursing facilities. Medicaid can play an important role in supporting states’ efforts with LTSS rebalancing, which is commonly defined as achieving a more equitable balance between the share of spending and use of services and supports delivered in home and community-based settings relative to institutional settings.

From the beginning of the Medicaid program in 1965, states were required to provide medically necessary nursing facility care for most eligible individuals, but coverage for HCBS was generally not included. However, over the past several decades, states have used several federal authorities, as well as federally funded grant and cooperative agreement programs, to develop a broad range of HCBS to provide alternatives to institutionalization for eligible Medicaid beneficiaries. Consistent with many beneficiaries’ preferences of where they would like to receive their care, HCBS have become a critical component of the Medicaid program and are part of a larger framework supporting person-centered community integration of older adults and individuals with disabilities. This framework spans efforts across the federal government, including advancing state efforts to comply with Title II of the Americans with Disabilities Act, 2022-03-31 Page 9 of 88

42 U.S.C. §§ 12131–12134, including as interpreted by the Supreme Court in Olmstead v. L.C., 527 U.S. 581 (1999), which requires public entities to administer services to individuals with disabilities in the most integrated setting appropriate to their needs.

LTSS Demographic Trends

Several demographic trends in the United States indicate an increasing demand for LTSS:

• Number of adults age 65 and older is expected to more than double in size between 2014 and 2060, with the largest increase expected from 2020 to 2030;

• Number of adults age 85 or older will grow the fastest over the next few decades, constituting 4 percent of the population by 2050;

• Number of older adults with significant physical or cognitive disabilities is projected to increase from 6.3 million in 2015 to 15.7 million in 2065;

• Approximately 60 million people live in rural areas across the United States, including millions of Medicare and Medicaid beneficiaries. Nineteen percent of the rural population is 65 years or older, compared with 15 percent in urban areas;

• The older adult population is growing more racially and ethnically diverse. From 2015 to 2050, non-White older populations—Hispanic, Black, Asian, Pacific Islander, Native American, and other races—are projected to increase much more rapidly than the White older population; and

• Life expectancy among individuals with intellectual and developmental disabilities (I/DD) is increasing and now ranges from mid-fifties to the seventies, depending on the impact of individuals’ disabilities.4

As states plan, design, and implement LTSS rebalancing strategies, projected increases in both the aging population and diversity of LTSS populations will become especially relevant.

Further, evidence will continue to emerge concerning the impact of the COVID-19 public health emergency (PHE) on discharges from hospitals to home and community-based settings rather than nursing facilities due to bed capacity and the risk of infection. Through MFP planning cooperative agreement awards, states may identify strategies to improve the systems that underlie successful transitions.

Advancing and Expanding State Home and Community-Based Systems

States are in a unique position to accelerate the expansion of HCBS. States implementing an array of HCBS strategies and approaches that promote community living over institutionalization offer older adults and individuals with disabilities choice, control, and access to services that help them achieve independence, optimal health, and quality of life.

Several interrelated key elements of an effective system to advance HCBS are: (1) person-centered planning and services; (2) No Wrong Door systems; (3) community transition support;

(4) direct service workforce and caregivers; (5) affordable and accessible housing to support community-based living options; (6) employment support; and (7) convenient and accessible

4 CMS Long-Term Services and Supports Rebalancing Toolkit

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Since the inception of the MFP Demonstration, states have exercised broad flexibility to incorporate many of these key HCBS system elements into their program design, strategies, and service provision. MFP states have developed tools and processes to support successful transitions, built partnerships with state housing agencies, offered supports to improve community integration for MFP participants, coordinated programs across the HCBS system, integrated transition services into the HCBS delivery system, and advanced initiatives to increase direct service workforce participation, among others. Despite these advancements, states continue to face challenges around the lack of supply of affordable and accessible housing opportunities and direct service workforce capacity issues. CMS expects current MFP Demonstrations and award recipients to continue to address these challenges.

CMS expects and encourages recipients to take steps to identify and address barriers to ensure equitable access to the MFP program. In general, services should be provided in a manner that is compatible with the cultural health beliefs and practices and the preferred language of the participant. Further, LTSS delivery systems may encourage recipients to furnish services to advance equity as defined in the Executive Order on Advancing Racial Equity and Support for

Underserved Communities through the Federal Government. The order defines the term, equity, as “the consistent and systematic fair, just, and impartial treatment of all individuals, including individuals who belong to underserved communities that have been denied such treatment, such as Black, Latino, and Indigenous and Native American persons, Asian Americans and Pacific Islanders and other persons of color; members of religious minorities; lesbian, gay, bisexual, transgender, and queer (LGBTQ+) persons; persons with disabilities; persons who live in rural areas; and persons otherwise adversely affected by persistent poverty or inequality.”5 For approaches and strategies to advance equity under the MFP Demonstration Expansion Project, except as otherwise permitted by applicable law, such approaches and strategies may not propose actions that selectively target or discriminate against beneficiaries based on race, ethnicity, national origin, religion, gender, sex, age, mental or physical disability, health status, receipt of health care, claims experience, medical history, genetic information, evidence of insurability, geographic location, or income.

A4. Program Requirements

A.4.1. Key Terms

This NOFO uses many terms and acronyms throughout. All acronyms are defined at first mention in the text and can be referenced in the Glossary of Terms (Appendix VIII).

5 The Executive Order can be found at https://www.whitehouse.gov/briefing-room/presidential-actions/2021/01/20/executive-order-advancing-racial-equity-and-support-for-underserved-communities-through-the-federal-government/

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Throughout this NOFO, “applicant” refers to the state applying for the funding opportunity, and “recipient” refers to the state selected to receive the cooperative agreement.

A.4.2 Demonstration Performance Period and Associated Funding

This Notice of Funding Opportunity (NOFO) will make funds available for a 16-month Planning Phase during which award recipients will work with stakeholders to design and develop an MFP Demonstration and Demonstration application that supports the states’ unique LTSS system reform goals. Award recipients will also have the opportunity to implement capacity building initiatives during and after the end of the Planning Phase. Funding requests are available for planning and capacity building for an amount up to $5 million per state. Funding will be available to states for the year in which it was awarded and four additional years.

Following the Planning Phase and CMS approval of certain recipient requirements as described further in this NOFO, the state will submit a budget request for supplemental funding; additional information on the process for requesting supplemental funding and on requirements for receiving supplemental funding will be made available to award recipients during the Planning Phase. Upon approval, the Program Implementation and HCBS Transitions Phase will begin with an award of funds to serve MFP enrollees in accordance with the MFP PTCs. During this Program Implementation and HCBS Transitions Phase, recipients will receive cooperative agreement funding for qualified HCBS, demonstration services, and supplemental services, as well as for administrative activities and personnel costs. Award recipients will be able to continue implementing capacity building activities that were initiated during the Planning Phase.

A.4.3 Planning Phase

The 16-month Planning Phase begins on the anticipated Notice of Award project and budget date, September 1, 2022. Award recipients will partner with relevant state agencies and community stakeholders to develop a draft Operational Protocol (OP) that describes how MFP will be implemented and reflects each state’s needs and priorities. During the Planning Phase, funds are available to states to:

• establish partnerships with community stakeholders, including stakeholders representing diverse and underserved populations; Tribal entities and Tribal governments; key state and local agencies, including state and local public housing authorities, and community-based organizations involved in transitions;

• conduct an HCBS system assessment and gap analysis, including an analysis of populations served and provider capacity;

• develop community transition programs;

• establish or enhance Medicaid HCBS quality improvement and assurance systems;

• recruit transition coordination and other HCBS providers;

• procure technical assistance; and

• conduct other planning activities as deemed necessary by the recipient and approved by

CMS.

The recipient must hire a full-time equivalent MFP project director, a full-time equivalent data and quality analyst, and other MFP staff as deemed necessary to properly and efficiently conduct

2022-03-31 Page 12 of 88 the planning activities during the Planning Phase period. Administrative, personnel, and capacity building costs incurred by the recipient during the Planning Phase, including the costs of a full-time project director and full-time data and quality analyst and other staff, can be reimbursed 100 percent with cooperative agreement funding.

Planning Phase Activities

Conduct a System Assessment and Gap Analysis

During the Planning Phase, recipients will conduct an assessment of the state LTSS system (under Medicaid, Older Americans Act, Rehabilitation Act, other federal entities, and state and local entities), including demographic (e.g., race/ethnicity, age, gender) and LTSS utilization trends of older adults, individuals with physical disabilities, individuals with I/DD, individuals with mental and/or substance use disorders, and rural LTSS populations, including data related to diversity of populations served and whether they reflect the population in the state. Additionally, the system assessment will include engagement with key stakeholders, including HCBS beneficiaries, as well as an analysis of the states’ HCBS system capacity, including current HCBS covered under the Medicaid program, HCBS provider capacity, Medicaid quality improvement and assurance systems, strength of Medicaid cross-agency collaborations, affordable and accessible housing capacity (including wait times to access housing), and an inventory of community-based networks and resources that support community integration. The assessment will identify LTSS population needs, geographic area(s) of need, and information on gaps in HCBS capacity. These findings are crucial for understanding and informing MFP program design and MFP capacity building and planning activities. The findings will be informed by the results of previous MFP evaluations and may include ways the state can test new approaches and flexibilities in their Medicaid programs to strengthen HCBS through the MFP demonstration; to provide opportunities to furnish MFP demonstration services in a more equitable manner; and to determine measurable, attainable, and timely MFP demonstration goals and outcomes.

Each recipient will also collaborate fully with CMS to assess Medicaid quality improvement and assurance systems and information system needs as these relate to MFP requirements.

Recruit Transition Coordination Entities

Recipients of the award may consider developing a strategy for recruiting transition coordination providers, including providers that represent diverse and underserved populations, developing contracts, establishing billing procedures, and providing training and education to transition coordination providers. This strategy can leverage existing transition coordination capacity, contractual relationships, and trained workforce within the No Wrong Door System among aging and disability community-based organizations and health care providers in the state. See also

Appendix VIII. Glossary of Terms.

Procure Technical Assistance

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Recipients of the award may consider procuring technical assistance to support the drafting and development of the OP, provide training to potential providers, and develop marketing materials, among other activities.

Draft Operational Protocol (OP)

Award recipients will leverage input from stakeholders, including HCBS participants and providers, to design the programmatic and operational elements of the MFP Demonstration and draft the OP. The OP is the state’s description of its MFP Demonstration design and implementation strategy. Only after CMS approval of the OP may a recipient enroll participants in MFP and request reimbursement for MFP-funded services.

The OP includes the following elements:

• Organization and Administration

• Target Population(s) Transition Benchmarks

• Participant Recruitment and Enrollment

• Targeted Outreach to Underserved Populations

• Informed Consent and Guardianship

• Outreach/Marketing/Education

• Stakeholder Involvement

• Benefits and Services

• Consumer Supports

• Self-Direction

• Quality Measurement, Assurance, and Monitoring

• Housing

• Continuity of Care Post-Transition

• Budget Projections

More information on the OP element requirements will be made available to award recipients.

The recipient shall submit an OP draft during the Planning Phase period. The OP must be reviewed and approved by CMS. The recipient must revise the OP, if needed, throughout participation in the MFP demonstration. The awardee’s OP must be approved by CMS prior to implementing the Program Implementation and HCBS Transitions Phase and receiving funds for services to MFP participants.

Capacity Building Activities

During the Planning Phase, award recipients can design and implement capacity building activities to further the Demonstration. This funding is expected to strengthen focus and attention on LTSS rebalancing among MFP recipient states and to support MFP projects with making meaningful progress. Examples of capacity building activities that award recipients can implement include (but are not limited to):

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• Assessing HCBS system capacity and determining the extent to which additional providers and/or services might be needed, including self-directed services and providers that serve communities of color and other underrepresented populations;

• Assessing racial and ethnic or other disparities in the state’s HCBS system and developing strategies to address them;

• Assessing institutional capacity and determining the extent to which the state could reduce this capacity;

• Developing and implementing strategies to reduce institutional bed capacity and transition impacted individuals to more integrated settings;

• Engaging stakeholders in system planning, development, and implementation activities;

• Provider/direct service worker recruitment, education, training, and technical assistance (including training people with disabilities to become direct service workers);

• Caregiver and transition coach training and education;

• Assessing and implementing changes to reimbursement rates and payment methodologies to expand HCBS provider capacity and/or improve HCBS quality;

• Provider quality improvement activities;

• Developing and implementing improvements to HCBS eligibility and assessment process (to expedite HCBS eligibility, streamline processes, etc.);

• Building Medicaid-housing partnerships;

• Pre-admission diversion strategies that divert individuals from nursing facilities before they are admitted;

• Quality measurement and improvement strategies; and

• Expanding Health IT capacity.

A.4.4 Program Implementation Phase

During the Program Implementation Phase, participating states may receive cooperative agreement funding for qualified HCBS, demonstration services, and supplemental services, as well for administrative activities and personnel costs. States also receive an MFP-enhanced FMAP on qualified HCBS and MFP demonstration services during an MFP participant’s 365-day enrollment period, which commences when a beneficiary is discharged from a qualifying institution to an MFP-qualified home or community residence. Once the 365-day MFP enrollment period ends, the beneficiary continues to receive Medicaid HCBS services as long as they continue to meet Medicaid eligibility requirements for the services. MFP supplemental services are one-time services to support an MFP participant’s transition that are otherwise not allowable under the Medicaid program. Supplemental services are not expected to be continued after the 365-day enrollment period. Administrative activities and personnel costs related to operationalizing the demonstration are fully cooperative agreement funded during the Program Implementation Phase. Award recipients will also be able to continue implementing capacity building activities that were initiated during the Planning Phase (see section A.4.3 for more information).

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In accordance with section 6071(b) and section 6071(c) of the DRA, the awardee must provide information and assurances for addressing MFP eligibility and implementation requirements in the OP. Specific requirements must be submitted in the OP and are subject to CMS review and approval prior to initiating the Program Implementation Phase.

Eligible Individuals:

As amended by the CAA, section 6071(b)(2)(A)(i)(2) of the Deficit Reduction Act of 2005 (DRA) defines an “eligible individual” as “an individual in the State-

“(A) who, immediately before beginning participation in the MFP demonstration project- “(i) resides (and has resided for a period of not less than 60 consecutive days) in an inpatient facility;

“(ii) is receiving Medicaid benefits for inpatient services furnished by such inpatient facility; and “(iii) with respect to whom a determination has been made that, but for the provision of home and community-based long-term care services, the individual would continue to require the level of care provided in an inpatient facility and, in any case in which the State applies a more stringent level of care standard as a result of implementing the State plan option permitted under section 1915(i) of the Social Security Act [42 U.S.C. 1396n(i)], the individual must continue to require at least the level of care which had resulted in admission to the institution;

and

“(B) who resides in a qualified residence beginning on the initial date of participation in the demonstration project.”

Additionally, section 6071(d)(3) expressly waives the income and resource eligibility rules (section 1902(a)(10)(C)(i)(III)) in order to permit a state to apply institutional eligibility rules to individuals transitioning to community-based care.

Inpatient Facility

Section 6071(b)(3) of the DRA defines the term “inpatient facility” as “a hospital, nursing facility, or intermediate care facility for individuals with [intellectual or developmental disabilities]. Such term includes an institution for mental diseases, but only, with respect to a State, to the extent medical assistance is available under the state Medicaid plan for services provided by such institution.”

Home and Community-Based Services

Section 6071(b)(1) of the DRA defines the term “home and community-based long-term care services” as “with respect to a State Medicaid program, home and community-based services (including home health and personal care services) that are provided under the State's qualified HCB program or that could be provided under such a program but are otherwise provided under the Medicaid program.”

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The qualified HCBS program6 is the Medicaid service package(s) that the recipient will make available to a demonstration participant when they move to a community-based residence. This program can be comprised of any Medicaid home and community-based state plan and waiver program services. Awardees are permitted to claim an MFP-enhanced match rate for the first 365-day post-transition period for qualified HCBS for demonstration participants who transition from an institutional setting into the community. Recipients are also required to continue the qualified HCBS service provision after the conclusion of the demonstration program. See Appendix III for a list of MFP-qualified HCBS.

Of note, section 6071(d)(3) authorizes the Secretary to waive four provisions of title XIX of the Social Security Act (the Act), to the extent necessary to enable a state initiative to meet the requirements and accomplish the purposes of the demonstration. These provisions are:

• Statewideness (Section 1902(a)(1)) – In order to permit implementation of a State initiative in a selected area or areas of the State.

• Comparability (Section 1902(a)(10)(B)) – In order to permit a State initiative to assist a selected category or categories of individuals enrolled in the demonstration.

• Income and Resource Eligibility (Section 1902(a)(10)(C)(i)(III)) – In order to permit a State to apply institutional eligibility rules to individuals transitioning to community-based care.

• Provider agreement (Section 1902(a) (27)) – In order to permit a State to implement self-direction services in a cost-effective manner for purposes of this demonstration program.

MFP Qualified Residence

Section 6071(b)(6) of the DRA defines the term “qualified residence” as “with respect to an eligible individual-

“(A) a home owned or leased by the individual or the individual's family member;

“(B) an apartment with an individual lease, with lockable access and egress, and which includes living, sleeping, bathing, and cooking areas over which the individual or the individual's family has domain and control; and “(C) a residence, in a community-based residential setting, in which no more than 4 unrelated individuals reside.”

Individual Choice and Equity

In addition, consistent with section 6071(c)(6) of the DRA, CMS will require that individuals targeted as potential demonstration participants have been provided with individual choice regarding participation in the demonstration. Further, each eligible individual or the individual’s authorized representative will have input into and approve the selection of the qualified residence in which the individual will reside and the setting(s) in which the individual will receive HCBS.

6 For the purposes of this NOFO, CMS will use the term “HCBS program” when referencing section 6071 of the DRA definition of an “HCB program”.

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Cultural, linguistic, and disability-competent knowledge should be an ongoing developmental process at all levels of the LTSS delivery system. In general, LTSS should be provided in a manner that is compatible with the cultural health beliefs and practices and the preferred language of the participant. Further, LTSS delivery systems may encourage recipients to furnish services to advance equity as defined in the Executive Order on Advancing Racial Equity and

Support for Underserved Communities through the Federal Government.7 The order defines the term, equity, as “the consistent and systematic fair, just, and impartial treatment of all individuals, including individuals who belong to underserved communities that have been denied such treatment, such as Black, Latino, and Indigenous and Native American persons, Asian Americans and Pacific Islanders and other persons of color; members of religious minorities;

lesbian, gay, bisexual, transgender, and queer (LGBTQ+) persons; persons with disabilities;

persons who live in rural areas; and persons otherwise adversely affected by persistent poverty or inequality.”

Recipients may adhere to the following standards, based on the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care8, including behavioral health9, for the provision of services to participants in the MFP Demonstration:

• provide access to language assistance services, at no cost to each MFP participant with limited English proficiency at all points of contact, in a timely manner during an MFP participant’s transition and 365-day MFP enrollment period.

• assure competence of language assistance provided to limited English proficient MFP participants by interpreters and bilingual staff.

• Not use family and friends to provide interpretation services (except at the request of the patient/consumer).

• make available easily understood consumer-related materials.

• offer and provide effective communication, at no cost, to each MFP participant and companions with disabilities at all points of contact, in a timely manner during all hours of operation. Effective communication may require the provision of auxiliary aids and services.

o Auxiliary aids and services are ways to communicate with individuals with communication disabilities. These ways include qualified sign language interpreters, qualified readers, large print, communication in Braille, qualified speech-to-speech transliterators, assistive listening devices, captioning, and accessible electronic information and technology.

• assure that interpreters are qualified, meaning they are able to interpret effectively, accurately, and impartially, both receptively (i.e., understanding what the person with the

7 The Executive Order can be found at https://www.whitehouse.gov/briefing-room/presidential-actions/2021/01/20/executive-order-advancing-racial-equity-and-support-for-underserved-communities-through-the-federal-government/ 8 National Standards for Culturally and Linguistically Appropriate Services in Health Care https://cccm.thinkculturalhealth.hhs.gov/PDF_Docs/CLAS_Standards.pdf 9 Behavioral Health Implementation Guide for the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care https://www.minorityhealththinkculturalhealth.hhs.gov/minority-mental-health/clas/assets/pdfs/EnhancedNationalCLASStandards.pdf

2022-03-31 Page 18 of 88 disability is saying) and expressively (i.e., having the skill needed to convey information back to that person) using any necessary specialized vocabulary.

In order to ensure that the above standards are consistently met, states should engage in ongoing assessment and quality improvement activities related to cultural, linguistic, and disability competency. These activities should include stakeholder input, integration of quality measures and performance metrics into internal audits, and evaluations of services and programs. States should work with organizations that represent and providers that serve diverse populations as they develop assessment and quality improvement activities.

Public Development Process

In accordance with section 6071(c)(1) of the DRA, the recipient must provide assurance of a stakeholder engagement process during the design and implementation of the Planning Phase, as well as during the Program Implementation Phase and the evaluation of the demonstration.

Recipients are expected to engage a broad community of stakeholders, including but not limited to, Medicaid agency leadership, participants in HCBS programs, residents in long-term care facilities, family members and other caregivers, HCBS providers, the aging and disability network, health plans, housing providers, and the direct care workforce, to inform the state’s approach to the design of the MFP demonstration and the ways in which the state can leverage the MFP Demonstration to expand and enhance the HCBS system.

Continuity of HCBS for MFP Participants

In accordance with section 6071(c)(2) of the DRA, the MFP project must operate in connection with a qualified HCBS program to assure continuity of services for eligible individuals. The MFP project operates in conjunction with a qualified HCBS program that is in operation in the state for such individuals in a manner that assures continuity of Medicaid coverage for such individuals so long as such individuals continue to be eligible for medical assistance and meet the programmatic requirements for the receipt of HCBS.

An awardee must assure access to an approved Medicaid HCBS program for MFP participants during the 365-day enrollment period. Approved Medicaid HCBS programs may include state plan benefits that include HCBS, HCBS state plan and waiver programs, research and demonstration programs including section 1115 demonstrations, integrated care programs including Programs for All-Intensive Care for the Elderly (PACE), and managed LTSS (MLTSS), including those authorized under section 1915(a) or section 1915(b) of the Act.

Recipients must provide assurances for the continuity of HCBS and participant health and welfare after the MFP enrollment period ends for as long as an individual remains eligible for medical assistance.

MFP Service Area(s) and Target Population(s)

In accordance with section 6071(c)(4) and section 6071(c)(5) of the DRA, recipients are required to specify the MFP participant target population(s) they plan to recruit and enroll in the

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Individuals targeted for program participation must meet statutorily defined requirements outlined within the statute. As required by statute, states must transition eligible individuals into a qualified residence from an inpatient facility, as defined above, including individuals with physical disabilities, mental health and substance use disorders, and individuals with intellectual and developmental disabilities. Additionally, recipients are required to specify the projected numbers of eligible individuals in each target group for each year of the demonstration program.

Quality Assurance and Quality Improvement

In accordance with section 6071(c)(11)(A) of the DRA, recipients are required to develop and implement a comprehensive and integrated quality management strategy and plan, subject to CMS review and prior approval. The plan will focus on quality assurance and quality improvement for HCBS under the state Medicaid program, including a plan to assure the health and welfare of individuals participating in the MFP Demonstration. The presence of such a strategy enhances the state’s capacity to assure that the LTSS system operates as designed and that the critical processes of discovery, remediation, and systems improvement occur in a structured and routine manner.

The plan must include targeted system performance requirements to which the critical processes apply, aligning with assurances defined within the section 1915(c) HCBS waiver program, including that 1) the state conducts level of care need determinations consistent with the need for institutionalization; 2) plans of care are responsive to participants’ needs; 3) qualified providers serve participants; 4) health and welfare of participants is protected; (5) State Medicaid Agency retains administrative authority over the program; and (6) the state provides financial accountability of the program.

Further, states with MFP Demonstrations will carry out activities to develop and implement continuous quality assurance and quality improvement systems for HCBS.

To ensure that procedures are in place and comparable to those required under Medicaid’s qualified HCBS program, recipients will be required to implement and report on a CMS-defined set of nationally standardized HCBS quality measures to provide quality assurance for eligible individuals receiving Medicaid HCBS and to provide for continuous quality improvement in such services. See Reporting Requirements below for more information.

Continuous Quality Improvement

In accordance with section 6071(f) of the DRA, technical assistance will be available under MFP to support recipients in developing a comprehensive quality management strategy to include use of data collection tools and resources, reporting, data quality monitoring, and program evaluation methods. Examples of quality management strategies include (but are not limited to):

• Providing the information technology infrastructure to support single point of entry functions, including person centered planning, eligibility and enrollment;

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• Identifying, assessing, and tracking persons who have transitioned into the community across service providers, including the setting they transitioned to (while meeting federal privacy and confidentiality requirements);

• Designing, developing, or modifying information technology applications to support program processes that are person-centered, enable consumer control over services and budgets, and allow for measurement of participant satisfaction, outcomes and choice (including choice of setting);

• Building or significantly enhancing existing data warehouses and/or data…