Update on Appendix K Flexibilities Issued During the COVID-19 Public Health Emergency
During the initial response to the coronavirus disease 2019 (COVID-19) pandemic, the South Carolina Department of Health and Human Services (SCDHHS) announced multiple policy changes. Most of these policy changes were issued using emergency authorities derived from the federal public health emergency (PHE). The COVID-19 federal PHE ended May 11, 2023.
For home and community based services (HCBS) delivered through waiver programs, SCDHHS implemented temporary flexibilities through a series of Appendix K waivers approved by the Centers for Medicare and Medicaid Services (CMS). CMS granted SCDHHS an extension for the Appendix K flexibilities, which gave SCDHHS the ability to temporarily further extend flexibilities that were created under this authority to determine which flexibilities would expire and which would continue. As a result of this extension, SCDHHS is announcing updates to the temporary policy changes it issued previously. Affected HCBS waivers include:
- Intellectual Disability/Related Disabilities (ID/RD);
- Community Supports (CS);
- Head and Spinal Cord Injury (HASCI);
- Community Choices (CC);
- Mechanical Ventilator Dependent (VENT);
- Medically Complex Children (MCC); and,
- Palmetto Coordinated System of Care.
SCDHHS evaluated all Appendix K flexibilities to determine those that would continue and those that would end no more than six months following expiration of the PHE (no later than Nov. 11, 2023). The updates announced in this bulletin are specific to the temporary flexibilities that were created during the COVID-19 PHE through Appendix K waivers and do not impact other agency policies that existed prior to the PHE or addressed in other Medicaid bulletins regarding temporary flexibilities unless specifically indicated.
Flexibilities that Will be Extended Further
Pending approval from CMS, SCDHHS is proposing to update the current primary caregiver policy for self-directed services in HCBS waiver programs to allow primary/family caregivers that are not legally responsible individuals to be paid for providing these services. This change would be limited to self-directed services only. This policy change would allow for legal guardians and spouses who are not designated legally responsible individuals to continue to provide self-directed services. It will not allow parents of minors to provide self-directed services.
SCDHHS will issue additional communication on this temporary change once it has received approval or additional direction from CMS.
Flexibilities that Will Expire no Later Than Nov. 11, 2023
The following temporary flexibilities, which are listed by waiver in the table below, will expire no later than Nov. 11, 2023. SCDHHS and waiver operators (the South Carolina Department of Disabilities and Special Needs [DDSN] and SC Continuum of Care) will coordinate unwinding activities during the timeframe leading up to November 2023.
|Temporary Flexibility||CS SC.0676||ID/RD SC.0237||HASCI SC.0284||CC SC.0405||HIV/AIDS SC.0186||Vent SC.40181||PCSC SC.1686||MCC SC.0675|
|Remove weekly limits from the Attendant Care/Personal Assistance service for needs related to closure of DDSN day programs or Adult Day Health Care (ADHC) centers.||X||X|
|Add Respite/Personal Care service hours for those displaced from Day Programs and/or ADHC services||X|
|Allow up to two (2) home-delivered meals per day/fourteen (14) meals per week for ADHC recipients.||X||X|
|Allow non-traditional Home-Delivered Meal service providers||X||X||X||X||X|
|Allow Day Services (Day Activity, Career Preparation, Community Services, Employment Services) to be provided in residential settings||X||X||X|
|Renew participant service plans for 12 months under certain conditions (if a meeting is held with the individual and/or representative, if the case manager contacts the participant using allowable remote contact methods)||X||X||X|
|Modify service plans for additional supports and/or services in response to the COVID-19 pandemic||X||X||X||X||X||X|
|Allow for completion of critical incident or Abuse, Neglect and Exploitation (ANE) final report outside of typical timeframes (10 days)||X||X||X|
|Suspend requirement of two (2) waiver services monthly provided to the participant||X||X||X|
|Allow all reviews by the state’s Quality Improvement Organization and other auditing activities to be performed as off-site, desk reviews of information shared by the provider, or deferred past the required timeliness period if onsite reviews are required||X||X||X||X|
|Disallow visitors of the participant’s choosing at any time to minimize the spread of infection related to the COVID-19 pandemic||X||X||X||X||X||X||X||X|
|Authorize case management entities to provide direct service (Conflict of Interest).||X||X||X|
|Allow an extension for reassessment and reevaluations up to one year past the due date||X||X||X||X|
|Conduct assessments, evaluations, and person-centered service planning meetings virtually/remotely in lieu of face-to-face meetings||X||X||X||X||X||X||X||X|
|Add an electronic method of signing-off on required documents (e.g. service plans). This will discontinue use of verbal attestation. Existing electronic signature processes will remain in place.||X||X||X||X||X||X||X|
|Add an electronic method of service delivery (e.g. telephonic) for the following services: case management, in-home habilitation, monthly monitoring||X||X||X||X||X||X|
|Add an electronic method of service delivery (e.g. telephonic) for the RN Care Coordination Service||X|
|Add an electronic method of service delivery (e.g. telephonic) for the following services: case management, monthly monitoring||X||X||X|
|Add an electronic method of service delivery (e.g., telephonic) for case management, monthly monitoring and high fidelity wraparound services||X|
|Add In-Home Supports as a participant-directed service. The service can be provided by a legally responsible person and/or a relative/legal guardian.||X||X|
|Allow parents of minor children to provide personal care services||X||X||X|
|Allow up to one (1) additional home-delivered meal per day/one (1) additional case of nutritional supplements per month||X||X||X|
|Delay onsite review of environmental modifications throughout the PHE||X||X||X|
|Evaluate performance/ completeness of environmental modifications electronically||X||X||X|
|Add an electronic method of signing off on required documents such as the person-centered service plan; and allow services to continue to be provided remotely for high fidelity wraparound.||X|
|Allow all reviews and other auditing activities to be performed as off-site, desk reviews of information shared by the provider, or deferred past the required timeliness period if onsite reviews are required||X|
|Allow HCBS settings reviews scheduled to occur at enrollment, annually or when the participant’s residence changes to be performed off-site throughout the duration of the public health emergency||X|
|EXpand settings where services may be provided (e.g. hotels, shelters, schools, churches)||X||X||X||X|
|Exceed service limitations (including limits on sets of services as described in Appendix (C-4)||X||X||X||X||X||X|
|Modify provider qualifications||X||X||X|
|Modify licensure or other requirements for settings where waiver services are furnished||X||X||X|
|Increase the cost limits for entry into the waiver||X|
Additional COVID-19 PHE Policy Guidance
Providers are also reminded that the following temporary flexibilities were suspended in DDSN-operated waivers (CS, ID/RD, HASCI), effective July 1, 2021:
- The ability to provide Residential Habilitation in settings other than those licensed by the state/allow the issuance of provisional licenses by DDSN for settings with expired licenses due to COVID-19;
- Reviews performed by the state’s Quality Improvement Organization and other auditing activities may no longer be performed as off-site, desk reviews of information shared by the provider.
- Reviews may no longer be deferred past the required timeliness period if onsite reviews are required.
Additionally, providers are reminded that initial, quarterly and re-evaluation visits by case managers have again been required to be conducted face-to-face in the Healthy Connections Medicaid member’s place of residence since Jan. 1, 2023, as announced in Medicaid Bulletin #22-022. Guidance on case management requirements issued by DDSN was also referenced in the bulletin.
A comprehensive list of the COVID-19-specific policy guidance SCDHHS issued during the PHE is publicly available at www.scdhhs.gov/COVID19. Individuals with questions regarding this bulletin should submit those questions to MedicaidWaiver@scdhhs.gov.
Thank you for your continued support of the South Carolina Healthy Connections Medicaid program.