Frequently Asked Questions are used to provide additional information and/or statutory guidance not found in State Medicaid Director Letters, State Health Official Letters, or CMCS Informational Bulletins. The different sets of FAQs as originally released can be accessed below.Frequently Asked Questions are used to provide additional information and/or statutory guidance not found in State Medicaid Director Letters, State Health Official Letters, or CMCS Informational Bulletins. The different sets of FAQs as originally released can be accessed below.
Frequently Asked Questions
What is reuse?
The Centers for Medicare & Medicaid Services expects states receiving Federal Financial Participation to share with other states project artifacts, documents and other related materials, and systems components and code for leverage and reuse.
Read the state Medicaid director letter (SMD #18-005) on reuse (PDF, 70.77 KB). Reuse can be accomplished through sharing or acquiring:
- An entire set of business services or systems, including shared hosting of a system or shared acquisition and management of a turnkey service
- A complete business service or a stand-alone system module
- Subcomponents such as code segments, rule bases, configurations, customizations, and other parts of a system or module that are designed for reuse
How do states get started with reuse?
To get started with reuse, a state can:
- Review the state Medicaid director letter (SMD #18-005) on reuse (PDF, 70.77 KB)
- View the introductory video to get familiar with the concept and framework of reuse
- Contact the Medicaid Enterprise Systems (MES) at MES@cms.hhs.gov to request access to the MES Reuse Repository
What is the Reuse Repository, and how can states access it?
The Centers for Medicare & Medicaid Services (CMS) established the Medicaid Enterprise Systems (MES) Reuse Repository to support states’ ability to share and reuse project life cycle artifacts. The repository is available on the CMS zONE (Opportunity to Network and Engage). States must have a CMS Enterprise Identity Management login to access the Reuse Repository.
View complete instructions for accessing the Reuse Repository.
Contact MES at MES@cms.hhs.gov for additional assistance in accessing the repository.
Is training available for reuse concepts and tools?
The reuse webpage on Medicaid.gov features an introductory video and more information about reuse. The webpage also has policy guidance documents.
The Medicaid Enterprise Systems Reuse Repository has instructions on how to use its features. These include how to add artifacts, search for artifacts, use the discussion forum features, and more.
How do states share?
States can share reusable artifacts with others in several ways. States can participate in workgroups such as the Medicaid Management Information System Cohort, State Technical Advisory Group, and any other relevant state groups to facilitate knowledge sharing, partnerships, and collaboration. States with access to the Reuse Repository also may add their reusable artifacts directly to the repository.
View complete instructions for accessing the Medicaid Enterprise Systems (MES) Reuse Repository. Contact MES at MES@cms.hhs.gov for additional assistance in accessing the repository or participating in workgroups.
If a state is reusing a system or module already certified in another state, do they still need to go through certification review and decision?
Certification is required for any new implementation, whether it is a custom- developed module that is transferred from another state, or a commercial off-the-shelf module that is being configured and integrated. The certification process looks at the state’s implementation of the solution to ensure the state has met all federal requirements.
States may reuse system documentation and other supporting evidence from a previous state certification if it is available and applicable to their systems and has been reconfirmed by independent verification and validation.
What aspects of reuse do states need to be aware of when developing advance planning documents (APDs)?
APDs must demonstrate a reuse-friendly design that includes the sharing of systems, modules, code, and any other developed artifacts. States could include language describing their efforts to find and learn from or reuse components from similar systems, or efforts the state is making to ensure that other states more easily can reuse the proposed system once it is developed.
What is the Centers for Medicare & Medicaid Services (CMS) policy regarding ownership rights?
From an intellectual property standpoint, reuse is supported by the general grant conditions for Federal Financial Participation (FFP) under 45 CFR 95.617, which require states to "include a clause in all procurement instruments that provides that the State or local government will have all ownership rights in software or modifications thereof and associated documentation designed, developed, or installed with FFP under this subpart."
Further, according to 42 CFR 433.112(6), CMS has "a royalty free, non-exclusive, and irrevocable license to reproduce, publish, or otherwise use and authorize others to use, for Federal Government purposes, software, modifications to software, and documentation that is designed, developed, installed or enhanced with 90 percent FFP."
In practice, this means that vendors retain ownership rights to software and other products they have developed under their own initiative and funding, while states and CMS have ownership rights to and may share any software, customizations, configurations, or add-ons funded with FFP.
How can residential and adult day settings comply with the HCBS settings requirements while serving Medicaid beneficiaries who may wander or exit-seek unsafely?
Many Medicaid beneficiaries living with dementia and other conditions can have a heightened risk of wandering, or attempting to leave a setting (exit-seeking) unsafely. These behaviors are not necessarily constant or permanent.
Wandering occurs in ways that may appear aimless but often have purpose. People may wander simply because they want to move. Sometimes wandering responds to an unmet basic need like human contact, hunger, or thirst; a noisy or confusing environment; or because people are experiencing some type of distress, like pain or the need to use the toilet. Wandering can be helpful or dangerous, depending on the situation. Although people who wander may gain social contact, exercise, and stimulation, they can also become lost or exhausted.
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.3 Person-centered services involve knowing individuals, and their conditions, needs, and history and using this knowledge to create strategies to assure that individuals are free to interact with others and the community in the most integrated way possible and still prevent injury for those who wander or exit-seek unsafely. Home and community-based settings must demonstrate that person-centered planning drives their operations and services for each person. The beneficiaries the settings serve must drive the person-centered planning process with assistance from a trained, competent, assessor, care manager or similar facilitator. The beneficiary should be able to get input from people who are important to him or her, while still reflecting the individual's input as much as possible. Person-centered plans and related decisions should be consistent with the person's needs and preferences, and informed by family members, caregivers, and other individuals that the beneficiary has identified as playing an important role in his or her life. The role of person-centered planning and the process for realizing this role is described in the final HCBS regulation and in guidance found on the Medicaid.gov website.
Person-centered service plans should be developed with the individual, and include their representatives as appropriate. The person-centered planning process should include a process that:
- is informed by discussions with family members or other individuals who are important to them about key aspects of daily routines and rituals;
- focuses on an individual's strengths and interests;
- outlines the individual's reaction to various communication styles;
- identifies the individual's favorite things to do and experience during the day, as well as experiences that contribute to a bad day;
- proposes experiences that the person may enjoy as community engagement, and describes those factors or characteristics that the individuals would find most isolating or stigmatizing
To promote effective communication, which is at the core of person-centered planning and service delivery, 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. Training programs may include important information on issues such as:
- The most common types of conditions, diseases and disorders that lead to wandering behavior; the various stages of key conditions that result in increased risk of wandering and what to expect over time; and the potential impact of these conditions on the individual's ability to function.
- Differentiating between most common types of conditions, diseases and disorders that lead to wandering behavior from serious mental illness or adverse environmental conditions such as overmedication or neglect.
- Assessing individuals for co-occurring conditions (including barriers to sufficient adaptive skills and the ability to communicate with others) that increase risk for unsafe wandering or exit-seeking.
- Understanding situations that led to past instances of unsafe wandering or exit-seeking or the desire to engage in them;
- Principles of person-centered care planning and service delivery;
- Strategies for identifying and handling behavioral expressions of need or distress.
In addition to previous guidance provided by CMS on the implementation of person-centered planning requirements outlined in the federal HCBS regulations defining home and community-based settings, integration of the following promising practices around person-centered planning specifically for people who wander or exit-seek unsafely is recommended:
- 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.
- This FAQ was released as part of a larger set. View the full set. (PDF, 144.19 KB)
Can provider-controlled settings with Memory Care Units with controlled-egress comply with the new Medicaid HCBS settings rule? If so, what are the requirements for such settings?
Yes, but only if controlled-egress is addressed as a modification of the rules defining home and community-based settings, with the state ensuring that the provider complies with the requirements of 42 C.F.R. 441.301(c)(4)(F), 441.530(a)(vi)(F) and 441.710(a)(vi)(F). Any setting using controlled-egress should assess an individual that exhibits wandering (and the underlying conditions, diseases or disorders) and document the individual's choices about and need for safety measures in his or her person-centered care plan. The plan should document the individual's preferences and opportunities for engagement within the setting's community and within the broader community.
Settings with controlled-egress should be able to demonstrate how they can make individual determinations of unsafe exit-seeking risk and make individual accommodations for those who are not at risk. Should a person choose a setting with controlled-egress, the setting must develop person-centered care plans that honor autonomy as well as minimize safety risks for each person, consistent with his or her plan goals. For example, spouses or partners who are not at risk for exit-seeking and who reside in the same setting should have the ability to come and go by having the code to an electronically controlled exit. Technological solutions, such as unobtrusive electronic pendants that alert staff when an individual is exiting, may be used for those at risk, but may not be necessary for others who have not shown a risk of unsafe exit-seeking. Importantly, such restrictions may not be developed or used for non-personcentered purposes, such as punishment or staff convenience.
In situations where a setting uses controlled-egress on an individual basis to support individuals who wander or exit-seek unsafely, consistent with our regulations, the person-centered plan must document the individual's:
- Understanding of the setting's safety features, including any controlled-egress,
- Choices for prevention of unsafe wandering or exit-seeking
- Consent from the individual and caregivers/representatives to controlled-egress goals for care
- Services, supports, and environmental design that will enable the individual to participate in desired activities and support their mobility
- Options that were explored before any modifications occurred to the person-centered plan
Regulations require the person-centered plan to be reviewed at least annually with the Medicaid beneficiary and his or her representative, to determine whether it needs revision. If a secured memory unit is no longer necessary to meet the individual's needs, the individual must be afforded the appropriate services in that setting to integrate into the community and exercise greater autonomy as well as being offered the option of a setting that does not have controlled egress.
To assure fidelity in complying with the regulations defining home and community-based settings, Memory Care Units should attempt to implement as many options as possible that are outlined within this guidance regarding staffing, activities and environmental design to assure optimal community integration for HCBS beneficiaries.
Note that the regulations provide that Medicaid beneficiaries receiving services in home and community-based settings must be free from coercion and restraint. Consistent with this, home and community-based settings should not restrict a participant within a setting, unless such restriction is documented in the person-centered plan, all less restrictive interventions have been exhausted, and such restriction is reassessed over time.
- This FAQ was released as part of a larger set. View the full set. (PDF, 144.19 KB)