New Hampshire Supportive Housing Toolkit
Introduction Overview of Permanent Supportive Housing for Persons with Developmental Disabilities Exploration Development Housing Operations Supportive Services Other Living Expenses of Individuals Putting It All Together: Budgeting For The Individual Developing and Maintaining Your Nonprofit Tax-Exempt Entity Additional Resources Glossary |
A) Designing Supportive Services Plans for IndividualsThe Visions Experience:
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V. "Developmental disability" means a disability:
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New Hampshire has two additional waivers which may be relevant to providers of I/DD Supported Housing,[4] one serving children, the In Home Support Waiver for Children with Developmental Disabilities[5] (the “IHS Waiver”), and one serving individuals who suffer brain injury after age 21, the Acquired Brain Disorder Waiver (the “ABD Waiver”).[6] The current DD, IHS and ABD Waivers cover the years 2016 through 2021. While renewals are expected, these funding streams are vulnerable to future shifts in policy and politics at both the state and federal levels.
When a service is funded by Medicaid, but not through one of the Waivers, it is covered under State Plan Medicaid. State Plan health care services are usually provided through managed care. See https://www.dhhs.nh.gov/ombp/caremgt/recipients/group3. There are two Medicaid managed care plans available in New Hampshire: New Hampshire Healthy Families (Nhhealthyfamilies.com) and Well Sense (WellSense.org). Each Medicaid recipient must elect one of the plans or will be assigned one. For a comparison of eligibility, services, and other variables between New Hampshire’s State Plan Medicaid and the various Waivers, see the linked chart.
When a service is funded by Medicaid, but not through one of the Waivers, it is covered under State Plan Medicaid. State Plan health care services are usually provided through managed care. See https://www.dhhs.nh.gov/ombp/caremgt/recipients/group3. There are two Medicaid managed care plans available in New Hampshire: New Hampshire Healthy Families (Nhhealthyfamilies.com) and Well Sense (WellSense.org). Each Medicaid recipient must elect one of the plans or will be assigned one. For a comparison of eligibility, services, and other variables between New Hampshire’s State Plan Medicaid and the various Waivers, see the linked chart.
Linked document Long Term Services and Supports Chart Comparing NH Waivers
and NH State Plan Medicaid - 2018
and NH State Plan Medicaid - 2018
View Footnotes
[1] There are four federally-approved Section 1915(c) Medicaid Waivers in New Hampshire.
[2] For a summary of waiver services over the lifespan, see Linked Document: HCBS Services.
[3] BDS and its area agencies impose an additional criteria for DD Waiver eligibility: that the individual must have aged out of the State’s educational system. Imposing this requirement would appear to run afoul of the State’s own eligibility criteria under its waiver application, which, once approved by federal Medicaid authorities, arguably carries the force of law. This issue has yet to be challenged in a court.
[4] New Hampshire’s fourth waiver, the Choices for Independence Waiver (the “CFI Waiver”), serves Medicaid-eligible individuals aged 65 and over, and individuals with physical and other disabilities aged 18-64 years. See Linked Document Choices For Independence Program. The current CFI Waiver covers the years 2017 through 2022.
[5] See Linked Document Medicaid & Home Care for Children with Severe Disabilities.
[6] For more information about the Waivers, see www.dhhs.nh.gov/dcbcs/bds.[1] There are four federally-approved Section 1915(c) Medicaid Waivers in New Hampshire.
[2] For a summary of waiver services over the lifespan, see Linked Document: HCBS Services.
[3] BDS and its area agencies impose an additional criteria for DD Waiver eligibility: that the individual must have aged out of the State’s educational system. Imposing this requirement would appear to run afoul of the State’s own eligibility criteria under its waiver application, which, once approved by federal Medicaid authorities, arguably carries the force of law. This issue has yet to be challenged in a court.
[4] New Hampshire’s fourth waiver, the Choices for Independence Waiver (the “CFI Waiver”), serves Medicaid-eligible individuals aged 65 and over, and individuals with physical and other disabilities aged 18-64 years. See Linked Document Choices For Independence Program. The current CFI Waiver covers the years 2017 through 2022.
[5] See Linked Document Medicaid & Home Care for Children with Severe Disabilities.
[6] For more information about the Waivers, see www.dhhs.nh.gov/dcbcs/bds.[1] There are four federally-approved Section 1915(c) Medicaid Waivers in New Hampshire.
c) “1001,” “525,” and “521” Budgets
The terms “1001 budget” and “525 budget” are sometimes used in New Hampshire as shorthand to describe, respectively, HCBS service delivery managed by a provider (through a “1001 budget”), and HCBS service delivery managed by the individual or their guardian (through a “525 budget”).
i) He-M §1001
“1001” refers to New Hampshire statute He-M §1001, which sets forth the Certification Standards For Community Residences in which HCBS services may be delivered.
ii) He-M §525
“525” refers to New Hampshire statute He-M §525, which allows individuals with disabilities to receive HCBS services through Participant Directed and Managed Services (“PDMS”). These budgets are actually run by the family. Under PDMS, the individual or their guardian identifies their needs, designs the services and supports, selects who will provide the supports and services, and decides how authorized funding will be spent (within permissible parameters). The family can move money around in the budget as long as all expenses are Medicaid-allowed. A family can hire their own day staff and they also have to submit the notes. The area agency is usually the employer of record unless a family member has experience dealing with withholding.
A provider operating supportive housing would most typically, but not necessarily, be serving clients with “1001 budgets.” Relying on 525 budgets for each resident might relieve the setting of having to become a Medicaid provider. On the downside, services funded through 525 budgets cannot be shared among recipients, which is unlikely to be practical for the operation of a supported housing setting.
A provider operating supportive housing would most typically, but not necessarily, be serving clients with “1001 budgets.” Relying on 525 budgets for each resident might relieve the setting of having to become a Medicaid provider. On the downside, services funded through 525 budgets cannot be shared among recipients, which is unlikely to be practical for the operation of a supported housing setting.
iii) He-M §521
“521” refers to New Hampshire statute He-M §521, under which services look similar to EFC under 1001 but follow different rules. Under 521, the person served typically lives with a Residential Home Provider (an “HCP”), in a setting certified by the State, and attends a day program. The significant difference between 1001 and 521 is that a family member can be the HCP in a 521 setting and in a 1001 a family member cannot. Like participant-directed services under 525, the 521 scheme was conceived of in part as a way to provide families an opportunity to care for a family member.
One significant difference between the 521 and 525 programs is in the percentage of an individual’s budget that the area agency takes off the top as an administrative fee (in addition to Case Management fees of $3,088). The fee for new 521 budgets, and 1001 budgets as well, is generally between 3% and 8% of the individual’s total budget (although in older budgets that percentage may be higher). For 525 budgets, the fee is much higher, always the maximum allowable under the regulations, 12%.
One significant difference between the 521 and 525 programs is in the percentage of an individual’s budget that the area agency takes off the top as an administrative fee (in addition to Case Management fees of $3,088). The fee for new 521 budgets, and 1001 budgets as well, is generally between 3% and 8% of the individual’s total budget (although in older budgets that percentage may be higher). For 525 budgets, the fee is much higher, always the maximum allowable under the regulations, 12%.
d) Becoming a Provider of Medicaid Services
The requirements for becoming and remaining a provider of Medicaid-funded developmental services in New Hampshire are set forth in two manuals published by the New Hampshire Department of Health and Human Services.
Volume I discusses the procedures and requirements applying to all New Hampshire Medicaid providers.
Volume I discusses the procedures and requirements applying to all New Hampshire Medicaid providers.
Linked document: NH DHHS Provider Manual Volume I
Volume II discusses additional requirements and procedures which relate specifically to providers of developmental services.
Linked document: NH DHHS Provider Manual Volume II
Entry into New Hampshire’s Medicaid provider system is via application.
Linked document: NH DHHS Provider Application
Operating as a provider requires completing New Hampshire’s Medicaid provider enrollment process and, on an ongoing basis, meeting the licensure/certification requirements specific to providing developmental services, complying with all federal and state regulations, and meeting all requirements listed in the manuals. The ongoing administrative burdens of satisfying Medicaid’s record-keeping and billing requirements are substantial.
The Visions Experience:
Becoming a Provider
Incorporate as a 501(c)(3) before becoming a provider. Anyone starting out should closely review the provider requirements.
All of our clients are clients of the local area agency, Pathways.[1] There is nothing to prevent us from having clients from other area agencies but, we don’t. Clients who come to Visions from beyond the region switch area agencies to become Pathways clients.
Providers can now bill Medicaid directly, though Visions is too small to make that worthwhile. Visions bills Pathways, and Pathways bills the State.
All of our clients are clients of the local area agency, Pathways.[1] There is nothing to prevent us from having clients from other area agencies but, we don’t. Clients who come to Visions from beyond the region switch area agencies to become Pathways clients.
Providers can now bill Medicaid directly, though Visions is too small to make that worthwhile. Visions bills Pathways, and Pathways bills the State.
View Footnotes
[1] Pathways of the River Valley. https://pathwaysnh.org/.
d) DD Waiver Services
DD Waiver funds can be used for health, social, recreational, and employment-related transportation and supports. Family members can provide some waiver services. Participant Directed and Managed Services (“PDMS” or “525”) budgets are permitted. The waiver funds services in the following categories:[1]
- Direct Care
- Day Services
- Case Management/Service Coordination
- Respite
- Supported Employment
- Assistive Technology
- Community Support Services/Independent Living
- Crisis Response Services
- Environmental and Vehicle Modifications
- Participant Directed and Managed Services
- Specialty Services
Linked document: Medicaid Home and Community-Based Waiver Services for Persons with Developmental Disabilities
For clients who take prescription medications, RN contracts are anticipated in, and funded through, each individual’s DD Waiver budget.
Case management is funded through the Waiver. The identity of the agency typically providing case management may be changing as the State goes through the process described in footnote [conflict-free management FN], but for the moment, each area agency is the default provider of case management for persons on the DD Waiver. Bear in mind that each individual, or their guardian, if they have one, has the statutory right to select the case manager of their choice.
Caregiver and client training are typically provided by a provider, as part of a DD Waiver-funded service. Many providers include training in their budgets. Individual waiver budgets include some funding for minimal training for staff.
Case management is funded through the Waiver. The identity of the agency typically providing case management may be changing as the State goes through the process described in footnote [conflict-free management FN], but for the moment, each area agency is the default provider of case management for persons on the DD Waiver. Bear in mind that each individual, or their guardian, if they have one, has the statutory right to select the case manager of their choice.
Caregiver and client training are typically provided by a provider, as part of a DD Waiver-funded service. Many providers include training in their budgets. Individual waiver budgets include some funding for minimal training for staff.
View Footnotes
[1] The following are the technical terms for services funded under the DD Waiver:
• Assistive Technology Support Services;
• Case Management/Service Coordination;
• Community Participation Services (Day Services), Levels 1 –6;
• Community Support Services;
• Crisis Response;
• Environmental and Vehicle Modifications;
• Medical/Behavioral Respite Care;
• Participant Directed and Managed Services (PDMS);
• Personal Care Services/Residential, Levels 1-7;
• Respite Care Services;
• Specialty Services, Levels 1 & 2;
• Assessments/Consults;
• HRST;
• START Services, Levels 1&2;
• Assessment/Consults;
• Center Stays;
• Supported Employment Services, Levels 1-3; and
• Wellness Coaching
• Assistive Technology Support Services;
• Case Management/Service Coordination;
• Community Participation Services (Day Services), Levels 1 –6;
• Community Support Services;
• Crisis Response;
• Environmental and Vehicle Modifications;
• Medical/Behavioral Respite Care;
• Participant Directed and Managed Services (PDMS);
• Personal Care Services/Residential, Levels 1-7;
• Respite Care Services;
• Specialty Services, Levels 1 & 2;
• Assessments/Consults;
• HRST;
• START Services, Levels 1&2;
• Assessment/Consults;
• Center Stays;
• Supported Employment Services, Levels 1-3; and
• Wellness Coaching
See Linked Document NH LTSS Chart Comparing Waivers and State Plan 2018.
e) Medicaid State Plan and Medicare Services
Linked document: New Hampshire Medicaid State Plan Services updated 2018
Individuals who have received Social Security Disability benefits for at least twenty-four months are automatically eligible for Medicare. People who qualify for Social Security Disability benefits should receive a Medicare card in the mail when the required time period has passed.[1] Persons eligible for both Medicare and Medicaid are “dual eligible beneficiaries,” often referred to as “dual eligibles.”
Prescription medications and Durable Medical Equipment (“DME”) are typically covered under Medicare Part D or under Managed Care if Medicare is not in effect.[2] PT, OT, ST, and Dietician services are provided for episodic care only.
For dental coverage, individuals under age twenty-one will receive most dental services such as regular check-ups every 6 months. After the age of twenty-one, coverage is limited to extractions as treatment for acute pain or infection.
For vision services, after age eighteen, Medicaid enrollees receive one complete eye exam every twelve months to determine the need for glasses.
Hospice is reimbursable under Medicare. For those without Medicare eligibility, pro bono hospice may be available from a non-profit provider.
Licensed[3] Nursing Assistants (“LNAs”) help patients with activities of daily living and other healthcare needs under the direct supervision of a Registered Nurse (“RN”) or Licensed Practical Nurse (“LPN”). LNAs are credentialed by the state’s Board of Nursing, must complete training programs, pass skills and knowledge assessments, and clear criminal background checks. For those for whom LNA service is available, it is typically limited to a maximum of sixteen hours per day and eighty hours per week.
The Personal Care Attendant (“PCA”) program[4] is independent, with its own eligibility criteria.[5] It funds a direct care provider who assists the client with dressing, bathing, toileting, eating, transferring to or from a bed or chair, etc. It is not known that anyone receiving New Hampshire’s DD Waiver receives PCA services. Some recipients of the CFI Waiver may be eligible for PCA hours. Currently the only provider of PCA services in New Hampshire is Granite State Independent Living.
Prescription medications and Durable Medical Equipment (“DME”) are typically covered under Medicare Part D or under Managed Care if Medicare is not in effect.[2] PT, OT, ST, and Dietician services are provided for episodic care only.
For dental coverage, individuals under age twenty-one will receive most dental services such as regular check-ups every 6 months. After the age of twenty-one, coverage is limited to extractions as treatment for acute pain or infection.
For vision services, after age eighteen, Medicaid enrollees receive one complete eye exam every twelve months to determine the need for glasses.
Hospice is reimbursable under Medicare. For those without Medicare eligibility, pro bono hospice may be available from a non-profit provider.
Licensed[3] Nursing Assistants (“LNAs”) help patients with activities of daily living and other healthcare needs under the direct supervision of a Registered Nurse (“RN”) or Licensed Practical Nurse (“LPN”). LNAs are credentialed by the state’s Board of Nursing, must complete training programs, pass skills and knowledge assessments, and clear criminal background checks. For those for whom LNA service is available, it is typically limited to a maximum of sixteen hours per day and eighty hours per week.
The Personal Care Attendant (“PCA”) program[4] is independent, with its own eligibility criteria.[5] It funds a direct care provider who assists the client with dressing, bathing, toileting, eating, transferring to or from a bed or chair, etc. It is not known that anyone receiving New Hampshire’s DD Waiver receives PCA services. Some recipients of the CFI Waiver may be eligible for PCA hours. Currently the only provider of PCA services in New Hampshire is Granite State Independent Living.
View Footnotes
[1] If this does not happen, contact the local Social Security office.
[2] Some durable equipment, such as a shower chair, that is not reimbursable through Medicare or State Plan Medicaid may be available through the CFI waiver.
[3] New Hampshire is currently contemplating replacing the LNA role with certified nursing assistants. The hope is to increase the availability of nursing assistants by reducing the barriers to credentialization. Training requirements would not change.
[4] See Linked Document Personal Care Attendant Services.
[5] A person may be eligible for Personal Care Attendant services if:
1. The person has New Hampshire Medicaid;
2. The person is at least 18 years of age;
3. The person is their own legal guardian;
4. The person is wheelchair-mobile;
5. The person is able to participate in activities of daily living (i.e. bathing, dressing, toileting);
6. The person is able to self-direct;
7. The person must live in a non-institutional setting;
8. The person requires at least 2 hours per day of medically oriented Personal Care Attendant services per day;
9. The person needs assistance with at least 2 of the 7 following activities of daily living: bathing/grooming, dressing/undressing, eating, mobility, passive range of motion exercise, taking medication and/or toileting.
[2] Some durable equipment, such as a shower chair, that is not reimbursable through Medicare or State Plan Medicaid may be available through the CFI waiver.
[3] New Hampshire is currently contemplating replacing the LNA role with certified nursing assistants. The hope is to increase the availability of nursing assistants by reducing the barriers to credentialization. Training requirements would not change.
[4] See Linked Document Personal Care Attendant Services.
[5] A person may be eligible for Personal Care Attendant services if:
1. The person has New Hampshire Medicaid;
2. The person is at least 18 years of age;
3. The person is their own legal guardian;
4. The person is wheelchair-mobile;
5. The person is able to participate in activities of daily living (i.e. bathing, dressing, toileting);
6. The person is able to self-direct;
7. The person must live in a non-institutional setting;
8. The person requires at least 2 hours per day of medically oriented Personal Care Attendant services per day;
9. The person needs assistance with at least 2 of the 7 following activities of daily living: bathing/grooming, dressing/undressing, eating, mobility, passive range of motion exercise, taking medication and/or toileting.
g) Title XX of the Social Security Act
The Social Services Block Grant (“SSBG”) is funded under Title XX of the Social Security Act and provides home and community-based services targeting elderly (age 60 and older) and younger adults between age 18 and 60 who have a chronic illness or disability. SSBG services, also known as Title XX services, are provided to promote independence, prevent unnecessary institutionalization and protect individuals from abuse, neglect and exploitation.
These services are not offered under the DD Waiver and are typically accessed in group living situations:
These services are not offered under the DD Waiver and are typically accessed in group living situations:
- Adult Medical Day Services
- Adult In-Home Care
- Essential Services (Chore, Emergency Support, Respite)
- Home-Delivered Meals
- Homemaker Services
h) The Service Agreement
The services and supports an area agency client receives are set forth in a Service Agreement. This is a written document prepared pursuant to statutory requirements.[1]
View Footnotes
[1] He-M 503.11.
The Visions Experience:
Financing Supportive Services
Eighteen months before opening, ensure your prospective residents have written individual budgets. Once an individual’s budget is submitted to an area agency, there is typically a six to twelve month wait before the individual gets any funding. Any resident on a §525 budget should be transitioned into §1001 funding. (Area agencies keep 12% to 21% of an individual’s §525 budget for administrative costs.) Bear in mind that in New Hampshire, individual budgets are determined once and do not rise with inflation over the course of the individual’s lifetime (absent a material change in situation or health etc.). Individual budgets at Sunrise Farm range from a low of $36,500 to a high of $101,000.
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