This Primer is designed to encourage use of the Medicaid program in a manner that minimizes reliance on institutions and maximizes community integration in a cost-effective manner. Its intended audience is policymakers and others who wish to understand how Medicaid can be used--and is being used--to expand access to a broad range of home and community services and supports, and to promote consumer choice and control. In addition to comprehensive explanations of program features states can implement to achieve these goals, the Primer presents examples of state programs that have taken advantage of Medicaids flexibility to expand home and community services for people of all ages with disabilities.
Road Rage Royale activation code generator
Long-term care includes a broad range of health and health-related services, personal care, social and supportive services, and individual supports. This chapter recounts the legislative, regulatory, and policy history of Medicaid coverage of long-term care services. Both institutional and home and community long-term care services are covered, with the latter described in greater detail. (Medicaids coverage of primary and acute care is not included in the discussion.)
But neither the statutory provisions nor the revised Federal regulations and HCFA State Medicaid Manual guidelines dictate that a state must change the scope of its pre-1993 personal care coverage. In order to take advantage of these changes, a state must file an amendment to its state plan. Taken together, therefore, these ground-breaking changes in Federal policy can help pave the way for a state to make its coverage of these services much broader than was the case in the past. But the states must act to bring about these changes in their own personal care programs.
Personal care services provided through the state plan are an optional benefit. When personal care services were first authorized, services had to be prescribed by a physician in accordance with a plan of treatment. In 1993, Congress removed the requirement for physician authorization and gave states the option to use other methods to authorize benefits in accordance with a service plan approved by the state. There are no other Federal statutory or regulatory requirements regarding coverage under the personal care option. Nor are there guidelines for minimum or appropriate service criteria. Within the broad parameters of the Federal definition of personal care services, states are free to determine criteria for service eligibility as well as the amount, scope, and duration of the benefit.
This chapter begins with an overview of the broad types of Medicaid home and community services and supports a state may offer. It then describes major Federal and state considerations that influence decisions concerning whether to offer a service as a regular Medicaid program benefit or via an HCBS waiver program. The chapter concludes with more detailed descriptions and illustrations of coverage options--focusing first on services that may be offered under the regular Medicaid state plan and then on services that may be offered under an HCBS waiver program.
A state may define a target population broadly (e.g., all Medicaid-eligible individuals with a developmental disability) or more narrowly (e.g., Medicaid-eligible individuals with a developmental disability who also have a mental illness). Although the targeting aspects of this case management coverage make it somewhat akin to the HCBS waiver program, there is one important difference. As with any other state plan service, once a state has established its target population, case management services must be furnished to all eligible individuals. A state may not limit the number of eligible individuals who may receive these services.
This definition parallels the scope of personal care services that may be furnished under the Medicaid state plan. States frequently broaden the standard waiver definition to include assisting the individual with IADLs and with participation in activities outside the individuals home. A state may cover personal care services under both its state plan and an HCBS waiver program. But to do so it must demonstrate that the proposed HCBS waiver coverage is different from--or in addition to--services in the state plan (as discussed in the section on Federal policy considerations earlier in this chapter).
A more substantive reason why state HCBS waiver services vary so widely is differences among states in the services already covered under the state Medicaid plan. In states that have broad, comprehensive state plan coverages, the services a state offers under its HCBS waiver program will consist mainly of those that cannot otherwise be covered under the state plan. This explains why, for example, some states cover therapeutic services under their waiver programs and others do not. It also explains why HCBS waiver programs that principally serve children usually offer fewer services than programs that principally serve adults with disabilities. Since Federal law mandates that states provide the full array of state plan services to children, whether or not they are covered under a states plan, HCBS waiver programs for children furnish a more limited array of additional services.
Congress agreed to remove this test as a provision of the Balanced Budget Act of 1997. This step prompted some states that had not previously covered supported employment services to add them to their waiver programs. By early 1999, most states had changed their coverage of supported employment services to broaden their availability to all HCBS waiver participants. In a recent letter to State Medicaid Directors, HCFA clarified that these services can be offered to all waiver participants who can benefit from them, not just to persons with mental retardation or other developmental disabilities.
These services may be offered to Medicaid eligible persons regardless of whether the person participates in an HCBS waiver program. Consequently, they may be made available without regard to type or funding source to all Medicaid-eligible individuals (including HCBS waiver participants) who need home and community services. This makes targeted case management a potentially very useful coverage option in establishing a broad-based coordinated service system.
Thus, a central task for states interested in promoting CD services is a thorough assessment of their provider qualifications to determine whether they need to broaden the types of organizations and individuals who may qualify as providers. It is not necessary to limit providers to traditional service agencies. Provider qualifications may be expressed solely with respect to the competencies and skills individual workers must possess. Many types of Medicaid HCB services may be furnished by friends, neighbors, and family members (other than spouses and parents of minor children). In various states (e.g., Kansas), families are encouraged to seek out individuals in their communities who can provide some types of HCB services for people with developmental disabilities.
States may obtain FFP for this purpose in three major ways: through the targeted case management optional state plan service, through an HCBS waiver program, or through administrative claiming. (Chapter 5 provides a detailed discussion of the pros and cons of each of these approaches.)4 For a structure organized around target groups, there may not be much difference between the three alternatives. For a single point of entry system, however, the targeted case management option is particularly advantageous for two reasons. First, targeted case management may be made available to all Medicaid-eligible individuals (including HCBS waiver participants) who need home and community services without regard to type of funding source. This coverage option can be very useful in establishing a broad-based service coordination/point of entry system. Second, in the case of individuals with a developmental disability or a mental illness, a state may limit the providers of targeted case management services to the case management authorities already established in state law. This enables states to tie delivery of targeted case management services for these populations into point of entry systems that are already established.
One reason states are employing HCBS waiver programs so extensively as a means to underwrite the expansion of home and community services is that the authority states have to limit the number of beneficiaries permits them to better predict spending and keep it within available state dollars. With respect to some policy objectives, especially in terms of making benefits broadly available, state plan coverage of home and community services is the best choice.
Denuvo Anti-Tamper is the current de-facto standard for securing DRM schemes on modern titles. Since its original release back in 2014, it has been used to strengthen the DRM of over 150 titles; some with great success, others less so. At its core, it uses various obfuscation techniques, such as unique hardware-based code paths, virtualization, and more, to make tampering with the account-based DRM protection of a game (e.g. Epic Games Launcher, Microsoft Store, Origin, Steam, or Uplay) harder in an attempt to delay piracy. It is embedded in the executable of the game, and only stores licensing data (the "offline token" used to launch the game) separately on the storage drive. This licensing data is typically a couple of kilobytes in size, and is (re)created when the system environment changes enough to necessitate a new token.
A consequence of its use of unique hardware-based code paths, Denuvo Anti-Tamper requires an online connection periodically as the system environment of the operating system changes with new hardware and/or Windows updates. While everything that might invalidate the token stored on the storage drive is not fully known, this happens frequently enough for the anti-tamper protection to be described as requiring a periodic online connection every fortnight or so. This is generally not an issue or hindrance for those with an always present online connection, but can be an annoyance for people primarily using roaming data. Players gaming offline for a long period of time can also suffer if proper preparations are not made in advance to ensure the validity of the offline token. The lack of transparency on storefronts regarding this process from Denuvo Anti-Tamper is a hindrance for potential purchasers, as it means people might not be aware of its presence and periodic online requirement before purchasing a game that, after purchase, the purchaser may find unplayable when an online connection is unavailable. 2ff7e9595c
Comments