Structured Family Caregiving Frequently Asked Questions

From FSSA

The following FAQs are designed to share information about what care managers and providers can expect with Structured Family Caregiving (SFC) beginning in July 2024 for the Health & Wellness (formerly Aged & Disabled), the Traumatic Brain Injury (TBI), and Indiana PathWays for Aging Waivers. This FAQ is being released along with this guidance regarding Legally Responsible Individuals, attendant care, and SFC. 

Pending approval from the Centers for Medicare and Medicaid Services (CMS), FSSA will be implementing the following changes with regards to Structured Family Caregiving: 

• FSSA updated the waivers so that eligible individuals and their family can receive skilled respite services outside of Structured Family Caregiving. 
• FSSA added waiver provisions to allow foster parents to provide SFC to foster children. 

Receiving the Structured Family Caregiving Service 

• When can a waiver recipient who is a child start receiving the Structured Family Caregiving service on the Health and Wellness and Traumatic Brain Injury Waivers?
• July 1, 2024, pending approval the Centers for Medicare and Medicaid Services (CMS). Families interested in receiving this service in July can start planning now with their care managers. Please see this guidance.

• When can a waiver recipient who is receiving support from a spouse start receiving the Structured Family Caregiving service on the Health and Wellness, PathWays, and Traumatic Brain Injury Waivers? 
• Wavier recipients whose spouse will provide Structured Family Caregiving can work with their care manager at anytime to consider including this service in their service plan. Please see this guidance.

• Who determines what level (1, 2, or 3) of Structured Family Caregiving an individual received? 
• For members who are 18 and older, the care manage will determine the levell using a needs-based assessment.  Eligible individuals under age 18 will be assigned an SFC tier. From now through July 1, 2024, the SFC level will be determined based on authorized attendant care hours as of May 1, 2024: 
• SFC Level One: 1-20 hours/week
• SFC Level Two: 21-40 hours/week 
• SFC Level Three: 41+ hours/week
• More guidance is located here. 

• What does a “daily rate” or “per diem” mean for how Structured Family Caregiving is compensated? 
• FSSA pays a daily rate to the Structured Family Caregiving provider when services are delivered on that day based upon an approved service plan. 

SFC Provider Requirements 

• Will the process remain the same to become a SFC provider as it was previously for becoming a SFC provider after July 1? Or will the expedited process continue?  
• The expedited path is in place to get potential SFC providers enrolled to begin service delivery by July 1 to ensure capacity as eligible individuals shift from attendant care to Structured Family Caregiving. FSSA intends to re-evaluate this summer whether the prioritized path continues to be needed to ensure adequate capacity for this service. 

• What is the actual requirement for a backup plan? Does it always have to include agency staff?  
• Backup plans should be person-centered, reflect the assessed needs of the individual and does not have to always include agency staff. Best practice would include a regular revisiting of the backup plan to ensure it remains appropriate and reflects any changes for the recipient or principal caregiver’s needs

• Can current SFC providers continue with the back up plans they already have in place for waiver recipients?  
• Yes. Current SFC providers on the A&D waiver would continue with back up plans they already have in place with existing waiver recipients.

• Who is determining the Level of Care for clients?  
• Care managers complete the SFC tier assessment to determine the SFC level based on the individual’s assessed needs. The SFC Level of Service assessment is completed at the initial, annual, any re-entries, or if it’s believed Level of Service has changed.

• Will the "common wall" continue to be acceptable for the living together requirement (ie-duplex, townhome)? 
• This continues to be permitted. 

• Can a registered nurse (RN) work for an SFC provider (Personal Care Services Agency or PSA) even though the PSA is non-medical? 
• Yes. An RN may be contracted or employed by a PSA delivering SFC services. The RN is not delivering hands-on care in this service model.

• Under what regulations will the RN be able to assess, administer medications, provide wound care, etc.?   
• The RN for SFC is in place on an as-needed consultative basis depending on the needs of the individual and principal caregiver. The RN is not delivering hands on care, but is serving in an oversight capacity to support the principal caregiver in conjunction with the support offered the caregiver coach. RNs are in a supporting capacity to enhance the caregiver coach on the more medical aspects of caring for the person receiving services. The need for skilled care or intervention would fall to home health services or delivered separate from the SFC service. 

Structured Family Caregiving Service & Other Medicaid Services 

• Can a waiver recipient receive Structured Family Caregiving and State Plan Home Health?  
• Yes, if the individual qualifies for State Plan Home Health. The home health benefit requires prior authorization. There is no limitation on home health strictly due to receipt of SFC. 

• Can a family caregiver be paid for delivering Structured Family Caregiving on the same day the member being supported is receiving other waiver services?  
• Yes. A member can receive other waiver or other Medicaid services while also receiving SFC unless those are explicitly prohibited because the service is considered duplicative in nature. Members are encouraged to find additional service options to add to their SFC services. 

• What services cannot be received when a waiver recipient has Structured Family Caregiving?
• Separate payment may not made for home and community assistance, assisted living, attendant care or adult family care. 

• Caregiver coaching is currently available to members as a unique service, but is it required under SFC? 
• Within the SFC service, there is caregiver coaching component and/or RN support. This is intended to be person-centered, depending on what an individual’s assessed needs reflect and the support required to ensure the principal caregiver has the training and skills to meet the ongoing needs of the individual. The separate coaching service on the waiver could also be provided outside of the SFC service. An SFC provider would need to ensure they make available both a caregiver coach and an RN for a household; the SFC assessment information and identified needs of the principal caregiver would determine what is needed and utilize these available resources as necessary.  The Caregiver Coaching service does not allow for separate payment for Structured Family Caregiving, so both services are not allowed to be authorized together. 

Respite & Structured Family Caregiving 

• Is respite included in SFC? 
• Respite is considered temporary relief to caregivers to provide opportunities for caregivers to take a break while ensuring the member’s needs continue to be met during that relief period. 
• Unskilled Respite is included in Structured Family Caregiving.  Up to 15 days of unskilled respite care per year is included in the SFC service. A member and their caregiver should work with their chosen SFC provider to access this respite care.  Effective July 1, SFC providers are to coordinate and provide the unskilled respite care offered in this service.

• What is unskilled respite care?
• Unskilled respite care are those services that are provided temporarily or periodically in the place of the usual caregiver that are not required to be provided by licensed personnel to support a recipient’s activities of daily living in lieu of the usual caregiver. These could be provided by a direct service worker (which could be a family, friend, or neighbor) employed or contracted by your SFC provider agency. Unskilled respite can occur in home and community-based settings. 

• How is unskilled respite care provided within SFC?
• The agency provider must provide the principal caregiver up to fifteen (15) days of unskilled respite per calendar year. Funding for this respite is included in the daily rate paid to the provider agency, and these respite services must be provided by a qualified caregiver familiar with the participant’s needs.

• What is skilled respite care?  
• Skilled Respite services are those services that are provided temporarily or periodically in the place of the usual caregiver that require licensed or credentialed personnel (e.g., home health aide or nurse). Skilled Respite can occur in home and other community-based settings. Under this waiver service two forms of skilled respite are allowable:
• Home health aide services (RHHA)
• Skilled nursing services (RSKNU)  
• The level of professional care provided under skilled respite services depends on the needs of the participant and caregiver determined in the person-centered planning process. 
• The agency providing skilled respite service is responsible for tracking participant’s skilled respite hours and notifying participant and care manager of hours used as well as hours remaining. 

• How does an individual access skilled respite services on the waiver?  
• The individual should work with their waiver care manager to assess needs related to the respite being requested and coordinate the skilled respite services.

• Is regularly scheduled skilled respite care allowed?
• Regularly scheduled respite (for example every Monday and Wednesday) does not meet the service definition of “temporarily and periodically.” 

• What should a member do if the 15 days of respite included in SFC have been fully utilized and more respite is needed?
• The member and their caregiver should work with the individual’s care manager to determine if the individual may qualify for support through the skilled respite waiver service.

• When counting ‘days’ of unskilled respite in Structured Family Caregiving, is one (1) day considered to be 8 hours? Or 24 hours?  
• The state requires the SFC service to have at least 15 days of unskilled respite. The way in which unskilled respite time is calculated (as only used as a full day or accessed hourly, for example) depends on the SFC provider.  Individuals are encouraged to ask prospective SFC providers how they support the unskilled respite requirement in this service.