An Introduction to Consumer Rights in the Family Care & IRIS Programs

1. An Introduction to Consumer Rights in the Family Care & IRIS Programs Fourth Annual Statewide Self-Determination Conference November 9, 2011 Jennifer Borgh & Teresa Thomas Disability Rights Wisconsin Disability Rights Wisconsin

2. Plan for Today • Introduction to Family Care & IRIS Programs • Eligibility • Benefit Packages • Structure • Member-Centered Plan Development • Grievances & Appeals • Q&A Disability Rights Wisconsin 2

3. Introduction to theFamily Care & IRIS Programs Disability Rights Wisconsin 3

4. Four Options Statewide • Family Care • Most counties except Northeast and Dane (see implementation map) • IRIS (“Include, Respect, I Self-Direct”) • All counties with Family Care • There are two additional options but these are not available in northern counties: • Family Care Partnership • Only some Northwest, Dane and Milwaukee counties • PACE (Community Care for the Elderly/CCE) • Only Waukesha and Milwaukee counties Disability Rights Wisconsin 4

5. Disability Rights Wisconsin Disability Rights Wisconsin

6. Disability Rights Wisconsin

7. Cap on Enrollment (July 1, 2011) • Contact your ADRC to learn whether there is a waiting list for services in your county • Consumers with needs that are urgent or put their health or safety at risk may be able to bypass the waiting list • Consumers who would like to relocate into the community from a nursing home may still enroll immediately by contacting their ADRC Disability Rights Wisconsin

8. Goals of Family Care & IRIS • Member-driven • Flexible • Cost-effective • Comprehensive services • Provide “self-directed supports” • Empower individuals • End waiting lists Disability Rights Wisconsin 8

9. Eligibility Disability Rights Wisconsin

10. Aging and Disability Resource Centers’ Main Roles in Adult Long Term Care • Information and Assistance • Eligibility for Programs • Income, Assets, & Cost-Share • Functional Eligibility • Options & Enrollment Counseling • Explain the programs • Explain the options within each program • Explain options beyond LTC programs Disability Rights Wisconsin

11. Functional Eligibility:The Adult LTC Functional Screen • Adult Long-Term Care Functional Screen determines functional eligibility • Different from the children’s LTCFS • Inventory of activities people need to do every day • Gathers information about whether help is needed and if so, how much • Looks at individual’s ability to do: “ADLs” and “IADLs” Disability Rights Wisconsin 11

12. Target Groups • There are three target groups: • Frail Elders • Adults with Developmental Disabilities • Adults with Physical Disabilities • This is only the first step in determining whether a person is functionally eligible for the programs Disability Rights Wisconsin 12

13. Activities of Daily Living (ADLs) • Bathing • Dressing • Eating • Mobility in the home • Toileting • Transferring Disability Rights Wisconsin 13

14. Instrumental Activities of Daily Living (IADLs) • Meal Preparation • Money management • Medication Management and Administration • Laundry and other chores • Ability to use the telephone • Arrange and use transportation • Overnight care or oversight supervision and/or employment Disability Rights Wisconsin 14

15. Other Components of LTCFS • Living Situation • Supports (natural/formal) • Behavior • Risk Factors • Not all questions affect eligibility Disability Rights Wisconsin

16. Levels of Care • Family Care • Two Levels of Care • Nursing Home Level of Care • Members may access full benefit package • Non-Nursing Home Level of Care • Members receive case management to assist with coordinating Medicaid Card services • IRIS • Requires a Nursing Home Level of Care Disability Rights Wisconsin

17. Financial Eligibility • Same rules as Medical Assistance • Low income and low assets • Cost-share, if any, calculated by income maintenance agency Disability Rights Wisconsin

18. Benefit Packages Disability Rights Wisconsin

19. FAMILY CARE = COP / CIP Home & Community Based Services + Medicaid CardLong Term Care Services Disability Rights Wisconsin Disability Rights Wisconsin

20. IRIS =COP/CIP Home & Community Based Services and Customized Goods and Services**Medicaid Card Services are separate; however, those who are eligible for personal care may use IRIS Self-Directed Personal Care (SDPC) or obtain this service from a Medicaid Personal Care (MAPC) Agency Disability Rights Wisconsin Disability Rights Wisconsin

21. Structure Disability Rights Wisconsin

22. Managed Care: Funding of MCOs • Receive flat rate from State • Not treated as a limit on the cost of any individual member’s service plan • MCO manages the funds to pay for services needed to support all members’ outcomes Disability Rights Wisconsin

23. Managed Care Organizations (MCOs) • Required to work with members to: • Identify member’s “outcomes” (goals) • Help determine appropriate supports and services & coordinate and oversee service plan • Provide opportunities for self-directing supports and services Disability Rights Wisconsin 23

24. Managed Care Organizations (MCOs) • Interdisciplinary Team • Case Manager • Nurse • Member + anyone else the member chooses to be part of the team • Provider Network • Available online • Opportunity to request out of network providers • Network does not limit member’s choice of physician/dentist/eye doctor because this is not part of the Family Care benefit Disability Rights Wisconsin

25. Managed Care Organizations (MCOs) • Most counties have one MCO: • Northern Bridges • Community Health Partnership • Community Care of Central Wisconsin • Western Wisconsin Cares • Care Wisconsin • Community Care, Inc. • Southwest Family Care Alliance • Lakeland Care District • Milwaukee County Department of Family Care Disability Rights Wisconsin 25

26. IRISInclude, Respect, I Self-Direct • Self-Directed Services Waiver • Provides consumers with an alternative to managed care • Participant plans meet long term care related needs within an individual budget amount • Budget based on LTCFS, and allows for increase when needed or exceptional expenditures • Participant along with family/friends and IRIS Consultant creates service plan • IRIS – Self Directed Personal Care is an add on to the IRIS budget and can be spent only on personal care. Disability Rights Wisconsin

27. IRISInclude, Respect, I Self-Direct • Participant supported by: • IRIS Consultant Agency • IRIS Consultant can assist with developing and submitting service plan that is approved by Consultant Agency • Financial Service Agency • Pays claims according to approved service plan • Serves as employer agent for participants who hire their workers directly (currently approximately 6,500 workers) • May use IRIS budget to purchase support broker if additional assistance coordinating supports and services is needed Disability Rights Wisconsin

28. Member-Centered Plan Development Disability Rights Wisconsin 28

29. The development of a Member-Centered Plan begins with the member’s outcomes. Disability Rights Wisconsin

30. 12 Outcome Areas 1. I decide where and with whom I live 2. I make my own decisions regarding my supports and services 3. I work or do other activities that are important to me 4. I have relationships with family and friends I care about 5. I do things that are important to me Disability Rights Wisconsin 30

31. 12 Outcome Areas 6. I am involved in my community 7. My life is stable 8. I am respected and treated fairly 9. I have privacy 10. I have the best possible health 11. I feel safe 12. I am free from abuse and neglect Disability Rights Wisconsin 31

32. Outcomes are Individual • Each member’s outcomes are unique • Each member’s services will depend on each member’s outcomes • Different outcomes → Different services Disability Rights Wisconsin 32

33. The MCO’s first step in working with a member to develop his/her MCP is the comprehensive assessment. This is also the start of an on-going discussion about the member’s outcomes. Disability Rights Wisconsin

34. MCO’s Comprehensive Assessment • Looks at member’s: • Needs – Builds on the LTCFS • Strengths • Resources • Preferences • Conducted in-person • May include others • Includes a discussion about the options for self-direction Disability Rights Wisconsin 34

35. The Member-Centered Plan Outcomes + Comprehensive Assessment + “Resource Allocation Decision” (RAD) Method Disability Rights Wisconsin 35

36. Individual Service Decisions:The RAD Method • Service authorization policy developed by DHS and adopted by MCOs • Helps to identify cost-effective way to meet outcomes • Creatively looks at options, including natural/informal supports DOES NOT EQUAL “cheapest” Disability Rights Wisconsin 36

37. Individual Service Decisions:The RAD Method • Completed by the Interdisciplinary Team: • Member + anyone member chooses to participate in the discussion • Case Manager • Nurse • Begins with the goal or problem and asks a series of questions to help identify the most appropriate option • Available on DHS’ website Disability Rights Wisconsin 37

38. The RAD Method Six Questions: What is the need, goal, or problem? Does it relate to member’s assessment, service plan, and desired outcome? How could the need be met? Disability Rights Wisconsin 38

39. The RAD Method 4. Are there policy guidelines to guide the choice of option? 5. Which option does the member (and/or family) prefer? 6. Which option is most effectiveandcost-effective in meeting desired outcome(s)? Disability Rights Wisconsin

40. Individual Service Plan • The Individual Service Plan is part of the Member-Centered Plan • Result of IDT’s work with member, including discussion about outcomes, comprehensive assessment, and use of the RAD method for determining specific services and supports • Lists approved services and supports • Amount • Frequency • Duration • Provider • Both paid or unpaid/natural supports • Includes services or supports not provided/arranged by MCO • Members should be given a copy of their MCP, including the ISP, by their Family Care team. Disability Rights Wisconsin 40

41. Member Rights: Grievances & Appeals Disability Rights Wisconsin

42. Family Care Grievances & Appeals Disability Rights Wisconsin

43. Grievances & Appeals • Right to receive written notice of MCO decisions (called a “Notice of Action”) • Terminations or reductions of services • Must receive Notice of Action at least 10 days before the effective date of the action • Denials of requests for services • MCO must authorize service or provide NOA within 14 days of the request • MCO may ask for additional 14 days to consider request Disability Rights Wisconsin 43

44. Grievances & Appeals • Notice of Action Requirements – 1 of 2 • Effective date • Description • Reasons • Any applicable laws • Right to appeal • How to file an appeal Disability Rights Wisconsin 44

45. Grievances & Appeals • Notice of Action Requirements – 2 of 2 • Right to appear in person at MCO appeal • Assistance with filing an appeal • Free copies of records relevant to appeal • Right to continuing benefits if MCO intends to terminate or reduce services Disability Rights Wisconsin 45

46. Grievances & Appeals • Right to continuing benefits • Must specifically request continuing benefits when you submit your appeal • Must request before effective date of the intended action • MCO mustgrant all timely requests • Member may be liable for cost of continuing benefits Disability Rights Wisconsin 46

47. Grievances & Appeals • Appealing MCO Decisions • If a member disagrees with a MCO’s decision, he or she has the right to appeal the decision • Examples: • Terminations, reductions, or denial of services • Failure to provide timely services • Unacceptable Member Centered Plan Disability Rights Wisconsin 47

48. Grievances & Appeals • Members may also appeal decisions made by County Economic Support agencies or ADRCs • If a member disagrees with an ES agency’s or ADRC’s decision, member has the right to appeal by requesting a State Fair Hearing. • Examples: • Functional and financial eligibility • Cost share amounts • Members’ only option for appealing these decisions is to request a fair hearing • This presentation, however, will focus on the options available to appeal MCO decisions

49. Grievances & Appeals • Appeal/Review Options • MCO Grievance & Appeals Committee • Request review by MetaStar • State Fair Hearing • Do not have to meet with Committee or request review by MetaStar to request a State Fair Hearing • But, if member wants to meet with Committee, he/she must do so before State Fair Hearing • Review by MetaStar will happen automatically if member requests a State Fair Hearing Disability Rights Wisconsin 49

50. Grievances & Appeals • MCO Grievance & Appeals Committee • Committee made up of individuals selected by MCO and include: • no MCO employee involved in earlier decision • at least one person who is eligible for a Family Care target group or that person’s guardian • Individuals with appropriate medical or clinical expertise for this member’s issue • Member may bring advocate, friend/family member, witnesses, and evidence Disability Rights Wisconsin 50