Consolidated personal care services webinar training for licensed home providers
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Consolidated Personal Care Services Webinar Training for Licensed Home Providers. Program Eligibility, Independent Assessments, and Recipient Notifications Talbatha Myatt, Division of Medical Assistance Robyn Reasor, The Carolinas Center for Medical Excellence July 26, 2012.

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Consolidated Personal Care Services Webinar Training for Licensed Home Providers

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Consolidated personal care services webinar training for licensed home providers

Consolidated Personal Care Services Webinar Training for Licensed Home Providers

Program Eligibility, Independent Assessments, and Recipient Notifications

Talbatha Myatt, Division of Medical Assistance

Robyn Reasor, The Carolinas Center for Medical Excellence

July 26, 2012


Presentation overview

Presentation Overview

  • Review: Recipient eligibility criteria, independent assessment (IA) requirements, and IA scheduling

  • Walk-through: IA tool and process

  • Preview: IA notification process


Consolidated pcs

Consolidated PCS

  • January 1, 2013 program implementation

  • Comparable benefit for beneficiaries in private residences and licensed homes

    • Recipient eligibility criteria

    • Service definition

    • Reimbursement rate and methodology


Proposed clinical coverage policy 3l

Proposed Clinical Coverage Policy 3L


Eligible beneficiaries

Eligible Beneficiaries

Eating

  • Have a medical condition, disability, or cognitive impairment, and

  • Demonstrate unmet need for hands-on assistance with qualifying activities of daily living (ADLs).


Covered services for adults

Covered Services for Adults


Additional services for children

Additional Services for Children


Eligibility determinations for current licensed home residents

Eligibility Determinations for Current Licensed Home Residents

  • Medical attestation

  • Independent assessment (IA) conducted in recipient’s home by Carolinas Center for Medical Excellence (CCME) RN Assessor


Transition planning resources

Transition Planning Resources


Medical attestation form

Medical Attestation Form


Independent assessments

Independent Assessments


Preliminary projected timeline

Preliminary Projected Timeline


Preliminary projected timeline1

Preliminary Projected Timeline

  • Licensed care facilities with paid Medicaid PCS claims for Jan-May 2012 dates of service

  • Additional facilities use New Admission assessment request

  • New Admission request process to be announced and implemented this fall


Assessment scheduling

Assessment Scheduling

  • CCME contacts facility in advance by phone to confirm dates and verify Medicaid resident list

  • Provider reports discharges and new admissions

  • CCME makes return visits this fall to assess new admissions since initial visit


Consolidated personal care services webinar training for licensed home providers

The Independent Assessment


Cognitive mental capacities to participate in assessment

Cognitive/Mental Capacities to Participate in Assessment

  • Fully able– Resident is alert and oriented to person, place and time; can verbalize general information about conditions and medications appropriately.

  • Requires limited assistance– Resident alert and oriented greater than 50% of time with periods of confusion, but can be redirected easily; questions may need to be repeated, but resident verbalizes appropriate answers to basic questions.

  • Requires extensive assistance— Resident alert and oriented less than 50% of time; may need basic questions repeated several times; generally not able to answer complex questions appropriately.

  • Requires full assistance – Cognitive impairment prevents resident from participating in assessment.


Resident s ability to self manage medications

Resident’s Ability to Self-Manage Medications

  • Totally able; no assistance required

  • Can do with set-up assistance only

  • Can do with verbal cueing and supervision only

  • Can do with set-up assistance and verbal cueing/supervision only

  • Can do with limited hands-on assistance with taking medications

  • Can do with extensive hands-on assistance with taking medications

  • Cannot do at all; full staff assistance required


Assessor s overall self performance capacity rating

Assessor’s Overall Self-Performance Capacity Rating

  • Totally able— Recipient able to self-perform 100% of activity, with or without aids or assistive devices and without supervision or set-up assistance

  • Needs verbal cueing or supervision only— Recipient able to self-perform 100% of activity, with or without aids or assistive devices, and requires supervision, monitoring, or set-up assistance.

  • Can do with limited hands-on assistance — Recipient able to self-perform more than 50% of activity, and requires hands-on assistance to complete remainder.

  • Can do with extensive hands-on assistance— Recipient able to self-perform less than 50% of activity, and requires hands-on assistance to complete remainder.

  • Cannot do at all— Recipient unable to perform any of the activity; activity must be completely performed for recipient.


Consolidated personal care services webinar training for licensed home providers

INDEPENDENT ASSESSMENT

Data Transmission

Quality Review

Assessment Processing

Eligibility Determination

Service Level Determination

RECIPIENT NOTIFICATION


Recipient notification

Recipient Notification

  • Recipient notified of assessment results and authorized service level in formal Decision Notice

  • Approval notices sent by U.S. mail

  • Adverse decision notices sent by trackable mail

  • Current provider receives notice copy

  • Notification timelines will be announced when finalized


Recipient appeals and mos

Recipient Appeals and MOS

  • Adverse decision = service reduction or denial

  • Recipient may appeal adverse decision

  • Decision Notice includes appeal rights, appeal request form, and instructions

  • Providers may assist beneficiaries who wish to appeal

  • beneficiaries who appeal timely, within 30 days of decision, are entitled to Maintenance of Services (MOS) until appeal is resolved


Upcoming provider trainings

Upcoming Provider Trainings


For more information

For More Information

Consolidated Personal Care Services (PCS): http://www.ncdhhs.gov/dma/pcs/pas.html

CCME Independent Assessment Help Line:

1-800-228-3365

CCME IA e-mail: [email protected]

(Do not include PHI.)


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