Navigating the HCBS Elderly Waiver Presented by Linda Duffy, LMD Consulting, LLC for the Iowa Assisted Living Association 2013 Annual Conference & Trade Show
Menu of Waiver Services • Available to members/tenants by an AL: • PERS-personal emergency response system • CDAC-consumer directed attendant care • On-Call Service Upper Limits of Reimbursement • PERS-Effective 1/1/13, provider’s rate in effect 6/30/12 plus 2%. If no 6/30/12 rate: Initial one-time fee: $50.52; on-going monthly fee: $39.29 • CDAC-Effective 7/1/13, provider’s rate in effect 6/30/12 plus 2%, converted to a 15-minute rate. If no 6/30/12 rate: $5.15 per 15-minute unit, not to exceed $119.05 per day • On-Call- $25 per day Elderly Waiver: $1,300
Determination of the Member’s Health and Safety Needs • Assessment process • EW Case Manager completes a comprehensive assessment and periodic reassessment that includes: • Taking the member’s history, including current and past information and social history which is updated annually. • Identifying the needs of the member. • Gathering information from other sources, i.e., family/legal rep, medical providers, social workers and other providers (IAC 90.5 (1)). • CDAC Agreement
Role of the IDT Members (IAC 441-83.22(2)) The team shall identify: • The member’s need for services based on the member’s needs and desires. • Available and appropriate services to meet the member’s needs. • Health and safety issues for the member that indicate the need for an emergency plan, based on a risk assessment conducted before the team meeting. • Emergency backup support and a crisis response system to address problems or issues arising when support services are interrupted or delayed or when a member’s needs change.
Importance of the Individual IDT Members • Member should always be the focus of services. • Case manager is responsible for advocacy, referral, authorizing and monitoring services. Face to face contact with the member is to occur quarterly along with monthly contact with the member, legal representative, family, service providers or other entities or individuals. • Provider is responsible for the provision of services and informing the case manager of changes in the member’s needs.
Medicaid Documentation Requirements • IAC 441-79.3 has not changed: • Name of the service provided; complete date of service; complete time of the service; specific location of service provision; name, dosage and route of any medication dispensed or administered as part of the service; any medical supplies dispensed; first/last name and credentials if any of person providing service; outcome of service (member’s progress in response to the services rendered, including any changes in treatment, alteration of the plan of care or revision of the diagnosis). • Use of a census log to document on-call service
Changes to CDAC Scope of Service IAC 441-78.37 (15) a. Service planning. The member, parent, guardian, or attorney in fact under a durable power of attorney for health care shall: (1) Select the individual, agency or assisted living facility that will provide the components of theattendant care services. (2) Determine with the selected provider what components of attendant care services the provider shall perform, subject to confirmation by the service worker or case manager that those components are consistent with the assessment and are authorized covered services. (3) Complete, sign, and date Form 470-3372, HCBS Consumer-Directed Attendant Care Agreement, to indicate the frequency, scope, and duration of services (a description of each service and the time agreed on for that component). The case manager or service worker and provider shall also sign the agreement.
Changes to CDAC Scope of Service IAC 441-78.37 (15) (4) Submit the completed agreement to the service worker or case manager. The agreement shall be part of the member’s service plan and shall be kept in the member’s records, in the provider’s records, and in the service worker’s or case manager’s records. Any service component that is not listed in the agreement shall not be payable. (5)Assisted living agreements with Iowa Medicaid members must specify the services to be considered covered under the assisted living occupancy agreement and those CDAC services to be covered under the elderly waiver. The funding stream for each service must be identified.
Changes to CDAC Scope of Service IAC 441-78.37 (15) • h. Excluded services and costs. Services, activities, costs and time that are not covered as consumer-directed attendant care include the following (not an exclusive list): (1) Any activity related to supervising a member. Only direct services are billable. (2) Any activity that the member is able to perform. (3) Costs of food. (4) Costs for the supervision of skilled services by the nurse or therapist. The supervising nurse or therapist may be paid from private insurance, Medicare, or other third- party payment sources, or may be paid as another Medicaid service, including early and periodic screening, diagnosis and treatment services.
Changes to CDAC Scope of Service IAC 441-78.37 (15) (5) Exercise that does not require skilled services. (6) Parenting or child care for or on behalf of the member. (7) Reminders and cueing. (8) Services provided simultaneously with any other similar service regardless of funding source, including other waiver services and state supplementary assistance in-home health-related care services. (9) Transportation costs. (10) Wait times for any activity.
New IAC Subrule • 441-78.37 (19) General Service Standards. All elderly waiver services must be provided in accordance with the following standards: • a. Reimbursement shall not be available under the waiver for any services that the member can obtain as other nonwaiver Medicaid services or through any other funding source. • b. All services provided under the waiver must be delivered in the least restrictive environment possible and in conformity with the member’s service plan. • c. Services must be billed in whole units.
General Service Standards • d. For all services with a 15-minute unit of service, the following rounding process will apply: • (1) Add together the minutes spent on all billable activities during a calendar day for a daily total. • (2) For each day, divide the total minutes spent on billable activities by 15 to determine the number of full 15 –minute units for that day. • (3) Round the remainder using these guidelines: Round 1 to 7 minutes down to zero units; round 8 to 14 minutes up to one unit. • (4) Add together the number of full units and the number of rounded units to determine the total number of units to bill for that day.
Requirements for a Service Plan (IAC 441-83.22 (2) ‘c’ ) • Developed by the case manager and: • Includes least costly services appropriate to the problems and specific needs or disabilities of the member. • Completed before services are provided and is reviewed at least annually and when there is a significant change in member’s needs. • The content of the plan shall address: • Observable or measurable goals. • Interventions and supports needed to address the goals and incremental action steps if appropriate. • The names of staff, people, businesses or organizations responsible for carrying out the interventions or supports.
Content of the Service Plan • Desired individual outcomes. • Identified activities to encourage the member to make choices, to experience a sense of achievement, and to modify or continue participation in the service plan. • Description of any restrictions on the member’s rights, including the need for the restriction and a plan to restore the rights. For this purpose, rights include maintenance of personal funds and self-administration of medications.
Rights Restrictions (IAC 441-90.1) • “Rights restriction” means limitations not imposed on the general public in the areas of communication, mobility, finances, medical or mental health treatment, intimacy, privacy, type of work, religion, place of residence, and people with whom a person may share a residence. • Even when the member requests the assistance, the AL must treat it as a restriction, e.g., administering medication.