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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. Plan for Today. Introduction to Family Care & IRIS Programs Eligibility

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an introduction to consumer rights in the family care iris programs

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

plan for today
Plan for Today
  • Introduction to Family Care & IRIS Programs
    • Eligibility
    • Benefit Packages
    • Structure
  • Member-Centered Plan Development
  • Grievances & Appeals
  • Q&A

Disability Rights Wisconsin

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four options statewide
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

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Disability Rights Wisconsin

Disability Rights Wisconsin

cap on enrollment july 1 2011
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

goals of family care iris
Goals of Family Care & IRIS
  • Member-driven
  • Flexible
  • Cost-effective
  • Comprehensive services
  • Provide “self-directed supports”
  • Empower individuals
  • End waiting lists

Disability Rights Wisconsin

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Eligibility

Disability Rights Wisconsin

aging and disability resource centers main roles in adult long term care
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

functional eligibility the adult ltc functional screen
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

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target groups
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

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activities of daily living adls
Activities of Daily Living (ADLs)
  • Bathing
  • Dressing
  • Eating
  • Mobility in the home
  • Toileting
  • Transferring

Disability Rights Wisconsin

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instrumental activities of daily living iadls
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

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other components of ltcfs
Other Components of LTCFS
  • Living Situation
  • Supports (natural/formal)
  • Behavior
  • Risk Factors
  • Not all questions affect eligibility

Disability Rights Wisconsin

levels of care
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

financial eligibility
Financial Eligibility
  • Same rules as Medical Assistance
      • Low income and low assets
  • Cost-share, if any, calculated by income maintenance agency

Disability Rights Wisconsin

benefit packages
Benefit Packages

Disability Rights Wisconsin

family care cop cip home community based services medicaid card long term care services

FAMILY CARE = COP / CIP Home & Community Based Services + Medicaid CardLong Term Care Services

Disability Rights Wisconsin

Disability Rights Wisconsin

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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

structure
Structure

Disability Rights Wisconsin

managed care funding of mcos
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

managed care organizations mcos
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

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managed care organizations mcos1
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

managed care organizations mcos2
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

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iris include respect i self direct
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

iris include respect i self direct1
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

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Member-Centered Plan Development

Disability Rights Wisconsin

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the development of a member centered plan begins with the member s outcomes

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

Disability Rights Wisconsin

12 outcome areas
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

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12 outcome areas1
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

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outcomes are individual
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

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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

mco s comprehensive assessment
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

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the member centered plan
The Member-Centered Plan

Outcomes +

Comprehensive Assessment +

“Resource Allocation Decision” (RAD) Method

Disability Rights Wisconsin

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individual service decisions the rad method
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

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individual service decisions the rad method1
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

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the rad method
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

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the rad method1
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

individual service plan
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

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Member Rights: Grievances & Appeals

Disability Rights Wisconsin

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Family Care

Grievances & Appeals

Disability Rights Wisconsin

grievances appeals
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

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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

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slide45
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

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slide46
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

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grievances appeals1
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

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grievances appeals2
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
grievances appeals3
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

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slide50
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

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grievances appeals4
Grievances & Appeals
  • MCO Member Rights Specialist can assist with obtaining records and filing appeals
      • Will not represent consumer
      • Will not gather evidence to support his/her case

Disability Rights Wisconsin

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grievances appeals5
Grievances & Appeals
  • Right to request Department of Health Services review
    • MetaStar is DHS’s external quality review organization
    • Attempts to resolve concerns informally
    • Cannot require MCO to change decision
      • But, MetaStar can make recommendation to DHS, and DHS can instruct MCO to change its decision
    • Automatically reviews requests for State Fair Hearings

Disability Rights Wisconsin

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grievances appeals6
Grievances & Appeals
  • State Fair Hearing
    • May file an appeal with the State (the “Division of Hearings and Appeals”)
    • Held in front of an Administrative Law Judge (ALJ)
    • May bring advocate, friend/family member, witnesses, and evidence

Disability Rights Wisconsin

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grievances appeals7
Grievances & Appeals
  • Deadline to file appeals
    • File as soon as possible
    • File no later than 45 calendar days from receipt of the Notice of Action
    • To request continuing benefits, must file appeal before effective date of intended action

Disability Rights Wisconsin

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IRIS:

Reviews, Grievances & Appeals

Disability Rights Wisconsin

iris reviews plan review and approval
IRIS Reviews:Plan Review and Approval
  • Consultant Agency reviews and approves plans
  • Do the chosen goods, services and supports:
    • Correlate to the participant’s long term care related outcomes?
    • Match service standards and provider qualification requirements?
    • Fall within the IRIS policy guidelines?
    • Represent the most cost effective approach to reach outcomes?
    • Cost more than the current budget amount?

Disability Rights Wisconsin

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IRIS Reviews:

IRIS Budget Increase Requests

Disability Rights Wisconsin

  • If the budget is insufficient, there are two types of requests:
    • Exceptional Expense (time limited request)
      • Examples: ramp, widen doorways, adaptive equipment, temporary respite
    • Ongoing Expense (ongoing need)
      • Examples: increased daily caregiver hours, ongoing job coaching, start new service
slide58
IRIS Budget Increase Requests

Disability Rights Wisconsin

Verify accuracy of LTCFS & correct any errors

IRIS Consultant first helps participant create plan within budget

Consultant helps participant create the request for additional funds to be added to budget

iris budget increase requests
IRIS Budget Increase Requests
  • Consultant finalizes request, submits to central office Consultant Agency Specialist, who prepares it for DHS review
  • DHS convenes review committee; Committee approves, modifies or denies request—or seeks additional information.
  • If unsatisfied with decision, participant may seek review by Bureau of LTC Director and also a State Fair Hearing

Disability Rights Wisconsin

iris budget increase requests not reviewed
IRIS Budget Increase RequestsNOT REVIEWED
  • Request for items or cares coverable by another source e.g.) Insurance, Medicare, ForwardHealth Card
  • Requests which can be funded with a new budget calculated by a new LTCFS
  • Requests made that are not presented by the IRIS Consultant Agency
  • Requests for goods or services contrary to IRIS coverable services policy

Disability Rights Wisconsin

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IRIS Budget Increase Requests

Consultant Duties

Disability Rights Wisconsin

  • Use DHS prescribed forms
  • Prepare all pertinent info needed by Review Committee
    • Include narrative statements that describe request
    • Gather supporting documents or information
    • Ensure most cost effective approach was chosen
  • May arrange expert opinion to support need to be heard by DHS Committee
  • Participant may prepare own request, but must be reviewed and submitted by Consultant Agency
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IRIS Budget Increase Requests:

Possible Outcomes

Disability Rights Wisconsin

  • Approve request
  • Approve and assign time limit
  • Attach conditions to approval
    • E.g., may require progress plan update with timeline for restoring prior level of independence
  • Modify (approve lesser dollar amount and/or for different duration than requested)
  • Table until more information is received
  • Deny request
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Assistance with Appeals

Disability Rights Wisconsin

boaltc ombudsman program
Board on Aging and Long-Term Care

Family Care and Partnership members/potential members age 60 and older

www.longtermcare.state.wi.us

800-815-0015

BOALTC Ombudsman Program

Disability Rights Wisconsin

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drw s family care iris ombudsman program
DRW’s Family Care & IRIS Ombudsman Program
  • Family Care, Family Care Partnership, and IRIS Enrollees/Potential Enrollees Age 18-59
  • Types of Assistance
    • Information
    • Investigation and informal negotiation with the Disability Resource Center, Managed Care Organizations, and the IRIS Consultant Agency
    • Representation
  • In addition to FCIOP, as Wisconsin’s protection and advocacy agency, DRW may assist Family Care, Partnership, IRIS, and PACE enrollees of any age

Disability Rights Wisconsin

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Q & A

Disability Rights Wisconsin

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