Residential Services in Family Care

1. Residential Services in Family Care WAHSA LTC Managed Care Committee April 22, 2010

2. Three Buckets to Residential Services • Room and Board • Member Contribution • Care and Services

3. Room and Board • History of R&B in LTC Waivers • Work to Standardize R&B in Waivers • R&B Issues in FC • MCO/ DHS R&B Workgroup • Future of R&B in FC

4. What is Room and Board • CMS Definition for all Waivers Items related to room and board – NOT ALLOWABLE waiver costs 1.       Rent, mortgage payments, title insurance, mortgage insurance. 2.       Property and casualty insurance 3.       Building and/or grounds maintenance costs 4.       Resident's food 5.       Household supplies and equipment necessary for the room and board of the individual 6.       Furnishings used by the individual (does not include office furnishings) 7.       Utilities, resident phones, cable TV, etc. 8.       Property taxes 9.       Specific individual special dietary needs

5. How R&B worked in Legacy Waivers • Established via computation of facility rate worksheet • Based on audit allowable cost policy guideline • Cost – individual ability to pay= county levy, state COP, unfunded, etc • Wait lists, caps on proportion of COP W used in substitute care

6. What Happened with R&B at Expansion? • Many MCOs “inherited” county strategies without county levy, state COP, other public funding sources • Variation was magnified by one MCO in multiple counties & by multiple MCOs in one county

7. Along Came “In Lieu of” An in lieu of service must be: 1. Health related, and 2. Cost-effective, and 3. Like the covered Medicaid State plan service for which it is substituted.

8. Rules and Responsibilities with In Lieu of • DHS obligation to better clarity and standardization of room and board • Definition of R&B • Rates paid for R&B • Process of subsidization of R&B • Cap on Room and Board

9. MCO R&B Workgroup • Reviewed existing MCO R&B rate setting methods • Revitalized earlier DHS work with Counties and Providers on standardizing R&B • Explored existing methods and reached ‘consensus’ on HUD FMR R&B Rate Setting Method

10. HUD FMR R&B Rate Method • Features • Correlates typical facility size to R&B rates • Recognizes county variation • Standardized the rate across all MCOs • Things to note in HUD FMR • Typically aligns facility size and R&B costs • Additional specific exceptions in Draft Memo • Being finalized during 2010 for full implementation January 2011

11. Scope of Services /Defining R&B • Physical Space- sleeping accommodations in compliance with facility regulations including, access to all areas of facility and grounds. • Furnishing - all common area furnishings and bedroom furnishings including all of the following: bed, mattress with pad, pillows, bedspreads, blankets, sheets, pillowcases, towels and washcloths, window coverings, floor coverings. • Equipment- all equipment that becomes a permanent part of the facility, such as grab bars, ramps and other accessibility modifications, door alarms, pull-stations and/or call lights. • Housekeeping services- including laundry services, household cleaning supplies, and bathroom toilet paper and paper towels.

12. Scope of Services/ Defining R&B • Building Maintenance - including interior and exterior structure integrity and upkeep, pest control, and garbage and refuse disposal • Grounds Maintenance – including lawn, shrub, and plant maintenance, snow and ice removal. • Building Protective Equipment- carpet pads, wall protectors, baseboard protectors, etc. • Building Support Systems- including heating, cooling, air purifier, water and electrical systems installation, maintenance and utilization costs. • Fire and Safety Systems- including installation, inspection and maintenance costs. • Food- 3 meals plus snacks, including any special dietary accommodations, supplements, thickeners and consideration for individual preferences, cultural or religious customs of the individual resident. • Telephone and Media Access- access to make and receive calls and acquisition of information and news (e.g. television, newspaper, internet)

13. Member Contribution April 2010 • Standardizing Instructions for how member income is identified as available to contribute to R&B. • Areas of Attention • Earned Income • Medical and Remedial Expenses & Specialized Medical Supplies and Equipment • OTC, Supportive Home Care Services, & the Kitchen Sink • Corporate Guardian Fees- On Hold

14. Residential Care and Services • Overview • History of Residential Rates/ Service Purchasing in Waivers • Experiences in Family Care and Expansion with residential services • Work thus far and Next Steps

15. Legacy Waivers • Multiple funding streams • varying rules • criteria • amounts of money tied to each • Individually operated by 72 counties

16. Family Care Expansion and Residential Service Rates • MCOs inherited rates in many counties • Created challenges • Blended benefit package – personal care, etc • Program rules- bed size, county match, etc • Different Contracting Requirements for MCOs from the various legacy waivers • Identified need to align to Family Care Program

17. Activities across MCO with Residential Service Purchasing • Residential Care and Services Cost • 2009 Residential Rate Workgroup • Sharing& Brainstorming • Products • Scope of services definition • Contracting principles

18. Current MCO Residential Service Purchasing Strategies • 4- 5 using acuity based method • 2-3 using rate bands • 1-2 using cost based, audit allowable rates • 2-3 using a combination of more than one within method and across facility types

19. Current Status of Residential Services in MCOs • Standardized Instructions for Member Contribution to R&B: April 1, 2010 • Implementing standard R&B Rate Setting Method: January 2011 • Details being worked through now • DHS Residential Rate Setting Method Workplan: January 2011 • Listening Sessions April 16 & 23

20. Goals of Standard Methodology • Promote access to and quality of services for members, • Treat consistently providers offering similar services, • Establish predictability for purchasers and providers of residential services, • Maintain transparency and good stewardship of resources; and • Ensure consistency with CMS guidelines.

21. Emerging Issues • Revising FC Service Definitions • Including more standardization • Quality Management Systems in FC • MCO Reporting Requirements • Critical Incidents – Definitions • Draft white paper on AL & MCO Interface with denials of physician orders • Involuntary Discharge

22. Questions?