In-home Services New Exception Request Rules and Process 411 … Exceptions... · within 14 days...

In-home ServicesNew Exception Request Rules

and Process411-030-0071

Aging and People with Disabilities

April 2018

Scott Spencer; Exceptions Coordinator

1

Agenda

• Background

• Summary of changes

• Rules and process changes

– In-home hours

– Homecare Worker (HCW) Cap

– HCW Cap Exception Process

– New 514

• This webinar will also briefly discuss the changes related to Shift

Services and removal of the 14 day rule for consumers to employ a

HCW/In-Home Care Agency

2

What’s up with all the changes??

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• ADL/IADLs

• Live-in

• Service Period

• Etc..

October Changes

wait wait, go back!

October Restorations

• Work with advocacy groups

• New Exceptions Process

• Shift Care Clarification

New Rules

Legal Sufficiency

Issues Raised

Summary of Changes

• Exception criteria and process is now in rule

• Consumers will receive more information about

exceptions

• Consumers can ask for exceptions and “run the process”

• Consumers will need to sign the revised 514

• Consumers will get notices of the decision about their

exception request

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Exception Process

5

Consumer given information

about exceptions

Consumer requests exception

CM assists consumer in

gathering info

LO makes decision to

approve or deny

If CO approval is needed, LO sends to CO

CO makes decision

Consumer sent notice

Rules and process changes

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Effective April 23, 2018

Rules and process changes

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The Specifics

Consumers* initiate the

request

Consumers* provide the information

Consumers* manage their

plan

Rule #1: The Consumer is #1

• Exceptions will be consumer drivenWith a little help from their great Case Managers

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*Consumer or their representative

Exception Rules - Eligibility

• We will still determine a need for

hours above what is allowed

• AAAs and APD (that’s you and me)

can still deny requests if they are

not needed

9

Eligibility for an exception

has not changed

Exception Rules - Consumer Responsibility

• The consumer can do this by talking

to you or providing a written

document

• Consumer must sign the new 514

• IHCA or HCWs providers may not

submit requests

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A consumer,

or their

representative,

may make an

exception request

Exception Rules - Consumer Responsibility

• CMs must help:

– Complete the 514

– Get the consumer’s signature

– Gather any necessary documentation

• Time logs

• Exception calculator

• Medical records

• etc..

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CM may still

suggest or

request an

exception

Application Process

• We have a new 514 that the consumer will need to fill out with CM

help

• CM should still talk about, but not mandate, other ways to meet the

extra care needs e.g.,

– Assistive technology;

– Environmental modifications

– Adult Day Services

• They need to submit their requests within 3 months of their CA/PS

assessment

– This can be waived for if waiting till a new assessment would

negatively impact the consumer’s health, safety or welfare

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Pretty much the same process to apply

Pretty much the same stuff

Required Documentation

• We can still ask for additional information if needed

– The consumer or the CM must provide the requested information

within 14 days

• Exceptions are only provided for ADL and IADLs and matching

assistance types

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• We’ll still need the form to be filled

completely, honestly and accurately

Pretty much the same rules

Decision Making Authority

• Tier II and Tier III rights remain the

same

• The local office manager must

review the entire exception

application before approving, denying

or sending to CO for approval

• Tier II may approve different hours

than requested

• Tier II can deny requests that only

Tier III (CO) can approve

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Central Office

Decision Making Authority

• Requests that require CO approval need to be submitted within 3

business days of the date of the application

• CO will make a decision within 30 days

– Unless in emergency circumstances where a decision will be

made within 2 business days

• Please make it clear that it is imperative that an exception

must be approved due to an emergent need

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Central Office

Decision Making Authority

• CO will only approve of hours that are supported by the available

documentation

– CO may approve different hours than requested

• If we, LO or CO, deny any portion of the request, the consumer may

request a hearing on the exception hours

16

Application Reviews and Decision Making

• Exception approvals are effective no

earlier than the date the Exception

Application is requested by the

consumer and received by the CM

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Some changes to the effective date

Exception Decision Notice

There will be a NEW notice form that will include:

• The name of the applicant

• Date the request was approved or denied

• For each ADL and IADL, the number of hours requested, compared

to maximum hours in OAR and total approved hours

• A reference to the 514 Exception Application

• A summary of the reasons why the exceptional hours

requested were approved or denied

• If approved, the duration of the exception

• If denied, information on hearing rights and how to request a hearing

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A little different here

Duration and Reassessments

• Reassessments

– If a consumer has an existing exception, the exception will be

reviewed prior to the exception end date

Requests must be submitted on time to reduce

interruptions to consumer service plans

– Exceptions may be reviewed at reassessments, change of

situations or change of conditions

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Same as before• Duration

– An exception is valid for the period defined in the

notice not to exceed one year

Homecare Worker Cap Exceptions

• Only changes are:

– The process and criteria are now in rule

– Consumer’s can apply using the

new 514 form

– Consumer will receive written decision

– Consumer can appeal

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No big changes here

• All exceptions to the hourly cap must have prior

approval by CO

• Remember Cap exceptions are only to meet the

needs of the consumer not the HCW

New 514 Form – Page 1

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This page is for

the consumer

or CM to

complete

New 514 Form – Page 2

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This page is for

the consumer

or CM to

complete too

New 514 Form – Page 3

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This page is for

the consumer

or CM to

complete too

New 514 Form – Page 4

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Form is being translated

into top 6 consumer

languages

Most of this

page is for LO

A Few Things To Remember

• Exception hours must be based on need

• Exception hours may be provided in any ADL including cognition

• Individuals who qualify for shift services may be eligible for

exception hours too

• We may deny high exception requests if the way services are being

delivered may harm the consumer

• Timeframes are in rule now and must be followed

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Questions?

Shift Services Highlights

• Shift services is a covered service option

in the In-Home Rules

• Oregon ACCESS has been updated to

ensure this option is assessed

• If approved, the hours are 16 hours per

day or 224 per pay period (the amount

stated in APD-PT-18-012 needs

correction)

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Shift Services Highlights

• The criteria for the Shift Service option is the

same as the former Live-in Service option

(however the weekly HCW cap still applies)

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Shift Services Highlights

• An individual that appears to meet eligibility

requirements for shift services may have the

request made through the SPD Exceptions box.

However, if the needs of the consumer can be

met in a more cost effective manner than shift

services, then that determination may be made.

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Employing a HCW/Agency Provider Within 14

Business Days

• Rule 411-030-0040(6) will be updated to

remove the requirement that a HCW or In-

Home Care Agency must be employed

within 14 business days after the previous

provider stops working for the consumer.

• Consumers are allowed to receive

services such as HDM, ADS, or even

waivered case management as their only

service.

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Employing a HCW/Agency Provider Within14

Business Days

• Consumers that are not currently

employing a HCW/In-Home Care Agency

may have a “placeholder” in place instead

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Additional information and direction will be provided in

a future Policy Transmittal