Upload
others
View
2
Download
0
Embed Size (px)
Citation preview
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??
3
• 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
4
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
6
Effective April 23, 2018
Rules and process changes
7
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
8
*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
10
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..
11
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
12
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
13
• 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
14
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
15
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
17
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
18
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
19
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
20
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
21
This page is for
the consumer
or CM to
complete
New 514 Form – Page 2
22
This page is for
the consumer
or CM to
complete too
New 514 Form – Page 3
23
This page is for
the consumer
or CM to
complete too
New 514 Form – Page 4
24
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
25
26
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)
27
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)
28
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.
29
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.
30
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
31
Additional information and direction will be provided in
a future Policy Transmittal