NC Department of Health and Human Services DMA 1915 (c) Waiver Training January 2012 Andrea Misenheimer Medicaid Director – PBH Patti French Waiver Consultant

NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina

DMA

1915 (c) Waiver Training1915 (c) Waiver TrainingJanuary 2012January 2012

Andrea Misenheimer Andrea Misenheimer Medicaid Director – PBHMedicaid Director – PBH

Patti French Patti French

Waiver ConsultantWaiver Consultant


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Welcome to

NC Innovations


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Used to implement a mandatory managed care program that includes HCBS waiver services in the managed care contract.

The 1915(c) waiver allows a state to target eligibility and provide the HCBS services. The 1915 (b) waiver then allows a State to mandate enrollment in managed care plans that provide these HCBS services.

States must apply for each waiver authority separately and comply with the statutory and regulatory requirements of each

1915 (b) (c) concurrent waivers


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A New Tool Kit for the 1915 (c ) waiver Rate setting authority allows PIHP to adjust rates according

to local conditions

Closed Network allows for competition and choice while rightsizing the marketplace; ensures health of providers

Utilization Management gives PIHP the tools to ensure consumers receive both the appropriate service and amount of treatment to meet their needs

Care Coordination is an important activity that directly intervenes to ensure consumers receive the care needed when it is needed in order to prevent use of higher cost services when appropriate treatment is delayed.


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Vision NC Innovations is a tool to guide the I/DD

service system

Goals for the Waiver: Value and Support of individuals as members

of the community The ability to self direct services to the extent

each individual chooses Offer choice in where people live, work and

spend their day Promote promising practices Development of stronger natural support

networks


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Slots and PrioritizationFinite number of Slots for use in Finite number of Slots for use in

the waiver:the waiver: Each year of waiver operation,

(January 1-December 31) the number of slots available is specified in the waiver

Slots are unduplicated Slots are frozen once used and can

not be filled until the following waiver year. ( A person may re-enter in the same waiver year)


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Prioritization PrioritizationPrioritization Individuals are determined potentially eligible through

Access and wait on the Registry of Unmet (waitlist) needs until waiver slots are available, typically in January of every year

Screening for potential eligibility includes a clinical review (Risk Support Needs Assessment and the SIS) and review against the eligibility criteria

Potentially eligible individuals are allocated waiver Potentially eligible individuals are allocated waiver funding as follows:funding as follows:

Non-Reserved CapacityNon-Reserved Capacity First come, first serve Based on date of application for services


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Prioritization Reserved Capacity Emergency Process:Emergency Process:

A clinical team inclusive of 1 psychiatrist and a minimum of one developmental disability specialist determines the allocation of emergency slots as referrals are made

Emergency CriteriaEmergency Criteria Significant imminent risk of serious harm due to primary

caregiver /support system inability to meet the persons basic needs

Protection from confirmed abuse, neglect or exploitation Meets all other waiver eligibility criteria

Emergency slots will be maintained at the state during the transition period.


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Transition from CAP-MR/DD and Cardinal Innovations due to change in Medicaid county

Due to Medicaid county change to the MCO area If there is no available slot, contact DMA for next steps

Transition from CAP-C when children age out and meet the eligibility criteria

Due to aging out of CAP –C at age 21 If there is no available slot, contact DMA for next steps

Deinstitutionalization from an ICF-MR for children 0-17 Children moving from an ICF-MR ( state or community) If there is no available slot, contact DMA for next steps

Money Follows the Person Individuals who meet the MFP criteriaIf there is no available slot, contact DMA for next step

Military Transfers Individuals who transfer from other states into North Carolina

and need continued waiver funding.

Reserved Capacity


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Initial Level of Care ProcessEligibility Criteria = ICF-MR Criteria DMA Clinical Eligibility Criteria = ICF-MR Criteria DMA Clinical

Coverage Policy No: 8Coverage Policy No: 8 Referral disability is Mental Retardation (Intellectual

Disability ) or a condition closely related to Mental Retardation :licensed psychologist or licensed psychological associate completes the assessment. The assessment includes a review of a psychological evaluation inclusive of an adaptive behavior assessment

Referral disability is medical in nature, epilepsy or cerebral palsy:A physician completes the assessment

The Level of Care evaluation is valid for 30 days once signed.


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Annual Reassessment of Level of Care Reassessment of continued eligibility is completed

by the Care Coordinator

Completed annually during or up to 30 days prior to the birth month

The annual assessment includes completion of the NC Innovations Risk Support Needs Assessment.

If the individual’s condition or needs have changed significantly during the past twelve months and continued eligibility is questionable, the individual is referred through the full evaluation to verify continued eligibility.


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Level of Care Form Initial NC Innovations Level of Care Form

Level of Care Form is completed on all individuals screened for NC Innovations waiver funding

If the referral disability is medical in nature the Medical addendum can be used to support the eligibility .

Annual NC Innovations Level of Care Reassessment

LOC Reassessment is documented on the Signature Page of the ISP


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LOC and Transition To ensure a smooth transition, the

waiver eligibility determination by the CAP-MR/DD program will be accepted in the NC Innovations waiver until the next annual re-evaluation of eligibility in the individual’s birth month.


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Freedom of Choice

Freedom of Choice is documented:Freedom of Choice is documented: Initial when new to the waiver Annually as a component of the ISP


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Individual BudgetingIndividual Budgets: The budget is developed during the

planning process to inform the person of the amount of funding available for them to plan within.

Budget Authority: Individuals have the authority to make

decisions about how to spend their waiver dollars.


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Building BudgetsEach budget has two parts: Base Budget Services- the services that are are the core habilitation and

support services in the waiver. Add On (Non Base) Budget Services –

services which are provided to ensure prevention, education or enhanced independence.


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Base Budget services Base Budget Services include:

Community Networking Services Day Supports In-Home Skill Building In-Home Intensive Supports Personal Care Residential Supports Respite Supported Employment


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Add On (Non Base) Services Budget Add On Budget Services include:

Assistive Technology Equipment and Supplies Community Transition Services Crisis Services Individual Goods and Services Home Modifications Natural Supports Education Specialized Consultation Services Vehicle Modifications Community Guide


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Individual Budget In combination the Base and Add On budgets

may not total more than $135,000

If the individual decides to participate in Individual Family Direction, they will additionally have a Self Directed Budget

The current CAP-MR/DD cost summary will be accepted as the individual budget for the person.


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Limitations on Living Arrangement

Own Home/Private Family

or

Residential Facility of: 6 beds or less 3 beds if newly constructed The facility bed requirement of 6 or fewer beds

does not apply to individuals transitioning from CAP-I/DD on the date their LME transitions to NC Innovations.


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Role of Care Coordinator Treatment Planning Case Management Educating participant/family/providers about

services, waiver requirements, options Assessment of support needs (completing,

arranging for, obtaining) Linkage to needed MH/DD/SA resources

(includes ensuring provider choice) Facilitation of Planning / Plan Development Monitoring plan implementation, including

health and safety Medicaid eligibility coordination


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Role of Community Guide Advocacy Support

Linkage to community resources

Assistance obtaining medical care

Supporting Employers of Record in Individual and Family Directed Services option

Care Coordinators do not perform functions of Community Guide


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ISP Development The NC SNAP will be used until the

Supports Intensity Scale is fully implemented.

Assessment is the first and most important step in developing an Individual Support Plan.

The quality of the Person Centered Plan is directly tied to the quality of the Assessments.


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ISP Development Obtaining/reviewing updated

records/assessments relevant to the person’s interests and needs for support

The NCSNAP must be completed annually until such time as the SIS has been completely implemented.

Orientation to Individual and Family Direction


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Risk/Support Needs Assessment Risk/Support Needs Assessment to

determine supports needs and risks that need to be mitigated/addressed

- Demographic Information - Material Supports - Physician Supports - Professional Supports - Medication Supports - Medical Treatment - Health and Wellness


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Planning Meeting

Review of assessment information/draft plan

Development of long range outcomes


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Plan Development Individual Support Plan and Individual Budget

developed by Care Coordinator, including Positive Behavior Support Plan as required or otherwise indicated

Care Coordinator reviews plan with participant/legally responsible person and obtain signatures (including Freedom of Choice for Innovations participants)

Plan (with all accompanying documents) submitted toUtilization Management per PIHP guidelines.


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Individual Support Plan – How It’s Different.

Based on an ELP model Focus on the person’s voice Demographics at the end Summary of the Risks that need to

be mitigated is in the plan Requires a back-up support plan be

documented


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Plan Implementation Providers/Employers of Record develop short-range

goals and accompanying interventions/strategies/ task analyses

Staff Training

Provision of service as outlined in plan

Documentation of the services provided

Monitoring of plan implementation by Care Coordinator


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Plan Implementation ISP is updated/revised as needed

Update to Individual Support Plan (most often includes update to Individual Budget)Demographic Information - UpdateUpdate to Crisis Prevention and Intervention


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Support PlanningSIS™ Identifies/Measures

support needsIdentify desired life

goals/experiences/choices using person centered tools

Person Centered Planning IndividualSupport

Plan (ISP)

Risk/Support Needs Assessment / Other Other Assessments

Natural and FundedResources


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ISP and Transition The CAP-MR/DD person centered plan will

be accepted in the NC Innovations waiver until the next annual individual service plan (ISP) is developed in the individual’s birth month. The participant’s ISP will continue to be reviewed as needed due to changes in care needs and on an annual basis. The NC Innovations waiver includes services that crosswalk to the CAP-MR/DD waiver.


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Waiver Incident Reporting

Failure to provide Back Up Staff will require a Level 1 Incident Report

This applies to all Provider Directed and Employer Directed Services


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Service Options through Innovations

Traditional Provider Directed Option Individual/Family Directed Option

(Self Direction) - Agency with Choice If the person tries an option and is not

satisfied they can change The person has the flexibility to direct

only the services that they choose


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Individual Family Direction


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CMS RequirementsCMS Requirements No other Model of Self-Direction except the model approved No other Model of Self-Direction except the model approved

in the waiverin the waiver Payments may not be made directly to a waiver participant, Payments may not be made directly to a waiver participant,

or managing employer, either to reimburse for expenses or managing employer, either to reimburse for expenses incurred or to pay a service provider directlyincurred or to pay a service provider directly

No cost to the Participant or Managing EmployerNo cost to the Participant or Managing Employer Financial Manager or Agency With Choice manages funds Financial Manager or Agency With Choice manages funds Self-direct one or more servicesSelf-direct one or more services Service planning is led by the participantService planning is led by the participant Independent advocacy is availableIndependent advocacy is available Budget Authority to make decisions about how funding is Budget Authority to make decisions about how funding is

usedused


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Services that can be Individual/Family DirectedServices that can be Individual/Family Directed

In-Home Skill BuildingIn-Home Skill Building Personal CarePersonal Care In-Home Intensive SupportIn-Home Intensive Support Natural Supports EducationNatural Supports Education Community Networking Community Networking RespiteRespite Supported EmploymentSupported Employment Community Guide Community Guide Individual Goods and ServicesIndividual Goods and Services


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Model of Individual/Family Directed SupportsModel of Individual/Family Directed Supports

Agency With Choice (Managing Employer)


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Representative

The representative is someone who can assist The representative is someone who can assist the Managing Employer in performing some or the Managing Employer in performing some or all of their dutiesall of their duties


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Individual

If the individual is not the Managing If the individual is not the Managing Employer, they need to be as involved in Employer, they need to be as involved in the process as possiblethe process as possible


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Managing Employer is…Managing Employer is…

Innovations Waiver Participant if they are 18 and Innovations Waiver Participant if they are 18 and do not have a legal guardiando not have a legal guardian

OrOr Parent of a child under 18 Parent of a child under 18 OrOr The legal guardian of an Innovations participantThe legal guardian of an Innovations participant


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The Direct Support Worker Works for the Agency With Choice.Works for the Agency With Choice.

Works when and where the Managing Employer Works when and where the Managing Employer choose.choose.

Does what Managing Employer wants him or her Does what Managing Employer wants him or her to do.to do.

In the Agency With Choice Model, decisions are In the Agency With Choice Model, decisions are shared with the Agencyshared with the Agency


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Community Guide

Empowers the employer to define and direct Empowers the employer to define and direct servicesservices

Understands employers needs and Understands employers needs and preferencespreferences

May not be the employer, representative or May not be the employer, representative or family may not be paid to provide servicefamily may not be paid to provide service

Service can be mandatedService can be mandated


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Community Guide functions in Individual Family Direction

Links to ResourcesLinks to Resources Role plays to teach skillsRole plays to teach skills Connects to the communityConnects to the community Helps employer develop employee support Helps employer develop employee support

agreements/supervision plansagreements/supervision plans


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Community Guide will not…. Interview, hire, train or fire employeesInterview, hire, train or fire employees Complete employment formsComplete employment forms Find back up employeesFind back up employees Obtain extra money for the employer if Obtain extra money for the employer if

the budget is overspentthe budget is overspent Make decisions for the employerMake decisions for the employer Do the Duties of the Care CoordinatorDo the Duties of the Care Coordinator


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Care Coordinator functions in Individual Family Direction

Completes the assessmentsCompletes the assessments Completes the process for appointment of the representative, if Completes the process for appointment of the representative, if

neededneeded Completes referrals to the Agency With Choice and Community Completes referrals to the Agency With Choice and Community

GuideGuide Completes the Individual and Family Supports AgreementCompletes the Individual and Family Supports Agreement Completes the ISP/Update to ISP Completes the ISP/Update to ISP Sends the ISP to UM for approvalSends the ISP to UM for approval Sends a copy of the approved ISP to team members including Sends a copy of the approved ISP to team members including

Community Guide, Managing Employer, RepresentativeCommunity Guide, Managing Employer, Representative


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Annual Orientation to Individual Family Direction

Booklet Fact Sheets


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Review of Agency with Choice Comparison Chart


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Step 1 Managing Employer

The Care Coordinator will determine who the Managing Employer will be

The Care Coordinator will ask the Managing Employer if they plan to use a representative

Managing Employer and Prospective Representative attend training provided by the Community Guide


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Step 2 Assessments

Individual and Family Supports/Community Guide Assessment

Representative Screening Questionnaire


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Step 3 Consider if a Representative Needs to be appointed

Representative is someone who can assist the Managing Employer in performing some or all of the Employer duties

Follow procedures for appointment of representative if Employer agrees.


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Step 4 Individual Support Plans Determine staff qualifications and supervision

requirements of staff Document back up staffing plan Consider emergency plans that need to be developed Make sure the plan addresses how the participant will

be involved in self directing services Update the monitoring plan Include Community Guide outcomes in the plan Determine effective date


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Special Skills employees need to know…. Agency With Choice will ensure that staff

meet the minimum qualifications to provide the NC Innovations services

Managing Employer needs to add to the

ISP any additional skills they require for the staff related to services


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Back up Staffing Two levels of back up staffing are required for

each service Emergency responses to severe weather and

environmental emergencies Immediate coverage if the participant can not be

left alone Who to call if the plan is not working Ways to manage risk Contact numbers Unique to the participant Immediately accessible and operational


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Care Coordinator Monitoring of Individual/Family Directed Services

Monthly Monitoring Natural Supports can assist in monitoring


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Effective date of Individual/Family Effective date of Individual/Family DirectionDirection

Allow time for plan submission Allow time for Utilization Management review Allow time for Agency With Choice start up Allow time for staff to be hired Allow time for staff training


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Recruiting Managing Employer recruits the staff Can request that an ad be run through the

Agency With Choice Community Guide trains the Managing

Employer as needed on recruiting


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Agreements Individual/Family Directed Supports

Agreement Agency With Choice Agreement Employee Support Agreement/Supervision

Plan


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Agency with Choice Common Law Employer (agency is the employer of

record with IRS) Files claims for services, sets employee pay rates

and determines benefits Withholds taxes and unemployment insurance Carries Worker Compensation Insurance on

Employees Administers benefits Maintains accounts on participants funds Conduct background checks Purchases goods and services Produces records for audit Produces the quarterly financial reports for the

Managing Employers


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What will the Agency with Choice do for the individual?

In the Agency With Choice Model, the AgencyWith Choice: Provides a toll free service line so that the

Managing Employer can call the Agency With choice

Sends quarterly report to the Managing Employer and Care Coordinator describing services billed and Individual Goods and Services purchased

Answers questions about the report


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The Agency with Choice helps the Managing Employer by…. Paying employeesPaying employees Providing Workers Compensation Insurance Providing Workers Compensation Insurance

on employeeson employees Informing Employers of how much funding Informing Employers of how much funding

they have used (Quarterly Report)they have used (Quarterly Report) Filing tax forms for employeesFiling tax forms for employees Following state and federal rules about Following state and federal rules about

waiver fundingwaiver funding


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Managing Employer Responsibilities Participate in training and complete Self Participate in training and complete Self

Assessment with Care CoordinatorAssessment with Care Coordinator Decide skills and training that employees needDecide skills and training that employees need Lead/participate in the development or Update of Lead/participate in the development or Update of

the ISP the ISP Select an Agency With Choice to be the common Select an Agency With Choice to be the common

law employer of the employees law employer of the employees Find out pay rates and benefits offered by the Find out pay rates and benefits offered by the

Agency With ChoiceAgency With Choice Decide job duties and schedules with AgencyDecide job duties and schedules with Agency Refer prospective Employees to the Agency With Refer prospective Employees to the Agency With

ChoiceChoice


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Managing Employer Responsibilities Assist Agency in obtaining new hire paperworkAssist Agency in obtaining new hire paperwork Agency With Choice maintains Workers Agency With Choice maintains Workers

Compensation insurance on EmployeesCompensation insurance on Employees Work with Agency With Choice to make sure Work with Agency With Choice to make sure

employees are trainedemployees are trained Resolve issues or recommend replacement of Resolve issues or recommend replacement of

employeesemployees Review quarterly reports from Agency and Review quarterly reports from Agency and

stay within the Individual/Family Budgetstay within the Individual/Family Budget Make sure services are provided as written in Make sure services are provided as written in

the ISPthe ISP Ensure that the individual is healthy and safeEnsure that the individual is healthy and safe


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Managing Staff: Agency with Choice Model

Agency With Choice/Managing Employer work together to manage staff:

Provide or arrange training Schedule employees Evaluate employees Replace as needed


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Agency With Choice: What is the Agency With Choice: What is the Service Rate?Service Rate?

This is the Medicaid Service rate that the Agency

With Choice uses to pay for : Employee Training and Supplies Employment Advertisement Employee Salary, benefits Employer Taxes Workers Compensation Insurance Qualified Professional Supervision Record Keeping and Retention


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Termination from Individual/Family Direction A Managing Employer may be removed from the Individual and A Managing Employer may be removed from the Individual and

Family Directed Supports involuntarily under the following Family Directed Supports involuntarily under the following circumstances:circumstances:

Immediate health and safety concern, including mistreatment Immediate health and safety concern, including mistreatment of the individual of the individual

Suspected fraud and abuse of funds or evidence of unreported Suspected fraud and abuse of funds or evidence of unreported fraudfraud

No approved Representative available when the Managing No approved Representative available when the Managing Employer is determined to need oneEmployer is determined to need one

Refusal to accept needed Community Guide ServicesRefusal to accept needed Community Guide Services Refusal to allow Care Coordinator to monitor servicesRefusal to allow Care Coordinator to monitor services Non compliance with the Individual Family Supports, Agency Non compliance with the Individual Family Supports, Agency

with Choice, and /or Employee Support Agreementswith Choice, and /or Employee Support Agreements Inability to implement the approved ISP or comply with Inability to implement the approved ISP or comply with

Innovations requirements despite reasonable efforts by the Innovations requirements despite reasonable efforts by the MCO to provide additional technical assistance and support MCO to provide additional technical assistance and support ( 4th event requiring additional technical assistance/corrective ( 4th event requiring additional technical assistance/corrective action plan in twelve months)action plan in twelve months)


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Provider Responsibilityo Treatment Team Participationo Responsible for the development and

implementation of the short range goalso Responsible for the development and

implementation of the strategies/task analysiso Ensure short-range goals and strategies/task

analysis are in place prior to plan implementation


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Relative as Provider PolicyServices may be provided by: Legal guardians, parents of adult participants and other relatives who live

in the home of the individual

Waiver services that may be provided by relatives: Community Networking, Day Supports, Personal Care, In-Home Skill

Building, In-Home Intensive Support, Residential Supports

Conditions where relative may be employed: Other staff are not available to provide the service or Other staff are only willing to provide the service at an extraordinarily

higher cost than the fee or charge negotiated with the qualified family member or legal guardian.

Managing Employer may not direct a service that is subject to the managing employer’s direction

Typically no more than 40 hours per week of service or seven daily units per week, may be approved between all relatives who live in the same home as the individual.


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Submit application to the Network Cross Functional Team

Part A application-New Employees

Part B application-Existing Employees

Part C application-Request to Exceed 40 hours

Part D application if removed and reapply

Applications must be renewed annually

Relative as Direct Support Employee Process


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Review of Service Comparison Chart


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Completed for Direct Service Employees Checklist is valid for the location of service

provision The Provider Agency will make and document at a

minimum a monthly site visit H/S checklist is maintained at the agency and

reviewed during QM onsite monitoring.

Health and Safety Checklist


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School Policy Equipment and Supplies Location of Service Services in the Home of the Employee Out of State Provider Qualifications

Additional Guidance and Waiver Policy


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Services must be documented by all Medicaid providers and done so prior to service implementation

There should be follow-up documentation to reflect any service deviation.

All NC Innovations services require a daily or per service note or grid

Follow the procedures as noted in the Records Management and Documentation Manual 45-2 (Chapters 8 & 9).

Documentation


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Crisis Services Community Guide Individual/directed Goods and Services Natural Supports Education Specialized Consultative Services

Service notes:


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Community Networking Day Supports In-Home Intensive Supports In-Home Skill Building Residential Supports Personal Care Respite Supported Employment

Service Grids


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Completed quarterly

Should be documented within 7 working days of close of the quarterly progress period

Considered a ‘late entry” if not completed within required timeframe

Progress Summary


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o Progress summary requirements:o Individual’s nameo Date of quarterly review and dates the review

coverso Progress towards goalso Recommendations for continuation, revision or

termination of goalo Signature of individual completing review

Progress Summary


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Required for the following services: Community Networking Supported Employment Residential Supports In-Home Skill building Personal Care Day Supports

Progress Summary


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Absences, Terminations, and Transfers

Terminations Transfer to and from CAP-I/DD Transfers to and from other PIHPs Transfers to and from Cardinal

Innovations


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Performance Indicators

Used to demonstrate that waiver assurances and sub-assurances

Reported to CMS PIHP will remediate


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Lessons Learned Do things that are familiar Use your managed care tools to

increase felicity and quality of care Look for opportunities to suggest to

DMA less rules through better system management

Stay focused the Vision of the waiver in every system you implement and decision you make

Documents

NC Department of Health and Human Services DMA 1915 (c) Waiver Training January 2012 Andrea Misenheimer Medicaid Director – PBH Patti French Waiver Consultant