1915 (c) Waiver Training January 2012 Andrea Misenheimer Medicaid Director – PBH Patti French Waiver Consultant
Welcome to NC Innovations
1915 (b) (c) concurrent waivers 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
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.
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
Slots and Prioritization Finite number of Slots for use in 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)
Prioritization Prioritization 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 funding as follows: Non-Reserved Capacity First come, first serve Based on date of application for services
Prioritization Reserved Capacity 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 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.
Reserved Capacity 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 criteria If 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.
Initial Level of Care Process Eligibility Criteria = ICF-MR Criteria DMA Clinical Coverage 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.
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.
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
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.
Freedom of Choice Freedom of Choice is documented: Initial when new to the waiver Annually as a component of the ISP
Individual Budgeting Individual 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.
Building Budgets Each 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.
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
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
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.
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.
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
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
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.
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
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
Planning Meeting Review of assessment information/draft plan Development of long range outcomes
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 to Utilization Management per PIHP guidelines.
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
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
Plan Implementation ISP is updated/revised as needed Update to Individual Support Plan (most often includes update to Individual Budget) Demographic Information - Update Update to Crisis Prevention and Intervention
Support Planning SIS™ Identifies/Measuressupport needs Identify desired life goals/experiences/choices using person centered tools Person Centered Planning Individual Support Plan (ISP) Risk/Support Needs Assessment / Other Other Assessments Natural and Funded Resources
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.
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
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
CMS Requirements No other Model of Self-Direction except the model approved in the waiver Payments may not be made directly to a waiver participant, or managing employer, either to reimburse for expenses incurred or to pay a service provider directly No cost to the Participant or Managing Employer Financial Manager or Agency With Choice manages funds Self-direct one or more services Service planning is led by the participant Independent advocacy is available Budget Authority to make decisions about how funding is used
Services that can be Individual/Family Directed In-Home Skill Building Personal Care In-Home Intensive Support Natural Supports Education Community Networking Respite Supported Employment Community Guide Individual Goods and Services
Model of Individual/Family Directed Supports Agency With Choice (Managing Employer)
Representative The representative is someone who can assist the Managing Employer in performing some or all of their duties
Individual If the individual is not the Managing Employer, they need to be as involved in the process as possible
Managing Employer is… Innovations Waiver Participant if they are 18 and do not have a legal guardian Or Parent of a child under 18 Or The legal guardian of an Innovations participant
The Direct Support Worker Works for the Agency With Choice. Works when and where the Managing Employer choose. Does what Managing Employer wants him or her to do. In the Agency With Choice Model, decisions are shared with the Agency
Community Guide Empowers the employer to define and direct services Understands employers needs and preferences May not be the employer, representative or family may not be paid to provide service Service can be mandated
Community Guide functions in Individual Family Direction Links to Resources Role plays to teach skills Connects to the community Helps employer develop employee support agreements/supervision plans
Community Guide will not…. Interview, hire, train or fire employees Complete employment forms Find back up employees Obtain extra money for the employer if the budget is overspent Make decisions for the employer Do the Duties of the Care Coordinator
Care Coordinator functions in Individual Family Direction Completes the assessments Completes the process for appointment of the representative, if needed Completes referrals to the Agency With Choice and Community Guide Completes the Individual and Family Supports Agreement Completes the ISP/Update to ISP Sends the ISP to UM for approval Sends a copy of the approved ISP to team members including Community Guide, Managing Employer, Representative
Annual Orientation to Individual Family Direction Booklet Fact Sheets
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
Step 2 Assessments Individual and Family Supports/Community Guide Assessment Representative Screening Questionnaire