Waiver World has Rules

1
Waiver World has Rules

• The Queen Has Spoken..
• (And Esteemed Counsel as Well!!!)

2
Coverage and Limitations Handbook

• The document that gives us legal standing.at
  long last.
• CYA Does not stand for Color Your Apple!!
• Whew!!!!! WE can all now take a deep breath in
  and let it out.

3
Important Definitions

• Check these out
• Care planbased on the preferences and needs of
  the recipient

4
Important Definitions

• Community support coordinator page
  1-3interesting, huh? More to follow!!!
• TBI/SCI Medicaid Waiver Administrator...A/K/A
  the Queen or HRH orDragon Lady.

5
Pondering The Purpose

• Maintain and promote the health of individuals
  with TBI or SCI through the provision of needed
  supports and services to prevent or delay
  institutionalization.
• You will see the word needed frequently today!!!

6
Family Members as Providers????

• Parents of minors? No
• Spouses? No
• Guardians? No
• Relatives not legally responsible for the care of
  the recipient?
• Attendant, companion, or personal care but must
  meet provider qualifications.

7
Family Members as Providers????

• Relatives not legally responsible for the care of
  the recipient? continued

• May not provide other services like CSC.
• Reasons for using a relative must be clearly
  documented in the case file!!

8
CSC Provider Qualifications

• Educational or certification requirements
• Masters in counseling, rehabilitation
  counseling, or social work
• Bachelors degree in social, behavioral, or
  rehabilitative science or education 3 years
  professional experience in counseling or
  rehabilitation program

(continued next page)
9
More CSC Provider Qualification Requirements

• Educational or certification requirements
• Certification as a case manager by the
  Commission for Case Manager Certification or
• Certification as a disability management
  specialist by the Certification of Disability
  Management Specialist Commission.

(continued next page)
10
More CSC Provider Qualification Requirements
(continued)

• At the time of enrollment CSC applicants must
  show
• Familiarity w/ population served
• Knowledge of theories and practices in training
  population served
• Ability to communicate effectively with
  population served
• Knowledge of medical and psychological aspects of
  TBI/SCI and
• Effective writing skills.

(continued next page)
11
YIKES!!! More CSC Qualification
requirements!!!!!

• At the time of application or at the end of this
  training day.those who have other employment
  besides being a CSC for this program must submit
  a statement that addresses plans for dual
  employment
• Type of employment held
• Total hours worked per week
• Plan for how OUR recipients will be able to
  reach you during the hours employed in the other
  job
• How conflicting priorities, emergencies,
  and meetings, will be handled and
• How the CSC will reduce or terminate other
  employment if a full waiver caseload is assumed.

12
Let the Word Go Forth!!!!

• The waiver administrator must approve the dual
  employment plan .
• If the applicant or actively enrolled CSC cannot
  be available to meet the needs of his/her
  caseload, the application will be denied or the
  enrolled CSC will be dis-enrolled.
• A support coordinators caseload cannot exceed a
  maximum of 36 individuals even when that total
  includes participants of other programs.

13
Other Provider Qualifications

• Specified by service
• Services alphabetically.
• Note All require familiarity with population
  served.
• Why should you care what the quals are for other
  service providers???

14
Do you as CSCs wish to provide other services?

• For CSC in other waivers, request new location
  code
• IF you are qualified, you may request permission
  from BSCIP Headquarters to provide services such
  as Life skills training to TBI/SCI waiver
  recipients.
• However, these recipients cannot be those for
  whom you are the Support Coordinator.

15
If You Make a Change

• Moved?
• Change phone number?
• Change name?
• Terminate
• Enter witness protection program?
• Who ya gonna call??????

16
NOW HEAR THIS!!!!!!!!!!!

• Services are based upon the assessed individual
  needs of the recipient!
• Not every recipient will need every service!!!!
• Do you see the word want anywhere in the above
  two statements???

17
Eligibility

• Financial DCF determines
• Need to provide a DCF form 2515
• In most of FL, applications taken online.
• Medical. CARES determines
• Informed consent
• Referral package to CARES

18
FAMOUS LAST WORDS OH MY GOSH! I DID NOT KNOW
THAT?!!

• Eligibility must be re-determined annually.
• FYIaccording to the American Heritage
  Dictionary, annually means Recurring done or
  performed every year yearly
• PSSSSSSS! Did she really say annually??

19
She sure enough did!!!!!!

• Play it again, Sam.!!!
• If Medicaid financial eligibility is based
  solely on waiver participation, DCF will send
  notice to the recipient of time to re-certify.
• DOEA CARES does NOT send out noticesup to the
  CSC to submit referral package for update to
  annual level of care.

20
Medical necessity

• Defined in the FACthat means its in rule!!!
  That means we gotta pay attention!
• medical or allied care, goods or services,
  furnished or ordered must meet the following
  conditions
• Necessary to protect life prevent significant
  illness or disability, or to alleviate severe
  pain
• Be individualized, specific,and not in excess of
  the patients needs
• Not be experimental or investigational
• Be reflective of the level of service that can be
  safely furnishedno equally effective and more
  conservative or less costly treatment (service)
  is available statewide and
• Be furnished not primarily intended for the
  convenience of the recipient, his/her caregiver,
  or the provide.

21
More about Medically necessary

• The fact that a provider (even a physician!!)
  has prescribed, recommended, or approved medical
  or allied care, goods, or services, does not, in
  itself make such care, goods or services (a)
  medically necessary, (b) a medical necessity, (c)
  a covered service.

22
Waiver Services do not Supplant Others!

• Federal requirement must access State Plan
  Medicaid coverage and Medicare services before
  the provision of waiver services.
• Efforts to do so must be well documented in the
  case record.

23
CSC Responsibilities

• Must have extensive knowledge of existing service
  network in order to
• Ensure continuous coordination between the
  service providers and recipient and referrals to
  appropriate resources
• Refer recipients to non-Medicaid services when
  available and appropriate
• Ensure that recipients have a choice of
  providers
• Calculate the cost of care
• Maintain up-to-date case record

(continued next page)
24
CSC Responsibilities

• Monitor recipients satisfaction with services
• Ensure that recipients eligibility is
  maintained
• Notify BSCIP Regional Office staff of any
  emergency situations
• Report suspected abuse neglect, or exploitation
  and
• Inform recipients of their right to a fair
  hearing.

25
CSC Monthly Service Requirement

• Minimum requirements
• At least one face-to-face visit with the
  recipient and perform at least one other support
  coordination activity per month for each
  recipient in his/her caseload.
• Recognize that some of your clients will need
  much more assistance that others, and
• go with the flow

26
If Its Not Written DownIt Did Not Happen!

• I told you once, I told you twice and maybe even
  three times before.
• Your case notes are the only thing we have to
  show what is going on with the recipient and his
  service providers.

27
Talks

• You must meet documentation requirements on p.
  2-11, and
• Unless your documentation clearly shows that you
  have visited and interfaced with the client
  regarding his continued Medicaid eligibility,
  satisfaction with services, and unmet needs..
• YOU WILL NOT BE REIMBURSED!!!!!

28
Care Planning Rubber Hits Road!!!

• Ultimate goal help recipient live a dignified
  life in the least restrictive setting appropriate
  to his/her needs. (theres that word again!)
• Service needs identified
• Provider information provided
• Client chooses provider
• Plan developed with duration and scope of service
  specified.

29
Who Does This Care Plan Stuff??

• The initial care plan is developed by the BSCIP
  case manager.
• All other care plan amendments are recommended
  and arranged by the CSC!!!!
• RIMS access coming to you soon!!!

30
Who signs CRP?Who gets copy of CRP?

• Client and/or representative must be informed
  that signing the care plan indicates agreement
  with the duration, scope of services as well as
  right to a fair hearing and informed choice of
  provider (on bottom of CRP).
• CSC and case manager also sign.
• Care plans are submitted to Regional Manager and
  the Medicaid Waiver administrator for approval
  before services are finally authorized.
• Client must be given (sent) a copy of care plan
  and every amendment to follow!!!!!
• CSC should have hard copy in file.

31
But Were not There Yet

• Care plans are reviewed for appropriateness and
  completeness by the Regional manager.
• When a requested service or item is determined to
  be medically necessary, and the requested item
  meets the service definition in the TBI/SCI
  waiver, the proposed amendment is discussed with
  the client and developed in RIMS.
• The Waiver Administrator approves or disapproves.

32
Still More ..

• If sufficient information is not available to
  determine the service is medically necessary,
  additional information will be requested from the
  CSC, recipient or representative.
• If BSCIP determines service or item is not
  medically necessary, BSCIP will issue a written
  denial of service and notice of due process
  rights to recipient and his CSC.

33
CSCs Role in Implementation of CRP

• Identify potential providers
• Refer potential providers for enrollment
• Review service needs closely and often to ensure
  needs are being met
• Discuss recipients condition and progress with
  providers on ongoing basis
• Regularly check with providers to ensure capacity
  to continue services and
• Monthly F2F to determine ongoing service needs as
  well as satisfaction with current service
  provision.

34
Six Month CRP Review

• Required by the terms of the waiver.
• CSC notes should reflect that this is a 6 month
  review and needs are being met. (not much
  different, huh?)
• dates for annual and semi-annual care plan
  review are tied to the anniversary date of
  eligibility and NOT to the date of the last
  amendment!!!

35
FAQ When (and How!!) Can I Terminate Services!!

• Easy, straightforward ones first
• Recipient chooses to terminate services
• Moves out of state
• Becomes financially ineligible
• No longer meets the medical criteria
• No longer meets LOC criteria or
• Recipient dies

(continued next page)
36
Part 2When (and How!!) Can I Terminate
Services!!

• Service is no longer necessary to prevent
  institutionalization and to allow recipient to
  live in the least restrictive setting appropriate
  for his needs.
• Inform recipient slot will be held open for 90
  days.
• At end of 90 day period, close the case.
• If requested, return to wait list.

37
Part 2 When Can I Terminate?

• The recipient is non-compliant or repeatedly
  refuses to follow his written care plan or to
  cooperate with case managers (or CSC) as
  determined by the DOH.
• Remember what Dragon Lady has always told you
  If its not written down, it did not happen!!!

38
Contract of Expectations Behavior
Modification Contract

• This is necessary when the pleading, cajoling,
  and idle threats no longer work.
• Step 1Call me so we can discuss what behavior we
  are attempting to modify.
• Step 2Well develop contract together.

39
When All Else Fails

• After you are certain that all your documentation
  ducks are quacking happily
• Notice of Decision is sent 10 days prior to the
  adverse action.

40
When There are Rules, There Must be Rights

• I hate to admit this but
• Waiver World is not a dictatorship!!!!
• The Notice of Decision is to be used whenever an
  adverse action is taken. (This includes
  denial termination suspension or reduction).

41
In Accordance With 42 CFR, 431.221 (d)

• Due process must be given to all who enter waiver
  world!
• Upon receipt of the Notice of Decision, client
  has 21 days to request a hearing.
• If the request is made within 10 days, services
  must continue as before until the decision of the
  hearing is officer is rendered.
• CSC must assist in requesting the hearing if
  asked to do so by the client or representative.

42
How to Request Hearing

• Written request is sent to
• Office of Appeal hearings
• 1317 Winewood Boulevard
• Bldg, 5, Room 203
• Tallahassee, FL 32399
• or
• Request can be made by telephone to
• [phone]

43
Reimbursement

• Providers required to submit all claims and
  invoices within 60 days.
• Staff within the BSCIP Billing office will review
  the invoice and supporting documentation for
  accuracy prior to approving for payment.

44
RECOUPMENT OF FUNDS Boy, did that get your
attention!!!

• Reasons this action may be taken
• Failure to meet service standards
• Failure to properly document
• Receives for service not provided or
• Receives for unauthorized services
• Bills for more hours than authorized
• Bills for a different service or
• Bills at a rate not agreed upon.

45
Just What Species is an IOP?

• Why cant we just have one book
• to go by????

46
From wait list to waiver

• Wait list policy is found as appendix
• F-1 in the Handbook and Appendix A in the
  IOPs.
• Those waiting are prioritized
• according to need and length of time on wait
  list.

47
Wait ListStill Long.

• Screening instruments are scored
• Two mechanisms
• 1. people waiting in the community
• 2. people waiting in nursing homes.
• Score will be entered into RIMS along with date
  of initial contact.

48
YUPI Sure do Love that 701B, Dont You?

• First one done by the case manager
• All subsequent annual assessments are completed
  by the support coordinator.
• New assessment is also required if there is a
  significant change in the recipients physical
  condition or living situation.

49
Butits so Long and Some of Those Questions are
Ridiculous!!

• Why do we care.
• if the recipient has a pet?
• Or how many meals he eats?
• Or if he can manage ?
• Or if he is compliant with meds?
• Or how many times he talks with friends or
  relatives on the phone?
• Or if the lighting is adequate?

50
Training on the 701B

• Please contact your local CARES office and
  request the dates of the next training in your
  area.
• Does everyone know where CARES is?????

51
Whats This About an Individualized Care Plan?

• Care planning is the means by which the recipient
  has his medically necessary needs met.
• not his wants
• or his caregivers wants
• or gosh, Id like to have a new________.
• Copy of plan to recipient within 10 days of
  signature date.

52
Rehab Engineer Evaluation comes First!!!

• Fosters independence.
• May reduce the need for in-home care and
  supervision.
• Seeking rate increase. For nowlets get
  creative!!

53
Contrary to Popular Opinion

• All other resources must be tapped first.
• Medicare, Medicaid state plan family
• CIL BIAF FAAST church civic group?
• Check these out before developing the plan!!

54
This Choice Thing is Absurd! What do They
Think This isWal-Mart??

• Federal requirement
• As such, very near and dear to the heart of the
  Dragon Lady!!
• Not only thatthink about itwould you not want
  to choose who is going to come into your home,
  undress you, and bathe you????

55
The Welcome Mat

• From this day forward, all recipients must
  receive a welcome brochure which gives brief
  overview of services and explains their due
  process rights.
• When do they get this?
• NOW!
• New recipientsat the time of enrollment.

56
Summer, Spring, Winter, or Fall, all you gotta
do is call.

• And Ill come running to be by your side
• We are all inhabitants
• of this wondrous place
• Called
• waiver world

57
Go Forth Do Good

• and document the heck out of everything!!!

58
Questions? Dilemmas? Acid Indigestion? IBS?

• Contact information for Dragon Lady
• Kristen_Russell_at_doh.state.fl.us
• DOH phone [phone]
• Toll free line [phone]
• Cell phone [phone]