program - michigan association of community mental … · kelli dodson, children’s waivers...
TRANSCRIPT
Welcome and Introductions
Audrey Craft, Specialist, Federal Compliance
Section, MDHHS
Joan Deschamps, Children’s Waivers
Specialist, Retired, MDHHS
Kelli Dodson, Children’s Waivers Analyst,
MDHHS
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What Will We Cover Today?
Legal authority
Funding
Eligibility
Prescreens
Application
process
Plan development
Decision guides
Services
Provider qualifications
PDN
Budgets
Administrative hearings
Choice Voucher
Quality assurance
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Legal Authority
Authorized under Section 1915(c) of
the Social Security Act
Allows states to waive parental
assets and income and make a child
eligible for Medicaid as a “family of
one”
Provides additional services specific
to, and limited to, the waiver
population
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State Funding
An appropriation controlled by the
Michigan Legislature
Matched with federal funds
Limited to the number of children it
can support on the CWP
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CWP Eligibility Requirements
Up to age 18
Meets financial eligibility for Medicaid as a “family of one”
Resides w/parent(s)or guardian (relative)
Receives at least one waiver service per month
At risk of out of home placement
Has a Developmental Disability as defined in the mental health code AND meets criteria for an ICF/IID
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Intermediate Care Facility for the (ICF/IID )
An individual must have the need for an active treatment program of specialized and generic training, treatment, health and related services directed toward the acquisition of behaviors necessary to function with as much self-determination and independence as possible.
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When Considering a CWP
Pre-Screen
Is the child currently Medicaid eligible? If so, CMH is
responsible to provide medically necessary supports and
services.
Is the child developmentally disabled?
Does the child meet criteria for ICF/IID, including needing
“active treatment”?
What service needs have been identified?
Can services be provided through CMHSP and other
resources, including a commercial insurance benefit?
Assessing Eligibility for the
CWP
Per contract with MDCH, all CMHSPs are expected
to have a process in place to assess eligibility for the
CWP.
If a family requests a prescreen for the CWP and the
CMHSP determines the child is not eligible, the
CMHSP must provide the family with a Medicaid Fair
Hearing adequate notice denying the CWP.
If the CMHSP determines the child is eligible, then a
prescreen must be submitted via the Waiver Support
Application (WSA).
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Factor 10: Home Care Supports
Factor 9: Health & Safety; Medical/Behavioral
Challenges
Factor 8: Risk of Out-of-Home Placement
Factor 6: Family Stress and/or Physical Health
Problems
Factor 5: Other Children with Special Needs in the
Home
Factor 4: Child in Nursing Home
Factor 3: Child in ICF/IID (formerly ICF/MR)
Factor 1: Child in Foster Care
Prescreen Factors
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CWP Pre-screen Updates
Annual update is required
An update within the past six months is
necessary for an invitation to apply
If a child no longer qualifies for the CWP, or if the family no longer wants waiver services, the child’s name will be removed from the Priority Weighing List
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When Waiver Slots Become Available
DCH issues an “invitation to apply”
via the WSA
The case is moved to the Case Worker’s work
queue and the WSA generates an email to all CMH
staff with prescreen, case worker and supervisor
security roles
The assigned case manager contacts the child’s
parent(s) to confirm:
Child’s service needs
Current residence
Medicaid status
Family still wants waiver services
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Initial Application Process - CMHSP
Within 30 days the invitation to apply was issued
Complete Waiver Certification form, enter specified data
elements into the WSA and mail the signed form to MDCH
(please note date mailed in “comments” field on WSA
Certification tab)
Complete the Demographic tab in the WSA
Complete a DHS-49 form, enter specified data elements into the
WSA and retain the DHS-49 in the case file (do not mail to
DCH)
Documentation of a current annual physical for the child can
be used in lieu of a DHS 49 form (note “source” in comments
field on WSA DHS49 tab)
Supervisor approves and submits initial application to DCH via
the WSA
Initial Application Documents For
Children The CMHSP Believes Are
Eligible For PDN
PDN eligibility worksheet
Health care plan
Copy of physician’s order for PDN
Two weeks of the most recent
nursing notes (if child has been
receiving hourly nursing)
IPOS
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Approval Process
Clinical Review Team
(CRT) reviews waiver
application for clinical
eligibility
CRT “approves” case
on the WSA, completes
DHS-49-A tab & sends
signed Initial Cert to
CMH
Effective date is 1st of
month for which child
was invited to apply
WSA generates email
to CMH
CWP sends approval
memo to Medicaid
liaison with local
MDHHS
Medicaid liaison sends
approval packet to
family
Medicaid liaison sends
Policy Memo to local
MDHHS office
Medicaid Application
The family should
wait until they
receive the approval
packet to apply for
Medicaid.
The family should
follow the
instructions in the
approval packet
exactly.
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After Approval of Initial
Application The CMHSP: Completes relevant assessments and a Category of
Care narrative
Develops the child’s Individual Plan Of Service (IPOS)
Establishes a budget based on the IPOS and enters the budget detail into the WSA
Trains CLS and respite staff in the IPOS and assures staff meet all other training/provider requirements before providing services
Follows-up with the family regarding the Medicaid application and Medicaid eligibility
WSA Budget Detail Budget detail entered into the WSA
includes:
All services identified in IPOS
Procedure code for each service
Amount of service (# of units) to be
provided & frequency (month or year)
CMHSP’s charge for each service
The WSA calculates the estimated cost to
Medicaid at the lesser of charge or fee-screen
Budget detail is by fiscal year (not IPOS
year) and is not “sent” to DCH
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After DCH approves the initial application and the case status is “open”, the CMHSP should follow-up with the family regarding application for Medicaid and Medicaid eligibility
Did they make the application after receiving the
approval packet from DCH
Did they request retroactive eligibility
Did they have any problem with the application
Did the letter from DHS say anything other than
“Medicaid” (e.g., MIChild, Transitional Medicaid)
Is the Medicaid “start date” later than the CWP
Enrollment start date
Final Application Process
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As soon as the CMHSP confirms Medicaid is active,
the CMHSP should
Enter the MAID# on the Enrollment tab in the
WSA
Review detail for the Initial Budget on the Budget
tab in the WSA
“Approve and submit” the case to MDCH
CWP must “review & approve” the MAID# and Initial
Budget before CWP eligibility is uploaded to
CHAMPS
CWP claims cannot be paid until both the MA and CWP
Benefit Plans are on CHAMPS
Final Application Process - Continued
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Annual Renewal - CMHSP Annual Recertification form must be completed
within 365 days of the Initial Waiver Certification (or the most recent Annual Recertification)
Parent must sign section three (choice
assurance) of the Waiver Certification form
Medical Examination Form (DHS-49) must be completed within 365 days of the previous physical exam date
WSA Certification and DHS-49 tabs must be modified to update the specified fields
Neither form is sent to DCH; both forms are maintained in the local case file
DCH does not sign section four of the annual
recertification form
Annual Renewal - PDN
When the annual recertification is due for
children who qualify for PDN, the CMHSP
must submit
PDN eligibility worksheet
Two weeks of the most recent nursing
notes
Health care plan
Copy of physician’s order for PDN
Current IPOS
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What is a
Decision Guide ?
It is a tool to:
Assist the child’s team in determining the
amount of publicly supported CLS or PDN
hourly care.
Ensure consistency across the state of
Michigan
Review the care needs of the child and the
resources available to the family
Documentation of training must be
maintained in case managers personnel file
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DOCUMENTED CATEGORY OF NEED FOR HOURLY
CARE AUTHORIZATION*
ADDITIONAL FAMILY
RESOURCES
CATEGORY
IV
CATEGORY
III
CATEGORY
II
CATEGORY
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Section I – Number of
Caregivers
1. Two or more
caregivers live in
home; both work F/T
2. Two adult
caregivers; one
works F/T
3. Two adult
caregivers; neither is
employed
4. One adult caregiver
lives in home and
works F/T
5. One adult caregiver;
does not work F/T
4-8
2-8
2-4
4-8
2-6
6-10
2-8
2-6
4-10
2-8
8-12
4-10
4-8
8-12
8-10
12-16
10-16
8-12
12-16
10-14
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DOCUMENTED CATEGORY OF NEED FOR HOURLY
CARE AUTHORIZATION*
ADDITIONAL FAMILY
RESOURCES
CATEGORY
IV
CATEGORY
III
CATEGORY
II
CATEGORY
I
Section II – Health Status
of Caregivers
1. Significant health
issues
2. Some health issues
6-8
4-6
6-10
4-8
10-14
8-12
12-16
10-12
Section III – Additional
dependent children
1. Applicant has one or
more sibs, age five
or older
2. Applicant has one or
more sibs under
age five.
2-4
4-6
2-6
4-8
4-8
6-8
8-12
8-12
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DOCUMENTED CATEGORY OF NEED FOR HOURLY
CARE AUTHORIZATION*
ADDITIONAL FAMILY
RESOURCES
CATEGORY
IV
CATEGORY
III
CATEGORY
II
CATEGORY
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Section IV – Additional
Children with Special Needs
1. Applicant has one or
more siblings with
nursing needs
2. Applicant has one or
more siblings with
non-nursing special
needs
4-8
2-4
6-8
2-6
4-8
N/A
8-12
N/A
Section V – Night
Interventions
1. Requires 2 or fewer
interventions at night
or total time less
than one hour
2. Requires 3 or more
interventions
requiring one hour or
more to complete
2-4
4-8
2-6
6-8
4-8
6-10
8-12
8-12
Section VI – School
Child attends school an
average of 25 hours per
week
6 max
6 max
8 max
12 max
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Categories of Care Demonstrates mild level behaviors that may interfere with the
daily routine of the family.
Demonstrates a daily pattern of medium level behaviors including self-injurious, physically aggressive or assaultive behaviors that have not resulted in hospitalization or emergency room treatment for injuries in the past year, or has engaged in occasional, significant property destruction that is not life-threatening.
Demonstrates a daily pattern of moderate self-injurious, physically aggressive or assaultive behavior when medical intervention, or hospital emergency room treatment has been required for treatment of injuries in the past year without resulting hospitalization, or if the child has engaged in frequent, significant property destruction that is not life-threatening.
Demonstrates a pattern of severe self-injurious, physically aggressive or assaultive behavior, or life threatening property destruction that has occurred one or more times in the past year. Documented evidence of additional behavioral problems on a frequent basis each day supports a need for one-to-one intensive behavioral treatment.
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COC Documented Narrative
Assessment of Need
Type of behaviors
Frequency, intensity and duration of behaviors
How recently behaviors occurred
Effects of behavior on family & property
Additional Resources
# of caregivers
Health of Caregivers
Dependent Children
Children w/special needs
Night Interventions
School Schedule
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Services Available to Children
on the CWP
All mental health services included in
the CWP Services database when:
Used to address an assessed need
Identified in the IPOS
Services include:
“State plan” mental health services, and
“Waiver” services
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Waiver Services
Community Living Supports (CLS)
Enhanced Transportation
Respite Services
Home Care Training, Family
Specialty Services
Home Care Training, Non-Family
Specialized Medical Equipment & Supplies
Environmental Accessibility Adaptations
Fiscal Intermediary
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Medicaid State Plan Services
Private Duty Nursing
Occupational Therapy
Physical Therapy
Speech Therapy
Targeted Case Management
Durable Medical Equipment
Professional
Evaluations &
Testing
Health Assessments
Medication Review
etc.
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Community Living Supports H2015 - Community Living Supports; per 15
minutes
Must be trained in:
IPOS
Recipient Rights
Basic First Aid, CPR
Emergency Procedures
Can be provided in the child’s home or in the
community
Cannot be provided in the CLS provider’s
home
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Enhanced Transportation
Enhanced Transportation
S0215 - Non-Emergency Transportation; mileage (per mile)
CLS costs include transportation
Transportation may be billed when
provided by staff other than CLS
Limited to resident’s county or
surrounding county
Is identified in the IPOS
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Respite Care
T1005 - Respite Care, per 15 minutes
Can be provided in: child’s home,
licensed foster home, licensed respite
care facility, licensed camp
Respite limits: 1152 hours (4608 units)
per fiscal year beginning Oct. 1, 2012
Amount authorized and used can vary
by month to meet child’s & family’s
needs, as identified in the IPOS
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Family Training S5111 - Home Care
Training, Family; per session
Provided by MSW, LLP or QMRP
Includes: Instruction about
treatment regimens & use of equipment specified in the IPOS
A counseling service to families
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Specialty Services
G0176 for:
Music Therapy
Recreation Therapy
Art Therapy
97124 for:
Massage Therapy
Limit of 4 sessions
per month per type
of specialty service
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Non-Family Training
S5116 - Home Care Training, Non-Family;
per session
Provided to CLS and respite staff by an
MSW, LLP or other clinician (OT, PT, SLP or
nurse) who is a QIDP
The provider is selected on the basis of
his/her competency in the aspect of the
service plan on which they are conducting the
training
Reminder: Multiple Units of
Family & Non-Family Training
Beginning January 2013, CMS set “MEU”
parameters for many codes
The “medically expected unit” for family &
non-family training is maximum “1” per date-
of-service (DOS)
This means multiple units of these services
cannot be paid for the same DOS
Note implications for scheduling these services
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Specialized Medical
Equipment & Supplies
Must be:
Medically necessary and beyond what is ordinarily found in the home or expected to be provided by parents
Specified in the IPOS
Includes devices, controls and appliances not covered under Medicaid State Plan
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Environmental Accessibility
Adaptations S5165 - Home
Modifications must be:
Prior authorized by MDCH
Specified in the IPOS
Necessary to ensure the health, welfare and safety of the child
Fiscal Management Services
(FI)
The fiscal intermediary must meet
requirements as identified in the
“MDCH/CMHSP Managed Mental Health
Supports and Services Contract – Attachment
P.4.7.1 Medicaid Managed Specialty
Supports and Services Concurrent 1915(b)(c)
Waiver Program FY 15”
Monthly all-inclusive code – T2025
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Prior Authorization
Yours (locally authorized)
Adaptive toys: T1999
ADL aids: S5199
Allergy control supplies: T2028
Ours (CRT authorized)
Enhanced hours (CLS & PDN)
Environmental safety & control devices: T2029
Repair or non-routine service for DME: K0739
Vehicle modifications: T2039
Environmental accessibility adaptations: S5165
Durable medical equipment, misc.: E1399
• Therapeutic items; assistive technology; other DME for sensory, communication, mobility needs; generators; window air conditioners
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Administrative Hearing
A notice of action:
Must be sent whenever a Medicaid
covered service is denied, suspended,
reduced or terminated – for any reason
(including when child ages-out of CWP)
Provides consumer with the opportunity to
request an Administrative Hearing, held by
an Administrative Law Judge (ALJ)
All terminations must be done on the WSA
(Note: this includes those aging-out of CWP)
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The Choice Voucher System
Must be made available for children enrolled
in CWP
Provides parents of minor children a method
to control and direct how their child’s IPOS is
implemented and who are the providers
Participation by families is voluntary
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How the System Works Family & CMHSP,
using the PCP process, develop child’s IPOS identifying needed services and supports
A CWP budget is developed based on the IPOS
Parent implements arrangements through the Choice Voucher System
A Choice Voucher
Agreement between
the CMHSP and
Parent is signed
The funds in the
CWP budget are
lodged with a fiscal
intermediary
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Quality Assurance &
Improvement
CMS requires changes to quality assurance
and improvement strategies:
Bi-annual site-reviews (QMP & CWP); we
must review more records; CWP site review
protocol & Department-level processes
revised to align with “CWP Performance
Measures”; plans of correction still required;
we must report “remediation” of problems to
the consumer-level
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For Additional
Information
Medicaid Provider Manual-Mental
Health/Substance Abuse Chapter/Children’s
Waiver Program Section 14
Audrey Craft
517.241.5757 – [email protected]
Kelli Dodson
517.335.6078 - [email protected]
Children’s Waiver Program (CWP) User Training
Manual
WSA Splash Page - (Under Training Menu)