The Children s Waiver Program

Transcription

1 The Children s Waiver Program An Overview November

2 Welcome and Introductions Audrey Craft, Specialist, Federal Compliance Section, MDHHS Kelli Dodson, Children s Waivers Analyst, MDHHS 2

3 What Will We Cover Today? Legal authority Funding Eligibility Prescreens Waiver Support Application Application process Plan development Decision guides Services Provider qualifications PDN Administrative hearings Choice Voucher Quality assurance * Areas highlighted in red will change with

4 Other Topics of Interest? The CWP will become a part of the 1115 waiver when it is approved by CMS. What would you like to know about the CWP? 4

5 Other Topics of Interest? 5

6 Legal Authority Authorized under Section (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 6

7 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 (469) 7

8 CWP Eligibility Requirements Up to age 18 Meets financial eligibility for Medicaid as a family of one Resides w/parent(s)or guardian (relative) Meets the disability criteria for Social Security Has a Developmental Disability as defined in the mental health code AND meets criteria for an Intermediate Care Facility for Individuals with Intellectual and Developmental Disabilities (ICF/IID) 8

9 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. 9

10 When Considering a CWP Pre-Screen Is the child currently Medicaid eligible? If so, CMHSP 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 the CMHSP and other resources, including a commercial insurance benefit? 10

11 Prescreen Factors 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 11

12 Assessing Eligibility for the CWP Per contract with MDHHS, 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). 12

13 Assessing Eligibility for the CWP If a determination is made during scoring that Factor 9 of an initial prescreen does not include documentation of three or more areas of substantial functional limitations, the following steps will occur: The Factor 9 prescreen Scoring Comment section will: Identify insufficiently documented SFL (SFL) areas or state that no SFL areas were identified during the scoring review Specific questions will identify needed SFL detail Factor 9 will be scored a 1 until SFL documentation 13 is provided

14 Assessing Eligibility for the CWP A Hold will be placed on the Priority Weighing List that states: Pending submission within 60 days of preliminary documentation of 3 or more areas of substantial functional limitations to support a developmental disability. CMH will receive an automatic notification of the Hold. CMH must inform the family of the Hold. An invitation to apply cannot occur until the Hold is resolved. 14

15 Assessing Eligibility for the CWP Within 60 days after Hold placement, CMH is required to either: Submit an update that documents SFL (MDHHS will remove Hold after second tier internal review determination of adequacy), OR If CMH is unable to document SFL, CMH must provide adequate notice to the family of the right to fair hearing based on the determination that SFL evidence of a developmental disability cannot be documented. 15

16 Assessing Eligibility for the CWP If family requests a hearing after notice: The child s name remains on the Weighing List with a Hold until a Decision and Order (D&O) is received by MDHHS and reviewed by CWP staff. Next steps depend on the determination in the D&O: If the D&O indicates lack of SFL documentation, MDHHS will remove the prescreen from the Weighing List (without further action by CMH) OR 16

17 Assessing Eligibility for the CWP If the D &O indicates that adequate SFL documentation, the Hold will be Removed and the child will be eligible to receive an invitation to apply. A prescreen update (or new prescreen after removal) may be submitted at any time adequate SFL documentation becomes available. 17

18 CWP Prescreen Basics 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 18

19 CWP CONTEST QUESTION 19

20 When Waiver Slots Become Available DHHS issues an invitation to apply via the WSA The case is moved to the Case Worker s work queue and the WSA generates an to all CMHSP 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 20

21 Initial Application Process - CMHSP Within 30 days the invitation to apply was issued UPDATE: Complete Waiver Certification form, enter specified data elements into the WSA. Upload Initial Certification into the WSA under the documents 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 DHHS) 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 DHHS via the WSA 21

22 Approval Process Clinical Review Team (CRT) reviews waiver application for clinical eligibility CRT approves case on the WSA, completes DHS-49-A tab. Effective date is 1 st of month for which child was invited to apply WSA generates to CMHSP CWP sends approval memo to Medicaid liaison with local MDHHS Medicaid liaison sends approval packet to family. This letter is under the documents tab in the WSA. Medicaid liaison sends Policy Memo to local MDHHS office 22

23 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. 23

24 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 24

25 Final Application Process After MDHHS 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 DHHS Did they request retroactive eligibility Did they have any problem with the application Did the letter from local eligibility staff at DHHS say anything other than Medicaid (e.g., MIChild, Transitional Medicaid) Is the Medicaid start date later than the CWP Enrollment start date 25

26 Final Application Process - Continued 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 DHHS 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 26

27 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 DHHS; both forms are maintained in the local case file DHHS does not sign section four of the annual recertification form 27

28 CWP CONTEST QUESTION 28

29 Change in Process for Review of Private Duty Nursing (PDN) As of October 1, 2016, the CMHSPs no longer authorized PDN for individuals under the age of 21. The Program Review Division (PRD) at the Medical Services Administration (MSA) review information submitted by the PDN agencies to determine eligibility for PDN. 29

30 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. Medicaid Provider Manual: BH/IDD Chapterappendix A1 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 30

31 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 lifethreatening. 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. 31

32 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 32

33 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 33

34 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 34

35 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. 35

36 Community Living Supports H 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 36

37 Enhanced Transportation Enhanced Transportation S 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 37

38 Respite Care T 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 38

39 S 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 Family Training 39

40 Specialty Services G0176 for: Music Therapy Recreation Therapy Art Therapy for: Massage Therapy Limit of 4 sessions per month per type of specialty service 40

41 Non-Family Training S 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 41

42 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 dateof-service (DOS) This means multiple units of these services cannot be paid for the same DOS Note implications for scheduling these services 42

43 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 43

44 Environmental Accessibility Adaptations S Home Modifications must be: Prior authorized by DHHS Specified in the IPOS Necessary to ensure the health, welfare and safety of the child 44

45 Fiscal Management Services (FI) The fiscal intermediary must meet requirements as identified in the MDHHS/CMHSP Managed Mental Health Supports and Services Contract Attachment P Medicaid Managed Specialty Supports and Services Concurrent 1915(b)(c) Waiver Program FY 15 Monthly all-inclusive code T

46 Prior Authorization Yours (locally authorized) Adaptive toys: T1999 ADL aids: S5199 Allergy control supplies: T2028 Ours (CRT authorized) Enhanced hours (CLS) 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 46

47 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) 47

48 Transition Planning Children who continue to have documented habilitative service needs, are given priority to enroll in the Habilitation Supports Waiver (HSW), should the specialized supports and services available under that waiver be appropriate to the child's needs. 48

49 Transition Planning A young adult aging off the CWP does not have to wait for needed services because they are eligible for State Plan and b3 services provided by the PIHP, even if there are no HSW slots immediately available. 49

50 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 50

51 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 51

52 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 52

53 CWP CONTEST QUESTION 53

54 Questions? 54

55 For Additional Information Medicaid Provider Manual-Mental Health/Substance Abuse Chapter/Children s Waiver Program Section 14 Audrey Craft crafta@michigan.gov Kelli Dodson dodsonk@michigan.gov Children s Waiver Program (CWP) User Training Manual WSA Splash Page - (Under Training Menu) 55