IRIS Allowable Services List

Transcription

1 IRIS Allowable Services List Adaptive Aids Day Services Nursing Services * Adult Day Care Home Delivered Meals Specialized Medical Equipment and Supplies * Adult Family Home * (1-4 beds) Housing Counseling and Housing Start - Up Support Broker Communication Aids Relocation Services Supportive Home Care * Community Based residential Facility (CBRF) Home Modification Supported Employment * Consumer Education and Training Personal Emergency Response System Transportation * Counseling and Therapeutic Resources Prevocational Services Vocational Futures Planning Customized Goods and Services * Daily Living Skills Training * Respite * Residential Care Apartment Complex (RCAC) Note: IRIS Independent Consultant Agency and IRIS Financial Service Agency services are provided at no cost to monthly budgets * denotes a support or service that may be provided by a qualified legally responsible person 1

2 4. The Family Care Benefit Package What services are provided? Southwest Family Care Alliance s Family Care program provides long-term care services. The list of services we provide is called the Family Care Benefit Package. You and your Team will use the Resource Allocation Decision (RAD) method to find the most cost-effective care plan for you. Although the services in the benefit package are available to all members, it does not mean that you can get a service that is listed just because you are a Family Care member. You will only get services that are necessary to support your outcomes and assure your health and safety. Your Team must approve all services before you start receiving them. Southwest Family Care Alliance might provide a service that is not listed. Alternative support or services must meet certain conditions. You and your Team will decide when you need alternative supports or services to meet your outcomes. The services that are available to you generally depend on your level of care. Family Care has two levels of care : 1.) Nursing home level of care if you meet this level of care, it means that your needs are significant enough that you are eligible to receive services in a nursing home. A very broad set of services is available at this level of care. 2.) Non-nursing home level of care if you meet this level of care, it means that you have some need for long-term care services, but you would not be eligible to receive services in a nursing home. A limited set of services is available at this level of care. If you don t know your level of care, ask your Team. The following services are available if they are: Required to support your outcomes Pre-approved by your Team Stated in your care plan 2

3 Family Care Benefit Package Chart See Appendix B on page 62 for definitions of each service. Nursing Home Level of Care Non-Nursing Home Level of Care COMMUNITY BASED MEDICAID STATE PLAN SERVICES Alcohol and Other Drug Abuse (AODA) Day Treatment Services (in all settings) Alcohol and Other Drug Abuse (AODA) Services (except physician or inpatient) Care/Case Management Services Community Support Program Durable Medical Equipment (except hearing aids and prosthetics) Home Health Medical Supplies Mental Health Day Treatment Services (in all settings) Mental Health Services, except physician or inpatient Nursing (including respiratory care, intermittent and private duty) Occupational Therapy (except inpatient) Personal Care Physical Therapy (in all settings except for inpatient hospital) Speech and Language Pathology Services (except inpatient) Transportation (except ambulance) INSTITUTIONAL MEDICAID STATE PLAN SERVICES Nursing Facility including ICF-MR and IMD (for IMDs, coverage is for adults under age 21 or 65 and older) HOME AND COMMUNITY BASED WAIVER SERVICES Adaptive Aids Adult Day Care Adult Residential Care: 1-2 Bed Adult Family Home (AFH) 3

4 Nursing Home Level of Care Adult Residential Care: 3-4 Bed Adult Family Home (AFH) Adult Residential Care: Community Based Residential Facility (CBRF) Adult Residential Care: Residential Care Apartment Complexes (RCAC) Care Management Services Communication Aids Consumer Education and Training Counseling and Therapeutic Resources Daily Living Skills Training Day Services Financial Management Services Home Delivered Meals Home Modifications (environmental accessibility adaptations) Housing Counseling Personal Emergency Response Systems (PERS) Prevocational Services Relocation Services Respite Care Self-Directed Supports (SDS) Broker Skilled Nursing Specialized Medical Equipment and Supplies Specialized Transportation Supported Employment Supportive Home Care Vocational Futures Planning 4

5 What services are not provided? The following services are not in the Family Care long-term care benefit package: Alcohol and Other Drug Abuse Services (provided by a physician or in an inpatient setting) Audiology: including evaluation of hearing function and rehabilitation of hearing impairments Chiropractic Crisis Intervention Dentistry Emergency Care (including air and ground ambulance) Eyeglasses Family Planning Services Hearing Aids and Hearing Aid Batteries Hospice (supportive care of the terminally ill) Hospital: Inpatient and Outpatient, including emergency room care (except for outpatient physical therapy, occupational therapy, and speech and language pathology, mental health services from a non-physician, and alcohol and other drug abuse services from a non-physician) Services in an institution for mental disease (IMD) are not covered in most situations (it is only covered in a nursing home IMD for people under age 21 or age 65 and older) Independent Nurse Practitioner Services Lab and X-ray Medications/prescription drugs Mental Health Services (provided by a physician or in an inpatient setting) Optometry Physician and Clinic Services (except for outpatient physical therapy, occupational therapy, and speech and language pathology, mental health services from a non-physician, and alcohol and other drug abuse services from a non-physician) Podiatry (foot care) Prenatal Care Coordination Prosthetics Psychiatry School-Based Services Transportation by Ambulance 5

6 Family Care does not pay for any services listed on the prior page. However, your Team will work closely with you to help you get these services when you need them. This includes arranging for transportation as needed. If you have Medicare, Veterans (VA) benefits, or other insurance, these insurances may cover the services listed above. There might be a co-payment for these services. In addition to the above list, the following items and services are not provided: Services that your Team hasn t authorized or are not included in your care plan. Services or supports that are not necessary to support your outcomes. Normal living expenses like rent or mortgage payments, food, utilities, entertainment, clothing, furniture, household supplies and insurance. Personal items in your room at an assisted living facility or a nursing home, such as a telephone or a television. Room and board in residential housing. (See page 30 for more information). Guardianship fees. 6

7 IRIS Program Policies Within these IRIS Program policies, the word participant refers to the individual person in the program. The word participant also refers to situations where the participant is represented by another recognized decision maker such as in the case of a guardian or durable power of attorney. IRIS Funding Flexibility It is the IRIS Program Policy to provide funding for goods, supports or services listed on the participant s approved Support and Service Plan (Plan). Specifically, the IRIS Program funds are intended to meet the participant s needs related to his/her long term care related outcomes. Each participant is informed of the estimate (allocation) of the funding that may be needed to pay for necessary items on his/her IRIS Plan. The participant identifies what goods, supports and services are needed on the Plan to meet his/her long term care related outcomes and which will be funded by IRIS. The cost of a plan that is paid with IRIS funds is referred to as the participant IRIS budget. Program Startup Timelines The IRIS Consultant Agency provides individualized assistance and support to IRIS Program participants according to the timelines established by the Wisconsin Department of Human Services. The steps are numbered 1-7 below: 1. The IRIS Consultant Agency Service Center initiates a Welcome Call with the participant within two (2) calendar days of the referral. 2. The participant selects his or her IRIS Consultant. 3. The IRIS Consultant makes the first face-to-face visit with the participant within 14 calendar days of the referral. This visit includes an orientation to the IRIS Program. 4. The IRIS Consultant assists the participant as needed, to create his/her Support and Service Plan within 30 calendar days of the orientation. 5. The IRIS Consultant Agency Plan Specialist reviews and approves the plan within ten (10) calendar days of the plan completion date. 6. The IRIS Consultant Agency sends a letter to each participant that identifies his/her IRIS start date. 7. The IRIS Consultant Agency notifies the Financial Services Agency of approval by sending the approved plan upon completion. Referral to IRIS Without Starting The IRIS Consultant Agency will assist people who are referred to the program but decide to before starting the program to withdraw from the planning process. Persons who withdraw before starting the program are referred back to the ADRC so they can receive information on alternate program options. The IRIS Consultant Agency sends a letter to all persons who withdraw before starting in order to confirm the withdrawal. 7

8 Conflict of Interest It is the IRIS Program policy to identify and mitigate situations that may represent a conflict of interest. The policy explains the process to identify a conflict of interest, and identifies options to lessen or remove a conflict. Conflict of interest includes situations that may have the appearance of being a conflict of interest. When a conflict of interest exists, the IRIS Program is required by federal requirements to remove or minimize the conflict. This may require the participant make a different choice related to the provider of supports or services if the conflict of interest cannot be resolved. A conflict of interest is present when a person, or an agency, is involved in helping a participant make decisions that would benefit the person or agency making the decision. This might mean the person making or guiding the decision receives employment, money, or other gain, such as an offset to a daily living cost. A conflict of interest is more likely to occur when an individual or agency has several roles. Examples of conflict of interest situations covered by this policy include: The guardian or Power of Attorney elects to be a paid service provider for the person for whom he or she is the responsible decision maker. An IRIS Consultant assists a participant to make choices about the program, provider or services when the IRIS Consultant also works with the ADRC, or with a Managed Care Organization in the same area. An IRIS Consultant has a material interest in a business or provider agency that the IRIS participant might choose. The IRIS Consultant Agency, Financial Services Agency, guardian or other person that manages the participant s money also receives material or other benefit as a result of such decision making. A person who monitors health and safety of a participant and is also provider of the same service. IRIS Plan Changes It is the policy of the IRIS Program to provide a process for participants to update IRIS Support and Service Plans (Plans). Plans are updated when a new good, support, or service is added or changed in order to meet the participant s long term care related needs or outcomes. The plan is also updated at least once each year at the time of the participant s annual review that is coordinated by the IRIS Consultant Agency representative. Participant Employed Workers: Caregiver Hours Assurances It is the policy of the Department of Health Services, IRIS Program, to ensure that all federal regulations are met. Relevant federal requirements include: Free choice of providers. Preventing or mitigating conflict of interest. Assuring participant health, safety and welfare. Assuring cost effective service provision. 8

9 In accordance with 42 CFR as well as under the authority of 1915(c) of the Social Security Act and the Department approved 1915 (c) Medicaid Home and Community Based Waiver (IRIS), the Department of Health Services must also establish and implement safeguards to ensure that participant hired workers are qualified and that payments match program financial accountability standards. This policy communicates expectations for authorizing care giving hours and establishes limits on the hourly rate for the provision of Supportive Home Care (SHC), IRIS Self-Directed Personal Care (IRIS-SDPC) or similar services. This policy is a means to promote consistent interpretation and ensure alignment with IRIS core values including wise use of limited public funding, community integration, and the value and importance of unpaid informal supports. The Caregiver and Criminal Background Check, Conflict of interest documentation, Risk Assessment and Emergency Back-Up Plan contribute to assuring participant health and welfare. Additional IRIS Consultant Agency review and oversight is required of any situation when the number of paid care giving hours exceeds 40 per week. Participant Employed Workers: Caregiver Background Checks It is the policy of the IRIS Program to conduct caregiver and criminal background checks on all IRIS participant hired workers or caregivers. The background check also includes consultation with the Office of Inspector General. The background check is completed prior to the worker start date, and every 4 years thereafter. The background check result is shared with the participant employer. In accordance with the Department of Health Services IRIS Program as approved by the Centers for Medicaid and Medicare Services under Section 1915(c) of the Social Security Act, if a background reveals conviction of an offense listed on the Permanent Bar from Employment as a Caregiver List (below), or if the conviction record is related to the proposed caregiver work duties, worker may not be paid with IRIS funds. If a background check shows conviction of a serious crime not included on the permanent bar list, the participant employer may request that the Department of Health Services determine whether the conviction is substantially related to the proposed worker tasks. Agency based workers have background checks completed by the employing agency. A municipal citation is not considered a criminal conviction. Permanent Bar from Employment as a Participant Employed Worker List First Degree Reckless Homicide, Felony Murder, First or Second Degree Intentional Homicide or Assisting Suicide; First, Second or Third Degree Sexual Assault; Sexual Exploitation a Therapist or Failure to Report by a Therapist; Physical Abuse of a Child Intentional Cause Great Bodily Harm; Abuse or Neglect of Vulnerable Adults, Patients or Residents (misdemeanor of felony); Abuse of a Penal Facility Resident; 9

10 Finding by a Governmental Agency of Neglect or Abuse of a Client or of a Child; Misappropriation of a Client s Property; Theft, Robbery, Identity Theft or Financial Card Transaction Crimes; Certain Drug Crimes; Battery (felony); or Medicaid Fraud. This list is a summary of the convictions that represent a permanent Bar from Employment as an IRIS participant hired caregiver. Please contact the program fort a complete list if needed. IRIS Plan Submission and Approval It is the policy of the IRIS Consultant Agency to review all Support and Service Plans (Plans) to ensure consistency and accuracy prior to approval, denial or modification. This policy discusses the development, submission and approval of the IRIS participant s Plan. The IRIS Consultant and the IRIS Consultant Agency assist the individual to choose which goods supports and services which will assist the participant to achieve his/her long term care related outcomes in a cost effective manner. Chosen goods and services are consistent with the principles of self-determination: including freedom, authority, responsibility, confirmation, and support. The IRIS Consultant provides a link between the goods and services that are being authorized and the participant s individual long term care outcomes. The individual has the opportunity to creatively build the life he or she wants by identifying formal and informal supports that develop meaningful relationships; promote community participation, meaningful employment, safe housing; and finding and keeping reliable community services and supports. IRIS Participant Business Development It is the IRIS Program policy to support participants efforts to create microbusinesses that help meet personal outcomes. The IRIS Program does not endorse, promote or market one businesses of any type over another. Participants may talk to their IRIS Consultant or call the IRIS Service Center for help to start a business. The Service Center may connect them to a Program Specialist who has experience helping people who are interested in generating income. The IRIS Program helps participants develop businesses by: Identifying how starting a business could meet personal outcomes. Providing information and support for participants to explore options and find resources related to starting a business. Helping participants to learn about funding options to create, develop and promote a business. This includes using IRIS Program funding, as well as other sources. Allowing the business information to be linked to the IRIS website. This includes the following information: o Name. 10

11 o Product. o Brief description. o Website. Mileage Reimbursement and Payment It is the IRIS Program policy to pay mileage costs at the rate established by the federal Internal Revenue Service rate. The IRIS Program applies this rate to an operator who uses his or her vehicle to transport participants as approved on the participant s Support and Service Plan. The IRIS mileage rate includes the cost of gasoline, oil, insurance and all other car maintenance costs. The mileage rate does not include costs such as: Wages paid to the driver. Services, for example an attendant or modification of the vehicle, needed to safely transport the participant. Mileage payment does not apply to: Transit authority provided services. Transportation to or from Medicaid State Plan Service Providers that are Forward Card covered services are not expenses that can be paid through the IRIS Program. The participant would contact the state s medical transportation contractor to schedule medical trips. The Internal Revenue Service mileage rate is published at least once a year. It is based on an annual study of the costs of operating a car. This website provides further information related to this rate for mileage reimbursement: The IRIS Program changes the mileage rate amount on the participant s Support and Service Plan whenever the Internal Revenue Service rates change. In-State Moves It is the policy of the IRIS Program to assist participants who voluntarily move within the State of Wisconsin in a manner to ensure freedom of choice in where to live in the community and also to assure continuity of needed supports and services. The In-State Moves policy matches DHS policy related to the Wisconsin Long Term Care Reform efforts and the gradual implementation of this reform on a county-by-county basis. The policy is intended to provide IRIS participants with complete information related to his or her decision to move. The participant is provided complete information on the impact of a move prior to making his or her decision to move. The policy does not require an IRIS participant to meet minimum stay requirement. Participants should contact their local ADRC for information on moves within Wisconsin. Involuntary Disenrollment 11

12 It is the IRIS Program policy to make reasonable efforts to help a participant to address and resolve issues in order to prevent an involuntary disenrollment whenever possible. The Wisconsin Department of Health Services (DHS) may involuntarily disenroll a participant from IRIS when: One or more of the conditions listed in this policy exist. Efforts to resolve the issues are not successful. If a participant is disenrolled, then the IRIS Consultant Agency works with the participant/guardian and the Aging and Disability Resource Center to transition the participant to other services as appropriate. Participants may be involuntarily disenrolled from IRIS when one or more of these conditions exist: The participant s health and safety is at risk. Purchasing authority is mismanaged. For example, this includes but is not limited to: o Fraud. o Misrepresentation or willful inaccurate reporting of information. The participant moves to an ineligible living arrangement. The participant resides in a hospital, skilled nursing facility or state institution for longer than three months after the admission date to the facility. Note that if the participant informs the IRIS Program one of these settings will be a permanent living setting, then this is considered a voluntary disenrollment. The participant receives a Fair Hearing Notice related to his or her appeal rights. Failure to comply with Medicaid functional or financial requirements. This includes participating in the minimal number of required Support and Service Plan reviews. Failure to pay a Medicaid cost share or to meet Medicaid spend-down obligations. The participant does not identify a need for any IRIS Program service or support. Policies related to the IRIS Self-Directed Personal Care Option IRIS-SDPC Access It is the policy of the IRIS Program to offer Self-Directed Personal Care services to eligible IRIS participants. The IRIS Consultant Agency strives to assist participants in choosing care options that best meet their individual needs and are most cost effective. The IRIS Consultant Agency assists participants in maximizing Medicaid first to cover their personal care needs. IRIS-SDPC Representatives 12

13 It is the policy of the IRIS Program to ensure that individuals participating in the IRIS Self Directed Personal Care program understand the ability to designate a representative to assist with self directing personal care and the role of this individual in performing these tasks. A representative may not select him/herself to be the IRIS-SDPC worker. IRIS-SDPC Worker Timekeeping It is the policy of the IRIS Program to ensure accurate timekeeping and reporting of the IRIS Self Directed Personal Care Registered Nurse (RN) and direct care worker time associated with the provision of IRIS-SDPC services. IRIS-SDPC Worker Training It is the policy of the IRIS Program that a participant or representative in the Self- Directed Personal Care (SDPC) program is responsible for hiring, training, and supervising workers providing SDPC services. Participants have access to additional training as needed provided by or through the SDPC RN to meet any additional qualifications that a participant or representative thinks are needed or desired. IRIS-SDPC Nurse Oversight It is the policy of the IRIS Program s Self-Directed Personal Care (SDPC) program to provide IRIS SDPC RN Oversight Visits every 60 days. These IRIS SDPC RN Visits may be waived by the participant 1 or representative with agreement from the prescribing physician and IRIS SDPC RN. A participant or representative who chooses the IRIS SDPC option is responsible for hiring, training, and supervising individuals providing his/her personal care services. IRIS-Self Directed Personal Care Involuntary Disenrollment It is the policy of the IRIS Program to involuntarily disenroll participants from the IRIS Self-Directed Personal Care program when one or more of the conditions listed in this policy exist and efforts to resolve the issues are not successful. Before involuntary disenrollment begins, reasonable effort is made to assist the participant to address all areas of concern. The The participant s health and safety is in jeopardy. Purchasing authority is mismanaged. This includes but is not limited to: Fraud. Misrepresentation Inadvertent or mistaken reporting The participant chooses to move to an ineligible living arrangement. Participant no longer meets eligibility criteria for IRIS-SDPC. Persons who are disenrolled are supported and are helped to gain access to agency based personal care as appropriate. 13

14 IV. Enrollment and Disenrollment A. Enrollment The MCO Managed Care Organization (MCO): an entity that Department has certified as having capacity for financial solvency and stability, and which has agreed under this contract to make the services in the benefit package available to members. shall comply with the following requirements related to enrollment: 1. Open Enrollment Conduct continuous open enrollment consistent with the resource center enrollment plan approved by the Department. All applicants shall be enrolled provided the individual meets eligibility A person is eligible for membership in the Partnership program if the person meets all eligibility requirements defined in the 2009 contract. requirements as defined in Article III.A., Eligibility A person is eligible for membership in the Partnership program if the person meets all eligibility requirements defined in the 2009 contract. Requirements. Practices that are discriminatory or that could reasonably be expected to have the effect of denying or discouraging enrollment are prohibited. 2. Voluntary Enrollment Enrollment in the MCO is a voluntary decision on the part of an applicant who is determined to be eligible. 3. Enrollment While Eligibility is Pending MCOs will negotiate, or make a good faith effort to negotiate, an MOU Memorandum of Understanding (MOU): an agreement detailing the actions of two parties under circumstances specified in the agreement. or other written agreement with all counties within their service areas that describes the circumstances in which the MCO will provide services to an individual who is functionally eligible but whose financial eligibility is pending. This agreement can be to serve individuals whose financial eligibility is pending at the time of initial enrollment or during a period of disenrollment due to loss of financial eligibility. The MOU shall include a process for the resource center to inform the individual, or their authorized representative, that if he/she is determined not to be eligible, he/she will be liable for the cost of services provided by the MCO. The MCO will not receive a capitation A single payment offered in exchange for a good or service, typically involving the transfer of risk from one party to the other. payment for an individual during the time eligibility is pending. If and when eligibility is established, the MCO will receive a capitation payment retroactively to the date indicated as the effective date of enrollment on the Enrollment Request form (F-00046), up to a maximum of ninety (90) calendar days of serving the person while eligibility was pending. The effective date of enrollment entered on the Enrollment Request Form shall also be no earlier than the date on which an individual or their authorized representative signs an explicit agreement (not just the enrollee s signature on the enrollment form) to accept services during the period of pending eligibility. 14

15 If the individual is determined not to be eligible, the MCO may bill that individual for the services the MCO has provided. The MCO shall pay providers for services which were provided and prior authorized by the MCO. MCO providers may not directly collect payment from the individual. The timelines for completion of the comprehensive assessment and member A person who meets the eligibility criteria and has signed an Enrollment Request.-centered plan shall be the same as those indicated in Article V, Care Management Individualized assessment and care planning, authorizing, arranging and coordinating service in the ISP and periodic reassessment and updates of the ISP. Care management also includes assistance in filing complaints and grievances and obtaining advocacy services.. B. Disenrollment 1. Processing Disenrollments The enrollment plan, developed in collaboration with the resource center and income maintenance agency, shall be the agreement between entities for the accurate processing of disenrollments. The enrollment plan shall ensure: a. That the MCO Managed Care Organization (MCO): an entity that Department has certified as having capacity for financial solvency and stability, and which has agreed under this contract to make the services in the benefit package available to members. is not directly involved in processing disenrollments although the MCO shall provide information relating to eligibility A person is eligible for membership in the Partnership program if the person meets all eligibility requirements defined in the 2009 contract. to the income maintenance agency. b. That enrollments and disenrollments are accurately entered on CARES so that correct capitation A single payment offered in exchange for a good or service, typically involving the transfer of risk from one party to the other. payments are made to the MCO; and c. That timely processing occurs, in order to ensure that members who disenroll have timely access to any Medicaid fee-for-service benefits for which they may be eligible, and to reduce administrative costs to the MCO and other service providers for claims processing. 2. MCO Influence Prohibited The MCO shall not counsel or otherwise influence a member A person who meets the eligibility criteria and has signed an Enrollment Request. due to his/her life situation (e.g., homelessness, increased need for supervision) or condition (e.g., person with profound mental retardation, person with AIDS) in such a way as to encourage disenrollment. 3. Types of Disenrollment a. Member A person who meets the eligibility criteria and has signed an Enrollment Request. Requested Disenrollment All members shall have the right to disenroll from the MCO without cause at any time. 15

16 If a member expresses a desire to disenroll from the MCO, the MCO shall provide the member with contact information for the resource center; and, with the member s approval, may make a referral to the resource center for options counseling. If the member chooses to disenroll, the member will indicate a preferred date for disenrollment. The date of voluntary disenrollment cannot be earlier than the date the individual last received services authorized by the MCO. The resource center will notify the MCO and income maintenance agency that the member is no longer requesting services and the member s preferred date for disenrollment as soon as possible but this notification will be no later than one (1) business day following the member s decision to disenroll. The income maintenance agency will process the disenrollment. The MCO is responsible for covered services it has authorized through the date of disenrollment. b. Disenrollment when member is no longer accepting services. The MCO is responsible to monitor whether the services authorized for a member are received and to make good faith efforts to maintain contact with the member. If the member is no longer accepting services authorized by the MCO, other than care management Individualized assessment and care planning, authorizing, arranging and coordinating service in the ISP and periodic reassessment and updates of the ISP. Care management also includes assistance in filing complaints and grievances and obtaining advocacy services. efforts to contact the member, and the MCO is unable to determine the reason the member is not accepting services, the MCO shall send a certified letter to the member fourteen (14) calendar days prior to reporting the refusal to accept services to the Department. Fourteen (14) calendar days after the MCO has sent the certified letter to the member, if the member is still refusing to accept services, the MCO shall send a request for disenrollment due to refusal to accept services to the Department which includes: a disenrollment form, the last date on which services, other than care management, were provided to the member, a copy of the certified letter to the member and relevant case notes. The Department contract coordinator will establish a disenrollment date. The disenrollment date established shall be no later than the thirtieth (30th) calendar day after the member last received services other than care management. The Department contract coordinator shall inform the income maintenance agency that as of that date the member is no longer requesting services. The income maintenance agency will process the disenrollment. The MCO is responsible for covered services it has authorized through the date of disenrollment. c. Disenrollment Due to Loss of Eligibility A person is eligible for membership in the Partnership program if the person meets all eligibility requirements defined in the 2009 contract. i. The member will be disenrolled if he/she loses eligibility. The MCO is required to notify the income maintenance agency when it becomes aware of a change in a member s situation or condition that might result in loss of eligibility. Members lose eligibility when the member: a) Fails to meet functional eligibility requirements; 16

17 b) Fails to meet financial eligibility requirements; c) Fails to pay, or to make satisfactory arrangements to pay, any cost share amount due the MCO after a thirty (30) calendar day grace period; d) Initiates a move out of the MCO service area as defined in Article XIX.B., Geographic Coverage Where Enrollment Is Accepted, page 221; e) Dies; f) Is incarcerated; or g) Is admitted to an Institution for Mental Disease (IMD) and is no longer eligible for Medicaid. ii. In addition to the reasons listed above, Partnership and PACE A Program of All-inclusive Care for the Elderly, members may make choices below, that result in the loss of eligibility. When a member makes one of the following choices, the MCO will inform the income maintenance agency that the member is no longer requesting services and the income maintenance agency will process the disenrollment: a) Chooses a primary care physician who is not in the MCO provider network; b) Chooses to disenroll from, or if newly Medicare eligible chooses not to enroll in, any part(s) of Medicare for which s/he is eligible; or c) For Partnership and PACE only, chooses to disenroll from, or if newly eligible chooses not to enroll in, the MCO s Special Needs or PACE Plan. iii. When the MCO provides information to the income maintenance agency that has the potential for loss of eligibility due to items (i)(a-g) and (ii)(a-c), the income maintenance agency will determine whether the person is ineligible and, if appropriate, process the disenrollment. When the MCO notifies income maintenance, the MCO will also inform the resource center. The resource center will: a) If applicable, attempt to contact the member to offer disenrollment counseling. b) If applicable, attempt to determine whether the member understands the changes in circumstances or the choice that results in loss of eligibility and whether the member wants to and is able to take some action in order to remain enrolled. If the member wants to change a choice he/she has made in order to remain enrolled, the resource center will contact the income maintenance agency in an attempt to avert the disenrollment. The MCO is responsible for covered services it has authorized through the date of disenrollment. d. MCO-Requested Disenrollment When requested by the MCO, a member may be disenrolled with the approval of the Department and in accordance with the following procedures: i. The MCO s intention to disenroll a member shall be submitted to the Department for a decision and shall be processed in accordance with (iii) below. 17

18 ii. The MCO may request a disenrollment if: a) The member has committed acts or threatened to commit acts that pose a threat to the MCO staff, subcontractors or other members of the MCO. This includes harassing and physically harmful behavior. b) The MCO is unable to assure the member s health and safety because: The member refuses to participate in care planning or to allow care management contacts; or The member is temporarily out of the MCO service area. iii. MCO-Requested Disenrollment Procedure. a) The MCO shall submit to the Department a written request to process the disenrollment, which includes documentation of the basis for the request, a thorough review of issues leading to the request and evidence that supports the request. b) At the time the request is made to the Department, the MCO shall notify the member of the request for disenrollment, including a copy of the request and all supporting documentation, and make any appropriate referrals to adult protective services or other crisis services. c) The Department contract coordinator will consult with the MCO including problem-solving, alternative steps for providing services, assistance in managing a difficult case, and recommendations of outside experts who might be able to assist in resolving issues without disenrollment. d) The Department contract coordinator will, within fifteen (15) business days from the date the Department has received all information needed for a decision, notify the MCO and the member whether the request for disenrollment is approved, disapproved or that a process to consult and problem-solve with the MCO and member will be initiated. e) If a disenrollment request is approved: 1) The Department contract coordinator will set a disenrollment date and notify the income maintenance agency to process the disenrollment. 2) The income maintenance agency will process the disenrollment in CARES. A disenrollment date due to inability to assure health and safety will be set according to adverse action logic. A disenrollment date due to member acts that pose a threat will be set and processed immediately. 3) The MCO shall is responsible for covered services it has authorized through the date of disenrollment. f) If a disenrollment request is not approved, the MCO shall continue to serve the member. g) If a disenrollment request results in the Department contract coordinator deciding to consult 18

19 and problem-solve with the MCO and member: 1) The Department contract coordinator shall plan that process with the MCO. 2) The MCO shall cooperate with the contract coordinator s efforts to problem-solve. 3) If the Department contract coordinator determines that the effort to consult and problem-solve has been unsuccessful, the disenrollment will be approved. 4. Continuity of Services a. Until the date of disenrollment, members are required to continue using the MCO s providers for services in the benefit package. The MCO shall continue to provide all needed services in the benefit package until the date of disenrollment. b. The MCO shall assist participants whose enrollment ceases for any reason in obtaining necessary transitional care through appropriate referrals and by making member records available to participant s new providers with appropriate releases; and (if applicable) by working with the Department to reinstate participants benefits in the Medicaid system or other programs, if eligible. C. Enrollment, Disenrollment, and Re-Enrollment Process 1. Monitoring by the Department The MCO Managed Care Organization (MCO): an entity that Department has certified as having capacity for financial solvency and stability, and which has agreed under this contract to make the services in the benefit package available to members. shall permit the Department to monitor enrollment and disenrollment practices of the MCO under this contract. 2. Interactions with Other Agencies Related to Eligibility A person is eligible for membership in the Partnership program if the person meets all eligibility requirements defined in the 2009 contract. and Enrollment a. The MCO shall fully cooperate with other agencies and personnel with responsibilities for eligibility determination, eligibility re-determination, and enrollment in the MCO. This includes but is not limited to the resource center, income maintenance and the enrollment consultant if any. b. The MCO shall participate with these agencies in the development and implementation of an enrollment plan that describes how the agencies will work together to assure accurate, efficient and timely eligibility determination and re-determination and enrollment in the MCO. The enrollment plan shall describe the responsibility of the MCO to timely report known changes in members level of care, financial and other circumstances that may affect eligibility, and the manner in which to report those changes. c. The MCO shall jointly develop with the resource center protocols for disenrollments, per contract specifications. 19

20 d. The MCO shall support members in meeting Medicaid reporting requirements as defined in s. DHS (6) Wis. Admin. Code. Members are required to report changes in circumstances to income maintenance within ten (10) calendar days of the occurrence of the change. 3. Discriminatory Activities Enrollment continues as long as desired by the eligible member A person who meets the eligibility criteria and has signed an Enrollment Request. regardless of changes in life situation or condition, until the member voluntarily disenrolls, loses eligibility, or is involuntarily disenrolled according to terms of this contract. The MCO may not discriminate in enrollment and disenrollment activities between individuals on the basis of life situation, condition or need for long-term care or health care services. The MCO shall not discriminate against a member based on income, pay status, or any other factor not applied equally to all members, and shall not base requests for disenrollment on such grounds. 4. Dates of Enrollment and Disenrollment The enrollment date for an otherwise eligible individual can be set for the first day of the month in which she or he achieves the age specified in Article XIX, MCO Specific Contract Terms, Section D, except for PACE A Program of All-inclusive Care for the Elderly, in which the individual must have achieved the age of 55 prior to enrollment. The MCO shall begin serving individuals as of the effective date of enrollment recorded in CARES. The MCO is responsible to monitor ForwardHealth interchange enrollment reports for discrepancies in persons the MCO considers enrolled. a. The Department will consider requests for correcting enrollment dates in the past if the MCO has submitted to the Department monthly enrollment discrepancy reports on a form approved by the Department. The purpose of these reports is to identify discrepancies between the MCO s enrollment as documented in ForwardHealth interchange and the MCO s internal enrollment records. Such reports shall demonstrate that the MCO has taken steps to resolve discrepancies with the local resource center and income maintenance agency. If there is a discrepancy between the enrollment in ForwardHealth interchange and the MCO s internal enrollment records, the enrollment may be corrected as follows: i. If the discrepancy between ForwardHealth interchange and the MCO s internal records first occurred less than three (3) calendar months in the past, the enrollment start date may be corrected by income maintenance if the MCO has documented evidence that during the time in question the individual was functionally and financially eligible and the MCO was providing services to the individual. ii. If the discrepancy between ForwardHealth interchange and the MCO s internal records first occurred more than three (3) calendar months in the past, the enrollment start date may be corrected by the Department contract coordinator if the: 20

21 a) Discrepancy is identified on the MCO s monthly enrollment discrepancy reports no more than the last day of the month three calendar months after the discrepancy first occurred; and b) MCO provides documented evidence that during the time in question the individual was functionally and financially eligible and the MCO was providing services to the individual. b. A member-requested disenrollment shall be effective on the date indicated on the disenrollment form signed by the member or the member s authorized representative. The effective date cannot be earlier than the date the individual last received services authorized by the MCO. c. An MCO-requested disenrollment shall be effective on the date approved by the Department as the disenrollment date, but no later than the first day of the second month following the month in which the MCO filed the request. In order to allow time for the member to appeal an MCO-requested disenrollment decision from the Department, the Department shall retain the disenrollment form for fourteen (14) calendar days after the MCO and member have been notified by the Department of the decision to approve the disenrollment before forwarding it to the Medicaid fiscal agent or income maintenance agency to process the disenrollment. If the member files an appeal of an MCO-requested disenrollment decision to the DHA fair hearing process within fourteen (14) calendar days, disenrollment shall be delayed until the appeal is resolved. d. If the member dies, the date of disenrollment shall be the date of death. e. Loss of eligibility resulting in disenrollment shall have the effective dates as identified in i. through v. below. i. If an MCO member is planning to or has moved out of the MCO service area, the date of disenrollment shall be the date the move occurs. ii. If an individual has been incarcerated, the MCO shall report this change in circumstance to the income maintenance agency as this change may result in a loss of Medicaid eligibility. The MCO disenrollment date shall be the date of incarceration. iii. If a person who is at least 21 years old and less than 65 years old has been admitted to an IMD, the MCO shall report this change in circumstance to the income maintenance agency as this change may result in a loss of Medicaid eligibility. The MCO disenrollment date shall be the date of admission to the IMD. iv. If an MCO member loses eligibility for a reason other than those identified in (i) through (iii) above, the last day of eligibility shall be set according to adverse action logic in CARES. The disenrollment date will be the date eligibility ends. The MCO shall continue to provide services to the member through the date of disenrollment. 21

22 B. Provision of Services in the Family Care Benefit Package 1. Services for Members at the Nursing Home Level of Care A level of care provided in a nursing facility and reimbursable under the Medicaid program. The MCO Managed Care Organization (MCO): an entity that Department has certified as having capacity for financial solvency and stability, and which has agreed under this contract to make the services in the benefit package available to members. shall promptly provide or arrange for the provision of all health and long-term care services in the benefit package, consistent with the member A person who meets the eligibility criteria and has signed an Enrollment Request.-centered plan (MCP Member Centered Plan (MCP): a record that documents a process by which they member and the interdisciplinary team (IDT) further identify, define and prioritize the member's outcomes initially identified in the Comprehesive Assessment and identify, define and prioritize quality of life outcomes important to the member.) described in Article V.C., Member A person who meets the eligibility criteria and has signed an Enrollment Request.-Centered Planning Process, page 48. Coverage of services identified in each individual member s MCP must be consistent with the definition of "Services Necessary to Support Outcomes, in Article I, Definitions. Family Care services include all of the following: a. The home and community-based waiver services defined in Addendum XIII.A.; b. The long term care Medicaid State Plan Services identified in Addendum XIII.B.; and c. Any cost-effective health care services the MCO substitutes for a long term care service in the Medicaid State Plan identified in Addendum XIII.B. 2. Services for Members at the Non-Nursing Home Level of Care Family Care The following policies apply to Family Care members who are at the non-nursing home level of care: a. The MCO shall promptly provide or arrange for the provision of all services in the benefit package, consistent with the Member-Centered Plan, and as defined in Addendum XIII.B. b. If a member at the non-nursing home level of care is admitted to a nursing facility or ICF-MR, the LTC Functional Screen must be updated by a certified screener within ten (10) business days of admission to determine whether changes in the member s long-term health and care needs are consistent with the nursing home level of care. The Member-Centered Plan must be updated based upon review of the changes in care needs and the preferences of the member. The member must be rescreened to determine level of care within sixty (60) calendar days following discharge from the nursing home or ICF-MR. c. If a member at the non-nursing home level of care enrolls when residing in a nursing facility or ICF-MR, the LTC Functional Screen must be updated by a certified screener within three (3) business days of enrollment to determine the appropriate level of care. If the member remains at the non-nursing home level of care the member and nursing facility 22

23 must be notified that this service is not in the member s benefit package. If the MCO will terminate the nursing home service, it must provide appropriate notice in accordance with Article XI.D., Notice of Action and Appeal Rights. 3. Services for Members Eligible as Grandfathers Family Care Members eligible as grandfathers have access to the full Family Care benefit package and all rights of membership in the MCO. The MCO shall promptly arrange for the provision of all services in the benefit package consistent with the member-centered plan. If the care needs of an individual eligible for Family Care as a grandfather increase, the individual must be rescreened to determine whether the individual meets the nursing home or non-nursing home level of care. 23

24 Wisconsin s Self-Directed Supports Program IRIS Participant Appeal Rights Participant Rights As a participant of IRIS you have rights specific to the IRIS program and under Wisconsin State law. If you need assistance to understand this notice and your rights you may contact: The IRIS Participant Services Specialist, who can inform you of your rights, attempt to informally resolve your concern, and/or assist you in filing an appeal. He or she cannot represent you at a State Fair Hearing. You can contact an IRIS Participant Services Specialist at OR The following ombudsman agencies may be able to provide you with free assistance. These agencies advocate for IRIS program participants. For persons ages 18-59: Disability Rights Wisconsin (formerly Wisconsin Coalition for Advocacy): Madison Office 131 W. Wilson Street, Suite 700 Madison, Wisconsin Telephone: Toll Free: Fax: Rice Lake Office 217 W Knapp Street Rice Lake, WI Telephone: Toll Free: Fax: Milwaukee Office 6737 West Washington St. Suite 3230 Milwaukee, Wisconsin Telephone: Toll Free: Fax: TTY number for all three offices: Translation Services If you need this form in another language, Braille or large print, please call the IRIS Participant Services Specialist at Interpreter and translation services are available free of charge. 24

25 Appealing this Decision If you disagree with the decision in this Notice of Action, you have the right to request a State Fair Hearing. 1. To file for a request for a fair hearing, you must complete the enclosed State Fair Hearing request form and send it to the Division of Hearing and Appeals, along with a copy of this notice to: IRIS Request for Fair Hearing Wisconsin Division of Hearing and Appeals 5005 University Ave, Suite 201 PO Box 7875 Madison, WI OR Fax to A hearing will be scheduled with the State of Wisconsin, Division of Hearing and Appeals. The hearing will consist of a 15 minute teleconference with an independent judge which will give you an opportunity to state your reason for appeal. You may have someone present with you such as an advocate, friend, family member or witness. You may also present evidence at the hearing. This conference will also be attended by an IRIS representative. The Administrative Law Judge will hear your case and render a decision within 90 days of the hearing. 3. You should file your appeal as soon as possible. To meet the deadline for your appeal, it must be postmarked or faxed within forty-five (45) days of receipt of this notice of action. Continuing services during an appeal You have the right to request that the service(s) effected by this notice remain in place during the appeal. If you request a Fair Hearing before the effective date of the IRIS Notice of Action, you can ask that your services remain in place until after the results of the fair hearing are known. You must let the IRIS Consultant Agency know of your request to continue services within 10 days of receiving this notice by contacting a Participant Services Specialist at: Please note that you may be responsible for repaying the cost of the service(s) if you lose the appeal; however, you may not be required to repay this cost if it would be a significant and substantial financial burden on you. Copies of Your Records You or your legal representative has a right to a free copy of your records relevant to your appeal. To request copies, please contact a Participant Services Specialist at Hearing Decision Once a hearing decision is made, you will be sent a Certification of Administrative Action, which is the final ruling rendered by the Division of Hearings and Appeals. 25

26 Wisconsin s Self-Directed Supports Program Complaints and Grievances It is IRIS policy to protect your rights by having a process for you to express and resolve complaints about any IRIS matter. You can do this in several different ways. When you are dissatisfied with IRIS service or communication, you may submit an Informal Complaint or a Formal Grievance. IRIS encourages you to begin by discussing your concerns or complaints with your IRIS Consultant. What is an Informal Complaint? An Informal Complaint is when you discuss concerns or issues directly with IRIS staff. You do not have to make an Informal Complaint before filing a Formal Grievance. When Can I Make an Informal Complaint? An Informal Complaint can occur: 1. Any time before or during a formal grievance procedure as an additional way to resolve the complaint; 2. During a formal grievance, if all parties agree, the formal process may be suspended and an Informal Complaint process started. Applicable time limits may be postponed to allow the parties to attempt an informal resolution of the complaint. The IRIS Participant Services Specialist conducting the review facilitates this process. How Do I Make an Informal Complaint? Follow these steps for making an Informal Complaint: 1. Tell an IRIS employee that you have a complaint. 2. The IRIS employee will respond with one or more of the following methods: a. An attempt to resolve the complaint; b. Individual communication with the parties involved; and/or c. Consultation with a Mentor or Participant Services Specialist for help with the process as desired. 3. If the issue is resolved, the IRIS employee documents it in case notes; 4. If the issue is not resolved, you may choose to file a Formal Grievance; 5. You or the IRIS employee informs the Participant Services Specialist of the Formal Grievance request; 6. You may choose to return to the Informal Complaint process to resolve the matter at any point during the Formal Grievance process. What is a Formal Grievance? A Formal Grievance can be oral or written. It is an official, documented way to file a complaint. You can file a formal grievance with your IRIS Consultant. A Formal Grievance has certain time limits for submission and review. 26

27 How Do I Make a Formal Grievance? 1. Presentation: a. You submit a Formal Grievance to IRIS after the occurrence (the reason for the complaint). b. The Formal Grievance must be documented. c. The Formal Grievance Form must be completed and sent to the IRIS Consultant Agency in order to track the grievance. You may complete it or ask an IRIS employee to complete it. You may also request to review the form if an IRIS employee completes it. 2. Inquiry/Investigation a. When the IRIS Consultant Agency receives the Formal Grievance Form, an IRIS Participant Services Specialist will contact you. The Participant Services Specialist will listen to your concerns and make recommendations to resolve the issues. b. The Participant Services Specialist will tell you how you may file a formal grievance through a specific, orderly process. The Participant Services Specialist may also choose to initiate the grievance directly with the Department of Health Services directly for a final review. c. When the Participant Services Specialist has all the necessary information, he/she will: i. Review the information to see if the grievance can be supported; ii. Describes the facts and basis for this determination; iii. Describes the actions/recommendations for resolution (and a iv. timeline if appropriate); and Provides a copy of the Formal Grievance Form to you, the appropriate IRIS manager, administrator, and other relevant staff. 3. Grievance Review Process a. The IRIS Consultant Agency Program Manager: i. Reviews the Formal Grievance Form and any supporting information; ii. iii. iv. Makes a decision that is the official position of the IRIS program; Presents the decision to you either via phone, personally or by mail; and Includes a notice of how to request another review within 14 days of decision if you want to pursue further review. b. Department of Health Services (DHS) Administrative Review i. An Administrative review is done by the Wisconsin Department of Health Services (DHS); ii. iii. iv. The IRIS Consultant Agency Program Manager submits the original written report and written decision to DHS; The Bureau of Long-Term Care IRIS Manager, Director, or designated administrator independently conducts a review then renders a decision and report within 30 days of submission; and If you disagree with the State Administrative Review, you can request a final state review within 14 days of the decision. 27

28 c. Final State Review i. The Division Administrator receives all relevant grievance materials for review within 30 days; ii. You are presented with a decision and notice that there is no further administrative appeal except bringing action in court. 4. Action in Court You may take the Formal Grievance to court at any time during or after the grievance process. Exceptions This does not apply to complaints or grievances from service providers. Who Can Help Me? If you would like assistance with the complaint or grievance process, you may contact IRIS or any of the following independent agencies: IRIS Participant Services 1 South Pinckney Street, Suite 320 Madison, WI info@wisconsin-iris.com Persons with developmental disabilities or physical disabilities may contact Disability Rights Wisconsin at the nearest office: Disability Rights Wisconsin Madison Office Milwaukee Office 131 W. Wilson Street, Suite W. Washington Street, Suite 3230 Madison, WI Milwaukee, WI Telephone: Telephone: Fax: Fax: Toll-Free: Toll-Free: TTY: TTY: Rice Lake Office 217 W. Knapp Street Rice Lake, WI Telephone: Fax: Toll-Free: TTY:

29 F. MCO Grievance and Appeal Process The MCO Managed Care Organization (MCO): an entity that Department has certified as having capacity for financial solvency and stability, and which has agreed under this contract to make the services in the benefit package available to members. grievance and appeal process must meet the following requirements. 1. Assistance in Filing a Grievance or Appeal The MCO must designate a Member A person who meets the eligibility criteria and has signed an Enrollment Request. Rights Specialist (See Article X.E) who is responsible for assisting members when they are dissatisfied. The MCO Member Rights Specialist must offer assistance to members in submitting grievances or appeals. The Member Rights Specialist assigned to assist a member in a specific circumstance may be responsible for scheduling and facilitating meetings, but may not be a member of the MCO grievance and appeal committee that considers that specific circumstance. The Member Rights Specialist may not represent the MCO at a hearing of the MCO grievance and appeal committee, in a Department Review or at a State Fair Hearing. The MCO must attempt to resolve issues and concerns without formal hearings or reviews whenever possible. When a member presents a grievance or appeal, the interdisciplinary team and the Member Rights Specialist must attempt to resolve the issue or concern through internal review, negotiation, or mediation, if possible. a. The interdisciplinary team is the first level of support when a member is dissatisfied. Unless contrary to the expressed desire of the member, the IDT Interdisciplinary Team (IDT): the individuals identified by the MCO to provide care management services to members. will attempt to resolve the issue through internal review, negotiation, or mediation, if possible. If the IDT cannot resolve the issue, it will refer the member to the Member Rights Specialist or offer assistance to the member or other authorized person who wishes to file a grievance or appeal. b. The Member Rights Specialist will assist the member or other authorized person to understand the grievance or appeal options and help to complete any required paperwork to file the grievance or appeal. At the same time, unless contrary to the expressed desire of the member, the Member Rights Specialist will attempt to resolve issues through internal review, negotiation, or mediation. c. The MCO must provide members with any reasonable assistance in completing forms and taking other procedural steps. This includes, but is not limited to, providing interpreter services and toll-free numbers that have adequate TTY/TTD and interpreter capability. d. The MCO must allow members to involve anyone the member chooses to assist in any part of the grievance and appeal process, including informal negotiations. 2. Grievance and Appeal Decision Makers The MCO must ensure that the MCO grievance and appeal committee is comprised of: 29

30 a. Individuals who were not involved in any previous level of review or decision making; b. At least one member or guardian, or one person or guardian of a person, who meets the functional eligibility A person is eligible for membership in the Partnership program if the person meets all eligibility requirements defined in the 2009 contract. for one of the target populations served by the MCO. This person must be free from conflict of interest regarding his/her participation in the governing board/committee; c. Individuals who, if deciding any of the following, are health care professionals possessing the appropriate clinical expertise, as determined by the Department, in treating the member s condition or disease: i. An appeal of an action that is based on lack of medical necessity. ii. A grievance regarding denial of expedited resolution of an appeal. iii. A grievance or appeal that involves clinical issues. 3. Confidentiality The MCO shall assure the confidentiality of any member who uses the grievance and appeal process is maintained, including: a. Assuring that all members of the grievance and appeal committee have agreed to respect the privacy of members who bring a grievance or appeal before the committee and have received appropriate training in maintaining confidentiality and; b. Offering a member the choice to exclude any consumer representatives under Article XI. F.2.b from participation in a hearing on a matter the member is bringing before the grievance and appeal committee. 4. MCO Process for Medicaid Grievances a. Authority to File A member or a member s legal representative or anyone acting on the member s behalf with the member s written permission may file a grievance with the MCO. b. Timing of Filing A grievance can be filed with the MCO at any time. c. Acknowledgement of Grievance Receipt The MCO must acknowledge in writing receipt of each grievance. The acknowledgement must be provided to the member and the member s representative if applicable and must be mailed or hand delivered within five (5) business days of the date of receipt of the grievance. (See Article XI.F.4.a. for a description of individuals who may be authorized to submit a grievance.) d. Procedures 30

31 i. A grievance may be filed either orally or in writing with the MCO. In order to establish the earliest possible filing date for the grievance, the MCO must document all grievances whether received orally or in writing. ii. Unless contrary to the expressed desire of the member, the MCO must attempt to resolve all grievances through internal review, negotiation, or mediation. iii. A grievance that cannot be resolved through internal review, negotiation, or mediation, must be reviewed by the MCO grievance and appeal committee. iv. A member who files a grievance must be given the right to appear in person before the MCO grievance and appeal committee or its designee. v. The MCO grievance and appeal committee must issue a written decision on a grievance as expeditiously as the member s situation and health condition require, but no later than twenty (20) business days after the date of receipt of the grievance. vi. The MCO grievance and appeal committee must mail or hand deliver written notice of its grievance decision to the member and the member s representative if applicable. The written decision must include the results and date of the decision. For decisions not wholly in the member s favor the notice must include the right to request a Department Review and how to do so. 5. MCO Process for Medicaid Appeals a. Authority to File i. A member or a member s authorized representative or anyone acting on the member s behalf with the member s written permission may file an appeal with the MCO regarding any MCO action, with the exception of the actions specified in Article XI.F.5.a.ii. or iii. ii. There is no MCO level appeal of loss of functional or financial eligibility under s (1)(a), Wis. Stats. Or reduction in level of care; however, a member or member s authorized representative or anyone acting on the member s behalf with the member s written permission may request a State Fair Hearing regarding loss of functional eligibility or reduction in level of care. The MCO shall provide for functional eligibility re-screening by a different screener within ten (10) calendar days of a request by a member or a member s authorized representative. iii. There is no right to an MCO level appeal of a decision that has been issued by the MCO grievance and appeal committee or an administrative law judge as the result of a State Fair Hearing. b. Timing of Filing An appeal must be filed within forty-five (45) calendar days of the date of receipt of the notice of action being appealed. c. Acknowledgement of Appeal Receipt 31

32 The MCO must acknowledge in writing receipt of each appeal. The acknowledgement must be provided to the member and the member s representative if applicable and must be mailed or hand delivered within five (5) business days of the date of receipt of the appeal. See Article XI.F.5.a.i. for a description of individuals who may be authorized to submit an appeal. d. Procedures i. An appeal may be filed either orally or in writing with the MCO. However, for standard appeals, the individual must follow an oral filing with a written, signed appeal. In order to establish the earliest possible filing date for the appeal, the MCO must document all appeals whether received orally or in writing. The MCO will process oral requests for expedited appeals without requiring further action of the member. ii. Unless contrary to the expressed desire of the member, the MCO must attempt to resolve all appeals through internal review, negotiation, or mediation. iii. An appeal that cannot be resolved through internal review, negotiation, or mediation, must be reviewed by the MCO grievance and appeal committee. iv. A member who files an appeal must be given the right to appear in person before the grievance and appeal committee. v. The MCO grievance and appeal committee must make a decision on an appeal as expeditiously as the member s situation and health condition requires. The MCO must mail or hand deliver notification of the decision with an effective date of implementation of the decision not less than fifteen (15) calendar days from the date of the decision. a) Standard appeal resolution. Unless the member requests expedited resolution, for Family Care and Partnership the MCO must issue a written decision on the appeal no later than twenty (20) business days after the date of receipt of the appeal. This timeframe for resolution may extend the appeal by up to ten (10) business days, up to a total of thirty (30) business days if the member requests the extension or if the MCO determines there is need for additional information and that the delay is in the member s interest. For an extension not requested by the member, the MCO must mail or hand deliver to the member (and the Department if requested) written notice of the reason for the delay. b) Expedited appeal resolution. Members may request an expedited resolution if the standard resolution timeframe could seriously jeopardize the member s life, health or ability to attain, maintain, or regain maximum function. The MCO must make reasonable efforts to give the member prompt oral notice of approval or denial of the request for expedited resolution and a written notice within two (2) calendar days. If the MCO denies a request for expedited resolution it must reach a decision on the appeal within the standard timeframe. If the request for expedited resolution meets the criteria in this subsection, the MCO must make a decision on the appeal as expeditiously as the member s health condition requires, but not more 32

33 than seventy-two (72) hours after the date of receipt of the appeal. The timeframe for an expedited appeal may be extended by an additional eleven (11) days up to a total of fourteen (14) calendar days if the member requests the extension or if the MCO determines there is need for additional information and that the delay is in the member s interest. For an extension not requested by the member, the MCO must mail or hand deliver to the member (and the Department if requested) written notice of the reason for the delay. In an expedited review, the MCO must inform the member of the limited time available to present evidence and allegations of fact or law. The MCO must ensure that punitive action is not taken against a member or provider who either requests an expedited resolution or supports a member s request for an expedited resolution. vi. The MCO grievance and appeal committee will make its determinations related to authorization of services based on whether services are necessary to support outcomes as defined in Article I, Definitions. vii. The MCO grievance and appeal committee must immediately send written notice of its disposition of the appeal to the member and, if applicable, the member s authorized representative. The written resolution notice must include the results and date of the decision. For decisions not wholly in the member s favor the notice must include the right to request a State Fair Hearing and how to do so and the right to continue to receive benefits pending a hearing and how to request the continuation of benefits, and that the member may be liable for the cost of any continued benefits if the MCO s decision is upheld in the State Fair Hearing. 33

34 WISCONSIN FAMILY CARE PROGRAM RESOURCE ALLOCATION DECISION METHOD 1. What is the need, goal, or problem? The member and team staff together identify the core issue. To do so, keep asking, Why? Whose problem is it? Does the member see it as a problem, or do (some) staff? If the member/family is asking for an item or service, explore the reasons for the request. 2. Does it relate to the person s assessment, service plan and desired outcomes? Desired outcomes are those in FC s mission and the person s assessment and service plan. Is it essential to the person s health or safety? (What would happen if the need weren t met?) How does it relate to ADLs or IADLs, independence and other desired outcomes in the plan? Whose responsibility is it to address this particular need or problem? 3. How could the need be met? What s been tried in the past? How do people usually address similar needs? How could the member help solve this need/problem? What ideas does s/he have? Could adaptations in people, environment, or equipment help member meet this need? Can s/he afford to pay for this, or share cost if appropriate? What informal resources (family, friends, volunteers) might be able to help? What other community resources (e.g., thrift stores, senior center, organizations) could be sought? What options could CMO consider (e.g., loaner program, rental vs. purchase, incremental goals)? 4. Are there policy guidelines to guide the choice of option? If yes, those should be followed Which option does the member (and/or family) prefer? 6. Which option(s) is/ are the most effective and cost-effective in meeting the desired outcome(s)? Effective means it works to achieve a desired outcome. 2 Consider both short-term and longterm outcomes. Cost effective means effectively achieving a desired outcome (meeting a need) at reasonable cost and effort. Reasonable alternatives are those that: - Would probably solve the problem, i.e., are effective in meeting the desired outcome for peers (persons with similar needs). - Would not have significant negative impact on desired outcomes. Note that cost effective is always tied to outcomes, and that it does not always mean least expensive or inexpensive. How will we measure success/ outcomes in order to gauge cost-efficiency? Is member committed to using the suggested service/product? 7. Explain, Dialogue, Negotiate Consumer can appeal CMO s decision. 1 If related policies seem to lead to unacceptable conclusions in a particular case, the policy needs to be corrected or amended with criteria to allow exceptions. Please refer to management for follow up with DHFS. 2 Desired outcomes are the Family Care consumer outcomes (page 2) as prioritized by the individual and family. 34

35 Family Care Outcome Statements I decide where and with whom I live I make decisions regarding my supports and services I decide how I spend my day I have relationships with family and friends I do things that are important to me I am involved in my community My life is stable I am respected and treated fairly I have privacy I have the best possible health I feel safe I am free from abuse and neglect Updated May,

36 Using the Resource Allocation Decision Method A. PROGRAM GUIDELINES ARE PRIMARY This Resource Allocation Decision Method is to indicate choices among allowable options under Family Care guidelines. Those guidelines are primary. So, for example: Program Responsibilities: The CMO does not have to provide services that are outside its benefit package or outside its area of responsibility. The CMO cannot violate local, state, or federal laws and regulations. The CMO cannot refuse to provide a requested service if doing so would have significant negative outcome. Program Entitlement: The CMO cannot refuse to enroll someone because doing so would not be costeffective for the program. The CMO can only ask for cost-sharing when allowed by program policies. B. CHOICE OF RESIDENCE 1. All decisions should be based on Family Care outcomes as prioritized and expressed by the individual. Doug is a 23 year old man with moderate mental retardation who has lived all his life in institutions. He is ambulatory and non-verbal. He has limited sign language. He joined the CMO a month ago. Before doing personal futures planning with Doug, his guardian was advocating that he live alone, as he had behavior problems in the institution that required an array of interventions by staff. The guardian also thought Doug would like a job. The CMO network includes several small CBRFs on transportation routes and near to several potential job sites; placement there would facilitate supported employment for Doug. The personal futures planning process helped everyone discover Doug s individual outcomes. It turned out that Doug s behavioral symptoms communicated his dislike for institutional-like routines, but that he generally prefers to be with other people. He preferred to live with others in a family atmosphere in a residential neighborhood where he could rake the lawn and play ball in the yard and just hang around. He did not want to live alone. He wanted a dog. He was much more interested in this sort of daily living than in vocational endeavors /1/99, DHFS/OSF/CDSD, pg. 3

37 The personal futures planning helped Doug s team staff understand his priorities better. With Doug and his guardian, they looked for cost-effective ways to help Doug meet his outcomes. They found a residential provider to set up an adult family home for Doug and two other DD people in a tree-lined residential neighborhood. Doug helped with yard work and gardening and snow-shoveling for the house and even for some neighbors. With some help, Doug could walk the household dog around the neighborhood. His employment choice was volunteering part-time at the Humane Society; this suited his interests better than a full-time paid job at a packaging plant. 2. Long Term Residential Setting Considering cost-effectiveness in meeting desired outcomes is more than just considering costs. Long term nursing home placement could be appropriate or not appropriate depending on the impact on this person s desired outcomes. a. Sara s needs have increased to where she needs extensive hands-on personal and health care assistance in her home. Her in-home services now cost more than nursing home services would cost. Sara prefers to be around people, and feels increasingly isolated in her apartment. She is interested in finding a nursing home that she d like to move to. In keeping with Family Care s general policy of community-based services, the CMO is responsible for exploring all reasonable efforts to help Sara stay in her home or to help her find an alternative community residence. Team staff may determine that a nursing home would be the most cost-effective way to meet Sara s needs. In this case, the member prefers the most cost-effective option. The CMO is responsible for making sure that Sara s choice is fully informed (i.e., that she knows there are options for other settings) and that she can reject and appeal the CMO s recommendation that she move to a facility. b. Marge s needs have increased to where she needs extensive hands-on personal and health care assistance in her home. Her in-home services now cost 30% more than nursing home services would cost. Marge has lived in her house for decades, and does not want to leave it. She is adamantly opposed to moving, especially going to a nursing home or group home. Nursing home placement might not be reasonable for Marge because it would result in significant negative outcomes. Choosing where and with whom to live is very important to Marge. She also states that moving would be detrimental to her quality of life, social participation, daily routines and preferences; and that she would suffer negative outcomes from resultant depression. The CMO explores all options with Marge. Her team staff thinks she d be safer in a facility, and/or that in-home services are not the most cost-effective means to attain desired outcomes of safety and health. Marge disagrees and files an appeal to contest the CMO s recommendation for nursing home placement. She wins the appeal based on her arguments that moving to a nursing home would have significant negative impacts on outcomes most important to her /1/99, DHFS/OSF/CDSD, pg. 4

38 This case provides a good example of other important considerations besides costefficiency. Risk Risk may or may not be a factor in addition to cost-effectiveness in a case like Marge s. In other words, it s possible that in-home services could be safe but not the most cost-effective approach. It s important to be clear which factor is at play. If risk is an issue, that needs to be clearly discussed and documented. (Negotiating risk is the topic of another technical assistance document.) Conflicting values Marge s case could also be construed as a matter of values conflicts: Staff value health and safety, while Marge values staying at home, privacy, and independence. Some community-based staff may feel that institutionalization is inherently bad and/or a personal failure. Friction may develop between staff members who disagree over what s best for Marge. There may be underlying assumptions or attitudes at play (such as ageism) that team members can help each other identify. Many of these values conflicts are inherent in case management and will be sufficiently addressed through best practices of the inter-disciplinary team. When more help is needed, an ethics committee consultation might be appropriate. c. Teresa s needs have increased to where she needs extensive hands-on personal and health care assistance in her home. Teresa has been in a persistive vegetative state since a car accident seven years ago. Her parents want to keep her in their home, but they are able to do fewer and fewer tasks, and now require 24 hours/day in-home help with Teresa. Her in-home services now cost triple what nursing home services would cost. Team suggests nursing home placement as the most cost-effective way to meet Teresa s needs. The family appeals the CMO s decision for nursing home placement. The CMO s decision is upheld in appeal, on the grounds that institutionalization would have little to no impact on Teresa s outcomes, and that the extensive in-home services now needed exceed reasonable cost and effort. Reasonable here is that which works for peers (people with similar needs) and would have no negative outcomes. 3. Short-term versus long-term cost-effectiveness and outcomes Member is in the hospital, approaching time of discharge. Member has had unstable health and complex health care needs for months/years, which are expected to continue for several months at least. Family members have been providing some in-home assistance but are now refusing to continue. Member wants to go home next week. She would need a live-in caregiver, approximately 16 hours/day of nurses aide-level services and skilled nursing visits daily or more for several weeks. Her in-home costs are expected to be over $8,000 per month. She has no cognitive impairments, but is too sick at this time to direct her services. There is potential, through rehab, to increase her ability to regain strength and a more stable health status. The hospital and the CMO prefer to discharge her to a nursing home /1/99, DHFS/OSF/CDSD, pg. 5

39 The CMO would explain that the member s choice of going directly home is not the most cost-effective way to meet desired long term outcomes of stable health and improved strength, functioning, independence, and living at home. The CMO proposes instead a temporary stay in a nursing home for rehab until the member s health is more stable and she is more able to participate in her care. During this limited time: Member s strength and health would improve so that she could participate in her care more. Member s health status would be more stable so that less in-home nursing and aide services would be needed. CMO has time to hire and train direct caregivers and establish a stable home care plan. CMO can discuss with member and family to explore care giver stress and possibly negotiate for some family involvement with more support from the CMO. Note that the CMO is not denying the long-term outcome of the person s choice to go home, but is seeking the most cost-effective way to attain that outcome. This is not the same as long term nursing home placement with no rehab potential or discharge goals; in that case, the member might be able to cite significant negative impacts on her/his quality of life and other desired outcomes (as described in examples above). C. COST EFFICIENCY AND FAIRNESS 1. Normal Living Expenses Step 2 of the R.A.D. Method asks whose responsibility it is to address a specific need or problem; the CMO is not meant to replace an individual s responsibilities or to become the member s only community. Step 3 lists general ways in which an outcome could be met by self, informally, by other community resources, or by the CMO. All of these options should always be considered, so that the CMO does not pay for things the person could in fact do themselves or could get for low or no cost elsewhere. That s basic cost-efficiency. There are some things that people normally pay for themselves. A few examples include: housing expenses, utilities, food, normal home repairs, clothing, home decorations, furniture, bedding, cleaning and household supplies, and (perhaps) over-the-counter medications. In most cases, these normal living expenses would remain the responsibility of the person or her/his informal supports. For efficiency, this general policy should be shared with members during intake and enrollment. On the other hand, the criteria of effectiveness and cost-effectiveness (described in Step 6 of the R.A.D. Method) allow for flexibility to pay for normal living expenses if doing so in a particular instance makes sense. The CMO staff need to justify doing so for particular reasons, so that it s not an arbitrary (possibly unfair) decision, and so that you don t have to do it in every instance or for every member. As always, the intervention must relate to a desired 39 11/1/99, DHFS/OSF/CDSD, pg. 6

40 outcome identified with the member and documented on her/his assessment and service plan, and there must be clear measures to evaluate the success of reaching that outcome. In other words, the same criterion of cost-effectiveness justifies a general CMO policy of not paying for normal living expenses, but also allows for paying for the same things when doing so is more cost-effective in particular instances. 2. Specific Justifications Fairness means treating like cases alike. This is not the same as treating everyone the same. This is commonly misunderstood, as when members say, You bought her/him one, so you have to buy me one. Everyone needs to be clear that services are based on needs and outcomes for particular individuals in unique circumstances. (This is especially important for members and families to understand.) Your justifications for resource allocation decisions must be specific to an individual and her/his particular desired outcomes, unless you intend it to apply to all members. a. Member requests that the CMO purchase portable ramps so that she can visit her friends and family. This does seem effective in maintaining social involvement and ties to family and friends a desired outcome of the Family Care mission and of this member. However, since that outcome is applicable to all CMO members who use chairs or scooters, it could be argued that the CMO would have to buy ramps for all those members. More cost-effective options would include some sort of loaner program. The CMO could seek other community resources to create this program, or establish one. b. The CMO is asked to purchase air conditioners. In the absence of guidelines, if the CMO bought air conditioners for a few members, they d have to buy them for everyone for any reason, even if member lives with family who could purchase one. This is not cost effective. There are several points to start with: 1. What is the desired outcome within the CMO s responsibility (general comfort, or prevention of serious health problems)? 2. Is this item something people normally pay for themselves? 3. What are the most cost-effective options? Some of the WI Partnership sites have developed guidelines to purchase air conditioners only for those consumers who: a. Live alone with no access to a cooled area and b. Have end-stage COPD requiring continuous oxygen or end-stage Goldman class IV heart disease or c. Are on neuroleptic medications (mainly major tranquilizers) or d. Have history of dehydration or hypothermia /1/99, DHFS/OSF/CDSD, pg. 7

41 These guidelines let the programs purchase air conditioners when doing so would be effective for meeting specific desired health-related outcomes, and cost effective by avoiding bad health outcomes. Buying air conditioners for everyone for any reason would not be effective or cost effective. Use of this R.A.D. Method should reduce the need to write specific guidelines for particular items (e.g., air conditioners, hospital beds, power wheelchairs). For example, the CMO could write guidelines on when to provide power chairs similar to the guidelines for air conditioners above. Or, the CMO teams could instead just directly apply the R.A.D. Method as in the next illustration: c. Member s family requests power operated scooter for member who is blind and significantly cognitively impaired. The scooter would not be effective in meeting any outcomes because the member lacks the cognitive and visual ability to use it. Remembering to ask why the family is requesting this, team staff can identify specific problems that could be addressed to support the family caregivers. Each site can decide whether or not it s efficient to spend staff time developing guidelines for a specific service. 3. Complementary Therapies or Alternative Medicines Members request the CMO to purchase goods or services related to complementary therapies or alternative medicine. Consider whether a requested item or service has proven cost-effectiveness in meeting desired outcomes. A few examples of treatments with proven effectiveness for some problems, which may (or may not) be cost-effective for a specific problem: Physical therapy with objective data such as range of motion, strength, contractures, mobility, functioning level Acupuncture for specific problem with quantifiable or perceptible symptoms or level of function A few examples of treatments that have not (yet) been proven effective in meeting specific outcomes, and/or lack quantifiable or perceptible outcomes: Magnet therapy; aromatherapy; massage therapy for general well-being in absence of related condition This is not to say that a Family Care site may not choose to cover particular alternative therapies. But note that if the outcomes are general well-being, they apply to all members, as explained in example 2a above. And if there is no way to know a treatment s effectiveness, you cannot judge its cost-efficiency /1/99, DHFS/OSF/CDSD, pg. 8

42 D. GETTING TO THE REAL ISSUE Gladys has been receiving physical therapy at a clinic three days a week for several months. She is cognitively intact and fairly physically and socially active. The PT visits are social events for her, with exchanges of cookies, favors, and pleasantries with staff and others at the site. Her condition has improved to where PT is no longer medically necessary and is discontinued. She wants to continue PT at least two days a week, and is angry that it has been stopped. For the past two weeks, she has been isolating in her apartment, depressed. She is not following through on her activities or her medications. This is a good example of the first step of identifying the root of the problem. At one level it appears cost-effective to give her 2 PT visits/week to prevent her current isolating and selfneglectful behaviors and depression. In the long run, it might be more effective to keep asking, Why? to better understand exactly what she is seeking and to develop other ways to meet those needs/wants. (Note: The distinction between needs and wants is tricky; a better approach would be to (a) distinguish outcomes within the CMO s responsibility from those that are not, and (b) use criterion of cost-effectiveness to choose among options.) In this case, perhaps it s the socialization tha t Gladys wants, and she could become a volunteer at the clinic to continue that. Perhaps she fears she ll deteriorate without PT sessions, and needs help understanding rehab versus maintenance, and help establishing an exercise routine. Maybe it was all the physical contact she got during PT sessions, and a pet or a hightouch volunteer job would replace it. Perhaps there are issues with how she feels about her team staff and their decision-making process, and those need to be discussed. Maybe this loss stirs up unresolved grief issues, and she needs some help with those. Perhaps she finds comfort in the sick role. Maybe her behavior reflects a borderline personality disorder that calls for different responses from her team members and perhaps some help from mental health professionals. E. STAYING FLEXIBLE AND CREATIVE Member is severely depressed and talking about suicide since an accident rendered him quadriplegic last year. He says life has no meaning or purpose for him anymore; there s nothing for him to do. He s started to drink heavily and neglect his self-care. He was a construction worker who enjoyed the outdoors. His personal care worker notices that he s had a longstanding interest in oil painting, and they begin to discuss this as a way for him to find purpose and some joy in life again. Since he has no money and no family, his team decides to pay for art classes for him and a few supplies, for an overall cost of less than $100. He paints prolifically, stops getting drunk, and is no longer depressed. He calls himself an artist and regularly sells his paintings /1/99, DHFS/OSF/CDSD, pg. 9

43 This example illustrates how a Resource Allocation Decision Method can provide more efficient and consistent decisions without losing the flexibility that is so vital to the philosophy of Family Care. In this case, $100 of art supplies and classes was far more effective and costeffective in addressing the root of his problem (a lack of purpose and joy in life) than expensive professional treatment of his behaviors (self-neglect and getting drunk) would have been. Note that the justification is specific; it does not mean that the CMO has to fund everyone s hobbies. F. USING OBJECTIVE HISTORICAL FACTS Member requests all the latest equipment he finds in supply catalogs and on the Net. The CMO has purchased several items that member does not use but wants to upgrade. The CMO can refuse to purchase equipment that is not likely to be cost-effective. Equipment that is unused is not cost-effective. Given recent history of items purchased and not used by member, further purchases are likely to be not cost-effective. Also, outcomes of function, independence, etc., can be more cost-effectively met with equipment he already owns. Note that the focus is on objective historical data and patterns, not value judgments /1/99, DHFS/OSF/CDSD, pg. 10

44 The following chart shows the timeline that applies to persons selecting IRIS. The IRIS IRIS Consultant Agency and Financial Service Agency make the process clear and easy to understand. The Local ADRC provides non biased Enrollment Counseling except in the case of current waiver participants in programs: CIP 1A, CIP 1B, CIP II, COP-W, and BIW where the current Support and Service Coordinator/ Care Manager provides bias free enrollment counseling*. ADRC establishes publicly funded long term care eligibility Some eligibility steps may require Medicaid cost share or spend down actions ADRC refers person to the IRIS ICA. Current Case Manager refers existing waiver participants ICA welcomes person to IRIS and IRIS Consultant is chosen Services/goods received as per plan, IRIS FSA pays time sheets/invoices and completes participant employer agent paperwork IRIS ICA approves Plan, IRIS Financial Service Agency completes background and employment checks for participant-hired caregivers IRIS orientation provided, plan development begins, start date selected * Existing waiver participants receive enrollment counseling from their support and service coordinator care manager. Current managed care members and those on a wait list receive enrollment counseling from the local ADRC enrollment counselor. Persons choosing IRIS are referred to the ICA by the same counselor that provides them enrollment counseling. 44