HOME AND COMMUNITY BASED SERVICES

Transcription

1 HOME AND COMMUNITY BASED SERVICES FRAIL ELDERLY WAIVER Krista Engel, HCBS/FE Provider Manager HCBS/FE PROGRAM DESCRIPTION AND BACKGROUND Provides community based services as an alternative to nursing facility care, Promotes independence in the community setting, and Ensures residency in the most integrated environment In Kansas, if customers qualify for nursing facility care, they may choose home and community based services, if available, or enter a nursing facility CUSTOMER SNAP SHOT Customer is an 86 year old living in an assisted living facility. Due to a recent stroke the customer has recently left his farm of more than 50 years to be nearer to his daughter. The customer has had a difficult time adjusting to leaving the farm and acclimating to living in town. Family visits as often as they are able. The customer needs help with bathing, dressing, toileting, meal preparation, laundry, and housekeeping. After several months of private pay at the assisted living facility the customer has spent down his resources and is faced with the decision of applying for Medicaid. The family contacts the local case management entity for assistance with applying for HCBS/FE services. The targeted case manager assists them to complete the Medicaid application and to gather all the necessary documents. It is a stressful time for the family as they are not familiar with the processes and protocols relating to applying for and receiving in-home services. The targeted case manager is key in making this transition to HCBS/FE services successful.

2 ELIGIBILITY GUIDELINES Age - customer must be 65 years of age or older Customer Choice of HCBS/FE Functional Need based on the Long Term Care Threshold Guide of the Uniform Assessment Instrument (UAI) Medicaid Eligibility (financial) Available Service Providers Waiver Constraints FREEDOM OF CHOICE Targeted Case Management (TCM) was opened up to providers outside of the Area Agencies on Aging to comply with federal guidelines For a listing of available CMEs and the counties they serve visit KDOA's public website at: CaseMgmtEntities.htm SETTING UP A HCBS/FE CASE Referral is made to the Case Management Entity that provides TCM-FE Targeted Case Manager completes the Uniform Assessment Instrument Determines functional Long Term Care score SRS Eligibility Worker determines financial eligibility Process may take up to 45 days Important that facilities, customers, and families understand functional and financial eligibility is required to be determined prior to services being approved to begin

3 SETTING UP A HCBS/FE CASE Services are Implemented Plan of Care (POC) start date determined services are to begin within 7 working days of functional and financial eligibility determinations POC service(s) and hours must be prior authorized by KDOA POC Approvers POC implemented and customer begins receiving services Refer to Timeline Handout PLAN OF CARE APPROVAL HCBS/FE POCs cannot be back dated If SRS determines a customer Medicaid eligible October 1 st,the POC may only begin once the TCM is notified If SRS notifies the TCM of the above eligibility October 12 th the HCBS/FE services may begin October 12 th or after If SRS notifies the TCM of the above eligibility November 3 rd the HCBS/FE services may begin November 3 rd or after NEGOTIATED SERVICE AGREEMENT Identifies services to be provided by the facility Indicate which services and tasks will be paid for through the HCBS/FE program and therefore not the responsibility of the customer The TCM will review the NSA to verify that the customer or family are not paying for services within the Room and Board rate that should be covered through the HCBS/FE Plan of Care

4 ROOM AND BOARD RATE Consists of room rate, raw food charges and any non-covered services HCBS/FE services that are authorized by the TCM to be paid through the POC may not be included in the Room and Board rate Customers only have up to $727 per month Families may supplement the room and board rate and/or pay for non-covered services ROOM AND BOARD RATE Consists of room rate, raw food charges and any non-covered services Facility services must be unbundled to allow the HCBS/FE POC to cover all authorized services Monthly Private Rate = $ 3500 minus the following: Bathing / dressing = $ 400 (facility private rates) Meal preparation = $ 500 Housekeeping = $ 300 Medication admin = $ 450 Walking / mobility = $ 200 Maximum room/board rate = $ 1650 / month PLAN OF CARE SERVICES / HOURS Hours are determined by: TCM s authorize hours of service necessary to maintain the customer s health and welfare TCM reviews the Negotiated Service Agreement (NSA) and Functional Capacity Screen (FCS) TCM reviews time studies (e.g., meal prep, laundry) to support the authorized service hours TCM, along with the customer and facility staff, develop the POC

5 CHANGES TO PLANS OF CARE Before any changes may be made in the following areas it is required to have prior approval from the Case Manager: Functions or tasks Level of assistance Number of hours provided to a customer Notify the TCM of changes so appropriate POC updates may be made, if necessary A Notice of Action (NOA) is sent each time there is a change to POC hours or services TCM s will send the provider a NOA and the revised POC and CSW CLIENT OBLIGATIONS Client obligation is the amount over the Protected Income Level (PIL),determined by SRS The customer must pay this obligation to the provider each month for HCBS/FE services Example: Customer Income $830 PIL $727 Client Obligation $103/month Customers wouldn t pay the entire obligation when their services received are not in excess of their obligation amount For example, the customer received $250 worth of services and has a $375 client ob the customer would only pay $250 for services received REASONS TO CONTACT THE CASE MANAGER Any concerns regarding the customer, including functional decline, health changes, or welfare issues When the customer goes to the Hospital, Nursing Facility or is otherwise unavailable for services When services are not being provided to the customer, due to staffing issues, customer choice, etc If the customer is falling behind in payments or refusing to pay his/her monthly client obligation When giving a customer a 30-day discharge letter

6 UAI Code HCBS/FE SERVICES Services the facility may provide to HCBS/FE residents: Attendant Care Services Nursing Evaluation Visit Personal Emergency Response System Wellness Monitoring Services that may be provided to HCBS/FE residents but not by the facility: Assistive Technology Comprehensive Support Oral Health Services Service the facility may provide but not to those that reside in the facility: Adult Day Care HCBS/FE FORMS Customer Service Worksheet (CSW) Plan of Care (POC) Notice of Action (NOA) Important to know how to read and understand the forms *Example of Facility CSW, POC and NOA. KANSAS DEPARTMENT ON AGING Date 7 /_01 _/_08 CUSTOMER SERVICE WORKSHEET Customer Name Maggie Smith Address HomeTowne ALF Zip City Anywhere County PR Phone # (785) SS# HIPAA DOB HIPAA Billing ID# Emergency Contact Sydney Smith Relationship Phone # Alt. Phone # Sister (785) 3 Activities of Daily Living/ Instrumental Activities of Daily Living Bathing/Grooming Total Assist (4) Supervise (oversight) (2) Provider: Hometowne ALF Provider: Service Code: ATCR 2X Service code: 1 hour / 2 x week = 2 hours / week Provider: Service code: Informals/ Non-KDOA Admin 3 Specify: Type: / Oral Hygiene/ Hair Care/ Skin Care/ Shaving/ Other Dressing/Undressing Total Assist (4) 1 hour / week Supervise (oversight/cueing) (2) 1 3 Prosthesis, specify: Toileting Total Assist (4) Physical Assist (includes pericare) (3) Supervise (oversight/cueing) (2) Special Needs: Commode/ Bedpan/ Urinal/ Incontinence Mgmt/ Ostomy(HMA)/ Catheter Care(HMA)/ Other Transfer (non-bathing or toileting transfers) Total Assist (4) Supervise (oversight/cueing) (2) Special Needs: Assistive devices for transfers/ Other (specify) 1 hour / week Assist as needed. SS-009 (Rev. 7/1/2000) 1

7 *Example of Facility CSW, POC and NOA. KANSAS DEPARTMENT ON AGING Date 7 /_01 _/_08 UAI Code UAI Code CUSTOMER SERVICE WORKSHEET Provider: Hometowne ALF Provider: Activities of Daily Living/ Instrumental Activities of Daily Living Service Code: ATCR 2X Service code: Walking/Mobility Total Assist (bedfast) (4) Range of Motion (HMA) 2 hours / week Supervise (oversight/cueing) (2) Assist as needed. Assistive Device(s): Wheelchair/ Cane/ Walker/ Other (specify) Eating Total Assist (feed) (4) Physical Assist (includes cutting food) (3) Supervise (oversight/cueing) (2) Special Nutrition: Tube Feed (HMA)/ Other Meal Preparation Specify: Breakfast/ Lunch/ Supper/ Snack Total Assist: prepare and serve meal (4) Partial Assistance w/ meal prep. (3) 1 hour / 7 x week = Supervision (oversight/cueing) (2) 7 hours / week Specify: Special Diet, type / Future Meals/ Lives in congregate/family setting. Shopping Total Assist (unable to shop) (4) Physical Assist (accompany) (3) Supervise (oversight/cuing) *Informal only* (2) Provider: Service code: Informals/ Non-KDOA Admin Family provides. 3 Specify: Groceries/ Medication Pick-up/ Hygiene/Medical Supplies Money Management Total Assist *Informal only* (4) Supervise (remind/oversight) (2) Customer choose lower level or N/A Family provides. SS-009 (Rev. 7/1/2000) 1 *Example of Facility CSW, POC and NOA. KANSAS DEPARTMENT ON AGING Date 7 /_01 _/_08 CUSTOMER SERVICE WORKSHEET Activities of Daily Living/ Instrumental Activities of Daily Living Transportation Total Assist (4) 3 Supervise (2) Customer choose lower level or N/A Accompanying to Medical Appointments (specify frequency) Other, such as: to shop and social activities (*Informal only*) 1 Telephone Usage (*Informal only*) Laundry/Housekeeping Total Assist (4) Supervise (2) 3 Laundry as needed Specify: In home or apt. In the apt. complex Outside home or apt. complex Cleaning (non-chore tasks) Bathroom/ Kitchen/ Bedroom/ Vacuum/ Scrub Floors / Commode/ Change linens/ Remove Trash/ Dust/ Other Management of Medications/Treatments Total Assist (w/ med. admin. & performing treatments, HMA) (4) 3 Physical Assist (w/ med. Admin. & performing treatments, HMA) (3) Supervise (oversight/cueing) (2) Other, specify: Specify days and frequency: Check if supplemental page attached. Provider: Hometowne ALF Provider: Provider: Informals/ Non-KDOA Admin Service Code: ATCR 2X Service code: Service code: Family provides. 4 hours / week 25 minutes / day = 3 hours / week Days: Sunday Saturday Days: Days: 20 hours/week Units Per Units Per 80 Units Per week Check if more than one Customer Service Worksheet attached. ATTENTION CUSTOMER: Your signature on your plan of care certifies that you were involved in the decision of which services you will receive, the tasks that will be provided as outlined on this customer service worksheet, and the amount of services to be provided. SS-009 (Rev. 7/1/2000) 1 UAI Page 10 Plan of Care/Support Services Address Hometowne ALF Customer Maggie Smith Phone # (785) Social Security # Medicaid ID # # KAMIS Emergency Contact Sydney Smith Relationship Sister Phone: work home (785) PSA Service Code Self Direct Funding Source 13 ATCR 2X HCBS/FE Hometowne ALF 80 Week MAWMX HCBS/FE Hometowne ALF 1 55 days ASMT TCM SNEW AAA 5 Year CMGT S TCM SNEW AAA 4 Month Disaster Total Discharge Obligation/ Monthly Customer Provider Unit(s) Per Units Start Date End Date Cost of Monthly Code Unit Copay Cost Unmet Need Service Code, Availability Code, HCBS/FE monthly costs including customer obligation: Monthly Number of Units (HCBS amount must be reported to EES Specialist) 1, Service Availability Code bility Units Service Availa- Units SCA total cost including customer copay: Medicaid Average Acute Care Cost: = Code OAA total cost: HCBS/FE Total Cost: $1, Total customer obligation/copay: $0 caregiver) Additional Support/Services from Home Health, Family, Friend, Neighbor, Attorney, Landlord, Church, Club, Other Relationship Address Phone Paid Name Service Frequency Home Work Yes No (check if primary (indicate "same" if lives with customer) Sydney Smith Sister 210 Main CTKR 5 hours / month X Release of Information: I consent to the release of the information on this page so I can receive services. I understand the information included in these pages 1-10 will be released to Kansas Department on Aging, the Area Agencies on Aging and service providers as listed above to enable the delivery of services and program monitoring. Maggie Smith Tobi Imacm (785) _ Customer or Guardian Date Assessor Signature & Phone # Signature

8 PROGRAM: Older Americans Act State General Fund X HCBS/FE ESD Date of Notice: TO: Maggie Smith FROM: Tobi Imacm Hometowne ALF Agency SNEW AAA Anywhere, KS Attention: Phone: (785) Medicaid # (if applicable): Billing #: No. of Units Self Dates of Service Provider Service (Specify Per Dir. Provider Name From To Unit Cost Day or Week) Y/N? Attendant Care 80 units / No Hometowne ALF Ongoing $3.73 per Level 2 week 15 min Wellness Mont. 1 per 55 No Hometowne ALF Ongoing $39.37 days per visit Attached Customer Service Worksheet (check if applicable) Client Obligation: $ None Paid To: Comments, Message, or Explanation of Action: X Effective , your services and/or plan of care are being implemented as identified above; Or other: Dear Maggie, Due to changes in your functional ability and needing additional assistance with walking and medication management your HCBS/FE hours have been increased. Hometowne ALF will continue as your provider of Attendant Care Level II and Wellness Monitoring services. The increased hours will begin effective with 20 hours per week (80 units) of Attendant Care level II. Please contact me at the above number if you have any changes in your functional ability that may require a change to your services. cc: Hometowne ALF, file Regulatory Reference(s): KDOA FSM A.1. You may contact your case manager at the phone number above. Please read the back of this form carefully. Case Manager Signature: Tobi Imacm Date: _ DOCUMENTATION REQUIREMENTS HCBS/FE is fee for service Providers are reimbursed based on the amount of services rendered KDOA is working with the Kansas Health Care Association/Kansas Center for Assisted Living on how to improve and streamline HCBS/FE documentation requirements for facility settings Provider reviews are done post-payment Reimbursement is recouped if documentation is not complete or does not meet the general documentation requirements and the requirements specific to the KMAP program and services provided. DOCUMENTATION REQUIREMENTS To verify services provided in the course of a post-payment review, documentation in the beneficiary s medical record must support the level of service billed. Documentation for the HCBS program must validate services billed were provided in accordance with the plan of care. (provider manual 2700, general benefits 1/08, page 2-56)

9 DOCUMENTATION REQUIREMENTS Each HCBS/FE service has specific requirements Refer to the Provider Manual benefits and limitations section of each service for specifics Signature Limitations (posted 9/20/04) Customer limitations make it necessary for them to have assistance with the signature requirement Signing options: Customer s signature Customer s distinct mark Customer using their signature stamp Designated signatory KAMIS: Billing: Specialty: Description: U Description: Rate thru Rate effective Rate effective 6/30/06: 7/1/06: 7/1/08: MADCX S u = 1-5 hours u = $ u = $ u = $21.93 Adult Day Care 1 1 (Day Care Services, (2 u max per day) 2 u = $ u = $ u = $43.86 adult: per half day) ASTEX T Assistive Technology 1 u = 1 purchase 1 u = purchase 1 u = purchase 1 u = purchase (S5165, W1386, W1375) (Specialized Medical Equipment, Not otherwise specified) (lifetime max = $7500) ATCR1X S Attendant Care Services Level I 1 u = 15 minutes 1 u = $ u = $ u = $3.38 (Homemaker, NOS (not otherwise specified), Per 15 minutes) ATCR2X S Attendant Care Services Level II 1 u = 15 minutes 1 u = $ u = $ u = $3.73 (Attendant Care Services, per 15 minutes) ATCRUD S5125 UD 511 Attendant Care Services - Self-Directed 1 u = 15 minutes 1 u = $ u = $ u = $3.17 (Attendant Care Services, per 15 minutes) COMPX S Comprehensive Support - provider directed (effective 10/1/ 1 u = 15 minutes n/a n/a 1 u = $3.38 (Companion Care, adult, per 15 minutes) COMPUD S5135 UD 518 Comprehensive Support - self-directed (effective 10/1/08) 1 u = 15 minutes n/a n/a 1 u = $3.17 (Companion Care, adult, per 15 minutes) MEDRX S Medication Reminder (effective 1/1/05) 1 u = 1 month 1 u = $ u = $ u = $15.91 (Medication Reminder Services, non-face to face; per month) NUEVX T1001 (NPI) 515 Nurse Evaluation Visit 1 u = 1 face to face 1 u = $ u = $ u = $39.37 (Nursing assessment/evaluation) visit PERMX S Personal Emergency Response (rental) 1 u = 1 month 1 u = $ u = $ u = $26.52 (Emergency Response System; service fee; per month) PERMIX S Personal Emergency Response (install) 1 u = 1 x lifetime 1 u = $ u = $ u = $56.25 (W1367) (Emergency Response System; Installation and testing) MASCX T Sleep Cycle Support 1 u = 6-12 hours 1 u = $ u = $ u = $22.44 (Sleep Cycle Support, not to exceed 12 hours per day) MAWMX S5190 (NPI) 514 Wellness Monitoring 1 u = 1 face to face 1 u = $ u = $ u = $39.37 (Wellness Assessment, performed by non-physician) visit T1017 (NPI) 237 Targeted Case Management 1 u = 15 minutes 1 u = $ u = $ u = $10.83 (Targeted Case Management, per 15 minutes) (effective 7/1/07) n/a n/a Diagnosis Code for all HCBS services ACCC ACCC n/a Acute Care Cost = $ (effective 1/1/05) EDS PROVIDER SERVICE Information on: HIPAA PES (Provider Electronic Solutions) Provider Education / Workshops Manual Updates Bulletins Eligibility verification Claim inquiry and submission

10 HCBS/FE WAITING LIST? Implemented on April 22, 2002 Ended on April 26, 2004 Currently, there is not a waiting list for HCBS/FE QUESTIONS?? KRISTA ENGEL Krista.Engel@aging.ks.gov

11 Questions Q: What is the current Protected Income Level (PIL) for HCBS/FE Medicaid customers? For 2008, the PIL is $727/month. This amount may change annually. The customer must pay income over this amount, as determined by the SRS case worker, directly to the facility for their obligation for HCBS/FE services. Q: Which HCBS/FE services may be provided by a HP/AL/RHCF? A: With some limitations, the following services may be provided: Adult Day Care, Assistive Technology, Attendant Care Services, Nursing Evaluation Visit, Personal Emergency Response, Oral Health Services, and Wellness Monitoring. Q: Can a HP/AL/RHCF provide services in the community and bill HCBS/FE for services provided? A: No. For the HCBS/FE waiver program, KDOA requires that facilities provide services for which they are licensed. As a licensed Home Plus, ALF or RHCF you may provide and bill only those services provided within the facility. If a facility wishes to provide HCBS/FE services in the community, they must establish a state-licensed Home Health Agency. Q: What do I do when a customer goes to the hospital? A: The Case Manager must be notified immediately any time the customer is away from the facility for more than 24 hours. This includes, but is not limited to, hospitalizations, rehabilitation stays, vacation and time away with family. HCBS/FE services may not be provided or billed if the customer is not in the facility. Q: Can the family assist with payment of HCBS/FE services? A: No. Services that are on the HCBS/ FE Plan of Care may not be paid for by an organization, agency, family, customer or other individual per KAR Q: May a facility charge the customer or family the difference between the HCBS/ FE Plan of Care and the facility s private rate? A: No. This would be considered supplementation of HCBS/FE services which is not allowed per K.A.R Q: May a family pay the customer s room and board? A: Since the Plan of Care cost is separate from the room and board, the family, if able, may assist with payment of room and board as long as it is paid directly to the facility. Q: Is the amount the facility is paid for HCBS/FE services the same each month? A: No. The Plan of Care is not a billing tool; it shows the number of maximum units of service authorized. Only services that are provided and documented can be billed and paid. Contact Information: Provider Enrollment (785) Provider Assistance Unit (785) HCBS/FE Provider Manager (785) New England Building 503 S. Kansas Avenue Topeka, KS KDOA does not discriminate on the basis of race, color, national origin, sex, age, disability or religion. If you feel you have been discriminated against, you have the right to fi le a complaint with KDOA, (TTY: ). August 2008 KANSAS DEPARTMENT ON AGING HCBS/FE Provider Tips Home Plus Assisted Living Residential Health Care Facilities Home and Community Based Services for the Frail Elderly

12 What is Home and Community Based Services/ Frail Elderly? HCBS/FE helps Kansans age 65 or older who are in frail health. Services include: Attendant care, such as feeding, bathing and dressing. Household tasks, such as shopping, meal preparation, house cleaning and laundry. Health services, such as wellness monitoring, 24-hour response for medical emergencies. When authorized by a case manager, these services may be provided in a Home Plus, Assisted Living or Residential Health Care Facility (AL/RHCF). Facilities are required to have a Negotiated Service Agreement (NSA) with each customer. This agreement describes the services to be provided, identifies the provider of the service(s) and identifies the party responsible (customer, family, HCBS/ FE) for payment. Services that are included in the NSA and paid for within the room and board rate cannot be duplicated on the HCBS/FE Plan of Care. The facility is responsible for working with the customer to negotiate the Room and Board rate. The Room and Board rate is generally based on the customer s monthly Social Security, pension or other income and assistance from family, if available. Plan of Care Development and authorized services are based on the needs of the customer, as identified through the assessment process. The case manager will also: Encourage the customer to negotiate the room and board rate with the facility. Review the Functional Capacity Screen with facility staff for consistency. Review the NSA to identify tasks the facility will provide within the room and board charge. Request time studies from the facility staff for tasks that are completed for a number of customers at the same time (meal preparation and laundry, for example). Develop the Plan of Care with the customer and the facility staff based on the needs identified using the Uniform Assessment Instrument and Customer Service Worksheet. HCBS Customer Obligations are determined by the customer s case worker at the Department of Social and Rehabilitation Services (SRS). The amount of a customer obligation is based on the protected income level (PIL) and certain allowable expenses, if any. The PIL for 2008 is $727/month. Example: Income $845 PIL 727 Customer Obligation $118 The customer must pay the determined customer obligation to the facility each month for HCBS/FE services rendered. In limited instances the customer would not pay the entire obligation. For example, the customer goes to the hospital and does not receive a full month s worth of services; therefore, their services received are not in excess of their obligation amount. In this instance the customer would not pay the entire obligation amount but instead they would pay the lesser amount equal to the amount of services received. For example, a customer has a $375 obligation but received only $250 worth of services. The customer would pay the provider only $250 for their obligation that month since the customer did not receive $375 worth of services. Plans of Care are based on a 5-week month. Providers may bill only for the units of service provided; thus, the amount billed each month will vary from the total authorized Plan of Care hours. Examples of how Room and Board Rate, Plan of Care Cost and Customer Obligation work together: Customer Income $720 Room and Board $ 650 (negotiated with customer) Plan of Care Cost 2,200 Customer Obligation 0 Payment to facility per month: $ 2,850 Customer Income $1,000 Room and Board $ 900 (negotiated with customer and family) Plan of Care Cost ($1,200) 927 (customer obligation withheld) Customer Obligation 273 (paid to facility for HCBS/FE services) Payment to facility per month: $ 2,100 Customer Income $750 Room and Board $ 950 (negotiated with customer and family) Plan of Care Cost ($2,200) 2,177 (customer obligation withheld) Customer Obligation 23 (paid to facility for HCBS/FE services) Payment to facility per month: $3,150 Did you know? You should never start or increase services without a notice of action from the Case Manager. The Case Manager must authorize all changes. A Plan of Care written on a weekly basis allows for maximum flexibility in serving the customer s needs. You must document the services you have provided to the customer. Refer to the Kansas Medical Assistance Program Provider Manual for documentation requirements. It is the provider s responsibility to collect the Customer Obligation. If the customer falls behind in his/her payments, contact the customer s Case Manager.