1. Section Modifications

Transcription

1 Table of Contents 1. Section Modifications Overview Division of Medicaid General Information Provider Qualifications Record Keeping Participant Eligibility Prior Authorization (PA) A&D Waiver Individual Service Plan Residential Assisted Living Facility (RALF) Overview Provider Qualifications Payment Certified Family Home (CFH) CFH Services CFH Residential Habilitation Program Coordination Services for DD Waiver Participants Change in Participant Status Change of Provider Information Payment... 6 February 21, 2014 Page i

2 1. Section Modifications Version Section/ Column Modification Description Date SME 5.0 All Published version 2/21/14 TQD Provider Updated adult day care to adult day 2/21/14 D Baker Qualifications care (health) 4.0 All Published version 12/13/13 TQD Updated to reflect IDAPA requirements 12/13/13 S Perry Updated to reflect current DD process 12/13/13 S Perry Added language from IDAPA related to 12/13/13 M Wasserman services provided in a CFH Updated for clarity 12/13/13 M Wasserman Added language from IDAPA related to 12/13/13 M Wasserman services provided in a RALF Added language for DD plan of service 12/13/13 S Perry requirements Added language from IDAPA related to 12/13/13 M Wasserman individual service plan requirements 3.8 Old Section Removed language that a Healthy 12/13/13 M Wasserman Connections referral is required for DD waiver services Updated to align better with IDAPA 12/13/13 S Perry terminology Updated for clarity 12/13/13 M Wasserman Updated to better align record keeping 12/13/13 M Wasserman requirement language with IDAPA Updated for clarity 12/13/13 M Wasserman Updated for clarity 12/13/13 M Wasserman Replaced Regional Medicaid Services 12/13/13 M Wasserman with Dvision of Medicaid and updated for clarity Updated for clarity 12/13/13 M Wasserman 3.0 All Published version 3/08/11 TQD CFH Updated for clarity 3/08/11 S Scheuerer Payment CFH Updated for clarity 3/08/11 S Scheuerer RALF- Updated for clarity 3/08/11 S Scheuerer Payment PA Updated for clarity 3/08/11 S Scheuerer Participant Updated for clarity 3/08/11 S Scheuerer Eligibility Provider Updated for clarity 3/08/11 S Scheuerer Qualifications 2.0 All Published version 8/27/2010 TQD Added sections for CFH 8/27/2010 T Kinzler All Replaced member with participant 8/27/2010 C Stickney Updated PA information 8/27/2010 C Stickney 1.1 All Updated numbering for sections to 8/27/2010 C Stickney accommodate Section Modifications 1.0 All Initial document published version 5/7/2010 Molina/TQD February 21, 2014 Page 1 of 6

3 Overview This section covers Medicaid services provided for participants residing in the following settings: Residential Assisted Living Facilities (RALFs) Services in RALFs are available to Aged and Disabled (A&D) waiver participants, but are not available to Developmental Disabilities (DD) waiver participants Certified Family Homes (CFHs) Services in CFHs are available to A&D and DD waiver participants 2.2. Division of Medicaid The Division of Medicaid staff or its contractor in each of the state s seven (7) regions acts as the administrative case manager for the A&D Waiver, DD Waiver, and Personal Care Services. Participant needs are determined through the Uniform Assessment Instrument (UAI), or Scales of Independent Behavior-Revised (SIB-R), and waiver services are then authorized General Information This section covers all general claim information participants who receive the A&D Waiver, the DD Waiver, and Personal Care Services (PCS). It addresses the following: Provider qualifications Record keeping Participant eligibility Prior authorization (PA) Billing information Place Of Service delivery and exclusions Plan for Services Change of provider information Provider Qualifications All providers of services must have a valid provider agreement with Medicaid. Providers must meet the provider qualifications listed in IDAPA for PCS, IDAPA for A&D waiver services, and IDAPA for DD waiver services. Medicaid staff and Division of Licensing and Certification staff in each region will monitor performance under this agreement. providers must obtain separate provider numbers for non-medical transportation services and adult day care (health) services. Non-medical transportation services providers must be enrolled as Non-Emergent Transportation Providers with the Idaho Medicaid program; see Non-Emergent Non-Medical Transportation Providers for more information Record Keeping Medicaid requires all providers to meet the documentation requirements listed in the Provider Agreement and IDAPA rules. Providers must generate records at the time of service and maintain all records necessary to fully document the extent of services submitted for Medicaid reimbursement. Providers must also retain all records to document services February 21, 2014 Page 2 of 6

4 submitted for Medicaid reimbursement for at least five years after the date of final payment for the service Participant Eligibility For a participant to be eligible for Medicaid payment of waiver services, Medicaid or its contractor will determine eligibility Prior Authorization (PA) Medicaid must prior authorize all services prior to services being rendered. Approved PAs are valid for one year from the date of prior authorization by Medicaid unless otherwise indicated. Claims for services requiring PA will be denied if the provider did not obtain a PA from the authorizing authority. Payment will only be made for actual services rendered. There are no bed-hold payments when a participant is hospitalized or in a natural support setting. Services, Supplies, Room, Utilities, and Meals not disclosed in the written admission agreement can not be charged to the participant. See General Billing Instructions, Prior Authorization (PA), for additional billing information A&D Waiver Individual Service Plan Individual Service Plan. All waiver services must be authorized by the Department or its contractor in the region where the participant will be residing, and provided based on a written individual service plan. The initial individual service plan is developed by the Department or its contractor, based on the Uniform Assessment Instrument. The individual service plan must include the following: The specific type, amount, frequency, and duration of Medicaid reimbursed waiver services to be provided. Supports and service needs that are to be met by the participant's family, friends, neighbors, volunteers, church, and other community services. The providers of waiver services, when known. Documentation that the participant has been given a choice between waiver services and institutional placement. The signature of the participant or his legal representative, agreeing to the plan. The individual service plan must be revised and updated at least annually, based upon treatment results or a change in the participant's needs. All services reimbursed under the Aged or Disabled Waiver must be authorized by the Department or its contractor prior to the payment of services. The individual service plan, which includes all waiver services, is monitored by the Personal Assistance Agency, participant, family, and the Department or its contractor Plan of Service (POS) for DD Waiver participants The plan of service must be developed with the participant. Participants may develop their own plan or designate a paid or non-paid plan developer. With the participant s consent, February 21, 2014 Page 3 of 6

5 the person-centered planning team may include family members, guardian, or individuals who are significant to the participant. The plan of service is based on: The individualized participant budget Physician s health and physical Medical, social and developmental history SIB-R Behavioral or psychiatric needs The plan of service must identify the type of service to be delivered, goals to be addressed within the plan year, frequency of supports and services, and identified service providers. Unless the participant has a guardian with appropriate authority, the participant must make decisions regarding the type and amount of services required. The plan of service must include activities to promote progress, maintain functional skills, or delay or prevent regression. In developing the plan of service, the plan developer and the participant must identify services and supports available outside of Medicaid-funded services that can help the participant meet desired goals. The plan of service must be updated at least annually and as needed to meet the needs of the participant Residential Assisted Living Facility (RALF) Overview Adult residential care may be provided in an Adult Residential Assisted Living Facility (RALF). Adult residential care in a RALF consists of a range of services provided in a congregate setting licensed in accordance with IDAPA that provides commercial care for participants receiving PCS services or A&D waiver services. The service need identified by the Uniform Assessment Instrument (UAI) is negotiated between the facility and the participant and includes: Medication management Assistance with activities of daily living Meals, including special diets Housekeeping Laundry Transportation Opportunities for socialization Recreation Assistance with personal finances Administrative oversight must be provided for all services provided or available in this setting. An individual service plan will be developed between the participant or the participant s legal representative, and a facility representative. While in this setting, the participant will not be eligible for other waiver services except for dental services, day habilitation, nursing services, non-medical transportation, and specialized medical equipment and supplies. February 21, 2014 Page 4 of 6

6 Note: services are covered for Medicaid A&D waiver participants. See CMS-1500 Instructions, Appendix A.1.1 for covered services Provider Qualifications The facility must meet all applicable state laws and regulations. In addition, the provider must ensure that adequate staff is provided to meet the needs of all participants accepted for admission on a 24 hour, seven days per week basis Payment Payment will be made on a per diem or unit basis. The daily payment rate will be established by Medicaid. See CMS-1500 Instructions, Appendix A for covered services Certified Family Home (CFH) Adult residential care may also be provided in a CFH. When services are delivered in the home of the provider, the home must be a CFH. A CFH is defined in IDAPA Rules Governing Certified Family Homes as: A home certified by the Department to provide care to one (1) or two (2) adults, who are unable to reside on their own and require help with activities of daily living, protection and security, and need encouragement towards independence. A Certified Family Home may be granted an exception to the two resident limits if approved by Medicaid. With an approved exception, the Certified Family Home (CFH) may provide care and supervision to three or four residents. These providers are reimbursed to deliver services as outlined on the participant s plan of care. See CMS-1500 Instructions, Appendix A.1.2 for covered services CFH Services CFH services support the participant in daily living activities, household tasks, and other routine activities the participant is unable to accomplish. Other services may include the following: Monitoring of medications management Assistance with activities of daily living Meals, including special diets Housekeeping Laundry Transportation Recreation Assistance with personal finances Administrative oversight must be provided for all services provided or available in this setting. Additionally for DD waiver participants, the services and supports that may be provided consist of the following: Habilitation Self-direction Behavior-shaping and management Mobility Socialization Skills training February 21, 2014 Page 5 of 6

7 CFH Residential Habilitation Program Coordination Services for DD Waiver Participants Certified family home providers caring for DD waiver participants accessing services through the traditional option must receive program coordination services from the Department or its contractor. Program coordination services include: Initial, additional and ongoing training as identified in IDAPA c.-f. Development of a Program Coordination Plan and Program Implementation Plans (PIPs) Monitoring of the Program Coordination Plan and PIPs and making modifications as necessary Assistance with completing Provider Status Reviews when the plan has been in effect for six months and for the annual person-centered planning meeting Change in Participant Status It is the responsibility of the DD Residential Habilitation CFH provider to notify the service coordinator or plan developer when any significant changes in the participant s condition are noted during service delivery. Such notification will be documented in the service record Change of Provider Information If the provider has a change of name, address, or telephone number, immediately notify Idaho Medicaid in writing. Indicating updated provider information on a claim form is not acceptable and the appropriate changes cannot be made. Send corrections to: Idaho Medicaid Provider Enrollment PO Box Boise, ID Fax: 1 (877) Payment Payment will be made on a per diem or unit basis. The daily payment rate will be established by Medicaid. February 21, 2014 Page 6 of 6