Social Service Designee Presentation

Transcription

1 Social Service Designee Presentation Joette Novak, Program Manager Long Term Care Institutional Services DHHS Medicaid and Long-Term Care 1 OBJECTIVES Distinguish between Medicaid and Medicare Access applicable Medicaid policy and updates, Medicaid staff contact information, and identify Managed care vendors for Medicaid Determine the requirements for all that needs to be in place in order to file a claim and receive reimbursement from Medicaid Discuss the Pre-Admission Screening and Resident Review (PASRR) process and the reason for the process Discuss coordination with Managed Care Organizations 2 1

2 Medicaid and Medicare The terms Medicaid and Medicare are often used interchangeably however they are two separate programs. Medicaid DHHS adm inisters th e Medicaid Program which provides health care services to eligible elderly and disab led individuals and eligible low -incom e pregnant wom en,children and parents. The Nebraska Medicaid Program pays for covered medicalservices for th ose persons who are unable to afford to pay for m edically n ecessary services and w ho m eet certain eligibility req u irem en ts. Nebraska Medicaid is fu n d ed jointly by th e State and Federalgovernm ent. Nebraska Medicaid is available to certain low incom e persons including persons who are aged, blind,disab led,children,and others w ho m eet eligibility requirem ents. Medicare Medicare is a nationalsocialinsurance program adm inistered by th e Federalgovernm ent. Medicare covers m illions ofpeople age 65 and older as w ellas younger people w ith disab ilities. Part A: Hospitalinsurance Part B: M edicalinsurance Part C: M edicare Advantage plans Part D: Prescription drug plans 3 Nursing Facility Regulations NAC 471 Chapter Key Sections: 1. Level of Care (LOC) qualifier criteria: LOC process requirements: PASRR: /12-007; mixed throughout chapter NF per diem components: and MDS: Special need resident criteria:

3 ADDITIONAL MLTC RESOURCES TITLE 482 NEBRASKA MEDICAID MANAGED CARE (Managed Care Regulations) NAC 471 APPENDIX PROVIDER INFORMATION PROVIDER BULLETINS MEDICAID POLICY AND CLAIM COMPLETION INSTRUCTIONS NURSING FACILITY PROVIDER HANDBOOK CASEMIX WEBSITE (FOR CASEMIX ENROLLMENT FORMS/INSTRUCTIONS) RECENT WEB UPDATES 6 3

4 PROVIDER ENROLLMENT Maximus - Medicaid provider enrollment broker effective 12/1/15. Maximus customer service: nebraskamedicaidpse@maximus.com Maximus Web Portal: DHHS MLTC provider enrollment website: Medicaid provider enrollment contacts: Danny Vanourney DHHS MLTC Provider Enrollment Program Manager (402) , Danny.vanourney@nebraska.gov Erica Brooks DHHS MLTC Program Specialist Program Integrity Unit (402) , erica.brooks@nebraska.gov 7 NURSING FACILITY PROVIDER BULLETINS Explains the 34 levels of care assigned by Medicaid according to MDS assessments Nebraska Medicaid Minimum Data Set Requirements Level Of Care assessments for clients 64 years of age and under Level of care determinations by the League of Human Dignity Nebraska Casemix Internet System (NCIS) NCIS enrollment for all nursing facilities Level of Care Evaluation Requirements Required Notifications to DHHS Medicaid and Eligibility Staff Heritage health and NF Level of Care Process Coordination between Medicaid and Long-Term Care (MLTC) authorizing RN, Nursing Facility and Managed Care Organization (MCO) 8 4

5 Heritage Health Notify the plan in advance of facility admissions Provide requested documentation by due dates Follow guidance from each plan (i.e. complete timely discharge planning when notified by the plan that a client should be discharged to a lower level of care setting). The other option would be to appeal the decision if care staff disagree with the managed care decision. Complete level of care referrals (for clients not covered under a current PASRR Level II approval). 9 Heritage Health MANAGED CARE PLANS WILL NOT COVER: Room and Board for Long term (Custodial) Admissions Admissions on hospice or transition to hospice care during a current admission Any NF admissions where the managed care organization determines that the client can be appropriately served in a lower care setting. 10 5

6 Health Plan Advisories (HPA) Health Plan Advisories are written to provide instruction and clarification to the Heritage Health plans regarding certain policies and procedures. A couple of them that are of interest to nursing facility staff are: HPA DME for Medicaid Clients Residing in NF and ICF/DD HPA Notification of Nursing Home Admission of Heritage Health Members 11 For all questions about enrollment and plan selection: Heritage Health Enrollment Center TTY/TDD, call

7 Nebraska Total Care Provider/Member TTY/TDD: UnitedHealthcare Community Plan of Nebraska Member Provider TTY/TDD:

8 WellCare Of Nebraska Provider/Member TTY/TDD: For general questions about Medicaid eligibility: ACCESSNebraska Nebraska Medicaid Eligibility Helpline (Lincoln) (Omaha) TTDD:

9 For questions about Social Security or SSI: Social Security Administration TTY: ACCESSNebraska phone numbers for Economic Assistance IN LINCOLN IN OMAHA for Medicaid Program Assistance IN LINCOLN IN OMAHA address for Customer Service: In order to receive the Medicaid Notice of Action: Contact AccessNebraska and ask Customer Service about an Administrative Role for your resident. 18 9

10 PASRR (Preadmission Screening and Resident Review) Originated in 1987 to accomplish two main objectives: 1. Prevent inappropriate institutionalization while assuring optimal placement. 2. Ensure individuals with a PASRR disability receive appropriate services and supports if determined to meet NF placement criteria. 19 PASRR CONDITIONS (PASRR DISABILITIES) THAT ARE SCREENED BY PASRR: 1. Serious Mental Illness 2. Intellectual Disability 3. Related Conditions (To #1, #2 Or both) 20 10

11 PASRR Must be completed for anyone admitting to a Medicaid certified nursing facility (regardless of current pay source or number of Medicaid beds in the facility). Managed care clients are not excluded from the PASRR process. 21 PASRR Level 1: Identification Screen Required in the following events: Admission Prior to readmission to NF following psychiatric stay Delayed NF admission greater than 12 months from previous PASRR Level I per NAC A. Greater than 90 days from previous PASRR Level II determination date per NAC A. Significant change suggesting MI, ID/RC (worsening/increase of symptoms/behaviors, mood or previously undiagnosed PASRR MI/ID/RC) Stay extension (beyond short-term approval end date) Significant change of condition for an individual with known MI/ID/RC who experiences an improvement in condition that necessitates a care plan or placement recommendation change 22 11

12 TYPES OF PASRR DETERMINATIONS Negative Categorical Determinations Positive Level II Meets LOC/no specialized services (SS) Halted (not subject to PASRR i.e. has dementia primary dx) Does not meet LOC SS/Intensive Services or no SS/Intensive Services (via Level II determination) Cancelled determinations (if requested information not received within 14 days of request). 23 TYPES OF CATEGORICAL DETERMINATIONS Categorical Determinations are Desk-Based (Level II) Reviews for individuals who have a PASRR MI/ID/RC condition that do not require an initial on-site visit. *Exempted Hospital Discharge 30 Days (MOST COMMON) *Respite 30 Days Progressed Dementia ID/RC Serious Medical Exemption Primary Dementia/MI Halted *Emergency 7 Days Determination of a Categorical Determination is made at the Level I level. See qualifier criteria under NAC * = a new Level I must be completed if the individual will require additional care beyond the approval end date

13 DHHS CURRENT PASRR CONTRACTOR ASCEND MANAGEMENT INNOVATIONS A MAXIMUS COMPANY 840 CRESCENT CENTRE DRIVE, SUITE 400 FRANKLIN, TN Toll Free: (877) ext FAX: (877) LOG-IN WEBSITE: COMPANY WEBSITE: 25 Nebraska Medicaid Level of Care Determination Services coordinators from the Area Agencies on Aging and the League of Human Dignity or DHHS staff collect information on each individual seeking NF or waiver services to determine the functional abilities and care needs of that individual. Information may be gathered from a variety of sources (the individual, family, care providers, physicians, facility staff, case files, medical charts), using observation, documentation review, and/or interview until sufficient information is obtained to determine the individual's current functioning in each area

14 Level of Care Persons who require assistance, supervision, or care in at least one of the following four categories meet the level of care criteria for Nursing Facility or Aged and Disabled Home and Community-based Waiver services: 1. Limitations in three or more Activities of Daily Living (ADL) AND Medical treatment or observation. 2. Limitations in three or more ADL s AND one or more Risk factors. 3. Limitations in three or more ADL s AND one or more Cognition factors. 4. Limitations in one or more ADL s AND one or more Cognition AND one or more Risk factors. 27 Activities of Daily Living (ADL) The following ADLs are considered essential for independent living: Bathing-able to get to the bathing area and cleanse all parts of the body Continence-the control of one s body to empty the bladder and/or bowel on time and the ability to change, cleanse, and dispose of soiled articles; ability to manage ostomy equipment or self-catheterize Dressing/Grooming-ability to put on and remove clothing as needed Eating-the ability to take nourishment including getting the food from the plate to the mouth Mobility-the ability to move from place to place indoors or outside Toileting-ability to get to and from the toilet, management of clothing, and cleansing Transferring-moving from one place to another 28 14

15 Risk Factors Behavior Frailty Safety 29 Medical Treatment or Observation A medical condition is present which requires observation and assessment; or Due to the complexity created by multiple, interrelated medical conditions, the potential for the individual's medical instability is high or exists; or The individual requires at least one ongoing medical/nursing service such as: Routine catheter care, respiratory therapy, supervision for adequate nutrition and hydration, therapeutic exercise and positioning, colostomy or ileostomy care or management of neurogenic bowel and bladder, pressure ulcers, radiation, chemo, dialysis, etc

16 Cognition DHHS staff or service coordinators assess the memory, orientation, communication and judgment. A standard mini-mental test may be administered as appropriate. Additional exploration of judgment may also be necessary. 31 Minimum Data Set (MDS) The MDS is the assessment process for nursing facility residents that contains items reflecting the acuity level of the resident. Items on the assessment include diagnoses, treatments, and an evaluation of the resident s functional status. The comprehensive assessments also allow for documentation of the care plan for the resident and indicates which areas of the assessment require care planning. The MDS is also used as a data collection tool to classify Medicare and Medicaid residents into RUGs (Resource Utilization Groups). The RUG classification system is used in order to group residents into resource usage categories for the purposes of reimbursement

17 Nebraska Medicaid Use of the MDS Nebraska Medicaid uses the 34 grouper RUG model. By comparison, traditional Medicare uses a 66-group model. Nebraska Medicaid houses the assessments from CMS in our own Casemix system and uses this system interactively with our claims system for provider reimbursement. How Does the MDS Affect YOU? Because our Casemix system is linked to our claim payment system, it is important to have accurate information in the assessments such as correct admit date, date of birth, and SSN. 33 NCIS (Nebraska Casemix Internet System) In addition to using our casemix system for paying claims, we also make this system available to providers in order to run reports such as care level reports. These reports tell our providers what the latest status is of current residents and their current level of care. NCIS also enables users to enter hospital bed hold days. Easy to sign up! Visit and download/complete the External Access Confidentiality Statement (per user) Submit form to Greg Carlson via greg.carlson@nebraska.gov Application processing time is usually just a few days Notification to Greg is required when staff with access discontinue employment with your facility. and it s FREE! 34 17

18 NCIS Weighted Day reports-accounting, Office manager, etc. Carelevel Reports-MDS Coordinator, Billing, Social Services, Administrator Late assessments-billing, MDS Coordinator, Administrator Assessment error listing-mds Coordinator Reporting Bed hold-billing or Office Manager, Administrator, Social Worker, etc. 35 THE FORMULA FOR NF SUCCESS WITH MEDICAID NF CLAIM PAYMENT = Timely, complete, and accurate submission of: Claim + PASRR + Level of Care Referral + MDS + Coordination with Physical Health Managed Care (MC) plans for MC members 36 18

19 NEBRASKA MEDICAID CONTACTS MLTC INSTITUTIONAL SERVICES UNIT JOETTE NOVAK, PROGRAM MANAGER LONG TERM INSTITUTIONAL SERVICES (402) TERI ZIMMERMAN, ICF/DD PROGRAM SPECIALIST (402) GREG CARLSON, STAFF ASSISTANT II (402) ELLEN MCMILLAN, RN PROGRAM SPECIALIST OUT OF STATE NF, AGE 17 AND YOUNGER; SPECIAL NEEDS PRIOR AUTHORIZATION (402) NURSING FACILITY AND ASSISTED LIVING CLAIM CONTACTS GLORIA OVERSTREET, INSTITUTIONAL CLAIM MANAGER (402) MEDICAID INQUIRY LINE TOLL FREE: LOCAL: (402) To verify Medicaid client eligibility:

20 Nebraska Medicaid Contacts For questions about claim status: (Medicaid Inquiry) 39 QUESTIONS 40 20

21 JOETTE NOVAK PROGRAM MANAGER LONG TERM INSTITUTIONAL SERVICES Thank dhhs.ne.gov 41 21