LifeWays Operating Procedures

Transcription

1 SELF-DETERMINATION PRACTICE GUIDELINE I. PURPOSE The purpose of this practice guideline and procedure is to describe the philosophy of selfdetermination and its application within the LifeWays system, and to describe the responsibilities of each entity to ensure a successful experience for individuals wishing to participate in self-determination. II. III. VALUES AND PRINCIPLES UNDERLYING SELF-DETERMINATION A. Self-determination embodies the values of person-centered planning (PCP) and is based on the following four guiding principles that should apply to individuals with disabilities: 1. The freedom to choose where to live, with whom and the development of a personal lifestyle; 2. The authority to control the supports provided and the money that is spent on the individual's behalf; 3. The support to develop a life dream and reach toward that dream; and 4. The responsibility to use public funds efficiently and to contribute to the community through the expression of responsible citizenship. B. Self-determination is not appropriate for owner-operated living settings (group homes) or placements in unlicensed congregate living environments (more than 2 roommates). The intent of self-determination is to provide choice and control for an individual in their own home. Owner -operated and congregate living environments inherently limit choice and control. C. Generally, a person using arrangements that supports self-determination must live in his or her own home or apartment, or the home of a family member or friend. When the same person or entity provides room and board as well as 24 hours personal care or supervision for compensation to someone unrelated to him or her, the definition of foster care is met and the arrangement must be licensed pursuant to the Adult Foster Care licensing rules. These issues also arise when the same person is the landlord and the provider or the landlord and managing employer (such as the guardian). DEFINITIONS Choice Voucher The Choice Voucher System is one option for implementing arrangements that support self-determination. It provides a concrete set of methods for setting up contracts and payment mechanisms to make it possible for self-determination participants to exercise authority over employees and budgets. Page 1 of 22

2 Fiscal Intermediary (FI) An independent agency that manages the funds in the participant s individual budget, makes payments to providers of services as authorized, acts as an employer agent when the participant directly employs staff, and provides the participant with support and assistance as needed. Primary Clinician A person, usually a case manager/supports coordinator, who works with the participant to develop the IPOS and manages the corresponding self-determination budget as authorized by LifeWays and provides other assistance and support as needed. Employee Also referred to as a worker, direct care worker, or staff, a person that is employed by the individual to perform service. Individual Plan of Service (IPOS) The plan of services and supports that will be authorized and paid for to provide the participant with medically necessary public mental health treatment. The IPOS may also be referred to as the Treatment Plan. Self-determination budget Also referred to as Individual or Service Budget, the funding authorized to provide the expected services and supports sufficient to implement each goal in the amount, scope and duration identified in the participant s IPOS. Medicaid A government program that provides funding for services and supports that are deemed medically necessary to improve the individual s health outcomes. Participant/Employer A participant is a Medicaid recipient (individual) who is eligible for services and supports through the public mental health system and has chosen selfdetermination and the choice voucher system to exercise authority and control over their treatment. For the purpose of this procedure, the term participant/employer is inclusive of the participant s guardian if one has been appointed. Medical Necessity Services authorized under self-determination must be medically necessary for the participant, meaning the supports, services and treatment are: 1. Necessary for screening and assessing the presence of a mental illness, developmental disability or substance abuse disorder; and/or 2. Required to identify and evaluate a mental illness, developmental disability or substance abuse disorder; and/or 3. Intended to treat, ameliorate, diminish or stabilize the symptoms of mental illness, developmental disability, or substance abuse disorder; and/or 4. Expected to arrest or delay the progression of a mental illness, developmental disability, or substance abuse disorder; and/or 5. Designed to assist the beneficiary to attain or maintain a sufficient level of functioning in order to achieve his goals of community inclusion and participation, independence, recovery or productivity. Page 2 of 22

3 Amount, Scope, Duration What kind, how much and how often, and for how long the Medicaid services that are listed in a person s individual plan of service will be provided. IV. NOTIFICATION OF SELF-DETERMINATION A. LifeWays shall provide the necessary information, education and technical assistance to individuals/guardians and family members, employees of individuals, and service providers regarding self-determination and applicable LifeWays policies and procedures. B. LifeWays shall promote self-determination by making educational materials available at all points of access and provider agencies. LifeWays Access Center and Customer Services shall distribute the Member Handbook to all new individuals, which includes a brief explanation of self-determination at LifeWays. The LifeWays Self-Determination Coordinator is available to answer questions related to the self-determination process and can provide more detailed information to the individual as defined in this Operating Procedure. The LifeWays Self-Determination Coordinator is the subject matter expert and is responsible to ensure content of all published materials is accurate and describes the philosophy of self-determination and its application within the LifeWays system. When changes are made to self-determination policy or procedures either internally by LifeWays or externally by the Michigan Department of Health and Human Services, LifeWays shall ensure that appropriate revisions are made to the LifeWays Self-Determination Practice Guideline and Attachments and changes are clearly communicated in writing to participants. C. Individuals can request to receive services via a self-determined arrangement upon entry into services or at any time during the course of treatment. If a new individual is interested in self-determination, the LifeWays Access Center will follow the normal procedures for intake, eligibility and service referral and will specify the individual s request for self-determination, notifying the Self-Determination Coordinator via chart note through the electronic medical record (EMR), after which the LifeWays Self- Determination Coordinator will review the referral information to initiate the selfdetermination process by scheduling a meeting with individual/guardian and independent facilitator (if the individual has chosen independent facilitation) to develop a plan and discuss options, roles and responsibilities in a self-determination arrangement. For current individuals, LifeWays Network Providers shall, at the time of person-centered planning or when interest is expressed by the individual: 1. inform individuals of their choice to receive services under a self-determined arrangement; Page 3 of 22

4 2. review, with individuals, the LifeWays brochure explaining self-determination at LifeWays, and; 3. refer the individual to the LifeWays Self-Determination Coordinator if appropriate for additional information to assist the individual in making an informed decision. The primary clinician shall arrange for the LifeWays Self-Determination Coordinator to attend a planning meeting to discuss self-determination arrangement options PRIOR to beginning an arrangement. Failure to do so may result in the arrangement not being approved. D. LifeWays may choose not to support an arrangement if the individual/guardian is unable to manage the roles and responsibilities identified in the Self-Determination Agreement, if the individual resides in an unlicensed congregate setting, licensed group home, if the setting is owner-operated, if the employer has been unable to manage their budget in the past, if the employer is unable or unwilling to fulfill their responsibilities relative to staff, Medicaid requirements and budget monitoring and adherence. This denial to support an arrangement is not a denial of clinical services and individual notice is not required. Referral information to other agencies, network provider and community resources to meet the need will be given if needed. V. APPROVING A SELF-DETERMINATION BUDGET A. LifeWays Utilization Management (UM) Team shall provide information and assistance necessary to assist network providers, individuals and their supports in identifying available services that the individual may need as it relates to their individual treatment needs under medical necessity criteria. B. All individuals with Medicaid are eligible to participate in self-determination. The individual has the right to choose from qualified providers to execute the Individual Plan of Service (IPOS). C. Providers may be in or out of network and must meet the Medicaid qualifications to serve LifeWays individuals. D. Evidence-based practices (EBPs) are excluded from being provided under a selfdetermination arrangement due to the additional monitoring that LifeWays requires (i.e., biennial fidelity assessments, quarterly program outcome monitoring, etc.). E. Flexible community resources and natural supports must be utilized prior to utilization of LifeWays resources. F. Individual treatment planning shall be conducted using a person-centered planning approach and encouraging the utilization of independent facilitation. Page 4 of 22

5 G. The Self-Determination Coordinator, with the assistance of UM, shall coordinate authorization requests with the primary clinician through attendance at meetings and/or review of documentation submitted through the authorization process to assist the clinician in identifying what supports and resources the individual already has to meet their needs, what needs remain unmet, and how best to meet the remaining unmet needs (net need). UM shall follow the same eligibility criteria for service authorization under self-determination as for in-network services. H. UM shall approve authorizations in the EMR (LEO is LifeWays EMR) under the Fiscal Intermediary provider. A Budget Determination Summary will be created by the Self- Determination Coordinator once UM has approved the authorization(s) to assist the individual/guardian, primary clinician, and Fiscal Intermediary in establishing the selfdetermination budget. The Budget Determination Summary will identify the individual name, case number and diagnosis, the IPOS start date, primary clinician and fiscal intermediary names, authorized services, per unit rate, total units authorized and the total budget dollar amount per service type and in total (which are calculated by multiplying the unit rate by the total authorized units) for the treatment plan year. Thereafter, a complete budget shall be created for the individual/guardian with the support of the Fiscal Intermediary and primary clinician to include direct service and indirect costs (i.e. employment costs, FI service costs, etc.) of participating in selfdetermination. The budget must be within the scope of the authorized amounts provided in the Budget Determination Summary. I. The Budget Determination Summary, in addition to the monthly budget reports provided by the Fiscal Intermediary, shall be filed with the individual s IPOS as maintained by the primary clinician. If a change to the self-determination budget or a need for additional services is identified during the treatment period, the primary clinician is responsible for coordinating such change with UM, documenting the change through a formal addendum to the IPOS and requesting an updated authorization through the authorization process with UM and an updated Budget Determination Summary from the Self-Determination Coordinator. The individual/guardian, with the support of their primary clinician, fiscal intermediary, and circle of supports, shall manage their service utilization within the established budget. If the individual/guardian over expends budget through overutilization (utilizing services above the amount, scope and duration as defined by the approved authorization), approving a wage above the maximum allowable wage or allowing reimbursement for a non-authorized service, they will be held financially liable and required to reimburse for costs incurred. VI. CONTRACTS AND AGREEMENTS Page 5 of 22

6 A. Once an individual has requested participation in self-determination and the selfdetermination budget has been authorized, the Fiscal Intermediary shall initiate the contracts and agreements process. The following outlines the documents required to complete the self-determination enrollment: 1. Self-Determination Agreement Also known as the Choice Voucher Agreement, a signed agreement between the individual and LifeWays. The agreement outlines the purpose of the program and clearly defines LifeWays and the individual s responsibilities while the individual is enrolled in self-determination. This MUST be completed prior to employees working. The LifeWays Contract Management Team sends the agreement to the individual for signature and, once fully executed, retains a copy in the individual s electronic medical record and returns a copy to the individual. 2. Employment Agreement with Job Description A signed agreement between the individual and the employee with an attached Job Description. The agreement and job description outline the services to be provided, the rate of reimbursement, the employee responsibilities, and other employer-employee agreements necessary to facilitate the employment process. This MUST be completed prior to employees working. The FI facilitates signatures on the Employment Agreement and Job Description. Fully executed copies of these documents are retained in the office of the Fiscal Intermediary. 3. Medicaid Provider Agreement A signed agreement between LifeWays and the employee or organization serving the individual under the Employment Agreement. The agreement outlines the provider s responsibilities per Medicaid regulations and LifeWays standards. This MUST be completed prior to employees working. The FI facilitates signature on the agreement by the employee or organization serving the individual and forwards it to LifeWays for signature by the LifeWays Self-Determination Coordinator. The fully executed original is retained in the LifeWays Contracts office. 4. Staffing Agency Agreement A signed agreement between the individual and a provider agency. The agreement outlines the services to be provided, the rate of reimbursement, the responsibilities of the provider, and other agreements necessary to support the individual in the self-determination model. This MUST be completed prior to employees working. The Fiscal Intermediary facilitates signatures on the Staffing Agency Agreement. A fully executed copy of this document is retained in the office of the FI. 5. Ethical Standards An attestation signed by the employee to ensure ethical standards are followed during service delivery. This MUST be completed within Page 6 of 22

7 thirty (30) days of hire and annually thereafter. Once signed, the attestation is sent to the FI, and the copy is retained in the office of the Fiscal Intermediary. B. The primary clinician is responsible for assisting the FI with the agreement process, which may include coordinating the necessary signatures and ensuring all parties receive copies of respective agreements. C. LifeWays contracts for Fiscal Intermediary services. The contract between LifeWays and the FI outlines respective roles and responsibilities as well as the method of reimbursement. The LifeWays Provider Manual is an attachment to this contract and is available online at VII. SERVICE CLAIMS/TIMESHEETS A. In accordance with the Employment Agreement and/or Staffing Agency Agreement, the provider shall submit an invoice or time sheet and the corresponding support notes to the individual/guardian for review and approval signature. The individual/guardian shall submit the invoice or time sheet, along with corresponding Support Notes written by the provider, to the FI for processing. Time sheets submitted to the FI without corresponding Support Notes (including CSM/SC notes entered into LEO) will not be processed for payment. The provider is responsible for ensuring they are requesting payment for services as outlined and authorized within the individual s IPOS at the rate agreed upon within the Employment or Staffing Agency Agreement. B. A clean claim meets all of the following criteria: 1. The service(s) that constitute the claim has/have been authorized. 2. The service(s) has/have been provided and properly documented (including accurate start and stop times) according to source document requirements. 3. The service(s) is/are submitted to LifeWays without errors, all required data elements associated with the specific claim are present and in standardized format. 4. The claim(s) has/have been received by LifeWays within forty-five (45) days of service delivery. 5. No overlapping SAL except for allowable codes per MDHHS/PIHP/CMHSP Encounter Reporting HCPCS and Revenue Codes. 6. The service that constitutes the claim must be reimbursable as defined in the Employment Agreement or Staffing Agency Agreement and Medicaid Provider Agreement. 7. The service claim submitted to LifeWays is at a reimbursement rate equal to or less than the LifeWays issued rate for that service; any overage requested shall be denied. 8. The service claim submitted to LifeWays is for service provided to the individual. Page 7 of 22

8 Nonservice-related expenses, such as vacation or bonus pay, shall be denied. C. Submitting false documentation is considered a compliance violation, and could result in a substantiated Medicaid compliance investigation being issued against the employer of record. If an employee was paid with Medicaid dollars and a compliance investigation later substantiates that the claim constitutes fraud, waste or abuse, the employer of record shall be responsible to reimburse LifeWays CMH. This is because submitting a service note/time sheet to the fiscal intermediary is submitting a bill with the Federal Government and certifying employees earned the payment requested and complied with Medicaid billing requirements. If an employer of record knew or should have known the submitted claim was false, then the attempt to pay employees constitutes a violation. D. Time sheets must be approved by the individual/guardian (employer) or an authorized representative. LifeWays strongly encourages the individual/guardian to maintain this responsibility. If the individual/guardian chooses to delegate the responsibility of approving time sheets to a designated representative, this arrangement must be outlined in a written agreement. There are restrictions regarding delegation due to conflict of interest. Therefore, a Guardian Delegation of Self-Determination Timesheet Approval form must be signed and provided to the Fiscal Intermediary. A designated representative cannot be a person who financially benefits from the authorization of time sheets. It is preferred that an authorized representative be a natural support to the individual (i.e. friend). Staff shall not approve time sheets. E. Corrections to service notes/time sheets shall be made before submission to the fiscal intermediary. If corrections are needed please complete the following: 1. Draw one horizontal line through the word or words which are in error. 2. Above the error write the word "error" and initial it at its upper right-hand corner. 3. Write the correct word or words to the right of the error. F. Once submitted to the fiscal intermediary, the employer of record may not alter the documentation. G. Individuals enrolled in Children's Waiver shall ensure that the corresponding data sheet matches the description and time frames noted on the service note/time sheet prior to submission to the fiscal intermediary. If the technical elements of the data sheet and service note/time sheet (ex., units, time in/out, dates of services) are not consistent with each other, the employee may not be paid using Medicaid dollars. H. In the event that service claims submitted to the fiscal intermediary cannot be Page 8 of 22

9 reimbursed by Medicaid because the claim is improper, the employer of record is responsible to pay staff out of pocket for the hours the employee worked, but that cannot be paid out with Medicaid dollars. I. Examples of improper claims include: 1. Billing for services that an employee did not render; 2. Billing for services that are not authorized under the employer's individual plan of service; 3. Billing for services in an amount, scope and duration that exceeds that authorized under the employer's individual plan of service; 4. For children's waiver enrollees, failure of the service note/time sheet to match the corresponding data sheet; 5. Poor or no documentation describing the services rendered; 6. Paying staff with a prohibited conflict of interest (for example, paying a 7. CLS staff who is the guardian, or the spouse of the guardian.); 8. Paying staff who are not trained pursuant to state and federal regulations. J. The FI then submits a service claim to LifeWays through LEO Clean claims will be paid within thirty (30) days of submission. K. The Fiscal Intermediary is responsible for assisting the individual is managing employer related costs and shall have a process for building these indirect costs into the individual s budget. The cost of training is an administrative cost (training, fringes, etc.) withheld from the wage established by the employer. Because the time at training is not face-to-face with the individual LifeWays is supporting, this is not a valid encounter and LifeWays would be billed only for the direct service provision as a valid encounter. L. The FI may dispute a denied claim by contacting LifeWays Customer Services to initiate a formal appeal. (Reference: LifeWays Provider Manual, Customer Services: Grievance and Appeals Process) VIII. SELF-DETERMINATION BUDGET MONITORING A. Once the individual s self-determination budget has been established by LifeWays Self-Determination Coordinator based upon UM authorization process, all parties involved in self-determination have a responsibility to assist in monitoring utilization to ensure the individual s treatment expenses do not exceed the total self-determination budget. B. The Self-Determination Coordinator will complete a monthly desk audit of all budget reports received from the FI. The Self-Determination Coordinator will request a meeting with the primary clinician and individual/guardian when there are any Page 9 of 22

10 identified variances that may lead to concerns with overspending. These meetings will be documented in the chart note section of the EMR. The Self-Determination Coordinator will also complete, minimally, quarterly-face-to face meetings with individuals in arrangements to ensure they are receiving all necessary services, and monthly budget reports and to provide any education or assistance necessary to support the individual s success in their arrangement. C. The FI is responsible for meeting with the individual/guardian, initially, to review their IPOS services and associated expenses, including FI service fees and other related expenses that the individual must anticipate. It is the FI s responsibility to provide a monthly budget report to the individual to assist the individual in properly managing their self-determination budget. The FI must notify the individual/guardian, primary clinician, and LifeWays in writing when: 1) the individual is projected to be overspent before the end of the IPOS period, and/or 2) the individual is overspent and claims will no longer be paid. LifeWays will not pay for expenses, direct or indirect, that exceed the total Self-determination budget. D. It is the individual s responsibility to review the budget reports prepared by the FI and to stay within the parameters that were set by LifeWays to prevent overspending or spending at a faster rate than authorized. The self-determination budget is based on medical necessity to provide the amount, scope and duration of service to meet the individual s treatment needs. Using services at a higher intensity than requested at the time of treatment planning is inappropriate and may expend funds before the treatment period is over. Individuals may be flexible within their authorized budget with regards to units used within a service type (only within labor laws and medical necessity), as well as wage and choice of qualified staff. Once the self-determination budget is expended, no further services will be reimbursed by LifeWays for the treatment period; however, the individual shall continue to receive services from their employee(s). If an individual consistently inappropriately manages their selfdetermination budget, LifeWays will recommend alternative arrangements through a person-centered planning approach, which will include authorizing in-network services instead of self-determination arrangements. Continuity of service shall be ensured during a transition from self-determination to in-network services. The individual may appeal a decision to terminate a self-determination arrangement through the local Grievance and Appeal process (not a Medicaid Fair hearing action) by contacting LifeWays Customer Services. LifeWays may decline any request for self-determination participation if there are significant concerns that may impede the individual from being successful or if the self-determination budget is so small that the FI fee would comprise a large percentage of the budget. In these situations, it would be Page 10 of 22

11 recommended that the individual obtain services through an in-network provider and not through a self-determined arrangement. E. It is the primary clinician s responsibility to support the individual in monitoring their self-determination budget, which includes reviewing the individual s service array and assisting the individual in making necessary adjustments in usage to prevent overexpenditure. If medically necessary, the primary clinician should request additional services from LifeWays Utilization Management. F. It is LifeWays responsibility to facilitate all parties in appropriately monitoring and managing the self-determination budget and to provide necessary education to ensure the individual is receiving adequate care to achieve their treatment outcomes. G. Individuals providing services under self-determination are expected to adhere to LifeWays Ethical Standards and Medicaid regulations. Self-determination arrangements are NOT exempt from laws governing Medicaid funding. The LifeWays Corporate Compliance Committee shall investigate complaints of suspected fraud and abuse involving self-determination arrangements and shall notify the appropriate authorities as required by law. H. Repayment of paid claims may be required of the service provider (employee or provider agency) if, during the course of an investigation/review conducted by LifeWays, it is determined that: 1. There is no documentation to support a LifeWays paid claim; 2. Service delivery did not address the goal(s) of the treatment plan; 3. There is no treatment plan goal to support the service; 4. There is no current treatment plan for the date of service billed; and/or 5. Service utilization is outside of the defined intensity, scope and duration as defined by the approved authorization. I. LifeWays will seek recoupment of paid funds if any of the above reasons are substantiated. Written notification will be sent to the individual/guardian, service provider, Fiscal Intermediary and LifeWays Finance. The Fiscal Intermediary shall withhold the total amount of recoupment from the provider s next payment. Subsequently, LifeWays Finance shall withhold the total amount from the next provider pay to the Fiscal Intermediary. If necessary and appropriate, the provider can request a repayment plan with the Fiscal Intermediary, which should also be communicated to LifeWays Finance so FI provider pay withholding reflects the same schedule. IX. HIRING QUALIFIED EMPLOYEES Page 11 of 22

12 A. The individual is the employer under the self-determination model and has the right to choose their employees and direct and supervise their work. Employment Agreements and/or Staffing Agency Agreements document the terms and conditions of employment. The individual is primarily responsible to ensure their employees are qualified and competent by requiring the following minimum hiring standards be satisfied as a pre-condition of employment: 1. The person must be in good standing with the law. The person may not be currently under jurisdiction of the Court. For workers serving adults, the person may not be a fugitive from justice, a convicted felon who is either under jurisdiction or whose felony relates to the kind of duty to be performed, or an illegal alien. For workers serving children, the person may not be a fugitive from justice, a convicted felon or an illegal alien. 2. The person is not legally responsible for the individual, and is in compliance with provider requirements of LifeWays and the Michigan Department of Health and Human Services (MDHHS): a. At least eighteen (18) years of age; b. Able to prevent transmission of any communicable disease (as evidenced by successful completion of Infection Control/Blood Borne Pathogens training.); c. Able to communicate expressively and receptively in order to follow individual plan requirements and beneficiary-specific emergency procedures, and report on activities performed; d. Has not been excluded from participation in Federal Healthcare Programs and does not appear on either the Office of the Inspector General s Exclusions Database; or the Michigan Department of Community Health List of Sanctioned Providers. 3. Able to perform basic first aid procedures. 4. Must act within the scope of practice defined by their professional license. 5. Must have a valid driver s license and appropriate insurance to operate motor vehicles used to provide transportation if transporting the individual is a function of their employment. 6. Knowledgeable of the Individual Plan of Service (IPOS) for the individual and provides support to the individual according to the IPOS. B. Individuals as employers must adhere to labor laws and ensure their employees receive the required initial and ongoing trainings as described below. The FI can provide further assistance to the individual regarding the hiring process. The individual is encouraged to review Hiring and Managing Personal Assistants, a publication by The Arc Michigan ( ). Page 12 of 22

13 C. LifeWays reserves the right to exclude an individual or an organization from becoming an employee or staffing agency under self-determination if issues of non-compliance with Medicaid regulations are substantiated. Exclusion will be based on a review of significant adverse findings from internal or external sources and may include recipient rights violations, licensing violations/ sanctions, malpractice claims, unethical conduct, corporate compliance substantiations, certification/accreditation decisions, and/or non-adherence to LifeWays Self-Determination Practice Guideline. LifeWays shall render the decision to exclude a provider from serving under a self-determined arrangement based upon the severity of risk to individual care or in cases of Medicaid fraud or abuse. X. TRAINING REQUIREMENTS A. The individual is responsible for assisting their employees in obtaining required training. All employees must receive, minimally, training in Recipient Rights, Infection Control/Blood Borne Pathogens, HIPAA, Grievance & Appeals, Self-Determination, and other training as identified in the individual s Individual Plan of Service. Employees providing in-home services must also obtain certification in First Aid and Medication Administration training (if passing medications). Medication Administration training may be obtained by a qualified resource (i.e., Pharmacist, Registered Nurse, Physician, etc.). Training may be provided by LifeWays or external training resources. All training must be documented and provided to the Fiscal Intermediary. XI. LIFEWAYS RESPONSIBILITIES A. LifeWays Self-Determination Coordinator, Access Department and Customer Services shall be responsible for ensuring educational materials regarding self-determination are available to network providers, individuals and the public. B. LifeWays Self-Determination Coordinator shall provide technical assistance and training as needed to participants (individuals, guardians, employees of individuals, fiscal intermediary staff, etc.) regarding roles and responsibilities under selfdetermination and applicable LifeWays policies and procedures. C. LifeWays shall ensure compliance with self-determination policies and procedures and Medicaid regulations via a comprehensive compliance audit of the FI no less than every two (2) years (i.e. Certification Review, Billing Verification Review). This audit will include review for evidence of compliance with employee qualification standards. Funds paid to unqualified employees will be subject to repayment to LifeWays. D. LifeWays Contract Team shall be responsible for the development and enforcement of contract documents, to include: 1) the Self-determination Agreement between Page 13 of 22

14 LifeWays and the individual/guardian, 2) the Service Contract between LifeWays and the Fiscal Intermediary service provider, and 3) the Medicaid Provider Agreement between the employee and LifeWays. LifeWays will have available templates for employers to use for employment agreements/staffing agency agreements and job descriptions (service descriptions based upon the Michigan Medicaid Provider Manual and Self Determination Technical Advisory). E. LifeWays UM shall be responsible to monitor documentation of service provision through case reviews and the service authorization process to ensure medical necessity is present. Funds used in excess of the authorized self-determination budget may be subject to repayment to LifeWays by the Fiscal Intermediary. Funds unsupported by medical necessity will be subject to repayment to LifeWays by the service provider. F. LifeWays Self-Determination Coordinator shall advise individuals and providers on person-centered planning principles to ensure the appropriate information is obtained to determine medical necessity for services. G. LifeWays Self-Determination Coordinator shall develop the individual selfdetermination Budget Determination Summary based on UM authorized services. H. LifeWays Self Determination Coordinator shall receive a monthly budget report from the Fiscal Intermediary for each self-determination individual and is responsible to review said reports and facilitate communication regarding potential budget overages. However, the FI is primarily responsible to communicate potential overages in writing to the individual/guardian and primary clinician. I. LifeWays shall ensure appropriate training opportunities are available to providers of direct care and treatment. Costs associated with employee training that is not available through LifeWays may be submitted for payment to the FI from the individual s selfdetermination budget as an indirect cost. J. LifeWays Quality Management Team is responsible to monitor and report selfdetermination quality indicators to include customer satisfaction, demographics of the self-determination population and cost effectiveness of the model. K. LifeWays is the trustee of the funds that support the LifeWays self-determination process, and any remaining funds within the individual s individual self-determination budget at the end of the IPOS period shall remain with LifeWays. XII. PRIMARY CLINICIAN/EMPLOYEE RESPONSIBILITIES Page 14 of 22

15 A. The primary clinician shall be responsible to support and monitor the development and implementation of an Individual Plan of Service (IPOS) using person-centered planning principles and shall adhere to requirements outlined within the Michigan Mental Health Code, Medicaid Provider Manual, and LifeWays Provider Manual. Evidence of pre-planning and PCP meetings is required. B. The primary clinician shall develop measurable, recovery oriented goals with the individual and shall ensure services are being provided in accordance with the IPOS and authorized services. Plans should be submitted 5-10 days prior to the implementation date to allow for service review, budget development and reduce possible lapse in authorizations. C. The primary clinician shall contact LifeWays Self-Determination Coordinator prior to the initiation of any change in service. D. The primary clinician shall notify LifeWays if an amendment to the IPOS is needed to supplement the individual s treatment based on medical necessity. The primary clinician shall follow the required process to amend the IPOS and submit authorization requests to UM as needed. E. The primary clinician shall ensure that necessary treatment authorizations are current before service is provided. F. The primary clinician shall be primarily responsible to coordinate the individual s treatment under the self-determination model. G. The primary clinician shall ensure that the individual/guardian has the support needed to hire and manage qualified and competent employees. H. The primary clinician shall be responsible for assisting with the agreement process, which may include coordinating the necessary signatures and ensuring all parties receive copies of respective agreements. I. The primary clinician shall assist the individual in monitoring self-determination expenses through the monthly self-determination budget reports provided by the FI. J. The primary clinician shall ensure the individual s Fee Determination is complete and verified and that all supporting documentation is in place. K. The primary clinician shall ensure all required data elements are complete in the individual s electronic medical record. L. The primary clinician shall ensure medical record documentation supports medical necessity and service description criteria. Page 15 of 22

16 M. The primary clinician shall verify the individual s Medicaid eligibility at the time of service and prior to submitting requests for reimbursement. N. Providers serving the individual shall document their services in accordance with Medicaid documentation standards by using the LifeWays EMR or LifeWays-provided forms. For community living supports, checklists are acceptable forms of documentation, but shall not be the sole documentation maintained by the provider. All primary clinicians shall use EMR to document treatment. Minimally, the following forms must be completed in EMR: Consent to Exchange/Release Information, Consent to Participate in Services, Death Report, Discharge Summary, Financial Determination, Incident Report, Intake/Update Assessment, Progress Note, Pre-Plan, Treatment Plan & Crisis Plan, Treatment Plan Addendum and Treatment Plan Formal Review. O. Providers serving the individual shall ensure their services are provided in accordance with the IPOS-approved service authorizations and service descriptions as referenced in the Michigan Medicaid Provider Manual. P. Employees serving the individual have a duty to provide services as authorized at the determined level of care (amount, scope, duration) until the individual meets discharge criteria, declines service, or a referral is accepted by another service provider. XIII. FISCAL INTERMEDIARY (FI) RESPONSIBILITIES A. Safeguard, manage and account for funds disbursed from LifeWays. B. Disburse funds to participant providers only after obtaining: 1. Employment Agreements (in the case of individual employees) or Staffing Agency Agreements (in the case of organizations) for each provider signed by the participant and the provider; 2. Job Descriptions (in the case of individual employees) signed by the provider; 3. Medicaid Provider Agreement signed by each provider; 4. Authorization of service(s) from LifeWays; 5. Timesheets approved by the participant if determined to be legally competent, or by his/her authorized representative (legal guardian, power of attorney). 6. Support notes that document services provided (see additional detail below in item #4.) C. Assist each participant in assuring all necessary documentation is in place including but not limited to all agreements required by LifeWays. D. Assist each participant in assuring support notes support services provided and meet LifeWays minimum standards. For purposes of verifying that documentation exists to support the service provided and timesheet submitted, the FI shall review support Page 16 of 22

17 notes, prior to disbursing payment to the provider, to ensure they meet the following minimum requirements: 1. The name and case number of the person who is receiving the service 2. The date the service was provided 3. The time the service started and stopped 4. Legible entries including a narrative description of services provided 5. The signature date and signature of the person providing services 6. The FI review of support notes is limited to a good faith review to determine, to the best of its ability, that it contains the foregoing information. Any subsequent determination by LifeWays or some other third party that a progress note is deficient shall not result in any liability, either directly or through indemnification, for the FI. While LifeWays has additional requirements in terms of the clinical content of progress notes, the FI is not required to review notes for clinical content. 7. The FI shall upload support notes to individual individual records in the LifeWays Electronic Organizer (LEO) each pay period, with uploads not to exceed fourteen (14) calendar days from the date of receipt by the FI. E. Maintain complete current financial records, copies of all agreements and supporting documentation verifying expenditures paid by the FI on behalf of each participant for seven (7) years. F. Record, maintain and provide a monthly spending report for each participant, and provide a copy to LifeWays, the participant and the participant s primary clinician, and maintain records for seven (7) years. Monthly reports shall minimally include: total budget, expenditures for the month, year to date expenditures and budget balance. Flag, for LifeWays, the participant and the participant s primary clinician, any deviation (over or under) in an individual budget of 10% or more. G. Reconcile all accrued expenses/accounts for the fiscal year (October 1 September 30) and provide a reconciliation report to LifeWays by January 31. H. Make records regarding participants available to LifeWays as requested and allow each participant access to his/her own records. I. When a participant is directly employing workers, the FI shall act as employer agent and perform the financial administrative duties of employer, pursuant to the Internal Revenue Code Section 3504, IRS Revenue Procedure 70-6 and 80-4 and IRS Notice The tasks required for the FI to function as an employer agent include, but are not necessarily limited to: 1. Issue payroll payments to workers hired directly by participants. Page 17 of 22

18 2. Withhold income, Social Security and Medicare taxes from payroll payments, and make payments to the appropriate authorities for taxes withheld. 3. Make payments for unemployment taxes and worker s compensation insurance to the appropriate authorities, when necessary. 4. Issue W-2 forms and tax statements. 5. Obtain documentation from participants and file it with the IRS so that the FI can serve as Employer Agent for participants, and meet the requirements of state and local income tax authorities and unemployment insurance authorities. 6. Assist participants with purchasing worker s compensation insurance, if required. J. The FI shall provide employer support functions to ensure that participants are able to successfully use the Choice Voucher/Self-Determination system: XIV. EMPLOYEE VERIFICATION FUNCTIONS A. All workers hired through the Choice Voucher System must provide written verification that they meet employment requirements. The FI shall perform employee verification functions, including: 1. Perform criminal background checks on all workers post-offer of employment and prior to the person providing any services for LifeWays individuals to ensure they are in good standing with the law. Criminal background checks must be completed annually thereafter. Criminal background checks must also be performed on any workers who transition to the FI from a previous Fiscal Intermediary. For workers serving adults, the person may not be a fugitive from justice, a convicted felon who is either under jurisdiction or whose felony relates to the kind of duty to be performed, or an illegal alien. For workers serving children, the person may not be a fugitive from justice, a convicted felon or an illegal alien. 2. Verify citizenship or resident alien status of each worker. 3. Assure that each provider of services and supports retained by the participant is not a legally responsible person for the individual, and is in compliance with provider requirements of LifeWays and the Michigan Department of Community Health: a) At least eighteen (18) years of age; b) Able to prevent transmission of any communicable disease (as evidenced by successful completion of Infection Control/Blood Borne Pathogens training); c) Able to communicate expressively and receptively in order to follow individual plan requirements and beneficiary-specific emergency procedures, and report on activities performed; d) Provider/employee has not been excluded from participation in Federal Healthcare Programs and does not appear on either the Office of the Inspector Page 18 of 22

19 General s Exclusions Database; or the Michigan Department of Community Health List of Sanctioned Providers. e) Able to perform basic first aid procedures. f) Knowledgeable of the Individual Plan of Service (IPOS) for the individual and provides support to the individual according to the IPOS. B. The FI is responsible for safeguarding findings, reporting them to the appropriate participant, and maintaining records. C. Information and Guidance Functions: The FI shall make information and guidance available to participants when they are able to be the direct employer of workers. Such information shall assist participants in being successful employers. These supportive services shall include at least the following tasks: 1. Assist participants in understanding reporting, invoice processing and documentation responsibilities. 2. Provide participants with information on how to recruit workers. 3. Provide participants with sample job interview formats and job descriptions. 4. Arrange and facilitate participation in peer discussion groups aimed at supporting participants in being successful in the employer role. 5. LifeWays requires training of staff providing services to individuals under a selfdetermination arrangement (see Attachment to FI contract). 6. The FI shall: a. Notify participants of training requirements at enrollment and when LifeWays provides written notice of training requirement updates to the FI; b. Collect and retain evidence of staff training; c. Monitor compliance with training requirements, and; d. Notify the employer, the participant s primary clinician and the LifeWays Self- Determination Coordinator of non-compliance with training requirements. Notice of non-compliance with training requirements shall be provided in writing on a quarterly basis and shall specify the name of the person for whom evidence of required training has not been received by the FI and the name of the required training. 7. Assist each participant with the use and understanding of his/her individual budget as requested or needed. 8. Provide participants with resources that guide them through the process of finding and selecting qualified workers. 9. Assist participants with understanding legal developments that affect their roles and responsibilities as employers. Page 19 of 22

20 XV. INDIVIDUAL/GUARDIAN RESPONSIBILITIES A. Individuals and/or their legal guardians have the right to choose, direct and supervise the employee/staffing agency providing authorized services. B. Individuals/guardians shall be supported in the employment process by the primary clinician. C. Individuals/guardians shall ensure that employees meet basic requirements as defined in the Medicaid Provider Manual and listed under the Hiring Qualified Employees section of this procedure. Employees are NOT eligible to work until eligibility for employment is verified by the FI. D. Individuals/guardians are responsible for assisting their employees in obtaining required trainings. Individuals/guardians shall be primarily responsible to enforce all agreements made within the Employment Agreement or Staffing Agency Agreement. LifeWays Self-Determination Coordinator will follow up with the employer in the event requirements are not met and kept current as this can be a reason to terminate an arrangement. Individuals/guardians shall participate in person-centered planning to direct their treatment and develop measureable goals to support the authorized services. E. Individuals/guardians shall not pay employees more than the established LifeWays rate identified as the maximum allowable rate on the Budget Determination Summary. F. Individuals/guardians shall monitor service authorizations and the expiration dates to ensure service is provided within authorization parameters. The FI and primary clinician shall support the individual in this responsibility. The individual/guardian and the primary clinician shall ensure there is a current authorization before any service is provided, and that re-authorizations are requested when necessary. G. Individuals/guardians shall use the self-determination budget appropriately to pay employees for direct care or service delivery as documented in the IPOS authorized services or for employment related costs, such as worker s compensation, FICA, training costs, and FI fees. H. Individuals/guardians shall not use the self-determination budget to pay employee bonuses or vacation/sick pay, as the funds are only allowed to be used for actual service provided to the individual similar to a fee-for-service model. I. Individuals/guardians shall abide by all applicable labor laws. If overtime pay is necessary, the individual/guardian shall ensure that the total expenses remain within the authorized self-determination budget for the treatment period, as overtime pay may cause the individual to spend the self-determination budget more quickly than Page 20 of 22