NC Innovations Waiver Webinar - January 25, 2013 & January 28, 2013 Updated May 2013 Serving Durham, Wake, Cumberland and Johnston Counties
Background on the Policy CMS gives states the ability to choose whether relatives or legal guardians can provide services and under what conditions this may occur. There is no federal or state entitlement that relatives or legal guardians must be employed. North Carolina has chosen to allow relatives and legal guardians who live in the same home as the adult NC Innovations Waiver participant to provide services under specific conditions.
Relative DMA defines Relative as the Innovation s Waiver participant s mother, father, step-mother, stepfather, sister, brother, aunt, uncle, grandmother, or grandfather. Legal Guardian A guardian is someone who is appointed by the Clerk of Superior Court to act on behalf of an incompetent adult. All forms of guardianship, Guardian of the Person, Guardian of the Estate, and General Guardian are applicable to the Relative/Legal Guardian as provider process.
Adult DMA has defined adult participant, for the purpose of Relative/Legal Guardian as provider process, as a participant in the Innovations Waiver who is 18 years of age or older.
Application Process Flow Chart
Provider has a new employee that is a relative living in the individual s home. Provider has an existing employee that is a relative living in the individual s home. Provider has previous Relative/Legal Guardian as Direct Service Employee approval that was discontinued for cause. Provider completes the Verification of Relative/Legal Guardian as Direct Support Employee Part A Application and Addendum. Provider completes the Verification of Relative/Legal Guardian as Direct Support Employee Part B Application and Addendum. Provider completes the Verification of Relative/Legal Guardian as Direct Support Employee Part D Application and Addendum.
Provider completes Part C Application (in addition to Part A, B, or C) IF there is a Request to Exceed 40 hours per week/7 daily units for all relatives providing services within the same household. Provider submits the Application(s) and Addendum by the 1 st day of the individual s birth month to the designated Network Development Specialist for Cumberland, Durham, Johnston, and Wake. The Network Development Specialist reviews the Application(s) and Addendum. The applications will be accepted if the information is complete and documented on the correct form. All incomplete requests will be returned. Providers shall have one opportunity to resubmit a Part A or Part B request with the missing information. Requests still incomplete beyond the first resubmission will not be reviewed. The Provider Network IDD Specialist forwards applications on to the Credentialing Committee for review.
The Credentialing Committee reviews the application(s) for compliance with Innovations waiver policy. The Credentialing Committee s decision will be communicated to the provider via an Approval Letter or Denial Letter sent by read receipt email. Approval Received Provider keeps the approval letter on file. Denial Received Provider has 60 days to employ new staff. Provider keeps the denial letter on file.
Extension Request the provider may request an extension of the 60 day transition period if the provider has difficulty locating staff. The provider will submit the extension request in writing to the Chair of the Credentialing Committee s designee within 7 calendar days of the provider s receipt of the Denial Letter. The chairperson or the chairperson s designee will notify the provider in writing whether the extension has been granted or not.
Part D Application If reinstatement is granted, the approval will be conditional for a period of 90 days. Program Development/Evaluation will monitor the services and documentation provided by the relative/legal guardian under this policy during the conditional approval period. If reinstatement is granted, failure to resolve all issues that lead to the previous discontinuation within the conditional approval period will result in revocation of the reinstatement. Revocation of the reinstatement or any future discontinuation of approval for cause under this process will result in permanent discontinuation of this relative/legal guardian. The Revocation of reinstatement and permanent discontinuation decisions by Alliance are not appealable.
Questions & Answers
Where are the applications & addendums located? All applications and addendums are located on AllianceBHC.org. When are the applications due? Applications and addendums should be submitted to the designated Network Development Specialist per county via secure, encrypted email by the 1 st day of the participant s birth month.
Who may provide services? Legal guardians, parents of adult waiver participants, and other relatives that live in the home of the participant. NOTE: Parents and step-parents cannot provide Residential Supports.
What services may be provided by relatives/legal guardians? Community Networking Day Supports Personal Care In-Home Skill Building (Individual) In-Home Skill Building (Group) In-Home Intensive Supports Residential Supports
Under what conditions may a relative/legal guardian be employed as a provider? Justification for employing relatives/legal guardians is employment-based only. No other staff are available to provide the service. OR A qualified staff is only willing to provide the service at an extraordinarily higher cost than the fee or charge negotiated with the qualified family member or legal guardian.
What should we as an employer consider prior to hiring a relative or family member? Is this about the participant s wishes, desires, needs or about supplementing a family member s income? As an adult is it appropriate to still have mom and dad with the participant throughout the day? If a family member supports an individual from birth onwards into adulthood, does the individual learn to adapt to different people and increase he/she flexibility and independence?
-continued If a participant with a disability is always supported by a family member, what happens when the caregiver ages/dies? Who else has knowledge of the participant? Can a family member be a barrier to increased community integration or friendship development? Does having a family member as direct support staff expand the participant s circle of support or risk of shrinking it?
These reasons alone are not sufficient justification for employing a relative as a paid provider. Family preference. Participant has complex medical issues. Participant has a history of difficult interactions with nonfamily members. Participant has difficulty with communication. Past use of a relative/legal guardian.
May a relative/legal guardian provide more than 40 hours/week of service? Typically no more than 40 hours per week of service or 7 daily units per week may be approved between all relatives who live in the same household as the participant. Additional service hours furnished by a relative/legal guardian who resides in the same household as the waiver participant may be authorized to the extent that another provider is not available or it is necessary to ensure the participant s health and welfare.
What qualifications must the relative/legal guardian meet? The relative/legal guardian must meet the provider qualifications for the service provided. If medical tasks are required to meet the waiver participants needs, the employee only performs tasks that he/she is qualified to provide under the NC Nursing Practice Act. The provider will certify that there is documented training for the specific medical task by a professional appropriately qualified in the task (or equipment) and the employee receives nursing supervision to carry out the function as specified in the NC Nursing Practice Act. www.ncbon.com/workarea/showcontent.aspx?id=2134
In what instances is a relative/legal guardian not allowed to provide a waiver service to a participant? The relative/legal guardian is not paid to provide any service that they would ordinarily perform in the household of an individual of similar age who does not have a disability. The relative/legal guardian cannot be the managing employer in an Agency of Choice model. The relative/legal guardian cannot be a respite service provider.
-continued- The relative/legal guardian cannot be the spouse of the waiver participant. The relative/legal guardian cannot provide a service as an employee of a provider without the provider obtaining written approval from Alliance.
What are my responsibilities as a Provider Agency? Follow Alliance s Relative as Provider application process and use Alliance forms. Ensure that a qualified employee (who is not a relative) is not available to provide the service or is only willing to provide the service at an extraordinarily higher cost.
-continued- Verify that the relative/legal guardian is not paid to provide any service they would ordinarily perform in the household of an individual of similar age who does not have a disability. Consult with the NC Nursing Board if there is any question about which tasks are appropriate for an employee to perform.
-continued- Ensure the relative has met the required training requirements to perform tasks included in the ISP. Is responsible for the employee in the same way the provider is responsible for all other staff.
-continued- Provide supervision according to the requirements specified in 10A NCAC 27G.0204 and according to licensure or certification requirements. Monitor the provision of service on-site at a minimum of one time per month.
-continued- Ensure services are provided within the scope of the authorized hours/units. Must identify and provide qualified back-up staff for each employee including relatives/legal guardian employees. Must be enrolled to provide Crisis Services or have an arrangement with an enrolled Crisis Service provider.
-continued- Submit an annual application and addendum for Relative as Provider by the 1 st day of the participant s birth month. Submit a new application and addendum as warranted during the plan year (i.e. when a new service is added, or a new relative wants to provide a service).
-continued- Communicate with the relative/legal guardian the outcome of the application process. Maintain the Approval Letter/Denial Letter in your records. Identify a new staff to provide service within 60 days if the relative/legal guardian is not approved to provide a service.
How is the outcome of the Relative as Provider application process communicated? A read receipt email (with letter attached) will be sent to the provider agency. In addition to the email, providers will also receive a certified letter when the application is denied. It is the responsibility of the provider agency to communicate the outcome to the employee.
Why has an Application been returned to me? Incomplete requests will not be accepted by the Network Development Specialist and will not be reviewed by the Credentialing Committee. All providers that submit an incomplete application will be notified by their Network Development Specialist. The provider will have 1 opportunity to resubmit a Part A or Part B Application and Addendum with the missing information. Requests beyond the first resubmission will not be reviewed.
What would result in a denial? If a request does not meet criteria for 1, 2, 3, and/or 4 in Section III of the application, the request will be denied.
May a provider request reconsideration? No
How long may an extension be granted for? Provider Agencies may request an extension of the 60 day transition period if they have difficulty locating staff by submitting a written request to the Chairperson (or designee) of the Credentialing Committee. Extensions will typically be granted for up to 45 days with the ability to renew 1 time in extraordinary circumstances.
Who can the relative/legal guardian contact at Alliance with questions about the policy, concerns, or grievances? Doug Wright, Consumer Affairs, is the contact for relatives/legal guardians. dwright@alliancebhc.org 919-651-8400
Who can providers contact regarding the application process or policy? Provider can contact the designated Network Development Specialist in their county. Cumberland Rose-Ann Bryda, rbryda@mail.ccmentalhealth.org Durham Sara Wilson, swilson@alliancebhc.org Johnston Lori Caviness, lori.caviness@johnstonnc.com Wake Tammy Ramirez, tramirez@alliancebhc.org
Important Reminders A separate application and addendum will be submitted for each relative and service. Approvals of Relative as Provider are Provider Agency and Service Specific.
Important Reminders If there is a new/additional service request (to be provided by the relative/legal guardian) during the plan year beyond what was outlined in the initial application, a new Part B Application and Addendum must be submitted to Alliance by the Provider Agency. If the Relative/Legal Guardian changes the Waiver recipients services to a new Provider Agency, the new Provider Agency must submit a Part B Application and Addendum to Alliance.
Important Reminders Provider Agencies must submit renewal applications and addendums annually on the first day of the consumer s birth month. A Provider Agency cannot allow a Relative/Legal Guardian to provide a service without the written prior approval of Alliance.
Important Reminders Program Development/Evaluation will verify the provider s qualifications upon on-site review. If the provider agency does not follow the Relative as Provider policy or if the service is not being provided as approved by UM, this may result in Medicaid payback and/or further sanctions.
Important Reminders If issues arise concerning the qualifications of the relative/legal guardian and/or the health/safety of the participant, a request for re-review can be initiated by Care Coordination, Quality Management, or Program Development/Evaluation.
Applications for participants with January birthdays are due to the designated Network Development Specialist by Wednesday, January 30, 2013. Applications for participants with February birthdays are due Friday, February 1, 2013.
Questions?