Long Term Services and Supports (LTSS) Virginia

Long Term Services and Supports (LTSS) Virginia

What are Long Term Services & Supports (LTSS)? A variety of services and supports that help elderly individuals and/or individuals with disabilities meet their daily needs for assistance and improve quality of life, including assistance with: Bathing Dressing Laundry Shopping Transportation Other basic activities of daily life LTSS are provided over an extended period, predominantly in homes and communities, but also in facility-based settings (e.g., nursing facilities). LTSS were traditionally covered under Virginia s Elderly or Disabled with Consumer Direction (EDCD) waiver program. LTSS are also covered by HealthKeepers, Inc. under its Anthem HealthKeepers Medicare-Medicaid plan (MMP), a Commonwealth Coordinated Care (CCC) plan. 2

Virginia Program Virginia s Elderly or Disabled with Consumer Direction (EDCD) waiver program Members residing in nursing facilities Authorization/Precertification Requirements: All EDCD waiver and nursing facility services require authorization/precertification 3

LTSS Provider Responsibilities Assisted living facilities and nursing homes must retain a copy of the member s plan of care on file. Assisted living facilities are required to promote and maintain a home-like environment and facilitate community integration. All facility-based providers and home health care agencies must notify an Anthem HealthKeepers MMP case manager or care coordinator within 24 hours when a member dies, leaves the facility or moves to a new residence. LTSS providers will participate in the member s Interdisciplinary Care Team (ICT) as determined by the member s need and preference. 4

Interdisciplinary Care Team (ICT) A team of professionals who collaborate, either in person or through other means, with members to develop and implement a plan of care that meets their medical, behavioral, LTSS and social needs. ICTs may include physicians, physician s assistants, LTSS providers, nurses, specialists, pharmacists, behavioral health (BH) providers and/or social workers appropriate for the member s medical diagnosis and health condition, comorbidities and community support needs. ICTs employ both medical and social models of care. 5

Nursing Facilities The initial level of care (LOC) is determined by the state (custodial nursing home versus skilled nursing facility). HealthKeepers, Inc. is responsible for the coordination of annual redeterminations. The LOC Department of Medical Assistance Services (DMAS) Form should be completed and submitted to the state. 6

Nursing Facility Level of Care Criteria Custodial nursing facility (NF) Functional and medical components. Members must qualify on both functional and medical components. Functional (must meet one of the following): Dependent in 2-4 activities of daily life (ADLs), plus one of the following: Semidependent or dependent in behavior pattern/orientation, Semidependent in joint motion Dependent in medication administration Dependent in 5-7 ADLs, plus dependent in mobility Semidependent in 2-7 ADLs, plus dependent in mobility and behavior pattern/orientation 7

NF Level of Care Criteria Custodial NF (continued) Medical/nursing supervision (must meet one of the following): Requires observation and assessments to prevent destabilization, and patient has demonstrated an inability to self-observe or evaluate the need to contact skilled medical professionals Due to multiple, interrelated medical conditions, potential for medical instability is high or already exists Needs at least one ongoing medical condition; potential for medical instability is high or already exists Needs at least one ongoing medical/nursing service (e.g., applying aseptic dressings, routine catheter care, respiratory therapy, nutrition/hydration supervision, therapeutic exercise/conditioning, routine colostomy care, use of physical or chemical restraints, routine skin care to prevent pressure ulcers in immobile individuals, chemotherapy, radiation, suctioning, etc.) 8

NF Level of Care Criteria - Specialized Care Skilled Nursing Facility/Adult Specialized Care In addition to the general/custodial NF LOC criteria, to meet specialized care LOC, the individual must at a minimum: Visit a physician at least once every 7 days (may alternate visits between a physician and a physician s assistant/nurse practitioner) Receive licensed nursing services 24/7 Receive respiratory services provided by a licensed/certified respiratory therapist Take part in a coordinated multidisciplinary team approach 9

NF Level of Care Criteria - Specialized Care (continued) Additionally, to meet specialized care LOC, the individual must require at least one of the following: Mechanical ventilation Complex tracheostomy, meeting all of the following: Have potential for weaning or past failed attempts at weaning Require nebulizer treatments four times per day with or without chest physiotherapy Require pulse oximetry monitoring at least every shift Require respiratory assessment/documentation every shift by nurse of respiratory therapist Have physician s order for oxygen therapy with documented usage Require tracheostomy care daily Have physician s order for suctioning, when necessary Individual must be at risk to require subsequent mechanical ventilation 10 10

Reservation of Days Therapeutic Leave: A NF bed may be held for therapeutic leave when the member s/resident s Plan of Care (POC) provides for such leave and is noted in their chart. Leave includes visits with relatives and friends, or admission to a rehabilitation center for up to seven days for an evaluation. It does not include admission to an inpatient hospital. Limited to 18 days in any 12-month period and HealthKeepers, Inc. should be notified. Bed Reservation ( Bed Hold ) - Hospitalized Residents Bed hold payments to NF are not applicable per DMAS. All members/residents and their families should be informed that they have the right to be re-admitted at the time of the next available vacancy. 11 11

Consumer Direction Consumer direction (CD) affords members the opportunity to have choice and control over how eligible home and community-based services (HCBS) are provided and how much workers are paid for providing care, up to a specified maximum amount established by DMAS. Member participation in CD of HCBS is voluntary, and members may elect to participate in or withdraw from CD of HCBS at any time without affecting their enrollment. CD is offered for members who, through the needs assessment/reassessment process, are determined by care coordinators to need any service specified in DMAS rules and regulations as available for CD. These services include: Attendant care Personal care In-home respite care Companion care service 12 12

Consumer Direction (continued) A service that is not specified in DMAS rules and regulations as available for consumer direction shall not be consumer-directed. If members choose not to direct their care, they will receive authorized HCBS through contract providers. Members who participate in CD of HCBS choose either to serve as the employer of record for their workers or to designate a representative to serve as the employer of record on their behalf. The member must arrange for the provision of needed personal care and does not have the option of going without needed services. 13 13

Consumer Direction (continued) HealthKeepers, Inc. will contract with the DMAS designated fiscal/employer agent (F/EA), PPL, Inc., to provide the following services to EDCD waiver enrollees who choose CD of eligible waiver services: Criminal background checks for CD employees, with appropriate follow-up and communication to appropriate individuals Payroll expenses for authorized hours actually worked by CD employees, inclusive of employer share of state and federal taxes net patient pay The F/EA will withhold patient pay amounts from employees checks. Payments or payroll to the F/EA shall reflect (be net of) the patient pay amount Claims payment shall be provided to the F/EA for authorized eligible EDCD waiver services provided by CD employees. 14 14

Consumer Direction Service Facilitator A consumer direction (CD) service facilitator (SF) is a facility, agent, person, partnership, corporation or association providing supportive services, including assistance with hiring, training, supervising and terminating responsibilities of personal care aides/attendants who perform basic health-related services. Standards and requirements for CD SFs are established by DMAS. The role of SFs is to: Make sure individuals receive services needed Review the manual with individuals and family/caregivers, as appropriate. Train individuals on the required tasks of an employer Develop service plans and paperwork with individuals 15 15

Service Facilitator Consumer Direction (continued) Individuals may discuss employer concerns and questions with SFs at any time. The SF must be an enrolled Medicaid provider for service facilitation and cannot be: The individual receiving services The individual s spouse The individual s parent, if the participant is a minor A family member/caregiver who is also the CD employer The SF files claims for the services provided and follows the applicable codes established by DMAS for consumer-directed service facilitation. SF can not bill for assessments and reassessments as these functions are conducted by Anthem. 16 16

Patient Pay The patient pay amount is the member s contribution toward his or her care in a calendar month. The DMAS-225 form can be submitted by the provider to the Department of Social Services (DSS) to determine the member s patient pay amount. DSS returns the form to providers to confirm if the member has a financial responsibility toward the cost of his or her care, the amount and sources of the member s finances and the date for which the patient pay amount would begin. DMAS will provide the information to HealthKeepers, Inc. on a monthly basis with enrollment. The provider with the most authorized hours of services per month is considered the primary service provider and takes responsibility for collecting payment from the member. 17 17

Patient Pay (continued) When billing claims, providers indicate the patient pay amount on the 1500 claim form in box 29, when applicable. For a UB-04 form, the amount is indicated as a Value Code 23 with $0.00 or greater. This amount is deducted from reimbursement to the provider. HealthKeepers, Inc. will deduct the patient pay based on the information for the member received from DMAS on the enrollment files. The explanation of payment (EOP) to the provider indicates when the patient pay amount has been deducted from the payment to the provider with the most authorized hours of services. 18 18

Personal Care Services The number of hours billed is the amount authorized and approved in the plan of care. Only whole hours can be billed: If an extra 30 or more units are provided over the course of the calendar month, the next highest hour can be billed. If less than 30 units are provided, the lower is billed. Rounding hours can be done for the total monthly hours, not each time it is billed. Codes for Personal Care Services: T1019 T1005 S9125 19 19

Adult Day Health Codes for Adult Day Health: ADHS S5102 Transportation A0120 If members attend less than six hours on any given day, then it is considered a half day of services. At the end of the month, half days of service may be added and rounded to the nearest whole day of service. 20 20

Personal Emergency Response System (PERS) Codes for PERS: Installation S5160 Monitoring S5161 Only a one-time installation is billed for the member. Monthly monitoring includes administrative cost, time, labor and supplies associated with installation. 21 21