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Welcome to Lesson 1 in ODP s Nursing Services Overview. I am Jill Morrow, the Medical Director for the PA Office of Developmental Programs. I will be your presenter for this webcast. 2
This series of lessons is designed to help everyone involved with the intellectual disabilities/mental retardation system understand nursing services and how they are provided. Throughout this presentation, the intellectual disabilities/mental retardation system will be referred to as the ID/MR system. Today we are going to talk about nursing services that are provided through the healthcare system and the ID/MR system. We ll discuss the similarities and differences and give you some examples about how these systems can work together to provide services and supports to meet an individual s assessed healthcare needs regarding nursing. 3
There are two primary systems that are able to provide nursing services to people with intellectual disabilities in Pennsylvania: the healthcare system and the ID/MR support system. Throughout this presentation, the healthcare system is designated by the caduceus and the ID/MR system by the keystone designation used by the Commonwealth of Pennsylvania. The ID/MR support system is administered through the Pennsylvania Department of Public Welfare, Office of Developmental Programs referred to as ODP. We are going to talk a little bit about each of these systems to help you understand the similarities and the differences. 4
First, we ll discuss the healthcare system. The purpose of the healthcare system is to provide diagnosis, preventive screening and treatment for acute and chronic illness. Healthcare needs are identified through medical necessity by healthcare practitioners. This system includes home, outpatient, and inpatient services. Home services include home health services such as children s home shift care which is provided through the Early Periodic Screening, Diagnosis, and Treatment program, known as EPSDT. This is the child health component of Medicaid. Outpatient services include things like physician visits, outpatient procedures like surgery, and therapies, such as physical therapy. Inpatient or institutional services include nursing homes or nursing facilities, hospitals, and inpatient rehabilitation facilities. 5
The other system we ll be discussing is the Intellectual Disabilities/Mental Retardation, or ID/MR, Support System. Services in the ID/MR system are meant to be supportive services and are often long-term, such as someone who is supported through lifesharing. Through the Individual Support Plan or ISP team process, needs are identified through assessment and services to meet these assessed needs are discussed. This service system includes home, community, and institutional services. Home-based services include habilitation. Community services include residential group homes and employment. Institutional services include Intermediate Care Facilities for People with Mental Retardation, or the ICF/MR program. 6
So let s look at how funding works in these two systems. 7
In order to understand the funding in the healthcare system, it is important to understand the concept of insurance. Health insurance is the basis of funding for the healthcare system. Health insurance pays for medical expenses. People are most familiar with private or commercial health insurance. This is sometimes referred to as third party insurance. This type of insurance is often provided through employers. The other type of insurance is public insurance. People do not always think about Medicare or Medicaid as health insurance. For people with disabilities and the elderly, Medicare is one of the public health insurance options. For poor children and people with disabilities, Medicaid is the other option. Each of these types of insurance are designed to provide healthcare for particular groups of people. 8
In the healthcare system, funding is through multiple payers and an individual may have coverage by one or more of these. These include private or commercial insurance, Medicare, and Medicaid, of which EPSDT is part. In Pennsylvania, Medicaid is administered through Managed Care, Access Plus or Fee for Service. There is an order which determines who pays first. The insurance that pays first is called primary, while the payer at the bottom of the list is known as the payer of last resort. Private or commercial insurance pays first; Medicare, second; and Medicaid last. Each payer typically has slightly different coverage which means that one plan may pay for a particular service while another may not. That s called an exclusion. In addition, there may be different amounts of service covered. For example, one plan may pay for 10 visits and another for 15. Payment is based on medical necessity. Medical services can be provided in many different locations like inpatient hospitals, outpatient clinics, and home health services in the home. Some services are only paid for in certain locations. Services may require prior authorization which means that the insurance plan must approve payment for the service before the service is provided. 9
Here is an example of how this funding might work. Susan needs a new wheelchair. She has private insurance, Medicare and Medicaid. Each of these might pay for this. Susan works with her healthcare practitioner to request that her insurance pay for her new wheelchair. Because the wheelchair has to be prior authorized, if she does not get her insurance to authorize payment for her wheelchair before she gets the chair, then the plan does not have to pay for the chair. The first request for payment goes to her private insurance. They deny her request perhaps because wheelchairs are not covered under her insurance plan or because she had a new wheelchair last year and they only cover one every three years. The second request goes to Medicare with the denial of her primary which is her private insurance. Medicare will pay for the wheelchair, but there is a co-pay that Susan is responsible to pay. Because Susan also has Medicaid, Medicaid may pay Susan s co-pay. 10
We talked about funding in the healthcare system. Now let s move to talking about funding in the ID/MR system. In the ID/MR system, there are three types of funding: Institutional funding, or ICF/MR, which is a mix of federal and state dollars; Base funding, which is a mix of state and county dollars; and Waiver funding, which is also a combination of state and federal dollars. A significant majority of services for people with intellectual disabilities and mental retardation are funded through the Consolidated and the Person/Family Directed Supports Medicaid Waivers in Pennsylvania. What is a waiver? A waiver is a shortened term for the Medicaid Home and Community Based Waiver Program, which provides funding for ID/MR supports and services to help people live in their homes and communities rather than in an institution. The waivers are always payer of last resort. For services that are available through other funding streams like private health insurance or Medicaid, waiver can be used to supplement after the limits set by the funding streams have been exhausted. This can be done only if the person needs more than can be provided through these other funding streams and only after the additional service units are denied by all health insurances. Documentation of denials must be maintained according to the guidelines in the service definitions. 11
For more information on waivers in Pennsylvania, go to the DPW website listed on the slide. 12
Next we will talk about eligibility and coverage in the healthcare and ID/MR systems. 13
There are things healthcare systems cover and things that are not covered. There are limitations to what is covered based on the type of coverage and age. Services through the healthcare system could be short-term illness related or long-term based on medical condition. An example of short-term services is a person who has surgery and needs to have their bandages changed and the area cleaned until the wound heals. An example of long-term services is a person who has kidney disease and needs kidney dialysis several times per week. There may be limitations based on age. Some services are available for children but not for adults. EPSDT, which remember stands for Early Periodic Screening, Diagnosis, and Treatment, funding is only available until the individual turns 21 years of age. Shift nursing is only available through MA for individuals under the age of 21 years. Shift nursing refers to having a nurse present for part of a day as opposed to a nursing visit which is shorter. Both Medicare and Medicaid may cover nursing visits for adults depending on medical necessity. 14
Before we talk in detail about what can be covered through the ID/MR service system, let s talk first about services. What are services? Services can be defined as the performance of or assistance with duties or work for another. They are designed to protect health and welfare and support a person in their Everyday Life. Waiver services are not primarily for the purpose of treating medical conditions. If you are receiving kidney dialysis, then that is paid for through your health insurance and not through the waiver because it is a purely medical condition. 15
There are services that are covered and those that are not covered under the waivers. Payment by a waiver for waiver-covered services applies only to people enrolled in a waiver. There are overlaps in some services between the healthcare system and the ODP service system. For example, nursing can be paid for by both systems. There are limitations to what services are available. Service definitions include what services, how much or number of units, and whom the services can be paid for by the ODP Waivers. There are limitations to how much service is available based on how much service is needed and how frequently the service is needed. Please see the ODP service definitions for details about these limitations. One example of a limitation detailed in the service definitions is that waiver funding can only be used to pay for a certain amount of respite for each person in a year. Please note that although ODP services are for ages 3 to adult, individual services may also be limited by age. For services that are available through other funding streams, payment for waiver services can only be provided after the other funding streams, including private or commercial insurance, Medicare, and Medicaid State Plan have been exhausted. 16
The ID/MR service system is not an entitlement system. Enrollment into the waiver and the services received by an individual are based on eligibility and availability. Once enrolled in the waiver, the waiver services determined to meet an individual s assessed needs are paid for by the waiver within the limitations defined in that waiver. 17
Enrollment into the waiver is based on waiver eligibility, urgency of need and the availability of waiver capacity. To be eligible for an ODP waiver, the individual must have a diagnosis of mental retardation occurring before the age of 22 years. The individual must also meet ICF level of care meaning that the person has the ability to benefit from active treatment. Waiver enrollment is also based on the availability of waiver capacity and urgency of need. Priority is given to those whose situations have the most emergent need. There are currently people waiting for ID/MR services and supports. Participation in an existing entitlement program such as EPSDT does not automatically ensure waiver eligibility or enrollment. Children transitioning or aging out of EPSDT services at their 21 st birthday will be considered for waiver enrollment within the context of everyone applying for the ID/MR waivers. Enrollment will be based on the most emergent need of all of those individuals when waiver capacity is available. Waiver service provision is based on: An assessed need that can be met by a waiver service as defined in the service definitions; Availability of the service needed; and A willing and qualified provider. Services are developed through the Individual Support Plan (ISP) process and authorized by the Administrative Entity (AE) or County Program. 18
To be supported with a paid waiver service, a need must be supported by an assessment. If a need is identified, the role of the Individual Support Plan, or ISP, team is to identify how the need can best be supported. Natural supports, community supports, and multiple services might help meet this need. It is the role of the ISP team to determine what services and supports could best meet the person s need. The ISP team must consider limitations of the waiver and services that might be available through other funding streams like health insurance. 19
So let s look at an example of how an ISP team might plan to meet an individual s assessed needs. For example, Frank who is a young adult, uses a ventilator and needs assistance getting ready for work in the morning. On Monday, Wednesday and Friday, Frank s mom leaves for work at 9:00am and she is able to do his care and get him to work before she goes to work. On Tuesday and Thursday, Frank s dad is out of town and his mom starts work at 7:00am. A nurse comes to Frank s house to do his care before he goes to work. On Saturday, Frank goes to work at 10:00 am. Frank s dad is home and he is able to do his care. On Sunday, nobody in the family goes to work. Frank s mom and dad share his care in the morning. 20
In summary, individuals with ID/MR should work with their Supports Coordinator and ISP teams to identify their assessed needs and develop a plan to meet these needs. As we discussed, healthcare supports can be provided by multiple systems and will look different depending on the person and his or her needs. It is important that people and those who support them work together to figure out the best supports and services to protect a person s health and safety and promote an Everyday Life. 21
To access online resources related to the information discussed in this webcast, please click on the links shown on this slide. 22
If you have questions or would like additional information about nursing, there are a number of available resources. There is an additional lesson that will be available in the ODP Nursing Services Overview course. This lesson Lesson 2 Choosing Services to Meet Assessed Health Needs will provide information about using natural and community supports as well as nursing to meet health needs. When it is available, this lesson will be found in the same location where you accessed the webcast to which you are currently listening. If you are an individual or family member who is currently registered with a County MR program, you can contact your Supports Coordinator to discuss your situation and any questions you may have. ODP s Customer Service number is also available for questions. This toll-free number is 1-888-565-9435. The toll-free TTY number is 1-866-388-1114. 23
Thank you for viewing this webcast. I hope you learned about the ID/MR system and the healthcare system and their similarities and differences. Have a good day. 24