Home Health Services Prior Authorization for DDS Waiver Clients March 31, 2015

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1 Home Health Services Prior Authorization for DDS Waiver Clients March 31, 2015

2 Introduction Welcome to the Home Care Provider Webinar These webinars are open to all Connecticut Medical Assistance Program (CMAP) enrolled home healthcare providers and serve as a platform to optimize collaboration, identify opportunities to streamline and improve processes, and increase quality of care. You are encouraged to use the Home Care Provider Forum box at HCProvForum@chnct.org to forward your questions regarding information provided at these forums, or to share recommendations for future Home Care Provider Forum agenda topics. Please feel free to share your thoughts and ask questions at the end of today s presentation. Community Health Network of Connecticut, Inc. (CHNCT) is committed to maintaining an open line of communication with the home care provider community. At CHNCT, our goal is to ensure that all HUSKY program members are able to access medically necessary care that is delivered at the right time, in the right setting, and at the most appropriate level of service. 1

3 Overview The CHNCT Prior Authorization unit will be working in conjunction with the Department of Development Services (DDS) to coordinate care for HUSKY members with DDS waiver services. The goal of this coordination will be to get the member the care they need at the right time, in the right setting, and at the most appropriate level of service. HUSKY members residing in DDS medication-certified group homes will be authorized for skilled nursing visits required to administer injectable medication or perform fasting blood sugar checks. Oral medications and g- tube feedings will be expected to be administered by the medicationcertified staff, or a transitional plan will be expected to be initiated. Home Health Aide services should not be required for a HUSKY member residing in a group home. Personal care assistance is part of the services that are provided by the group home staff. 2

4 Overview (cont.) Skilled wound care may be required for HUSKY members in a group home, and will only be authorized as per coordination of benefits. If the HUSKY member is homebound (i.e., it is considered a taxing effort to leave the home because he/she requires the aid of a wheelchair/cane, or the assistance of a person) and has Medicare prime, the wound care should be billed to Medicare first. Medicare does consider care performed to maintain the status of an individual s condition, or to slow or prevent the deterioration of the condition, as skilled care. Therefore, skilled wound care is coverable under Medicare. It is important to note that the ongoing need for skilled level of care must be documented in order to receive reimbursement from Medicare. Please refer to the Provider Bulletin on the publications page of the website or Chapter 11 on the same site for further billing instructions. 3

5 Department of Developmental Services Guest Speakers Siobhan Morgan Director of Waiver Services Lakisha Hyatt Director of Health and Clinical Services 4

6 Department of Developmental Services Overview of 1915(c) Waivers 5

7 } Birth to Three Program } Intellectual Disability across the life span } Autism across the life span 6

8 } DDS serves 21,000 } B-3 serves 5,600 approx. } DDS serves 16,000 over the age of 3 } DDS Waivers serve 10,000 people } Most people DDS serves live with family or in their own homes 7

9 } } Intellectual Disability (formerly know as Mental Retardation) IQ of 69 or below } Meet criteria in CT General Statute 1-1g } } } } } Onset before age of 18, during developmental period Adaptive function Prader Willi Syndrome CT resident, no timeframe, no asset test Willing to apply, or eligible for Medicaid 8

10 } Autism Spectrum Disorder } IQ 70 or above } Onset before age of 18, during developmental period } Adaptive function } CT resident, no time frame, no asset test } Willing to apply, or eligible for Medicaid 9

11 q Did the person ever live or go to either Southbury Training School, or Mansfield Training School? q If they moved to CT, did they live in an institution in another state? q Look for a psychological or report that has IQ or adaptive functioning scores. q Do they have a guardian appointed by probate court? q Did they work with one of the ARC s in CT? q Guide if missing documents a=2039&q=

12 } DDS Eligibility does not mean the person is getting waivered services } Case management: not a waiver service } Family Grants: not a waiver service } Family Support Workers: not a waiver service } Family Support team: not a waiver service } Really important! 11

13 Currently 5 approved waivers: 1. Comprehensive Waiver: DSS code O 2. Individual and Family Support Waiver: DSS code I 3. Employment and Day Support Waiver: DSS code E 4. Autism Waiver: DSS code 6 5. Early Childhood Waiver: DSS code 7 Note: Code is very important! 12

14 } Services individuals who live in licensed Community Living Arrangements (CLA), Community Companion Homes (CCH), Continuous Residential Services (CRS), or in Assisted Living Facilities. } It can also be used to provide services to individuals who live in their own homes or in their family homes, and who are in need of comprehensive levels of support. } Generally, participants have significant physical, behavioral, or medical support needs. 13

15 } Designed to support individuals who live in their own homes or in their family homes, and need less extensive supports. } Typical service plans are less than $59,000 per year. } Combination of employment/work supports and in-home residential supports. 14

16 } Targeting young adults transitioning from school to work } Employment } Respite } Specialized Medical } Cost cap of $28,000 per year 15

17 } Started 1/1/2013. } Currently serves 100 individuals. q Approximately 75 adults and 25 children q Cap is $60,000 q Individuals live in their family home or in their own apartment } Serves individuals who are on the spectrum and have an IQ greater than

18 } Services include: q Life skills coach q Community Mentor q Clinical Behavior Support Services q Job Coaching q Specialized Medical q Respite } Services capped at $60,000. } Services occur in the person s own home or family home. 17

19 } Started 2/1/2014 } Currently serves 30 children } Currently on Medicaid } 3- and 4-year-olds } Services include: q Life skills coach, 8.5 hours per week q Clinical Behavior Support Services, 1.5 hours per week q Services capped at $30,000 q Transition to LEA services 18

20 1. Adult Day Health 2. Health Care Coordination (RN) - not direct nursing 3. Live-In Caregiver 4. Residential Habilitation, defined as CLA and CCH 5. Community Living Arrangement, or CLA 6. Community Companion Home, or CCH 7. Continuous Residential Services (CRS) 8. Individual Directed Goods and Services 9. Individualized Home Supports 10. Clinical Behavioral Support Services 11. Nutrition 12. Independent Support Broker 19

21 13. Assisted Living 14. Personal Support 15. Adult Companion 16. Prevocational 17. Respite 18. Supported Employment 19. Group and Individualized Day supports 20. Parenting Support 20

22 21. Environmental Modifications 22. Transportation 23. Specialized Medical Equipment 24. Personal Emergency Response System 25. Interpreter Services 21

23 } Community-based homes } Usually six or fewer individuals } Licensed by DDS } Funded by DDS for residential supports } Funded by DSS for Room and Board } Operated by DDS } Operated by Private Providers (qualified providers) } Assigned DDS Case Manager } House Manager } Nurse (agency hired or contracted) q 24-7 on-call nursing, delegation 22

24 } Community-based homes } Usually six or fewer individuals } Licensed by DDS } Oversight by the Department of Public Health } Funded by DSS for residential supports } Operated by Private Providers(qualified providers) } House Manager } Nurse Consultant } NO DDS Case Manager - QIDP - Qualified Intellectual Disability Professional 23

25 } Community-based homes } Home owned or rented by a Licensee } No more that 3 individuals } Licensed and funded by DDS } Room and Board is funded by the Individual s entitlements } Can receive oversight from Private Providers(qualified providers) or DDS CCH Staff } Assigned DDS Case Manager } Can access State Plan services including nursing 24

26 } Community-based homes } Usually three or fewer individuals } Operated by Private Providers (qualified providers) } Funded by DDS for residential supports } Funded by the individual s entitlements for Room and Board } May have a House Manager } Nurse coordination supports included in service } Assigned DDS Case Manager 25

27 } } } } } } } DDS Case Manager In home residential supports Employment/work supports Health Care Coordination Waiver service Must have a specified Level of Need Provided only by Qualified Provider Agency or q Independent HCC provider from DDS list q HCC agency will not provide: Hands on nursing On-Call nursing Nursing delegation Pre-pouring medications If Nursing supports beyond coordination are needed the individual can access State Plan services such as nursing etc.. 26

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31 Recommendations for Future Agenda Items n You can send an to HCProvForum@chnct.org q This is for future agenda items only. q Please do not send any specific member information or Prior Authorization requests or questions. 30

32 Questions/Comments 31