Consumer Directed Community Supports. Lead Agency Operations Manual

Transcription

1 Consumer Directed Community Supports Lead Agency Operations Manua

2 Tabe of Contents Introduction to Consumer Directed Community Supports (CDCS) 1 Impementation of CDCS Statewide HCBS Program Eigibiity and Access to CDCS Access to CDCS Service Option is Limited for Some Peope How Consumer Directed Community Supports Work Person-Centered Panning Process: The Foundation for Consumer-Directed Services Person-Centered Panning Features Consumer/Representative Roe in Person-Centered Panning Process and Pan Management Consumer Resources Lead Agency Roe and Tasks in Person-Centered Panning Process Other Services That Increase Fexibiity and Consumer Contro Toos and Resources to Support the Person-Centered Panning Process 14 Appendix A: Resources for Person-Centered Panning 15 Appendix A.1: CDCS Fexibe Case Management Pan Deveopment Notification Too Community Support Pan Requirements for A HCBS Programs Community Support Pan Formats (DHS 2925 or 4166) CDCS Requirements of a Person-Centered Community Support Pan CDCS Budget Amount on the Pan Appying Quaity Considerations to the CDCS Support Pan Heath and Safety: Persona Negotiated Risk Management Pan Backup Pans and Emergency Pans Reviewing the Pan Approva, Denia, or Partia Denia of a Proposed CDCS Pan Provision of Technica Assistance: Heping the Consumer Get a CDCS Pan Approved and Impemented Service Revisions and Pan Changes - Consumer Versus Lead Agency Approva Waiver Requirements Reated to A Aowabe Services Additiona Requirements for Cdcs Services: Consumer Outcomes Broad CDCS Service Categories Additiona Goods and Services That May Be Incuded in CDCS Budgets Additiona Services Authorized in Combination with CDCS Using CDCS to Purchase Conventiona Waiver Services A Note About State Pan Home Care Services 34 Appendix B: Crosswak Between Waiver & Home Care Codes and CDCS Service Categories Customizing Services Under CDCS Persona Assistance Treatment and Training 43

3 6.4 Environmenta Modifications and Provisions Guideines for Approving Specia Diets Under CDCS Sef-direction Support Activities Provider Quaifications: Persona Assistance: The Consumer Decides Provider Quaifications: Treatment & Training: Provider Quaifications: Environmenta Modifications & Provisions Provider Quaifications for Fisca Support Entities Provider Quaifications for Fexibe Case Management (FCM) Service Fexibe Case Management and Famiy or Lega Representatives Non-aowabe Expenses under CDCS Excuded Services, Support, and Items 54 Appendix C: Aowabe, Unaowabe Expenditure 55 Appendix C1: Aternative Treatment Too for MHCP-Enroed Physicians Comparison of Required and Fexibe (Optiona) Case Management Activity Required Lead Agency Functions Under CDCS Fexibe Case Management Functions & Limitations Excuded Time & CDCS The Consumer As Empoyer Three Modes of Fisca Support Entity Service Comparison of Consumer Roe as Empoyer Under 3 FSE Modes Fisca Support Entity Fisca Support Entity (FSE): Fisca Conduit & Payro Agent Services Fisca Support Entity (FSE): Agency with Choice Services Other FSE Requirements Other FSE Requirements (con t) FSE Reporting Requirements Readiness Review Invountary Exits from CDCS Procedures Reated to Invountary Exits Additiona Technica Assistance and Support Immediate Concern 75 Appendix D: Notice of Technica Assistance and Support Form Purchasing Persona Assistance Services (PAS) from a Spouse or Parent Criteria for Paying Spouse or Parent for PAS Determination of ADL Dependency Financia Considerations Limitations on Payment to Spouse or Parent Lead Agency Monitoring Requirements When Parent or Spouse is Paid for

4 Persona Assistance Service 81 Appendix E : Determining ADL Dependency in Chidren Age 18 and Under Edery Waiver and Aternative Care CDCS Budget Amount on the Pan Authorizations and Payments Under CDCS : EW and AC Summary of Changes to the Long Term Care Screening Document: EW & AC Service Agreement Changes for CDCS Under EW & AC: Procedure Codes Service Agreement Changes for CDCS Under EW and AC: Edits Other Procedure Codes That Can Be Authorized in Combination with CDCS Services: Edery Waiver and AC Caim Payments: EW and AC Consumer Scenario: Initia Opening Seects CDCS Consumer Scenario: Person Who Has Been Using CDCS Wants to Discontinue That Service Consumer Scenario: A Person Currenty Open to EW or AC Decides to Change to CDCS Consumer Scenario: Renewa of CDCS 93 Appendix F FY05 CDCS Budgets EW 94 Appendix F1: FY05 CDCS Budgets AC CDCS Service Authorizations & MMIS Activity: Persons Under Age Consumer Scenarios: Choosing CDCS Consumer Scenarios: Discontinuing CDCS Service Agreements: CAC, CADI, MR/RC, TBI Screening Document Edits Biing Cdcs Servicess CDCS & Enroment in Managed Care A.1 Medica Assistance Spenddowns When Choosing CDCS A.2 Specia Income Standard Edery Waiver and Waiver Obigation A.3 Non payment of Waiver Obigation or Spenddown Whie Using CDCS A.4 Spenddowns and Waiver Obigations under MnDHO & MSHO Notes About CDCS Under the Aternative Care Program CDCS and Unpaid Caregiver Supports Types of Caregiver Support Services HCBS Quaity Framework: Organizing Quaity Management Around Seven Quaity Focus Areas The HCBS QA/QI Pan - Loca Agency HCBS Quaity Assurance & Improvement Responsibiities Appying the Quaity Framework to CDCS 114 Appendix G: CDCS Quaity Assurance and Improvement Activity: Lead Agency Sef-assessment 116

5 Consumer Directed Community Supports Lead Agency Operations Manua Introduction Introduction to Consumer Directed Community Supports (CDCS) Consumer Directed Community Supports (CDCS) is a service that gives individuas more fexibiity in panning, and responsibiity for directing, their services and supports, incuding hiring and managing direct care staff. CDCS may incude conventiona goods and services, as we as sefdesigned services that provide needed support to recipients. Consumer Directed Community Supports (CDCS) is a service that has been avaiabe in 37 counties through the Home and Community-Based Waiver for Persons with Menta Retardation and Reated Conditions (MR/RC) since In an effort to make Consumer Directed Community Supports (CDCS) avaiabe to individuas in every county and on every Medica Assistance (MA) waiver program, the Department of Human Services (DHS) submitted amendments to a of the home and community-based waiver programs to the Centers for Medicare and Medicaid Services (CMS). The amendment, as approved, changes some aspects of CDCS as previousy impemented, and expands the CDCS service. The amendment incudes state-eve oversight of CDCS and ead agency administration of the service. The programs affected by the approved amendments are: Aternative Care (AC) program (A state-funded non-medica Assistance program) Community Aternative Care (CAC) Waiver Community Aternatives for Disabed Individuas (CADI) Waiver Edery Waiver (EW) Menta Retardation and Reated Conditions (MR/RC) Waiver Minnesota Disabiity Heath Options (MnDHO) Minnesota Senior Heath Options (MSHO) Traumatic Brain Injury Waiver (TBIW). There are sight differences as CDCS appies to some programs. These differences wi be indicated in the manua.

6 Impementation Consumer Directed Community Supports Lead Agency Operations Manua Impementation of CDCS Statewide DHS wi impement CDCS, as approved by CMS, across a programs and in a counties by Apri 1, There are two phases in the CDCS impementation pan. Phase I Impementation CDCS wi be impemented across a waivers first in the 37 counties previousy authorized to provide CDCS under the MR/RC Waiver, effective Oct. 1, This initia impementation wi incude transitioning individuas who are currenty receiving CDCS under the MR/RC Waiver to services that refect the new poicies, as we as initiating impementation of CDCS across a other programs, and MnDHO and MSHO in those counties. Phase II Impementation The second phase of impementation wi invove the remaining 50 counties, interested triba heath entities, and participating heath pans. These agencies wi begin to impement CDCS across a programs, and MnDHO and MSHO by Apri 1, Evauation of CDCS Impementation An evauation wi occur throughout impementation to determine the effectiveness and appropriateness of CDCS. The resuting recommendations wi be incorporated into CDCS poicies and procedures as appropriate.

7 Consumer Directed Community Supports Lead Agency Operations Manua Section 1: HCBS & CDCS Eigibiity 1.1 HCBS Program Eigibiity and Access to CDCS Consumer Directed Community Supports is a new service avaiabe under the home and community-based waiver and Aternative Care programs. It is not a new program. Like other services avaiabe under the state statute governing the Aternative Care Program, and the federay approved MA waiver pans, CDCS is avaiabe to an individua who is either aready receiving services on a waiver or under AC, or who meets a of the foowing eigibiity criteria for each program as determined by the ead agency. The person must meet Medica Assistance or AC financia eigibiity requirements An assessment competed by authorized professionas indicates the person needs the eve of care provided by an institution The person needs a waiver or AC service to support community aternative iving There is no aternative payor for the waiver or AC services needed The Community Support Pan, when impemented, can reasonaby ensure the heath and safety of the person Some waiver programs have additiona criteria such as diagnosis. Any person who meets a program eigibiity criteria, and receives a waiver sot aocation from the ead agency (county, tribe, or heath pan) can choose CDCS as a service option, with exceptions noted in the next section.

8 Section 1: HCBS & CDCS Eigibiity Consumer Directed Community Supports Lead Agency Operations Manua 1.2 Access to CDCS Service Option is Limited for Some Peope Living Arrangements: CDCS services are not avaiabe to waiver or AC recipients iving in residentia settings icensed by the Department of Human Services (DHS) or icensed or registered with the Minnesota Department of Heath (MDH). These incude famiy or corporate foster care, board and odge faciities, supported iving service faciities, and housing with services/assisted iving estabishments. See Department of Human Services Licensing at DHS_id_ hcsp and Department of Heath at Fraud or Abuse of Pubic Funds: CDCS services are not avaiabe to an individua or their representative who has at any time been restricted by the Primary Care Utiization Review (PCUR) Committee. Information about such restriction wi be found in the Recipient Primary Care Utiization Review (RPCR) screen in MMIS. The ead agency shoud check this information to determine whether the individua has been invoved with PCUR before discussing the CDCS option with that individua. Exits from the Waivers or AC: If a CDCS recipient exits the Waivers or AC more than once during the recipient s service pan year, the recipient is unabe to access CDCS services for the remainder of that service pan year. This does not precude the individua from using other waiver or AC services for the remainder of the service pan year. A person who does not meet a program eigibiity requirements. For exampe, a person participating in Medica Assistance whose needs can be met sufficienty with state pan home care services is not eigibe for a Medica Assistance waiver program because there is no need for a waiver service.

9 Consumer Directed Community Supports Lead Agency Operations Manua Section 2: How CDCS Works 2.1 How Consumer Directed Community Supports Work This manua wi provide more detaied information about the features of CDCS isted beow. They are presented here, in oose chronoogica order, to give ead agency case managers some context for other sections as they are presented. The outine beow aso represents the major activities the consumer, ead agency case manager and others wi perform when CDCS is eected. In addition, it outines those features of the service that ead agency case managers wi have to be most famiiar with in order to provide professiona support to consumers in decision-making about this service, as we as to carry out ead agency responsibiities under CDCS. The person is, or has been, determined to be eigibe for a home and community-based waiver program, or for the Aternative Care program. For some programs, a waiver sot has to be avaiabe to aocate to the cient before waiver program participation can begin. Persona preferences are combined with assessment information to outine a Community Support Pan. The ead agency case manager provides information about different services that can meet the person s needs and preferences, incuding CDCS. There are consumers who do not have access to CDCS as a service option. There are other options that increase fexibiity and choice-making in addition to CDCS. This incudes PCA Choice and aternative providers of waiver services such as homemaker or adut day care service. The ead agency gives the consumer information about budgets for CDCS and non-cdcs options. CDCS information given incudes written materias that outine the consumer s roe and responsibiity under CDCS, the ist of aowabe and unaowabe expenditures, generic support pan requirements and criteria for approva of a consumer-deveoped pan for CDCS. The person seects CDCS. The ead agency gives the consumer information about options for person-centered panning toos and approaches. The ead agency provides a summary of assessment information in order to guide the consumer s pan deveopment. The person deveops the support pan, with or without assistance from others. If desired, the person can receive forma assistance from three sources: If they sti ive in an institution and are eigibe for Medica Assistance, a Reocation Services Coordinator can assist in pan deveopment. If they are eigibe for AC, they can access AC conversion case management to assist in pan deveopment. They can choose to spend some of their CDCS budget to purchase assistance from a quaified Fexibe Case Manager. Fexibe Case Managers must pass a training course and receive certification from DHS to provide service under CDCS.

10 Section 2: How CDCS Works Consumer Directed Community Supports Lead Agency Operations Manua They can be served under a non-cdcs support pan and receive assistance from their waiver or AC case manager to deveop a CDCS pan to move from non-cdcs to CDCS at a point in the future. The ead agency provides a ist of DHS-certified Fisca Support Entities under contract with the county. The Fisca Support Entity is the Medicaid-enroed provider under CDCS. The consumer is the empoyer of support staff funded with CDCS. The consumer can purchase support to carry out empoyer functions. Every CDCS consumer must have an agreement with a Fisca Support Entity. The Fisca Support Entity assists the consumer in managing CDCS funding in a variety of ways, incuding support with empoyer functions, if the person chooses. The consumer submits the support pan for ead agency approva. The pan can incude conventiona and sef-designed services, paid and unpaid support, and persona risk management pans to meet heath and safety needs. CDCS services cannot begin unti the support pan is approved by the ead agency. The pan must incude emergency and backup pans, and break out panned services into severa categories. Some categories have restrictions. The consumer defines provider quaifications for persona assistance. The consumer can add training requirements to meet preferences. The consumer can request background checks of proposed staff. If that person fais this check, they cannot work for the consumer. The person outines a pan for monitoring service impementation and quaity. The pan incudes resuts or outcomes the person wants to achieve by impementing the pan. A spouse or parent can provide persona assistance and be paid for this assistance for up to 40 hours per week when other criteria are met. 3. The ead agency appies stated criteria to approve the pan or outine changes that need to be made to receive approva. The ead agency approves or denies the pan within 30 caendar days of receipt from the consumer. Any support the consumer is purchasing from a Fisca Support Entity or Fexibe Case Manager must be incuded in the pan, incuding specific tasks, the schedue of service, and negotiated payment for these tasks. A written denia of the pan, or reduction in services proposed in the pan, must incude specific reasons and appea rights (Fair Hearing) information. The signed, approved support pan is copied to the consumer, ega representative(s) and the seected Fisca Support Entity.

11 Consumer Directed Community Supports Lead Agency Operations Manua Section 2: How CDCS Works The ead agency creates a Service Agreement in MMIS for the person that can incude ony CDCS, required case management, state pan home care service, background checks, and higher costs for home modifications for certain programs. The consumer and Fisca Support Entity receive copies of the Service Agreement. The consumer enters into written agreements with seected support staff for whom the consumer acts as common aw and managing empoyer, and can deegate some empoyer tasks. The consumer can purchase support to carry out empoyer responsibiities. The pan is impemented. The Fisca Support Entity receives invoices for approved expenditures incuding support staff timesheets. The Fisca Support Entity submits caims to MMIS that break out CDCS spending into four categories of service: Persona assistance Environmenta modifications and provisions, and Sef-directed support The Fisca Support Entity provides monthy reports to the consumer and ega representative, and quartery summaries to the ead agency. The Fisca Support Entity is required to notify the ead agency when monthy spending significanty exceeds or fas short of projected spending in order to identify potentia probems with support pan impementation. There are opportunities for ead agency staff to provide interventions to hep the person succeed in the community with CDCS and meet program and service requirements. There are criteria for invountary exit from CDCS of an individua. The consumer, with or without paid or unpaid support, monitors and evauates the impementation of the pan, the quaity of service, and progress toward or achievement of outcomes. The ead agency continues to provide HCBS quaity assurances to a waiver or AC program participants as outined in their HCBS Quaity Assurance Pan submitted to the Department. Adut and Chid Protective Services referras and services continue to provide protections to vunerabe peope in the community. Reassessments are performed by ead agency staff at east annuay, and when significant changes in need occur. The person can make some amendments to their support pan without ead agency approva; other kinds of changes require ead agency participation and agreement.

12 Section 3: Support Panning Consumer Directed Community Supports Lead Agency Operations Manua 3.1 Person-Centered Panning Process: The Foundation for Consumer-Directed Services The phiosophy and process of person-centered panning provides the foundation for consumerdirected home and community-based services. Home and community-based services support peope in everyday ife. These services have an impact on the person s abiity to participate as a member within their community, and to fufi their own ife-stye choices. Person-centered panning can organize and direct resources in a manner that wi make a difference in a person s quaity of ife, eve of independence, and satisfaction with pubic services. Whie person-centered panning shoud be the foundation for a home and community-based services panning, an expicit person-centered panning process is required when an individua seects CDCS. Understanding person-centered panning processes is a key and necessary ead agency ski. Consumer Directed Community Supports aows greater fexibiity in taioring services to meet individua needs and preferences. It is through a person-centered panning process that the consumer, aong with sef-seected friends, famiy, and providers, determines what, where, when, how, and from whom they wi receive the assistance that is needed. The resuting pan refects goods and services designed by the consumer to meet identified needs and achieve individuay identified resuts or outcomes. Person-centered panning is an ongoing activity that incudes monitoring the effectiveness of the pan and progress toward achieving resuts, and changing the pan over time to incorporate new types of services or ways of deivering services, or to address changed needs, or support revised persona goas or desired resuts. There are various approaches to the person-centered panning process that have been put into pubic practice, and different approaches wi be preferred by individuas. Some peope wi choose to deveop their CDCS pan with itte or no assistance, whie others may want more support in pan deveopment. The ead agency must provide resources and information about the person-centered panning process, incuding the avaiabiity of Fexibe Case Management service to assist in pan deveopment, and offer choices in panning toos to consumers. The Department offers a too box of person-centered panning information and resources isted in Appendix A.

13 Consumer Directed Community Supports Lead Agency Operations Manua Section 3: Support Panning 3.2 Person-Centered Panning Features A person-centered panning approaches share some features in common. The foowing ist of features can be used to provide basic information about what a person-centered panning process might incude, and what opportunity and responsibiity the person has under person-centered panning. The individua chooses the type and extent of person-centered panning activity they want to participate in to deveop their CDCS Community Support Pan. The individua seects other individuas they want to participate in providing support and assistance in the panning process. The individua can seect a person to faciitate panning. The person chooses the meeting dates, setting, time, pace, and ength of any panning meetings. The individua chooses how to start, work through, and end any panning meetings, incuding what he or she wants to get done in a meeting. The individua chooses areas of ife they want hep from other in panning for. For some, a ife vision, dream, or desire forms the foundation for deveoping their personcentered pan. The person-centered panning process is respectfu of the individua, and buids on strengths and taents of the person to design a pan. The individua makes choices and decisions about services and goods. The person achieves increased opportunity for contro over their services under the pan. The person makes decisions about their:: Living situation Providers Service deivery schedue Daiy and vocationa activity Leve of contro and responsibiity Leve of risk management Back up and emergency pans These decisions are refected in the pan. The individua describes desired resuts, deveops persona outcome indicators to monitor and evauate the impementation of the service pan, and the schedue for monitoring.

14 Section 3: Support Panning Consumer Directed Community Supports Lead Agency Operations Manua 3.3 Consumer/Representative Roe in Person-Centered Panning Process and Pan Management One of the responsibiities a consumer accepts when seecting CDCS is taking the primary roe in support pan deveopment. Each consumer wi have persona preferences about the eve of contro they wish to assume in the overa person-centered panning process. The consumer can seect other peope to assist with the tasks isted beow, as ong as the person seected is not otherwise prohibited from performing these tasks. The foowing panning tasks wi be performed by the consumer (or their representative) under CDCS: Initia/Annua Activities Performed by the Consumer Direct the deveopment and revision of the Community Support Pan. Participate in a forma or informa person-centered panning process that addresses individua strengths, needs, and preferences, incuding preferences about the nature of the panning process. The panning process can be informa or forma, and can be competed without paying anyone to hep deveop the pan. Choose peope to assist them in the person-centered panning process if they wish. This assistance can come from friends or famiy or can be purchased.. Partner with the ead agency case manager in the pan deveopment, approva, and funding within the CDCS budget amount. Choose who wi provide direct services, goods, or supportive services, and decide how much service wi be required to meet identified needs. Negotiate payment rates for direct services, goods, and supportive services requested under the CDCS budget that are within reasonabe range of access to comparabe or ike services within the community, and that do not exceed any State-estabished rates. Deveop a pan to monitor service deivery and effectiveness. Outine desired resuts and a pan to measure achievement of resuts. Submit a pan for ead agency approva. CDCS services cannot begin unti the CDCS pan is approved by the ead agency. Ongoing Activities Performed by the Consumer Monitor pan impementation and effectiveness, and achievement of desired resuts. Make revisions to the pan as needed and submit back to the ead agency for approva as needed. This incudes revisions to back up or emergency pans. See Section 4 regarding revisions to the pan. Notify ead agency case manager of significant changes in need, function, or condition. Whie others may assist the individua in carrying out activities and tasks isted above, ony a Fexibe Case Manager can be paid to perform these tasks for the person, and ony at their request and agreement. 10

15 Consumer Directed Community Supports Lead Agency Operations Manua Section 3: Support Panning 3.4 Consumer Resources Additiona resources reated to the panning process are avaiabe to the consumer, are optiona and can be seected by the consumer in any combination or eve of invovement. The person can: Request the use of a particuar person-centered panning process, too or approach. If desired, seect a quaified Fexibe Case Manager (FCM) to provide support and assistance during the person-centered panning process. This assistance must be described in the preiminary CDCS pan, and incude projected tasks or functions the FCM wi perform, the schedue and ength of this service, and the rate approved by the consumer for payment for this service. Costs for this service ARE incuded in the CDCS service budget, and must be authorized on a Service Agreement in MMIS, and must be bied by a Fisca Support Entity chosen by the person. The tota CDCS authorization in this case coud incude the estimated costs for Fexibe Case Management, Fisca Support Entity services, and Required Case Management and Background Checks. Receive training or education to gain a better understanding of roes and responsibiities in the consumer-directed and person-centered panning processes. Estabish additiona quaification requirements for Fexibe Case Managers based on individua needs and preferences. These additiona requirements must be defined in the CDCS Community Support Pan aong with a process for documenting and monitoring that requirements are met for each person hired to serve in this roe. If the person has not seected CDCS because more assistance is requested for panning, the person may: Receive assistance in CDCS pan deveopment PRIOR to a fina seection of CDCS service by the waiver or AC case manager, bied as waiver or AC case management, for a person currenty supported by (or initiay opening to) any of the HCBS programs. Receive assistance in CDCS pan deveopment from a certified fexibe case manager PRIOR to fina seection of CDCS. Provision of this FCM must be approved by the RCM and outined on a form provided by DHS. Under these circumstance, the fexibe case manager wi receive payment ony when the pan is approved, effective the date CDCS services are authorized by the ead agency. See Appendix A.1. for a copy of the form. Receive assistance in CDCS pan deveopment from a Reocation Services Coordinator if they are eigibe for Medica Assistance and currenty reside in an institution. Persons eigibe for AC can access AC conversion case management. Receive conventiona AC or waiver services, incuding assistance in deveoping the CDCS support pan, under an interim Community Support Pan impemented whie the CDCS pan is deveoped. 11

16 Section 3: Support Panning Consumer Directed Community Supports Lead Agency Operations Manua 3.5 Lead Agency Roe and Tasks in Person-Centered Panning Process Information: A person needs information in order to decide if CDCS might be a good option for them. The ead agency must: Provide information and consumer education about the combination of aowabe goods and services that may be purchased under the consumer-directed community support budget. Provide information that heps the consumer understand their roes and responsibiities under consumer-directed services and person-centered panning processes. Provide information about resources, toos, and technica assistance avaiabe. Provide information about Fisca Support Entity services avaiabe, incuding those that aow the consumer varied eves of autonomy and contro as an empoyer. Provide information about the quaifications for and activities of a Fexibe Case Manager. Budget Amounts: DHS wi make individua CDCS budget information avaiabe to ead agency case managers as a monthy amount isted on the Long Term Care Screening Document for EW and AC (athough proposed expenditures for CDCS are not imited monthy by this amount), and as an annua budget for other waivers incuding CAC, CADI, TBI, and MR/RC in the Waiver Management System. The person needs to know how much money wi be avaiabe for goods and services to begin to sketch out a pan. The ead agency must: Inform the consumer of their CDCS and non-cdcs budget(s) avaiabe for purchasing services over a one-year period. Prorate the amount of money avaiabe under either CDCS or non-cdcs if the service pan wi cover ess than one year. Faciitate the Person-Centered Panning Process: The ead agency wi aso: Hep the consumer outine their interests, strengths, desired outcomes, and preferences for services during assessment, as is competed for a HCBS appicants or recipients. Outine panning process options so the consumer can choose the eve of direction and contro they prefer for the person-centered panning process. Give professiona feedback about the eve of provider training, standards, and quaifications the consumer shoud consider given assessed needs. Provide information about the background check process, benefits of the process, and how these background checks wi be paid for under CDCS. 12

17 Consumer Directed Community Supports Lead Agency Operations Manua Section 3: Support Panning 3.6 Other Services That Increase Fexibiity and Consumer Contro It is important that ead agency staff be thoroughy famiiar with other service options that increase consumer direction and fexibiity in services panning and deivery. This information must be avaiabe to consumers to hep them make the most informed choice about not ony services avaiabe, but the range of consumer direction and contro avaiabe in the waiver and AC service deivery system. Consumer Directed Community Supports, when propery impemented, offers the most fexibiity and consumer contro in service design, seection of supports, and managing individua budgets. However, some consumers may not want to assume the eve of responsibiity and contro expected under CDCS, but sti want more fexibiity in designing their services, may want to have more authority to direct their care, or may want more choices in who can provide support or service to them. PCA Choice, for exampe, can aow a person to recruit, hire, train, and supervise a direct support worker. Under this option, the person receives assistance in deveoping a service pan, and receives fisca management support from a PCA Choice provider. See the Disabiity Services Program Manua for more compete information about this option at and cick on CountyLink. The consumer guidebook for PCA Choice is aso avaiabe on the web. Look for Persona Care Assistance Program Consumer Guidebook, DHS Form Go to dhs.state.mn.us/fserver/legacy/dhs-3858-eng There has aso been an expansion of caregiver services and respite options for famiies of persons age 60 or oder that incudes new services, new fexibiity in the provision of these services, and an abiity to taior these services to meet individua caregiver and recipient needs. See Buetin for compete information about these options. In addition, quasi-forma and informa support networks exist in many communities that can offer very individuaized service provided by vounteer or paid staff support. These services can be very fexibe and incude socia service and nursing services such as Living At Home Bock Nurse Programs and respite. Agencies such as the Area Agency on Aging (AAA) or Centers for Independent Living may ink consumers and famiies with a variety of non-paid hep avaiabe from vounteers or from faith-based communities, for exampe. See Buetin for information about coaborations between AAAs and the communities they serve designed to increase avaiabiity of these kinds of supports. Go to pub/dhs_id_ pdf These quasi-forma community based supports can offer individuaized service and support from non-traditiona providers, and can be an important component of a Community Support Pan for CDCS as we as non-cdcs consumers. 13

18 Section 3: Support Panning Consumer Directed Community Supports Lead Agency Operations Manua 3.7 Toos and Resources to Support the Person-Centered Panning Process Panning toos and resources can assist the person in designing a meaningfu person-centered pan. The ead agency wi provide information about the avaiabiity of these toos and resources. Refer to Appendix A: Resources for Person-Centered Panning. Resources wi be made avaiabe through the Department to ead and other agencies free of charge to pass on to consumers free of charge. There are numerous additiona resources that peope can access without charge. The ead agency wi need to become famiiar with these resources in order to provide information about person-centered panning options, and to provide assistance with suppementa materias if needed. If a Fexibe Case Manager offers assistance in support pan deveopment and intends to use proprietary toos for which the person wi be charged, the person must be tod about and agree to these charges prior to competion of the agreement between the person and the vendor. In some cases, a person may discover a too that is perfect for them that they must purchase to use. In this case, resource materias for pan deveopment can be paid for under the person s CDCS budget using the Treatment and Training CDCS service category for caims. Support Pan Components are outined in Section 4, as are criteria for ead agency approva of a consumer-designed CDCS support pan. 14

19 Consumer Directed Community Supports Lead Agency Operations Manua Section 3: Support Appendix Panning A Appendix A: A Web Resource List on Person-Centered Panning Web Resources: is the main web address to the compete toos kit created for person-centered panning under CDCS. The text of and inks within the page are recreated here. Consumer Directed Tookit: The Consumer Directed Tookit contains a variety of resource materias to assist consumer direct and manage their own supports. Section 5 of the tookit focuses on person-centered panning. Minnesota Governor s Counci on Deveopmenta Disabiities, cick on Pubications: Two manuas are avaiabe through the Research and Training Center on Community Living, a division of the University of Minnesota: Increasing Person-Centered Thinking: Improving the Quaity of Person-Centered Panning - A Manua for Person-Centered Panning Faciitators (PDF): pcpmanua1.pdf Training Person-Centered Panning Faciitators: A Compendium of Ideas (PDF):

20 Appendix Section 3: A.1 Support Panning Consumer Directed Community Supports Lead Agency Operations Manua Appendix A.1: CDCS Fexibe Case Management Pan Deveopment Notification Too Consumer Name: Date of Birth: PMI #: This too can be used to inform a parties of the use of fexibe case management services to deveop an initia community support pan for Consumer Directed Community Supports (CDCS). The estimated cost of the pan deveopment wi be added to the consumer s CDCS budget and may be paid to the fexibe case manager after the pan has been approved. Estimated Cost of Pan Deveopment: I understand that a fexibe case manager who heps deveop the initia community support pan wi not be paid if the pan is not approved or if the consumer decides not to pursue CDCS. Fexibe Case Manager: Signature: Date: Consumer: Signature: Date: Lega Representative (if appicabe): Signature: Date: ***Note: This too is not a contract; it is an optiona too 16

21 Consumer Directed Community Supports Lead Agency Operations Manua Section 4: Support Pan Components 4.1 Community Support Pan Requirements for A HCBS Programs The Community Support Pan deveoped by a consumer who has chosen CDCS must incude certain components required for a HCBS waiver or AC pans. The pan must identify: A forma and informa services, goods, and supports that wi meet assessed needs The frequency and duration of service, the price for that good or service, and who wi provide the service or support Safeguards to reasonaby address and maintain the individua s heath and wefare Backup services, contingency pans, and emergency service to address potentia situations that may arise The person s desired outcome or resut to be achieved with the pan in pace Contact information. 17

22 Section 4: Support Pan Components Consumer Directed Community Supports Lead Agency Operations Manua 4.2 Community Support Pan Formats (DHS 2925, 4166 or 4556) The Community Support Pan (DHS-2925) form can be used to outine the required CDCS pan components, and can provide a basis for the person-centered panning process. Use of the budget pages and the caregiver support pan can hep the consumer outine proposed expenses and ensure caregiver panning occurs. The attached services grid can be used in combination with the crosswak found in Appendix B in this manua to organize conventiona waiver or AC services into the appropriate CDCS categories within the pan. DHS Form 4166 offers an aternative support panning format. Used as an eectronic form, detaied assessment information can be merged from the eectronic version of DHS Form 3428 (the assessment form) to popuate the support pan form. This wi aow the consumer to see summary information about assessed needs that must be addressed in the pan, either through paid or informa services, or through a persona risk management proposa. DHS Form 4556 is the Rue 185 compiant Community Support Pan and meets standards of the MR/RC Waiver. This pan can aso be used with the other home and community based waiver programs (CAC, CADI, TBI and EW and AC program). Any pan format can be used by the consumer that can outine a of the required pan components and that refects required documentation as isted in the next parts of this Section. The requirements can be isted on a form of the consumer s own creation to guide the panning process and ensure submission of a compete pan, or one can be created by a oca agency for OPTIONAL use by consumers. Forms isted in this manua can be accessed at (form number)-eng. 18

23 Consumer Directed Community Supports Lead Agency Operations Manua Section 4: Support Pan Components 4.3 CDCS Requirements of a Person-Centered Community Support Pan Within the overa pan requirements isted in Section 4.1, a pan deveoped with CDCS as the choice of service must incude the foowing detai: A description of a services and goods that wi be purchased under the individua s CDCS budget cap, incuding payment rates for each service or good, and staff, if known Informa or quasiforma supports that are part of an ongoing, predictabe, reiabe method to meet identified needs Schedue of services (how often, for how ong) Proposed aocation of CDCS doars between the four categories of CDCS services identified in Section 5.3 and more fuy described in Section 6 Choice of Fisca Support Entity option, incuding tasks, schedue, and fees Outine of pan to monitor pan impementation and effectiveness of services/supports, incuding desired resuts or outcomes, the schedue of monitoring activity, how progress wi be measured, and who wi perform monitoring activity Specific provider quaifications, incuding training requirements, estabished by the consumer Identification of the person(s) responsibe to ensure that provider quaifications and training requirements are met, incuding whether or not background checks are requested and who wi perform the checks Individuaized Fexibe Case Management pan, as proposed by the consumer, incuding tasks, schedue, and fees As noted in 4.1, heath and safety needs are addressed, incuding backup and emergency pans, and persona risk management pans, if appicabe. 19

24 Section 4: Support Pan Components Consumer Directed Community Supports Lead Agency Operations Manua 4.4 CDCS Budget Amount on the Pan The CDCS budget amounts avaiabe to purchase services wi be issued annuay by the department. Budget amounts wi be cacuated according to federa waiver authority for each waiver program, based on historica expenditures across the categorica popuations. The ead agency professiona conducting the LTCC or DD assessment process wi inform the consumer of their avaiabe budget amount and non-cdcs service cap amount as part of the information about CDCS services options presented to them when they are determined to be eigibe for HCBS, or at reassessment. This budget amount must be incuded on the pan in order for the consumer and the ead agency case manager to evauate cost effectiveness, and the ikey success of the proposed pan. The person-centered Community Support Pan can incude costs for services up to the annua CDCS budget amount. Unexpended CDCS budget funds cannot be carried over to subsequent service pan years. See Section 14 for more information about budgets and authorization processes for peope age 65 and oder, and Section 16 for information about budgets and authorizations under MnDHO and MSHO. Information about budgets and authorizations for peope under 65 is found in Section 15. Reassessment Reassessment may change the CDCS budget. If that occurs, the ead agency wi inform the person of the new budget amount. If the budget is increased, the individua shoud determine whether there are currenty unmet needs and if so, revise the Community Support Pan and submit to the ead agency for approva and/or reauthorization. If the budget decreases, and is ess than the amount currenty authorized, the individua must determine changes to services or supports within the new budget amount. The Community Support Pan wi refect these changes when re-submitted for ead agency approva. 20

25 Consumer Directed Community Supports Lead Agency Operations Manua Section 4: Support Pan Components 4.5 Appying Quaity Considerations to the CDCS Support Pan A. Program Requirements: Whie CDCS aows an individua to design services and goods that are unique and meet the person s needs and preferences, there are criteria for purchasing services under CDCS, as we as specific types of goods and services that are NOT aowed to be purchased with CDCS funding. Goods and services that are NOT aowabe are described in Section 8. The goods and services purchased through CDCS must meet a the basic waiver and AC requirements for authorized services. Proposed services: Meet the individua s needs identified in the Community Support Pan AND Assure heath, safety, and wefare AND Goods and services coectivey provide an aternative to institutiona pacement AND Are the most cost efficient (east costy aternative that reasonaby meets heath and safety needs) AND Be for the soe benefit of the person. B. Persona Outcomes: For every person participating in HCBS programs, taking about desired outcomes shoud be part of the initia discussions about service options. When a person thinks and taks about resuts they want, it heps them make choices about the types of services, the types of providers, goods, and supports that wi best hep them achieve those resuts. If a of the criteria for aowabe expenditures in A. are met, goods and services are appropriate purchases under CDCS when they are reasonaby necessary to support any or a of these individuaized outcomes: Maintain community iving. Enhance or maintain famiy or community invovement. Deveop or maintain socia, physica or work-reated skis. Decrease dependence on forma support services. Increase independence of the person. Increase abiity of unpaid famiy and friends to receive training and education needed to provide support. A CDCS Support Pan must incude the resuts the person wishes to achieve under the pan. 21

26 Section 4: Support Pan Components Consumer Directed Community Supports Lead Agency Operations Manua C. Measuring and Monitoring Pan Impementation and Resuts: Given the person s stated desired resuts, does the pan to monitor hep the person identify needs for revision to the pan, and hep demonstrate achievement of or progress toward desired outcomes or resuts? Does the pan incude a schedue to periodicay measure progress? What wi be measured (indicators)? Who wi do the monitoring? What steps wi be taken, by whom, if the pan proves to be ineffective? Exampes: Empoyment Desired Resut Measure I want to work at east 5 hours a week by summer and 10 hours a week by fa. What wi be monitored? By whom? How and how often? Improved Heath Increased Independence My evauation of my heath is fair now and wi be good in 6 months. I wi have no emergency room visits for one year. What wi be monitored? By whom? How and how often? I can create a menu, shop and cook for a week s meas within a year. What wi be monitored? By whom? How and how often? The pan to monitor and periodicay evauate the effectiveness of the pan in heping the person achieve desired resuts must aso incude what steps wi be taken if the pan does not seem to be effective, cannot be impemented according to the approved service design, or if backup or emergency pans are frequenty reied upon. 22

27 Consumer Directed Community Supports Lead Agency Operations Manua Section 4: Support Pan Components 4.6 Heath and Safety: Persona Negotiated Risk Management Pan Peope take risks every day as part of ife. Our abiity to assume and manage risk refects our competence, our independence, our abiity and right to make choices, and our right to assess benefits and consequences of choices we make in ife. A persona negotiated risk management pan is a refection of the consumer s choices that strike a baance between the recommended eve of service coverage (care, supervision, and safety) and the person s desired eve of independence. For exampe, a consumer with quadripegia may decide that 24 hour care and supervision impinges too much on their feeing of iving independenty in an apartment, does not aow them enough time to be aone, and interferes with persona privacy, and abiity to achieve restfu seep at night. The consumer may choose not to have services during a 10 hour period at nighttime, even though there are persona risks that something may happen. The person is aware of risks or consequences and has proposed a method to manage the risk. For exampe, an emergency aarm device is used at night, or a neighbor or friend agrees to be avaiabe in the event of an emergency. Home modifications may be part of a pan to address environmenta hazards or concerns about evacuation. An edery person agrees to home modifications but does not want to utiize a waker, and has a pan to impement in the event of a fa. The consumer has weighed the cost-benefit and has decided to assume a eve of risk and manage it. The persona negotiated risk management pan shoud be documented in the Community Support Pan and shoud be tied to the pans for backup services and community emergencies. A ead agency or fexibe case manager can hep identify potentia risks or consequences as part of the support and risk management panning. Uness a consumer s pan, incuding persona risk management, resuts in unaddressed heath and safety issues that are so significant that a referra to Adut Protective Services or Chid Protective Services wi resut, a pan shoud not be denied for heath and safety reasons. In other words, heath and safety considerations under CDCS shoud foow the practice in pace for a HCBS service pans and protections. Liabiity: According to MN Statute 256B.0916 Subd. 6a (c), MN Statute 256B.49 Subd. 16 (e), and MN Statute 256B.0915 Subd. 8 (c), the state of Minnesota, county agencies, triba governments, or administrative entities under contract to participate in the impementation and administration of the home and community-based waiver for persons with menta retardation or a reated condition, persons with disabiities, and the edery waiver: sha not be iabe for damages, injuries, or iabiities sustained through the purchase of support by the individua, the individua s famiy, ega representative, or the authorized representative with funds received through the consumer-directed community support service under this section. Liabiities incude but are not imited to: workers compensation iabiity, the Federa Insurance Contributions Act (FICA), or the Federa Unempoyment Tax Act (FUTA). (itaics added) 23

28 Section 4: Support Pan Components Consumer Directed Community Supports Lead Agency Operations Manua 4.7 Backup Pans and Emergency Pans The backup pan is a contingency pan that can be impemented if the primary services in the Community Support Pan are disrupted. It shoud be designed to address a variety of circumstances shoud they occur. A backup pan can refect a variety of resources and shoud be feasibe and readiy impemented. It shoud be documented in the Community Support Pan aong with a pan for maintaining contacts and monitoring feasibiity. Activation of the backup pan shoud be evauated for responsiveness and effectiveness. If a backup pan has to be impemented frequenty, the overa pan shoud be re-evauated and revised. An emergency pan is the pan that goes into effect during community-wide emergencies such as threatening weather, fires, eectrica outages and other circumstances that can create safety issues or barriers to care deivery. For exampe, a threatening storm is approaching and warnings have been issued to move to a basement area. Who wi assist in moving the consumer to the basement area? Is the pan feasibe at a times? Who wi monitor and maintain the pan in case of changing situations? The emergency pan shoud be documented in the Community Support Pan with responsibe persons noted and a schedue for periodic monitoring and revising this portion of the pan. 24

29 Consumer Directed Community Supports Lead Agency Operations Manua Section 4: Support Pan Components 4.8 Reviewing the Pan Lead agency case managers wi review each pan submitted by a person seecting CDCS for these eements and criteria: Aowabe Goods and Services Heath and Safety: Meeting Assessed Needs, Quaity of Care Quaity Pan: Consumer Outcomes Are proposed services and goods aowabe under the criteria outined in 4.5, and according to the definitions of CDCS aowabe costs, goods, services, and items as outined in Section 5 of this manua? Does the pan for persona assistance that incudes a spouse or parent who wi receive payment for this assistance meet criteria outined in Section 13 of this manua? Does the pan incude items or services that are expicity excuded as noted in Section 8 of this manua? Do pan components meet identified needs? Wi backup and contingency pans, incuding persona risk management pans, in combination with the proposed pan, reasonaby ensure the person s heath and safety in the community? Are proposed backup pans and emergency pans reasonabe and ikey to be effective? Are training, experience, educationa, and icensing requirements outined in the pan reasonabe and adequate given assessed needs and consumer preferences? Do providers meet the quaifications outined in Section 7 of this manua? Does the pan incude adequate and reasonabe informa caregiver training and other supports given the assessed needs and consumer preferences? Wi services and goods reasonaby support the achievement of consumer outcomes isted in the person s pan? Are the goods and services considered appropriate purchases under CDCS because they are reasonaby necessary to support any or a of the outcomes outined in Section 4.5 of this manua? Wi the monitoring schedue, activity, and indicators support achievement of person s desired resuts? Cost Effectiveness and Financia Accountabiity Are the proposed costs for goods and services reasonabe given the cost of purchasing simiar services or goods in the community? Are there aternative payors for proposed services such as Medicare? Does the pan represent a cost-effective way to meet needs? Does the agreement between the Fisca Support Entity and the consumer outine specific tasks to be performed by the FSE, and fees? Does the description of Fexibe Case Management service, if any, incude a cear description of what the person wants to buy from the FCM, at what price, for how ong? Can the pan be impemented within the person s CDCS budget? In genera, any pan submitted by a consumer that contains the required documentation and that meets the above criteria, as appicabe to an individua consumer, must be approved by the ead agency. See the next sections for information about denia of a proposed CDCS pan or portions of a pan. 25

30 Section 4: Support Pan Components Consumer Directed Community Supports Lead Agency Operations Manua 4.9 Approva, Denia, or Partia Denia of a Proposed CDCS Pan The ead agency must make a decision in writing about the proposed CDCS pan submitted by the consumer within 30 caendar days of receipt of the proposed pan. The ead agency can: Approve the pan. Send the consumer and the FSE a copy of the approva etter and a copy of the pan. Enter a Screening Document and Service Agreement into MMIS to authorize CDCS funding to support the pan. Send a copy of the Service Agreement to the consumer and FSE. Recommend changes needed to approve the pan before a fina decision. The ead agency case manager can negotiate with the consumer to change eements of the pan as needed to approve the pan. This negotiation can be informa and wi be the most effective method to resove concerns before the 30 day period for ead agency decision expires. Approve part of the pan. The pan submitted by the consumer may contain services, costs, outcomes, staffing proposa or other eements that the ead agency determines they cannot approve. In effect, approva of part of a pan represents a decision to reduce proposed service (by denying some portions). A written decision to deny portions of a proposed pan must be accompanied by an expanation detaiing the reason(s) for the denia or reduction of a requested service. Deny or refuse to approve the pan. A pan may be denied in its entirety. A written decision to deny the requested services must be accompanied by an expanation detaiing the reason(s) for the decision to deny. When the decision is to deny part or a of a proposed pan: The ead agency can use DHS Form 2828 to notify the consumer and their ega representative of this decision. That form incudes information about fiing an appea of the agency s decisions; the ead agency must provide assistance to the person who wishes to fie an appea and requests such assistance. The ead agency can aso use a simiar form if they have deveoped one, as ong as a of the same information is incuded on the form, and the information is accurate. The consumer can agree to the partia pan as approved by the agency, or they can ask the ead agency to reconsider any decision made, incuding whether they agree that the summary of assessed needs accuratey refects their needs. Conciiation conferences can aso be schedued to reconsider issues or concerns that prevented approva of eements of a pan or denia of the pan as a whoe. A consumer who requests a conciiation conference or informa negotiation shoud be informed that the Fair Hearing (appea) process incudes timeines that must be met. The consumer may wish to fie an appea as we as confer or negotiate. The request for a hearing can be withdrawn if conciiation conferences or negotiation resut in resoution of issues or concerns. 26

31 Consumer Directed Community Supports Lead Agency Operations Manua Section 4: Support Pan Components 4.10 Provision of Technica Assistance: Heping the Consumer Get a CDCS Pan Approved and Impemented As noted in Section 3.4, a person who wants assistance in CDCS support pan deveopment can access it in a variety of ways, incuding through assistance from their waiver or AC case manager or a Reocation Services Coordinator. These resources shoud aso be considered avaiabe to hep a person reshape a CDCS pan that has been submitted and either denied or partiay approved. If a pan is denied or partiay approved, a support pan that reies on conventiona waiver or AC services can be impemented, with additiona waiver or AC case management provided to address CDCS pan components in question. This support pan deveopment activity is currenty performed by case managers for any consumer who wishes to change their providers, their services, their schedues, and so on, and represents a we-estabished roe of the case manager in heping deveop a support pan that refects consumer choices, preferences, and participation. The person coud aso receive assistance in CDCS pan deveopment from a certified fexibe case manager PRIOR to fina seection of CDCS. Provision of this FCM must be approved by the RCM and outined on a form provided by DHS. Under these circumstance, the fexibe case manager wi receive payment ony when the pan is approved, effective the date CDCS services are authorized by the ead agency. See Appendix A.1. for a copy of the form. The person might aso receive approva for a CDCS pan that incudes Fexibe Case Management ony to assist in a CDCS support pan revision that resuts in overa pan approva. An important issue to consider under this option is how and to what extent a person s need for support and assistance wi be met during the interim Service Revisions and Pan Changes - Consumer Versus Lead Agency Approva Consumer Approva Ony Required The recipient or their representative may revise the way that a CDCS service or support is provided without the invovement or approva of the ead agency, when the revision does not change or modify the parameters authorized by the ead agency case manager in the Community Support Pan. For exampe, within the Community Support Pan parameters and budget, the recipient has the fexibiity to: Change caregivers (with the exception to deciding to pay a spouse or parent if not previousy authorized) Hire additiona caregivers Change the days or times of service Pay a business instead of staff (e.g. the oca aundry instead of persona assistant) Grant wage increase to persona assistant up to maximum permitted Pay one caregiver who has more experience a higher rate, etc. However, the caregiver(s) must meet the quaifications and training requirements that the county agency approved in the Community Support Pan 27

32 Section 4: Support Pan Components Consumer Directed Community Supports Lead Agency Operations Manua Lead Agency and Consumer Approva Required The person s Community Support Pan wi provide the foundation for purchase and deivery of services and achievement of individuay desired resuts. The pan must incude certain characteristic eements: A summary of assessed needs The person s desired service outcomes or resuts How the resut or outcome wi be achieved/how the need wi be met (description of services) What training and quaifications are required for staff How the service wi be monitored, and The budget The individua s budget must be panned for a 12 month period and wi incude a goods and services to be purchased through the waiver and State pan home care services with the exception of required case management and crimina back ground studies. Any service pan that is ess than a year must be prorated. These eements or parameters that are defined in the Community Support Pan cannot be atered without agreement from the ead agency. If a requested or proposed revision wi resut in a change or modification of the approved parameters of a Community Support Pan, the consumer or their ega representative wi work with the ead agency to reviewed and approve requested changes. The ead agency must respond to a request to change the approved pan within 30 days of the request submitted by the consumer. See Section 4.9 for the process required if a or part of a pan, incuding a request to revise the pan, is denied. A change in the pan that requires approva and/or authorization by the ead agency cannot be impemented nor paid for unti ead agency approva has been received by the consumer. Exampe: A homemaker comes to the consumer s home to do aundry, and the consumer decides to send it to the oca Laundromat instead. This change does not need ead agency approva since the outcome was aundry, and the aundry is sti done. However, if the homemaker was aso doing a heath and safety check whie doing aundry, ead agency approva is needed to ensure the heath and safety outcome wi sti be met. 28

33 Consumer Directed Community Supports Lead Agency Operations Manua Section 5: Aowabe Goods & Service Under CDCS 5.1 Waiver requirements reated to a aowabe services Whie CDCS aows an individua to design unique services and goods to meet the person s needs and preferences, these goods and services must meet a of the basic waiver program requirements for authorized services: Meet the individua s needs identified in the Community Support Pan AND Assure heath, safety, and wefare AND Goods and services coectivey provide an aternative to institutiona pacement AND Are the most cost efficient (east costy aternative that reasonaby meets heath and safety needs) AND Be for the soe benefit of the person. 5.2 Additiona requirements for CDCS services: Consumer Outcomes If a of the criteria in 5.1 are met, goods and services are appropriate purchases under CDCS when they are reasonaby necessary to support any or a of these consumer outcomes: Maintain community iving Enhance famiy invovement and community incusion Deveop or maintain socia, physica or work reated skis Decrease dependence on forma support services Increase independence of the person Increase abiity of unpaid famiy and friends to receive training and education needed to provide support. Goods and services that are NOT aowabe are described in Section 8. 29

34 Section 5: Aowabe Goods & Service Under CDCS Consumer Directed Community Supports Lead Agency Operations Manua 5.3 Broad CDCS Service Categories Consumer Directed Community Supports service can represent a variety of goods and services, designed by the consumer, and approved in the pan. Under the singe service caed CDCS, the waiver and AC programs provide reimbursement for four major types or categories of services: Persona assistance: Services and supports that typicay do not require a professiona icense, certification or other professiona credentiaing. : Primariy services and supports that require the person or entity performing the service to be professionay icensed, credentiaed or otherwise certified. Providers of treatment and training must meet a appicabe standards. Aso incuded in this category are consumer and paid or unpaid support staff training and education. Environmenta modifications and provision: Home and vehice modifications, chore, transportation, approved suppies and equipment, prescribed specia diets, and adaptive cothing are exampes of supports that woud be categorized here. Sef-direction support activities: Fisca Support Entity service, Fexibe Case Manager service, and some empoyer-reated costs fa under this category. These categories are NOT used for Service Agreements. They are used ony to cassify services and supports under an approved pan, and are used on caims to provide information about the kinds of service and support CDCS funding is used for. These categories represent broad kinds of support and assistance a person may need to ive in the community. Within these categories, consumers are abe to define the service that best meets their needs and preferences. More detaied information about use of these categories is presented in Section 6. 30

35 Consumer Directed Community Supports Lead Agency Operations Manua Section 5: Aowabe Goods & Service Under CDCS 5.4 Additiona Goods and Services That May Be Incuded in CDCS Budgets In addition to the kinds of goods and services isted above, the foowing goods and services can be incuded in an individua s pan, under the CDCS budget, as ong as they meet the criteria outined in Section 5.1 and 5.2. Goods and services that augment State Pan services (e.g. needed extended home care service) Goods and services that provide aternatives to conventiona waiver or State Pan services (e.g. purchasing empoyment ski training rather than day training and habiitation service, or purchasing assistance with activities of daiy iving from a neighbor rather than PCA or home heath aide service from an agency) Therapy, specia diets or behaviora supports not otherwise avaiabe through Minnesota Heath Care Programs (Medica Assistance and Prepaid Medica Assistance) that mitigate a disabiity and that are prescribed by a physician icensed to practice in Minnesota and enroed as an MHCP provider A currenty avaiabe waiver and AC goods and services can be purchased as part of a CDCS support pan. Providers of any service must meet SERVICE quaifications, whether purchased through conventiona AC or waiver or CDCS support pans. For exampe, if the consumer indicates they wish to purchase supported empoyment service, the provider must meet a required standards and icensing requirements. More information about provider quaifications under CDCS is found in Section 7. A of the services approved in a pan must be arranged in the categories isted in 5.3 to aow the Fisca Support Entity to separate and appropriatey bi approved services. A crosswak between the conventiona waiver and AC services and the CDCS category the service woud fa under can be found in Appendix B. 31

36 Section 5: Aowabe Goods & Service Under CDCS Consumer Directed Community Supports Lead Agency Operations Manua 5.5 Additiona Services Authorized in Combination with CDCS In addition to authorization of CDCS services and goods comprised of some combination of the categories of services isted in this Section, a Service Agreement can aso incude: State Pan home care services (not avaiabe to AC participants) Required Case Management services (Every Service Agreement wi incude Required Case Management) Background checks requested by the consumer. Background checks referred to throughout this manua refer to those checks that foow the provisions under MN Statutes, section 245C. Certain home modifications for persons under age 65. Required case management and background checks must be authorized separatey because the cost of these activities cannot be deducted from the individua consumer s CDCS service budget under the approved federa waiver pans. For person under age 65, and for persons purchasing CDCS service under the Aternative Care program, the costs of these components of a CDCS pan are covered by aggregate aocation funds. State Pan home care services can be authorized separatey in order to: Ensure access to, and first use of these benefits Aow the consumer to more easiy meet spenddown requirements by provider assignment Ensure heath pan provision of those home care benefits for which capitation payments have been made Appy waiver obigation cacuations appropriatey to ony waiver and not state pan home care services under the Specia Income Standard Edery Waiver Program (SIS-EW). Access Medicare coverage for home care services, which wi not be cacuated as part of the consumer s budget (whether CDCS has been chosen or not). Home Modifications and/or Assistive Technoogy: For peope eigibe for the MR/RC, CADI, CAC and TBI waiver programs, home modifications and/or assistive technoogy whose singuar or combined cost wi exceed $5, and that are approved by the ead agency are aso authorized on the Service Agreement separatey. See Section

37 Consumer Directed Community Supports Lead Agency Operations Manua Section 5: Aowabe Goods & Service Under CDCS 5.6 Using CDCS to Purchase Conventiona Waiver Services A currenty avaiabe waiver or AC goods and services can be incuded in a CDCS support pan and purchased with CDCS funding. This incudes services such as day training and habiitation, inhome famiy support, behavior anayst, extended suppies and equipment, extended PCA, adut day care, and transitiona services. If a consumer seects conventiona waiver or AC service as part of their support pan: The costs are incuded in the individua s CDCS budget. The provider of this service must be certified or icensed according to the Minnesota statute and rue reated to the SERVICE. The service is authorized as CDCS, and the costs are incuded in the CDCS authorized tota. The current waiver or AC service codes ARE NOT entered on the Service Agreement. The provider cannot bi MMIS directy. Rather, the Fisca Support Entity submits a caim for CDCS, using one of four CDCS categories of service on the biing to indicate what type of service was provided, and pays the vendor after service is deivered and according to the agreement between the consumer and the vendor. The crosswak for coding between the conventiona waiver or AC service and how this service wi be categorized if chosen by a person as part of CDCS support pan is shown in Appendix B. 33

38 Section 5: Aowabe Goods & Service Under CDCS Consumer Directed Community Supports Lead Agency Operations Manua 5.7 A Note About State Pan Home Care Services The consumer who meets waiver eigibiity criteria and who has chosen CDCS as their service option can seect, as part of their Community Support Pan, state pan home care services. State pan home care services are a those services identified in MN Statutes 256B.0627 and MN Rue Aternative Care participants are not eigibe for Medica Assistance benefits such as state pan home care. State Pan Home Care Services incude: Persona Care Assistance (PCA) PCA Supervision Home Heath Aide Skied Nursing Service Private Duty Nursing Extended Home Care Services incude: Extended Persona Care Assistance (PCA) Extended PCA Supervision Extended Home Heath Aide Extended Skied Nursing Service Extended Private Duty Nursing Acute and Primary Care Services incude: Physica Therapy Occupationa Therapy Respiratory Therapy Speech Therapy Suppies and Equipment Medica Transportation Behaviora and Menta Heath Services The costs of any state pan home care services seected by the consumer must be incuded under their individua CDCS budget. State pan home care services are provided by a icensed, certified agency. Authorized on the CDCS Service Agreement using state pan home care codes, and the home care agency can bi directy. The costs of any extended home care services seected by the consumer must be incuded under their individua CDCS budget. These extended home care services are provided by a icensed, certified agency. Authorized under the CDCS service code on the Service Agreement, must be bied by category by the Fisca Support Entity. Other services that can be part of a person s support pan are avaiabe under acute and primary coverage through MHCP. The consumer shoud be encouraged to access therapy and transportation under their acute and primary care benefit set, since the cost of these services IS NOT incuded under the individua s CDCS budget. These services do not appear on the CDCS Service Agreement, and they are bied directy by the therapy or suppies and equipment agency. Extended Acute & Primary Care Services incude: Extended Suppies and Equipment Extended Physica Therapy Extended Occupationa Therapy Extended Respiratory Therapy Extended Speech Therapy Extended Behaviora Therapy 34 A of the HCBS waiver programs offer extended suppies and equipment. Some HCBS programs aso offer services under the waiver that extend therapy benefits avaiabe under Medicaid acute and primary care coverage. If the person chooses extended therapy, or extended suppies and equipment or transportation, the costs of these services is incuded in the CDCS budget. Authorized under the CDCS service code on the Service Agreement, must be bied by category the Fisca Support Entity. Within a Community Support Pan, the consumer may combine state pan home care that wi be authorized and bied separatey by a home care agency with other CDCS supports. This incudes those designed to augment or provide an aternative to state pan home care or conventiona waiver services.

39 Consumer Directed Community Supports Lead Agency Operations Manua Section 5: Aowabe Goods & Service Under Appendix CDCS B Appendix B: Crosswak Between Waiver & Home Care Codes and CDCS Service Categories CAC WAIVERED SERVICE Case Management (Fexibe Case Management Ony) Case Management Aide (Paraprofessiona) Famiy Counseing Famiy Training Foster Care Home Heath Aide, Extended Homemaker LPN (Reguar Home Heath, Extended; Shared Home Heath, Extended 1:2) LPN (Compex Home Heath, Extended) Modifications Nutritiona Therapy, Extended Occupationa Therapy or Assistant, Extended Persona Care Assistant (Extended 1:1; Extended 1:2; Extended 1:3) Physica Therapy or Assistant, Extended Prescription Drugs, Extended RN (Reguar Home Heath, Extended; Shared Home Heath, Extended 1:2) RN (Compex Home Heath, Extended) RN (Supervision of Independent PDN) Respiratory Therapy, Extended Respite Care (In-home; Out-of-home) Speech Therapy, Extended Suppies/Equipment Transportation (One Way Trip) Transportation-Mieage Transportation Mieage (Noncommercia Vehice) Transportation-Attendant CDCS ALTERNATIVE Sef-direction support activities Not aowed Not aowed Persona assistance Environmenta modifications and provisions Persona assistance Environmenta modifications and provisions Environmenta modifications and provisions Environmenta modifications and provisions Environmenta modifications and provisions Persona assistance Note: Case Management here refers ony to Fexibe Case Management service seected by the person, and provided by a quaified person. Required Case Management is authorized separatey. See Section 10 for a description of Required and Fexibe Case Management tasks under CDCS. 35

40 Section 5: Aowabe Goods & Appendix B Service Under CDCS Consumer Directed Community Supports Lead Agency Operations Manua Adut Day Care Adut Day Care Bath CADI WAIVER Case Management (Fexibe Case Management ony) Case Management Aide (Paraprofessiona) Famiy Counseing and Training Home Deivered Mea Home Heath Aide, Extended Homemaker Independent Living Skis LPN (Reguar Home Heath, Extended; Shared Home Heath, Extended 1:2) LPN (Compex Home Heath, Extended) Modifications Occupationa Therapy or Assistant, Extended Home Heath Persona Care Assistant (Extended 1:1, Extended 1:2; Extended 1:3) Physica Therapy or Assistant, Extended Home Heath Prevocationa Services RN (Reguar Home Heath, Extended; Shared Home Heath, Extended 1:2) RN (Compex Home Heath, Extended) Respiratory Therapy, Extended Home Heath Respite Care (In-home; Out-of-home) Speech Therapy, Extended Home Heath Suppies and Equipment Supported Empoyment Transportation (One Way Trip) Transportation-Mieage Transportation-Mieage (Noncommercia Vehice) Transportation-Attendant CDCS ALTERNATIVE Persona assistance Sef-direction support activities Not aowed Environmenta modifications and provisions Persona assistance Environmenta modifications and provisions Persona assistance Persona assistance Environmenta modifications and provisions Environmenta modifications and provisions Environmenta modifications and provisions Environmenta modifications and provisions Persona assistance 36

41 Consumer Directed Community Supports Lead Agency Operations Manua Section 5: Aowabe Goods & Service Under Appendix CDCS B Adut Day Care Assistive Technoogy MRRC Caregiver Training and Education Case Management (Fexibe Case Management ony) Chore Service Crisis Respite Consumer Directed Community Supports Consumer Training and Education Day Training and Habiitation Environmenta Modifications Homemaker Housing Access Coordination In-Home Famiy Support Live-in Persona Caregiver Expenses Persona Care Assistant Services (PCA) (Extended 1:1; Extended 1:2; Extended 1:3) CDCS ALTERNATIVE Environmenta modifications and provisions Sef-direction support activities Environmenta modifications and provisions Sef-direction support activities Environmenta modifications and provisions Persona assistance Persona assistance Persona assistance Persona assistance Persona Support Persona assistance Respite Care (In-home; Out-of-home) Speciaist Service Supported Empoyment Supported Living (Adut; Chid) Transportation, Extended 24-Hour Emergency Assistance Transportation, Extended Transportation, Extended Persona assistance Environmenta modifications and provisions Environmenta modifications and provisions Environmenta modifications and provisions 37

42 Section 5: Aowabe Goods & Appendix B Service Under CDCS Consumer Directed Community Supports Lead Agency Operations Manua Adut Day Care Adut Day Care Bath TBI Behaviora Programming (by Professiona; Anayst; Speciaist; Aide Case Management (Fexibe Case Management ony) Case Management Aide (Paraprofessiona) Chore Services Cognitive Therapy (by Professiona, Extended; by BA/BS Personne, Extended) Companion Services Famiy Counseing and Training Foster Care Home Deivered Meas Home Heath Aide, Extended Homemaker Services Independent Living Skis (Counseing; Maintenance) Independent Living Skis Therapies (ILS: Individua; Group) LPN (Reguar Home Heath, Extended; Shared Home Heath, Extended 1:2) LPN (Compex Home Heath, Extended) Menta Heath Expanation of Findings, Extended Menta Heath Psychoogica Testing, Extended Modifications Night Supervision Occupationa Therapy or Assistant, Extended Home Heath Persona Care Assistant (Extended 1:1; Extended 1:2; Extended 1:3) Physica Therapy or Assistant, Extended Home Heath Prevocationa Services RN (Reguar Home Heath, Extended; Shared Home Heath, Extended 1:2) RN (Compex Home Heath, Extended) Residentia Care Respiratory Therapy, Extended Home Heath Respite Care Worker (In-home) Respite Care (Out-of-home) Speech Therapy, Extended Home Heath Supported Empoyment Structured Day Program CDCS ALTERNATIVE Persona assistance Sef-direction support activities Not aowed Environmenta modifications and provisions Persona assistance Not aowed Environmenta modifications and provisions Persona assistance Environmenta modifications and provisions Persona assistance Not aowed Persona assistance Persona assistance 38

43 Consumer Directed Community Supports Lead Agency Operations Manua Section 5: Aowabe Goods & Appendix B Service Under CDCS Suppies and Equipment Transportation (One Way Trip Transportation-Mieage Transportation-Mieage (Noncommercia Vehice) Transportation-Attendant Environmenta modifications and provisions Environmenta modifications and provisions Environmenta modifications and provisions Environmenta modifications and provisions Environmenta modifications and provisions Adut Day Care Adut Day Care Bath Assisted Living Assisted Living Pus EW Caregiver Training and Education Case Management (Fexibe Case Management ony) Chore Services Companion Services Corporate Foster Care Famiy Foster Care Home Deivered Meas Home Heath Aide, Extended Homemaker Services LPN (Home Heath, Extended; Shared Home Heath, Extended 1:2) Modifications and Adaptations Persona Care Attendant (Extended 1:1; Ext. Shared 1:2; Ext. Shared 1:3) Residentia Care Respite Care (Certified Faciity; Hospita; In-Home and Out-of Home) RN (Extended Home Heath; Extended Shared Home Heath 1:2) Suppies and Equipment, Extended Transportation, Extended Transitiona Supports CDCS ALTERNATIVE Persona assistance Not aowed Not aowed Sef-direction support activities Environmenta modifications and provisions Persona assistance Not aowed Not aowed Environmenta modifications and provisions Persona assistance Environmenta modifications and provisions Persona assistance Not aowed Persona assistance Environmenta modifications and provisions Environmenta modifications and provisions Environmenta modifications and provisions 39

44 Section 5: Aowabe Goods & Appendix B Service Under CDCS Consumer Directed Community Supports Lead Agency Operations Manua Adut Day Care Adut Day Care Bath Assisted Living Assisted Living Pus AC Caregiver Training and Education Case Management (Fexibe Case Management ony) Case Management (Conversion) Cash Payment Chore Services Companion Services Corporate Foster Care Discretionary Services Environmenta Modifications Famiy Foster Care Home Deivered Meas Home Heath Aide Home Heath Service (Skied Nurse) Homemaker Services Nutrition Service Persona Care Assistant (1:1; Shared 1:2; Shared 1:3) Private Duty Nursing (LPN reguar, shared, or compex; RN reguar, shared or compex) Residentia Care Respite Care (Certified Faciity; Hospita; In-Home and Out-of- Home) RN, Supervision of a PCA Suppies and Equipment Transportation CDCS ALTERNATIVE Persona assistance Not aowed Not aowed Sef-direction support activities Sef-direction support activities Sef-direction support activities Environmenta modifications and provisions Persona assistance Not aowed Sef-direction support activities Environmenta modifications and provisions Not aowed Environmenta modifications and provisions Persona assistance Persona assistance Persona assistance Not aowed Persona assistance Environmenta modifications and provisions Environmenta modifications and provisions 40

45 Consumer Directed Community Supports Lead Agency Operations Manua Section 6: CDCS Service Categories 6.1 Customizing Services Under CDCS Under CDCS, a person is abe to design services and supports that are meaningfu to and preferred by them. In customizing a support pan, the person can combine sef-designed services with AC services, or with federay-approved waiver services and state pan home care services. When a person seects a service that is ordinariy avaiabe as a waiver, AC, or state pan home care service, they are choosing to receive a service that meets a of the provisions of that ordinary service, incuding the service description, provider quaifications, and quaity assurance mechanisms inherent to the service (required background check of staff, e.g.). As noted in Section 5.7, state pan home care services, when seected by the person, can be authorized separatey on the Service Agreement and bied directy by the home care agency. When biing for conventiona waiver or AC and sef-designed services that augment or provide aternatives to conventiona services, a of these services and supports must be fit into one of the four CDCS service categories, and be bied under these categories by the FSE. A services within a pan other than those required to be authorized separatey must be categorized into one of the four service categories described in this section. 41

46 Section 6: CDCS Service Categories Consumer Directed Community Supports Lead Agency Operations Manua 6.2 Persona assistance Persona assistance is support or assistance provided by someone hired to hep with activities of daiy iving and instrumenta activities of daiy iving through hands-on assistance, cueing, prompting and instruction in tasks. Respite care and homemaker service are incuded in this category. Typicay, this assistance does not require a high eve of cinica knowedge or ski. Exampes of persona assistance under CDCS incude hep with daiy activity such as taking a bath, eating, or getting dressed. It can incude hep with transferring or mobiity, or homemaking, aundry and mea preparation. It coud be companion services. It coud be support in ski buiding such as mea or restaurant etiquette, assistance with shopping, or behaviora or street safety training. A person can use CDCS funding to receive persona assistance in a variety of ways, and in combinations from severa sources. For exampe, a person may: Hire a neighbor to cean the bathroom and kitchen Hire a friend for a weekend of respite care Hire a staff to hep the consumer get ready for work and whie being transported Hire someone to provide redirection to prevent acting out behaviors Hire someone to provide prompting to hep compete certain tasks Hire severa peope who can hep each day with a daiy activity with hands on assistance Hire a PCA from a PCA organization to meet ADL needs. If the person chooses to hire a PCA to provide assistance, the person must meet a PCA requirements. If a parent of a minor or a spouse is the paid provider of Persona Assistance Service, the rate negotiated between the consumer and the parent or spouse cannot exceed the State-estabished maximum for Persona Care Attendant (PCA) service for the fisca year in which the service is authorized, incuding a benefits. See Section 13 for additiona information about payment to a spouse or parent. 42

47 Consumer Directed Community Supports Lead Agency Operations Manua Section 6: CDCS Service Categories 6.3 incudes those services that promote the consumer s heath and abiity to ive and participate in the community. Supports and services categorized here are those typicay performed or provided by peope with speciaized ski, certification, or icenses. Exampes of services or support that can be covered under this category: Therapy or treatment provided by nurse, home care and therapy professionas that either augment those avaiabe under state pan benefits or are incuded in the CDCS pan as an aternative to state pan services. Trainer and educationa costs for paid or unpaid caregivers: Payment can be paid for training and education of caregivers to increase their abiity to care for the consumer. These costs may incude cost of a community CPR training forum, for exampe, and can incude time for paid staff to attend training. This training and education must be directy reated to the provision of care or support to the consumer. Trainer and educationa costs for recipients to increase their abiity to care for themseves or manage their CDCS pan, empoyees, or budget. For exampe, the cost of a nutrition cass for a person with diabetes, or transportation and parking costs to attend Dept. of Labor and Industry training on being a domestic empoyer. The person cannot pay themseves to attend training. Training and education proposas must be directy reated to an identified need resuting from a disabiity or heath condition, must be cost effective, and must be approved as part of the overa pan to meet the person s needs in the community. Training requested by the consumer and provided by a Fexibe Case Manager, or that provided by an FSE must aso be outined and approved in the pan, and be accounted for under the Sef-Directed Support Activity category of CDCS service. Therapies and behaviora supports not otherwise defined under state pan or waiver services woud be categorized here. If a consumer wants to incude a therapy not currenty avaiabe through the state pan, it must be prescribed by a physician icensed to practice in Minnesota and enroed in MHCP. Habiitative services: Habiitative services are required for persons receiving MRRC waiver services. Habiitation incudes therapeutic activities, monitoring, supervision, training, or assistance to a person. Whether the habiitation service meets the Persona Assistance Service definition or the Treatment and Training definition, the support pan shoud identify those services that are part of the required habiitative pan. Life or Empoyment Skis Deveopment and Community Integration: CDCS can be used to purchase services or supports that deveop or maintain ife or empoyment skis or community integration. Speciaized treatment, therapy or training: CDCS can be used to purchase counseing service, behaviora services, and cognitive or other therapy if the service is part of the approved pan, are prescribed by a physician icensed to practice in Minnesota, and enroed in MHCP, and are not covered under MHCP esewhere. 43

48 Section 6: CDCS Service Categories Consumer Directed Community Supports Lead Agency Operations Manua 6.4 Environmenta Modifications and Provisions Environmenta modifications and provisions incude supports, services and goods provided to the recipient to maintain a physica environment that assists the person to ive and participate in the community, or that are required to maintain heath and we-being. Exampes of services, supports, or goods that woud be bied under this CDCS service category incude: Assistive technoogy Home and vehice modification Transportation (costs of the person providing the transportation, the driver, or the transportation cost gasoine or fares) when the need for transportation service is due to a person s functiona imitation. CDCS funding cannot be used to meet transportation needs that woud be expected to be met by a parent or spouse if the chid or spouse did not have a functiona imitation (for exampe, transportation to after schoo activity or day care, or shopping centers or recreationa events). Environmenta supports necessary to maintain a cean, sanitary and safe home environment, and when the person cannot perform these necessary tasks due to functiona imitation. Transitiona services for Edery Waiver consumers. Expenses reated to moving from an institution and estabishing a home in the community such as ease or renta deposits, essentia furniture, utiity set up fees and deposits, and one-time pest treatment of the setting woud be categorized here. Suppies and equipment not avaiabe under state pan acute and primary care coverage, incuding durabe and non-durabe medica suppies and equipments necessary to meet functiona imitations. Suppies and equipment coud aso incude devices, contros or appiances not specificay excuded in Section 8 that increase a person s abiity to perform activities of daiy iving, or instrumenta activities of daiy iving, or to perceive, contro or communicate with the environment in order to be more independent or increase community integration. For exampe, a person may reduce the need for mea preparation with the purchase of a microwave (not considered a major appiance) or a modified can opener. Prescribed specia diets that are required to address nutritiona needs, which are directy reated to a disabiity or heath condition, and for which no MHCP coverage is avaiabe. See Section for guideines reated to approving specia diets. Adaptive cothing such as those speciay designed to increase a person s independence in dressing, grooming, toieting, or bathing, or designed to endure abnorma movement patterns or acting out. It coud aso incude items prescribed by a physician such as orthopedic shoes that are not covered under MHCP. 44

49 Consumer Directed Community Supports Lead Agency Operations Manua Section 6: CDCS Service Categories Home deivered meas provided to a person who is not abe to prepare their own meas and for whom there is no other person avaiabe to do so, or when the provision of a homedeivered mea is more cost-effective than staff preparation of a nutritionay adequate mea. Section Guideines for Approving Specia Diets Under CDCS Specia diets under CDCS must meet the foowing criteria: They are prescribed by a doctor They are part of the stated community support pan with identifiabe outcomes They are approved by the ead agency to meet heath and safety needs of the consumer The foowing diets are aowabe for payment under CDCS if the above criteria are met: Anti-dumping diet Controed protein diet (40-60 grams and requires specia products) Controed protein diet (ess than 40 grams and requires specia products) Guten free diet High protein diet High residue diet Hypogycemic diet Ketogenic diet Lactose free diet Low choestero diet Pregnancy and actation diet Note: Specia diets may be covered by an MSA specia needs payment or an MFIP specia needs payment. 45

50 Section 6: CDCS Service Categories Consumer Directed Community Supports Lead Agency Operations Manua 6.5 Sef-direction Support Activities This is the CDCS category of service that is used to bi for Fisca Support Entity service and Fexibe Case Management service. Some empoyer-reated expenses such as heath benefits, if offered by the consumer to support staff, are aso bied under this category. The consumer may manage their support staff, services and support pan independenty, or with assistance from an unpaid informa support. The consumer cannot, however, directy bi MHCP for approved services that have been provided, and wi need a Fisca Support Entity to act as their agent for at east this purpose. Other consumers may want to purchase assistance with a variety of administrative or management tasks. Sef-direction Support Activities incude services, supports, and expenses incurred in administering, or in assisting the consumer in administering, CDCS funding. The consumer cannot reimburse themseves for time spent in deveoping or administering the support pan, or in hiring, training, or managing empoyees. However, CDCS funding can be used if the consumer chooses to pay a Fexibe Case Manager to perform these functions or assist them in performing them. Fisca Support Entity Expenses: The Fisca Support Entity is the Medicaid-enroed provider, and is the ony entity that can submit caims and receive CDCS payments. These payments are then distributed to the consumer to pay workers, or directy to workers, and to pay for approved goods and other services. As such, every CDCS budget worksheet wi incude at east some FSE cost for this biing and dispersa of payment activity. The consumer may aso choose to pay the FSE to perform other empoyer-reated activity. See Section 11 for a compete description of the range of services a person can purchase from a certified Fisca Support Entity. Fexibe Case Management activities are optiona, provided by an individua or entity chosen by the recipient, and represent case management activities beyond those required to be performed by ead agencies under HCBS requirements. Fexibe Case Management service can incude, but is not imited to, assistance in support pan deveopment and impementation and in heping the person determine what service options might best meet their needs and preferences. A Fexibe Case Manager can provide assistance in brokering services, or in interviewing potentia support staff. The person may wish to buy some assistance in designing a quaity monitoring pan, and in defining measurabe, desired resuts. See Section 9 for more information about Required and Fexibe Case Management. A Sef-directed Support Activity, ike other CDCS services and supports, must be eected by the consumer, outined in the pan, and purchased under agreements between the consumer and the provider that specify tasks to be performed, schedues, and negotiated fees. 46

51 Consumer Directed Community Supports Lead Agency Operations Manua Section 7: Provider Quaifications 7.1 Provider Quaifications: Persona Assistance: The Consumer Decides Under the CDCS service option, the consumer or their representative determines the quaifications for providers of persona assistance. The person providing assistance does not need a icense, certificate or credentiaing uness required by the consumer. For exampe, a neighbor is hired to provide assistance with ADLs in the morning and at night. The consumer must document desired quaifications in the Community Support Pan and document how the neighbor meets the quaifications. The quaification might be simpy that the person can give a bath according to the consumer s instruction, or coud incude some transfer assistance training. This person does not have to be affiiated with a PCA agency or be certified as a PCA. On the other hand, the person may eect to use a Persona Care Attendant to meet persona care needs. In this case, the person hired, either as an individua or through an agency, woud have to meet a requirements for PCA service provision, incuding cearance under a crimina background check. The person can aso define additiona provider quaifications. For exampe, knowedge of sign anguage may be required, or vegetarian mea preparation, or competion of CPR training through the oca cinic or recognized community provider of this training. The consumer coud hire a person and pay for this training for the individua. 47

52 Section 7: Provider Quaifications Consumer Directed Community Supports Lead Agency Operations Manua 7.2 Provider Quaifications: Treatment & Training: The foowing persons can be providers of treatment and training: Unicensed persons who meet the quaifications specified by the consumer in their Community Support Pan. Documentation of competed training and quaifications must be maintained by the consumer. Licensed providers who meet a provisions of the ike waiver or AC service seected, incuding service description, provider quaifications and quaity assurance mechanism of the service. Therapists, physicians, nurses, and dieticians acting within their capacity as a provider of the service requested must be icensed. Providers must meet the certification or icensing requirements in state aw reated to the service the person wishes to incude in their pan. If the consumer needs nursing service, the person providing it must be a nurse. Training and education must be provided a recognized community expert in the training topic. To iustrate the fexibiity intended in CDCS, and to highight the point made above about provider requirements reated to the service, two exampes are offered beow. Both of these services woud be bied as Treatment & Training under CDCS, but the supported empoyment provider must meet a icensing and other requirements reated to supported empoyment service. Unicensed provider of Empoyment or Life Skis Deveopment service: The Handy famiy runs a oca hardware store. Mrs. L, who ives next door to the Handys, woud ike her 17 year od son Mike, a consumer of MR/RC Waiver services, to earn work skis from Mr. Handy. Mr. Handy has agreed to instruct, mentor and coach Mike in a variety of skis as needed. Mike is an empoyee of Mr. Handy. He is earning appropriate socia and work reated behaviors being on time, getting aong with other empoyees and customers, dressing appropriatey for the workpace, customer courtesy, etc. and receives wages. Mrs. L pays Mr. Handy $200 a month for his services. In the Community Support Pan the provider quaifications are: person must have experience running a sma business and supervising staff, patience and teaching abiity, understands the needs of persons with a deveopmenta disabiity in the workpace. Mr. Handy does not need a icense to provide supported empoyment services. He meets the quaifications in the Community Support Pan as determined by Mrs. L. Licensed provider of Empoyment or Life Skis Deveopment services: Mike s support pan incudes the seection of supported empoyment service. Mike wi attend a supported empoyment work site with his friend three days a week. A waiver service quaifications, rate maximums, and icensing standards must be foowed by the provider. The consumer does not have the authority to excuse the provider from state mandated reguations because they seected the CDCS service option. The supported empoyment job coach wi work with Mike three afternoons a week at Mr. Handy s, a oca hardware store in Mike s neighborhood. Mr. Handy agreed to provide a work site for Mike, and wages for work performed. 48

53 Consumer Directed Community Supports Lead Agency Operations Manua Section 7: Provider Quaifications 7.3 Provider Quaifications: Environmenta Modifications & Provisions Providers of home and vehice modifications must have a current icense or certificate and must meet a professiona standards and/or training requirements required by Minnesota Statutes or administrative rues for the services that they provide. If state aw does not mandate provider icenses, certificates or credentiaing, the consumer determines the provider quaifications in their Community Support Pan. A modifications must meet Minnesota code. Home modifications must meet buiding codes and be inspected by the appropriate buiding authority. Vehice modifications must meet any inspections requirements. Transportation fas within the CDCS category of Environmenta Modifications and Provisions when the cost appies to the person providing the transportation, the driver, or the cost of the transport gasoine or fares, for exampe. A person assisting the consumer during transportation is covered under the CDCS category of persona assistance. Private individuas may be designated to provide transportation when they meet the consumer s needs and preferences in a cost-effective manner. Drivers must have a vaid driver s icense and meet state requirements for insurance coverage. Drivers can substitute for common carriers if this is a cost-effective option. Medica Assistance state pan Medica Transportation shoud be accessed for trips to medica appointments. A person who wi perform chore or heavy housekeeping tasks must meet the consumer s quaifications. The consumer may purchase snow remova from the person who does snowpowing in the neighborhood, or heavy houseceaning from a oca maid service. (Homemaker service is incuded in the Persona Assistance Service category). The person may chose to require a person be bonded or insured, for exampe, as a provider of these services. 49

54 Section 7: Provider Quaifications Consumer Directed Community Supports Lead Agency Operations Manua 7.4 Provider Quaifications for Fisca Support Entities A Fisca Support Entity (FSE) is an umbrea organization that offers a range of financia management services to faciitate consumers use of Consumer Directed Community Supports services. Each consumer seecting CDCS must choose an FSE to provide at east fisca agent service. The FSE serves as an agent to the consumer for the purposes of: Biing DHS for CDCS payment and dispersing payment. The person must hire an FSE to process vendor and agency invoices to receive CDCS payment. The consumer may aso hire the FSE to pay the staff, vendor and agency invoices for goods and services provided in accordance with an approved Community Support Pan, or the consumer may receive a dispersed payment from the FSE and pay these invoices and wages directy. The person can aso choose to hire the FSE to manage state and federa payro taxes and workers compensation and other insurance either required or offered as a benefit by the consumer to support workers. The Fisca Support Entity must be an enroed MHCP (MA and AC) provider. In order to become enroed as a provider of FSE service, the agency must: Pass the State s Readiness Review and receive a certification of such Be abe to provide, at a minimum, fisca conduit and payro services for the consumer Have a contract with a oca county agency. Counties can agree to shared use of each other s contracts for FSE services in order to ensure choice between FSE providers at the oca eve. An FSE may choose to operate as an Agency with Choice in which case the agency acts as the common aw empoyer and the consumer is the managing empoyer. An FSE may aso offer quaified Fexibe Case Management service, but cannot provide this service to cients who are using them as their Fisca Support Entity. See Section 10 for information about the Consumer as an Empoyer under CDCS. Compete information about the Fisca Support entity and their quaifications, roes and responsibiities is found in Section 11. Readiness Review requirements are outined in Section

55 Consumer Directed Community Supports Lead Agency Operations Manua Section 7: Provider Quaifications 7.5 Provider Quaifications for Fexibe Case Management (FCM) Service A Fexibe Case Manager can assist the consumer primariy in: Deveopment, impementation, and monitoring of the Community Support Pan Empoyee management functions such as evauation of empoyee performance or interviewing for hiring. This is optiona support for the CDCS consumer. Some peope may want no Fexibe Case Management service at a; others may want to buy some support initiay and carry on independenty ater. Other peope may want ongoing support over a onger period of time. The Support Pan must ceary specify the consumer s pan for purchasing FCM, incuding tasks, schedues and rates. The consumer may aso require the person to meet additiona quaifications in order to provide FCM to that individua. In order to provide paid FCM service to any CDCS consumer, a person must be certified by the State of Minnesota. An onine DHS training modue is avaiabe to certify Fexibe Case Managers. ( Upon satisfactory competion of the training, DHS wi issue a certificate to the person competing the training. This certificate must be shown to consumers interested in purchasing FCM. Experienced ead agency case managers can test out of the training by taking and passing the test. A ead agency can provide Fexibe Case Management, but must aso offer other choices in providers of this service ocay. Lead agency Fexibe Case Managers cannot deegate these activities to paraprofessiona case managers. However, a paraprofessiona case manager at a ead agency may take and pass the training course and test, and directy provide FCM. A quaified Fexibe Case Manager: Is certified by DHS Cannot be the common aw empoyer (empoyer of record) Must be at east 18 Cannot be a direct care provider for the consumer (oca agency staff and heath pan representatives excuded) Cannot be an FSE who is aso a agency of choice provider for the consumer. Any person receiving fexibe case management services may not provide fexibe case management services to another person receiving CDCS services. A parent, spouse or ega representative can provide many of the same types of support to the consumer that a FCM can provide. However, neither a parent of a minor or a spouse can receive payment for FCM activity, since under the waiver amendments, a parent of a minor chid or a spouse can ONLY receive payment under the persona assistance service category. Pease see Section 7.6 for more information about prohibitions for payment of guardians and conservators. 51

56 Section 7: Provider Quaifications Consumer Directed Community Supports Lead Agency Operations Manua Refer to Section 9 which describes possibe roes and responsibiities of the Fexibe Case Manager in detai, and contrasts optiona with Required Case Management tasks. 7.6 Fexibe Case Management and Famiy or Lega Representatives A parent, spouse or ega representative can provide many of the same types of support to the consumer that a FCM can provide. However, neither a parent of a minor nor a spouse or a ega guardian or conservator can receive payment for FCM activity. Prohibitions on Payments to Guardians or Conservators Minnesota Statutes, Section states: Any individua or agency which provides residence, custodia care, medica care, empoyment training or other care or services for which they receive a fee may not be appointed as guardian uness reated to the respondent by bood, marriage, or adoption. Simiary, Minnesota Statutes, Section appies the same prohibition on conservatorship appointments: Any individua or agency which provides residence, custodia care, medica care, empoyment training, or other care or services for which they receive a fee may not be appointed as conservator uness reated to the respondent by bood, marriage, or adoption. Under this statute, a person receiving payment for services coud NOT be appointed a conservator or guardian. It makes sense then, that a person who has been appointed guardian or conservator cannot receive payment for services. Whie the guardianship statute exempts reatives, there is another pertinent ega citation that must be appied, as noted beow. Prohibitions on Payments to Parents of Minors or Spouses Under Minnesota Rues, parts [Provider Reimbursement], aso known as Rue 41: A provider may receive medica assistance reimbursement for home and community-based services ony if the provider meets the criteria in items A to K. Item K states: The provider is not the person s guardian or a member of the person s famiy. This item does not precude the county board from providing services if the person is a ward of the commissioner. This prohibition against paying famiy members was waived in the approved CDCS amendments. However, this approva was imited to persona assistance service ony and did not extend to other categories of service. See Section 9.3 for an exemption of these imitations for persons participating in the MR/RC waiver program ony. This exemption is part of the overa MR/RC waiver pan and not excusive to CDCS participation. 52

57 Consumer Directed Community Supports Lead Agency Operations Manua Section 8: Excuded Items, Goods & Services Non-aowabe Expenses 8.1 Non-aowabe expenses under CDCS CDCS funding, ike a waiver or AC program funding, is NOT to be used for any service: Avaiabe first through the State Pan (See Section 5.7 for notes about State Pan home care and CDCS.) Covered by any other third party payor incuding Medicare, or state educationa or vocationa services agencies That is diversionary or recreationa in nature That is for comfort or convenience That is an item or support normay furnished by the recipient s parents, famiy, or spouse That does not meet an identified need Not approved in the support pan. Repayment of Goods and Items Returned or Sod Items are purchased for the recipient and shoud remain with / be avaiabe to the recipient to the extent possibe. If an item is returned or sod, the remuneration from that item must be appied to the recipient s service pan. The same appies to any discounts or credits. 53

58 Section 8: Excuded Items, Goods & Services Non-aowabe Expenses Consumer Directed Community Supports Lead Agency Operations Manua 8.2 Excuded Services, Support, and Items Some services, items, and supports are specificay excuded from purchase with CDCS funding. The ist beow notes services, items, and goods for which CDCS cannot be used to pay for as specificay approved in the amendment submitted by DHS to CMS. Excuded Services or Supports Famiy or individua memberships to cubs, recreationa centers, museums, etc. Vacation expenses other than the cost of direct service incuding transportation, odging, meas Home-based schooing Experimenta treatment Fees for attorneys, advocates, or others who do not provide a direct service authorized in the service pan Room, board, and persona items that are not reated to the disabiity (there may be some exceptions reated to transitiona services) Services provided to peope iving in icensed foster care settings, settings icensed by DHS or MDH, or registered as housing with services (Assisted Living) estabishments Avaiabe services otherwise covered by the State pan, Medicare or other iabe third parties incuding education and vocationa services Expenses for trave, odging, or meas reated to training the individuas and his/her representative or paid or unpaid caregiver Tickets and reated costs to attend sporting or other recreationa events Services, goods, or supports provided to or benefiting persons other than the consumer Excuded Items Modifications or adaptations to ocations other than the recipient s primary residence or, in the event of a minor with parents not iving together, the primary residences of the parents Home modification that adds any square footage Pets and their reated costs Vehice maintenance, does not incude maintenance or modification reated to the disabiity MHCP fees and co-pays Insurance for the home, vehice, etc. Internet access or fees Whie the ist above notes specific excusions, any goods, services or items approved in a CDCS support must meet a criteria outined in Appendix C. In other words, the absence of a good or service from this excuded ist does not mean it can be automaticay approved in any pan. Each pan must be reviewed to ensure that a goods and services meet criteria for approva. Experimenta Treatment: See Attachment C1 for a form to be used by physicians to indicate whether a proposed treatment is experimenta as defined on the form itsef. If the physician indicates the treatment IS experimenta, it cannot be paid for using CDCS funding. 54

59 Section 8: Excuded Items, Goods & Consumer Directed Community Supports Lead Agency Operations Manua Appendix C: Aowabe, Services Unaowabe Non-aowabe Expenditures Expenses Appendix C: Attachment Submitted and Approved By CMS as Part of Waiver Amendment Consumer Directed Community Support Service Criteria for aowabe expenditures The Purchase of goods and service must meet a of the foowing criteria: 1. Must be required to meet the identified needs and outcomes in the individua s community support pan and assures the heath, safety and wefare of the individua; AND 2. Goods and services coectivey provide a feasibe aternative to an institution; AND 3. Be the east costy aternative that reasonaby meets the individua s identified needs; AND 4. Be for the soe benefit of the individua If a the above criteria are met, goods and services are appropriate purchases when they are reasonaby necessary to meet the foowing consumer outcomes: Maintain the abiity of the individua to remain in the community; Enhance community incusion and famiy invovement; Deveop or maintain persona, socia, physica, or work reated skis; Decrease dependency on forma support services Increase independence of the individua Increase the abiity of unpaid famiy members and friends to receive training and education needed to provide support Aowabe Expenditures Consumer directed community supports (CDCS) may incude traditiona goods and services provided by the waiver as we as aternatives that support recipients. There are four genera categories of services which may be bied: Persona Assistance Environmenta modifications and provisions Sef direction support activities Additionay, the foowing goods and services that may aso be incuded in the individua s budgets incude as ong as they meet the criteria and fit into the above categories: Goods and services that augment State pan services or provide aternatives to waiver or state pan services Therapies, specia diets and behaviora supports not otherwise avaiabe through the State pan that mitigate the individua s disabiity when prescribed by a physician who is enroed as a MHCP provider Expenses reated to the deveopment and impementation of the community support pan Costs incurred to manage the individua s budget Unaowabe expenditures Goods and services that sha not be purchased within the individua s budget are: Services provided to peope iving in icensed foster care settings, settings icensed by DHS or MDH, or registered as a housing with services estabishment Services covered by the State pan, Medicare, or other iabe third parties incuding education, home based schooing, and vocationa services Services, goods or supports provided to or benefiting persons other than the individua Any fees incurred by the individua such as MHCP fees and co-pays, attorney costs or costs reated to advocate agencies, with the exception of services provided as Fexibe Case Management Insurance except for insurance costs reated to empoyee coverage Room and board and persona items that are not reated to the disabiity Home modifications that adds any square footage Home modifications for a residence other than the primary residence of the recipient or, in the event of a minor with parents not iving together, the primary residences of the parents Expenses for trave, odging, or meas reated to training the individua or his/her representative or paid or unpaid caregivers Services provided to or by individuas, representatives, providers or caregivers that have at any time been assigned to the Primary Care Utiization and Review Program Experimenta treatments Membership dues or costs Vacation expenses other than the cost of direct services Vehice maintenance, does not incude maintenance to; modifications reated the disabiity Tickets and reated costs to attend sporting or other recreationa events Pets and their reated costs Costs reated to internet access. 55

60 Appendix Section 8: C1: Excuded Aternative Items, Treatment Goods & Too Services for MHCP-Enroed Non-aowabe Expenses Physicians Consumer Directed Community Supports Lead Agency Operations Manua CDCS Lead Agency Operations Manua Appendix C1 Experimenta/Aternative Treatment Form for Physicians Consumer Directed Community Supports (CDCS) Aternative Treatment Too for MHCP-Enroed Physicians Consumer s Name: Therapy, specia diet or behaviora support being prescribed: An MHCP enroed physician is icensed to provide heath services within the scope of his/her profession. According to Minnesota Rue , subpart 16, Experimenta Treatment means drugs, therapies, or treatments that are unproven, have been confined argey to aboratory use, or have progressed to imited human appication and trias, and ack wide recognition from the scientific community as a proven and effective measure of treatment. According to the above definition, is this therapy, specia diet or behaviora support considered experimenta for the condition it is being prescribed to treat? Yes* No What are the expected outcomes for the prescribed therapy, specia diet or behaviora support for this individua? Physician s Printed Name: Physician s Signature: Date: 56 *If Yes is checked, CDCS funds cannot be used to purchase the aternative treatment. HH

61 Consumer Directed Community Supports Lead Agency Operations Manua Section 9: Required & Fexibe (Optiona) Case Management 9.1 Comparison of Required and Fexibe (Optiona) Case Management Activity There are some case management functions performed by the ead agency that are not incuded in the CDCS budget. These functions are required if a person chooses to use CDCS. The consumer can choose whether they want or need assistance or support to carry out other pan or empoyee management functions, who wi provide that assistance, and whether the consumer wants to purchase it as part of paid services under CDCS. CDCS consumers must have a pan that is deveoped through a person-centered process. They must aso manage and monitor the CDCS services. If, after choosing CDCS, a consumer wants or needs assistance with these tasks, they may purchase support from a Fexibe Case Manager, or the consumer may choose to use unpaid supports. Required Case Management Functions In genera, case management functions that must be performed by the ead agency address: Intake for and access to HCBS Provision of information and assistance Eigibiity determination and re-determination Summary of assessment information and outine of required pan eements Authorization of service pan and funding, and changes to services and funding Monitoring quaity and systems performance. See the tabe in the next section for a more compete isting of required ead agency activity. 57

62 Section 9: Required & Fexibe (Optiona) Case Management Consumer Directed Community Supports Lead Agency Operations Manua 9.2 Required Lead Agency Functions Under CDCS LEAD AGENCY FUNCTIONS not incuded in the consumer s CDCS budget, not optiona for the consumer Screen and determine if consumers are MA or AC eigibe. Screen and determine if the individua is eigibe for waiver or AC services incuding eve of care determination. Provide information regarding HCBS aternatives to make an informed choice, incuding information about CDCS. If the consumer eects CDCS, provide them with their maximum budget amount & assessment summary. Provide CDCS consumers with resources and informationa too kits to assist them in deveoping the pan and managing the service. Evauate whether the consumer s heath and safety needs are reasonaby expected to be met given the care pan incuding provider training and standards. Evauate if the pan is appropriate incuding whether the goods and services meet the service criteria and provider quaifications, rates appear to be appropriate, etc. Provide feedback to the consumer about pan adjustments needed to approve if any. Authorize CDCS services in MMIS. Review and authorize additiona funding for environmenta modifications or assistive technoogy exceeding $5,000. Manage overa waiver and AC spending within the county s aowabe waiver and AC aocation. Monitor and evauate the impementation of the Community Support Pan, incuding heath and safety, satisfaction, and the adequacy of the current pan and the possibe need for revisions at east annuay. At a minimum, review the consumer s budget and spending before the 3rd, 6th, and 12th month of the first year of CDCS services, and at east annuay thereafter. Provide technica assistance regarding service impementation, budget and fisca records management and take corrective action if needed in order to ensure support pan impementation prior to invountary exit from CDCS. Investigate reports reated to vunerabiity or misuse of pubic funds per jurisdiction. Contract with providers and monitor provider s performance incuding maintenance of fisca records. Report satisfaction, utiization, budget, and discharge summary information to the state agency. Carry out minimum case manager contacts required under AC or each waiver program. 58

63 Consumer Directed Community Supports Lead Agency Operations Manua Section 9: Required & Fexibe (Optiona) Case Management 9.3 Fexibe Case Management Functions & Limitations Fexibe, Optiona DIRECT SUPPORT Is incuded in the consumer s CDCS budget, must be expicity panned and purchased by the consumer Not an incusive ist of those direct supports a consumer may design reated to panning, impementation, monitoring, evauating, managing services and empoyees If the consumer eects CDCS services, provide more detaied information about CDCS and provider options. Faciitate deveopment of a person centered Community Support Pan. Monitor and assist with revisions to the Community Support Pan. Assist in recruiting, screening, hiring, training, scheduing, monitoring, and paying workers. Faciitate community access and incusion. (i.e., ocating or deveoping opportunities, providing information and resources, etc.). Monitor the provision of services incuding such things as interviews or monitoring visits with the consumer or service providers. Provide staff training that is specific to the consumer s pan of care. Community Support Pan must incude specific tasks to be performed by a paid FCM and payment agreements. Limitations: A Fexibe Case Manager cannot have any direct or indirect financia interest in the deivery of services in the pan. In other words, a person heping a consumer deveop a pan and receiving payment for this assistance cannot, nor can they empoy others chosen by the consumer to, deiver services or supports. (County agencies and heath pans are exceptions to this imitation.) A Fexibe Case Manager, or an agency providing Fexibe Case Management service, cannot be the common aw empoyer for any recipient who is receiving Fexibe Case Management from them. A Fisca Support Entity cannot provide both FSE and FCM service to the same cient. A Fexibe Case Manager working independenty whie empoyed by a Fisca Support Entity or any other vendor that is providing services to a CDCS consumer MAY NOT provide FCM to a consumer who is using services from the vendor (FSE or otherwise) that empoys the FCM. A parent of a minor chid or spouse cannot be paid to provide Fexibe Case Management. A ega guardian or conservator for a person participating in the MR/RC waiver can be paid for either FCM or direct service but never both. A Fexibe Case Manager cannot receive payment for performing functions that dupicate those required to be performed by the ead agency. 59

64 Section 9: Required & Fexibe (Optiona) Case Management Consumer Directed Community Supports Lead Agency Operations Manua 9.4 Excuded Time & CDCS The eection of CDCS service option does not ater any provisions reated to the determination of the county of financia responsibiity. This determination is the responsibiity of financia workers, and is based on a variety of factors, incuding the receipt of what is referred to as excuded time service. In order to determine whether the services contained in an approved CDCS pan are excuded time services or not, the financia worker must appy the definitions of those services as they exist in aw. Financia workers wi make these determinations on an individua basis and on an individua pan basis. For instance, if a pan incudes PCA services from a PCA organization, that service ceary is defined as an excuded time service. If, however, the person buys hep in the morning from their neighbor, this service cannot be adjudged equivaent to PCA. Simiary, if a person s pan incudes icensed DT&H service, this is ceary defined as an excuded time service. But the person may choose to receive empoyment support from a oca business, and this service cannot be adjudged to be equivaent to DT&H. 60

65 Consumer Directed Community Supports Lead Agency Operations Manua Section 10: The Consumer As Empoyer 10.1 The Consumer As Empoyer One of the major differences between CDCS and other community-based service design and deivery is that the consumer is the empoyer of staff hired to provide services as outined in the approved pan. It may be hepfu to outine the tasks and activities a consumer carries out as an empoyer. This wi hep outine the choices a consumer can make about the extent of empoyer activity they want to perform themseves, and those they may wish to have someone ese perform for a fee. It wi aso serve to highight some of the differences in the Fisca Support Entity modes described in Section 11. Managing Empoyer: The managing empoyer recruits and advertises for staff. The managing empoyer interviews and hires staff, and discharges staff. The managing empoyer supervises, schedues, trains, provides direction in daiy tasks, and evauates empoyee performance. The managing empoyer under CDCS negotiates the wage paid to support staff. A consumer choosing CDCS must minimay act as managing empoyer. The consumer can perform these functions independenty, receive non-paid assistance from friends or famiy in performing these functions, or can hire a Fexibe Case Manager to hep perform these roes. When a consumer chooses an Agency with Choice as a Fisca Support Entity, some of the managing empoyer functions are shared between the consumer and the agency. Common Law Empoyer (sometimes referred to as Empoyer of Record): Other empoyer duties reated to payro, taxes, and insurance must be performed in addition to the managing empoyer functions. These activities incude coecting time cards, processing payro, processing checks, cacuating, coecting and submitting payro taxes (state, federa and FICA), making sure workers have the proper insurance coverage under workers compensation and unempoyment aws, and making sure staff are paid. The common aw empoyer woud aso manage other optiona empoyee benefits such as heath or retirement benefits. The CDCS consumer may act as the common aw empoyer, or purchase some or a of these tasks from a Fisca Support Entity (FSE). The extent to which a Fisca Support Entity performs (or offers to perform) common aw and managing empoyer functions defines the three modes of Fisca Support Entity service described in the next section. These are briefy described beow. 61

66 Section 10: The Consumer As Empoyer Consumer Directed Community Supports Lead Agency Operations Manua 10.2 Three Modes of Fisca Support Entity Service Fisca Conduit: A consumer who chooses to hire an FSE ony to submit caims and disperse payment (either to the consumer to pay for staff and goods or to staff and vendors as directed by the consumer) is eecting a Fisca Conduit mode of FSE service. Under this mode, the consumer is both the managing and the common aw empoyer. The consumer is withhoding taxes, submitting tax payments on behaf of workers, has purchased required workers compensation insurance for workers, and aso performs a managing empoyer functions. The person coud purchase assistance with managing empoyer functions from a Fexibe Case Manager, or coud receive non-paid assistance with these tasks. Payro or Fisca Agent: The FSE is the fisca agent for the person, managing state and federa empoyment taxes, payro, and insurances for support workers. The consumer purchases this service from the FSE. The consumer is sti considered the common aw and managing empoyer, but in this case is purchasing assistance with common aw empoyer activity. The person coud aso purchase assistance from a Fexibe Case Manager for managing empoyer tasks. Agency with Choice: Under this FSE mode, the FSE actuay hires the support staff, and performs a common aw empoyer functions. The staff is an empoyee of the agency. The consumer negotiates with the agency about the co-sharing of managing empoyee duties. The consumer can discharge the staff from service to them but cannot fire them from the agency. Minimay, the consumer wi seect their own worker, and can discharge them as a worker for them. Whie the consumer is technicay considered the managing empoyer, the range of managing activity wi vary. The Agency with Choice cannot provide Fexibe Case Management to a consumer for whom they are providing staff support, nor can the agency participate in the Community Support Pan deveopment. 62

67 Consumer Directed Community Supports Lead Agency Operations Manua Section 10: The Consumer As Empoyer 10.3 Comparison of Consumer Roe as Empoyer Under 3 FSE Modes An FSE must offer Fisca Conduit and Payro Agent services. When the FSE aso offers Agency with Choice services, it cannot imit consumers choice or require the consumer to purchase common aw empoyer service from the agency. Managing empoyer tasks are shaded. Tasks Fisca Conduit FSE Recruit and advertise for staff Consumer Consumer Payro or Fisca Agent FSE Agency with Choice FSE Agency or Consumer + Agency Hire Interview staff Consumer Consumer Consumer + Agency Terminate/Discharge staff Consumer Consumer Consumer + Agency Supervision of staff Consumer Consumer Consumer + Agency Schedue Consumer Consumer Consumer + Agency Train staff Consumer Consumer Consumer + Agency Ongoing direction of daiy tasks Consumer Consumer Consumer + Agency Empoyee evauation Consumer Consumer Consumer + Agency Coects time cards Consumer + FSE Consumer + FSE Consumer + Agency Taxes Payro ( State, Fed., FICA) Insurance ( workers comp. ) Insurance Consumer Consumer Consumer FSE on behaf of consumer FSE on behaf of consumer FSE on behaf of consumer Agency Agency Agency Submits caims to MMIS FSE FSE Agency Process checks for the staff Consumer FSE Agency Pay staff on a consistent basis Consumer FSE Agency Train or provide support to the consumer to be a common aw empoyer Train or provide support to the consumer to be a managing empoyer FSE, or non-paid FCM, or non-paid FSE, or non-paid FCM, or non-paid Agency repaces the common aw empoyer function for the consumer FCM, but not avaiabe through the agency, or non-paid 63

68 Section 11: Fisca Support Entity Services Consumer Directed Community Supports Lead Agency Operations Manua 11.1 Fisca Support Entity What is a Fisca Support Entity (FSE)? The FSE is the Minnesota Heath Care Programs (MHCP) enroed provider under CDCS, and must meet provider enroment requirements to participate in Medicaid-funded programs. Under the federay-approved amendment to add CDCS as a service options to a HCBS programs in Minnesota, each CDCS consumer must minimay purchase FSE service to act as a conduit for Medica Assistance payments for CDCS service. That is, a consumer cannot directy bi for approved CDCS services. The state-funded Aternative Care program CDCS service option wi adopt the same requirements and restrictions as approved in the federa waiver. A Fisca Support Entity (FSE) is an umbrea organization that must offer a range of financia management services to provide support to consumer using CDCS. Section 11.2 outines this range of service. An FSE must demonstrate the capacity to provide the required range of financia management services to consumers through competion of a Readiness Review in order to receive a provider certification from DHS. This certification is required to enro as a Medicaid provider of FSE service under CDCS. Section 11.7 outines the readiness review requirements. The FSE may not in any way imit or restrict the recipient s choice of service or support providers. The FSE must have a written agreement with the recipient or their representative that identifies the duties and responsibiities to be performed and the reated charges. An FSE must have a contract with the ead agency to provide FSE services to peope receiving Required Case Management from that ead agency. A county agency can enro as an FSE provider. 64

69 Consumer Directed Community Supports Lead Agency Operations Manua Section 11: Fisca Support Entity Services 11.2 Fisca Support Entity (FSE): Fisca Conduit & Payro Agent Services Every CDCS recipient must at east purchase FSE support to act as the fisca conduit to pay providers. An FSE must be abe to directy provide, at a minimum, payro assistance, and be capabe of submitting CDCS caims to MMIS to receive payment for approved CDCS services. Thus, any enroed FSE must be abe to provide those services and options outined in the shaded coumns in the tabe beow. Fisca Conduit Payro Agent Agency w/choice FSE submits caims to MA for approved, deivered services. FSE pays bis approved by the consumer. FSE returns payment to consumer who directy pays workers or for goods. Consumer is common aw and managing empoyer. Consumer takes responsibiity for payro tax coection, submission, payment of worker compensation premiums. Consumer recruits, hires, trains, supervises, evauates, schedues support staff. The consumer may purchase assistance from a Fexibe Case Manager to support their roe as a common aw and managing empoyer. Most Consumer Contro FSE submits caims to MA for approved, deivered services. The FSE pays the provider, incuding a paid staff. The FSE is the fisca agent, managing state and federa empoyment taxes and payro for support workers. The FSE pays workers compensation premiums and annua renewa premiums on behaf of consumer. Consumer is both common aw and managing empoyer, but buys assistance from the FSE for payro and insurance functions. The person may aso opt to use an agency to act as the common aw empoyer of support staff under CDCS. As common aw empoyer, the agency recruits, hires, trains, manages payro for, supervises, and evauates support workers. The agency handes taxes and provides worker s compensation insurance for workers. The consumer can bring individuas for hire to the agency, and can negotiate their management roe of support workers with the agency. The FSE acts as payor for services provided through an agency, which is the common aw empoyer of CDCS staff seected by the consumer. The consumer is the managing empoyer, and, minimay, wi seect his or her support worker, and can discharge the worker as a support worker for them. FSE submits caims to MA for approved, deivered services. The FSE pays the agency that provides empoyment management and is the common aw empoyer of staff. Least Consumer Contro 65

70 Section 11: Fisca Support Entity Services Consumer Directed Community Supports Lead Agency Operations Manua 11.3 Fisca Support Entity (FSE): Agency with Choice Services An FSE that aso acts as a common aw empoyer is considered an Agency with Choice. That is, the consumer is not the empoyer of staff hired. Rather, the agency with choice is the empoyer, and coaborates with the consumer to maximize individua contro over staff scheduing, quaifications, activities, wages, expected outcomes, and monitoring strategies. In these arrangements, the consumer is considered to be the managing empoyer but not the common aw empoyer. An FSE that offers Agency with Choice must aso provide fisca conduit and payro agent services to CDCS consumers who ony wish to purchase this type of financia management service, and cannot insist that any individua use them as their agency with choice, nor that the person empoy staff under an agency with choice mode. Furthermore, an FSE that incudes agency with choice service under its continuum of service must aow a consumer to eect a different agency with choice if they so choose. In this instance, the FSE woud bi MMIS and pay the other agency for provided services authorized in the support pan. The agency with choice woud be responsibe for a empoyment management such as payro taxes and insurance. For exampe, an FSE offers Agency with Choice, but a consumer uses a PCA Choice provider aong with other sef-directed services. The FSE acts as either a fisca consut or payro agent for purposes of biing a non-pca Choice services in the consumer s pan. 66

71 Consumer Directed Community Supports Lead Agency Operations Manua Section 11: Fisca Support Entity Services 11.4 Other FSE Requirements Act as Agent of Consumer In addition to providing payro support, the FSE must have the capacity to advise consumers about their obigations for workers compensation, incuding coverage avaiabe through workers compensation insurance poicies. The FSE must have the capacity to broker workers compensation insurance, assure payment of premiums and annua renewa of premiums, and must attempt to negotiate voume discounts. In order to provide fisca agent service, the FSE must obtain an IRS Authorization to act for the person. The consumer must provide this authorization if he or she wants the FSE to provide Fisca Empoyer Agent (FEA) services. Discosure of Financia Interests An FSE who has any direct or indirect financia interest in the deivery of: Persona assistance or Environmenta modifications and provisions that is being or wi be provided to the recipient must discose in writing the nature of that reationship, and must not deveop nor assist in the deveopment of the recipient s Community Support Pan. Charges for FSE Services FSE rates must be estabished on a fee-for-service basis. Charges to an individua consumer cannot be based on a percentage of the recipient s CDCS or payro budget, and may not incude set up or base rate or other simiar charges. A FSEs must estabish and make pubic the maximum rate(s) for their services. Individuaized Services The scope of FSE services to be provided to an individua must be determined by the consumer, and documented in the person s support pan. The rate for these services is negotiated between the recipient or the recipient s representative and the FSE and is incuded in the Community Support Pan. 67

72 Section 11: Fisca Support Entity Services Consumer Directed Community Supports Lead Agency Operations Manua 11.5 Other FSE Requirements (con t) Agreements The FSE must deveop and execute written agreements between the FSE and the consumer, the FSE and other support workers and vendors. These agreements shoud outine roes and responsibiities of the FSE, the consumer, and the support staff or vendor. The agreement shoud aso outine consequences for non-compiance with agreements. Crimina Background Checks The FSE must have the capacity to request crimina background checks on behaf of the consumer who is requesting such checks. The type and extent of background checks that the FSE is required to faciitate are those that foow the provisions under Minnesota Statutes, section 245C. An FSE may not require a consumer to have background checks on support workers, uness the FSE wi be the common aw empoyer (Agency with Choice) of staff seected by the consumer. In this case, the agency is responsibe to request the check and pay for these checks. When a icensed service provider is the common aw empoyer, staff hired are sti subject to background checks in order to be empoyed by the icensed service provider. The icensed provider requests and pays for the checks. Documentation Requirements: The FSE must maintain records to track a CDCS expenditures incuding time records of peope paid to provide supports and receipts for any goods purchased, invoices, payro summaries, and canceed checks. The records must be maintained for a minimum of five years from the caim date and must be avaiabe for audit or review upon request. The FSE must aso receive a copy of the recipient s Community Support Pan approved by the ead agency. Caims submitted by the FSE must correspond with services, amounts, time frames, etc. as authorized in the Community Support Pan. FSE and Fexibe Case Management An FSE may be paid for FCM if the organization does not have a financia interest in the consumer s direct supports. This means that if an FSE is the agency of choice, they CANNOT provide FCM for the same person. 68

73 Consumer Directed Community Supports Lead Agency Operations Manua Section 11: Fisca Support Entity Services 11.6 FSE Reporting Requirements As the MHCP-enroed provider, and the entity submitting caims and receiving payment, the FSE is in the most immediate position to provide summary information about spending and baances to both consumers and ead agencies. An FSE must provide monthy summaries to each consumer about the tota CDCS services that were bied, for which services, incuding charges for the FSE, and baances of authorized budgets. An FSE must provide quartery written summaries to the person s ead agency about the tota CDCS services that were bied, for which services, incuding charges for the FSE, and baances of authorized budgets. In addition, the FSE must provide monthy reports when a certain amount of over- or under-spending occurs for an individua. The foowing three tabes outine the required data eements and schedues for FSE reporting to consumer and famiies, the ead agencies, and other providers. The frequency of reporting isted represents the minimum standard. The two highighted items are recommended but not required. Individua tota yeary budget Tabe 1: FSE Reports to Cients/Famiies Data Eements Amount budgeted by service category: Persona Assistance Treatment & Training Environmenta Modifications & Provisions Sef-Directed Support Budget expenditures by category, and baance remaining in category Tota budget expended (used) Monthy Monthy Monthy Monthy % of Budget spent YTD Monthy Prorated % of budget expended YTD (what 1/12th of budget X number of months YTD woud tota) Projected staff costs: How much wi be spent if YTD staffing expenditures continue Payments made to other vendors in the reporting period (good, units, doars) Any overtime amounts paid in report period Monthy Monthy Monthy Monthy Frequency of Reporting 69

74 Section 11: Fisca Support Entity Services Consumer Directed Community Supports Lead Agency Operations Manua Tabe 2: FSE Reports to Lead Agency/County of Financia Responsibiity Data Eement By cient, same information as in report to consumer famiy in Tabe 1. Consumers who are spending tota budget by more than 15% of what the prorated YTD budget shoud be Consumer who have spent ess than 50% of what the prorated tota budget YTD shoud be Consumers who are spending their staffing budget by more than 15% of what the prorated YTD staffing budget shoud be Consumer who have spent ess than 50% of what the prorated staffing budget YTD shoud be Consumers paying staff overtime Range of payro owest to highest houry rate paid, average paid (to earn what is usua and customary) Summary of number of parents of minors and spouses being paid, and the number of hours/week being paid for Persona Assistance Service Number of consumers of the ead agency that the FSE is serving Tota number of consumers FSE is serving Number of consumers served under payro mode, fisca conduit, agency with choice. By consumer, names of support staff and hours submitted A consumer notices requesting missing required information such as invoices, timesheets or requests to purchase services or materias not incuded in the approved CSP. Frequency of Reporting Quartery Monthy Monthy Monthy Monthy Monthy As requested As requested As requested As requested As requested As requested As occurs Tabe 3: Reports to Other Providers Data Eements Schedue of Reporting Initia budgeted amount for their service, by consumer At start of service Any changes to the budget amount for the service they provide, by consumer YTD expenditures and amount remaining for that service, by consumer At any change Monthy 70

75 Consumer Directed Community Supports Lead Agency Operations Manua Section 11: Fisca Support Entity Services 11.7 Readiness Review In order to be certified as quaified to enro in Minnesota Heath Care Programs as an FSE provider, a potentia provider wi compete a Readiness Review with DHS. This review process wi incude submission of paper documentation, and can incude on-site review by DHS. The review wi evauate whether the provider demonstrates they meet these criteria: Be knowedgeabe about, and compy with, Interna Revenue Service requirements needed to process empoyer and empoyee deductions. Provide appropriate and timey submission of empoyer tax payments. Maintain documentation to support MMIS caiming. Have current and adequate iabiity insurance and bonding. Have sufficient cash fow. Have on staff or under contract a certified pubic accountant, or an individua with a baccaaureate degree in accounting. Aong with the specific requirement outined above, an FSE must provide core information to consumers interested in CDCS as a service option. These materias wi be provided by DHS to enroed FSEs. The FSE must aso deveop and maintain poicies and procedures, as outined in a poicies and procedures manua, that: Refects the phiosophy of consumer direction Describes poicies and procedures used to perform required FSE tasks Describes interna contros for tasks performed by FSE. This wi be important when an FSE is aso an agency with choice, or is aso a Fexibe Case Management provider. 71

76 Section 12: Invountary Exits Consumer Directed Community Supports Lead Agency Operations Manua 12.1 Invountary Exits from CDCS Under the federay approved waiver amendments, criteria for invountary exit from CDCS were identified. These criteria wi aso appy to AC participants. Invountary exit procedures are deveoped here to address: Immediate heath and safety concerns Matreatment of consumers Suspected fraud or misuse of funds Inabiity to impement the approved support pan or compy with CDCS requirements despite reasonabe efforts to provide additiona technica assistance and support as described beow. Definition of Terms In order to ensure equa treatment for peope receiving CDCS and provide usefu direction to ead agency and other staff, certain terms used in the paragraph above must be defined and appied to carry out the poicy decisions reated to invountary exits. Invountary Exit means ony the CDCS service is terminated, not the program. This termination of CDCS service is subject to MHCP Fair Hearing and notice requirements. However, unike other terminated services under MHCP, CDCS service is NOT avaiabe to the person during an appea process. Immediate Concern is defined as: Any matter jeopardizing heath and safety Evidence of unreported fraud Matreatment of the consumer Unapproved expenditures. Additiona Technica Assistance & Support means the ongoing invovement of the ead agency to resove issues surrounding pan impementation or expenditure of funds. This is assistance and support beyond that provided to a consumers through materias and competion of Required Case Manager functions. Reasonabe Efforts is defined as three documented events of need for additiona technica assistance and support during one pan year. This documentation must incude: Identification of the probem Corrective action needed A timeine in which to accompish the action or change. 72

77 Consumer Directed Community Supports Lead Agency Operations Manua Section 12: Invountary Exits 12.2 Procedures Reated to Invountary Exits When heath and safety concerns arise, or fraud or misuse of funds are evident, or a fourth occurrence from the date of CDCS authorization requiring corrective action (additiona technica assistance) is encountered, consumers may be immediatey exited from CDCS and returned to conventiona waiver or AC services. In the event that CDCS aternative services are terminated, a conventiona waiver or AC service pan woud be impemented as foows: Case manager discovers unreported fraud or abuse, or fraud or misuse of funds, or a fourth event requiring corrective action occurs when three previous efforts meet the requirements for documented technica assistance. Notice is sent informing consumer of termination of CDCS. This notice must incude information about the consumer s right to appea (Fair Hearing), their right to request assistance in fiing an appea, and must be deivered 10 days prior to the effect date of termination. The notice must aso incude information reated to inabiity to continue CDCS service during the appea process, and must outine the conventiona waiver or AC services to be authorized as repacement for CDCS service. A budget amount for the remaining service pan year must be cacuated. With the goa of retaining as many aspects of the person centered pan as feasibe, the Community Support Pan is updated to refect any needed changes to backup or emergency pans, or persona risk management pans, as we as services approved and desired consumer outcomes. Lead agency case manager reports heath, safety or abuse concerns to appropriate agencies such as Adut Protective or Chid Protective Services Lead agency case manager reports suspected fraud to SIRS. Screening Documents and Service Agreements are updated, terminating ine items for CDCS service and adding aternative services. The FSE is notified by the ead agency case manager of the effective date of the exit from CDCS. 73

78 Section 12: Invountary Exits Consumer Directed Community Supports Lead Agency Operations Manua 12.3 Additiona Technica Assistance and Support An individua s need for additiona technica assistance and support coud be reported to a ead agency by an FSE or FCM, or difficuties coud be discovered during ead agency monitoring. A person may be the subject of a matreatment report, or the person might seek assistance to resove probems encountered in pan impementation or services management. Whie not an incusive ist, the matters beow woud indicate a need for additiona technica assistance and support. Not spending enough for services needed to support heath and safety without a reasonabe expanation Over-spending at a rate that suggests the pan wi not be sustainabe over the service pan year On-going difficuty in arranging for services needed for heath and safety Unapproved expenditures Faiure to respond to notices requesting missing information from the FSE Not impementing the Community Support Pan as approved. Each discovery of non-compiance with the CSP that requires a corrective action coud cause a CDCS Notice of Technica Assistance and Support to be sent to the consumer with a copy retained in the ead agency fie. See Appendix C for a copy of this notice. However, the ead agency may choose to provide additiona assistance to consumers that does not meet the documentation requirements when successfu resoution of the issue(s) seems ikey. In order for an invountary exit to occur, there must be three documented efforts that DO meet the forma definition of Technica Assistance and Support and a fourth occurrence of need for corrective action before CDCS services can be terminated. Any action which woud trigger a fourth notice of quaifying additiona technica assistance and support woud cause an invountary exit from the program. Lead agency activity to assist in a corrective action or provide technica assistance under quaifying, documented occurance is bied as Required Case Management. 74

79 Consumer Directed Community Supports Lead Agency Operations Manua Section 12: Invountary Exits 12.4 Immediate Concern Heath and Safety Any matter arising which jeopardizes the consumer s heath and safety may resut in invountary exit. An incidence of substantiated abuse by a paid support staff, for exampe, coud ead to invountary exit if a backup pan cannot be impemented to assure heath and safety. Referras to Adut Protective Services for concerns arising about sef-negect rather than matreatment must occur in the same manner and for the same eve of concern for a person receiving supports under CDCS as for those receiving conventiona services. Reported Fraud Recognizing that some consumers may be vunerabe and may need assistance in the event of threat or coercion from their direct support worker, the process for invountary exit from CDCS must account for the timey reporting of fraud in the presence of coercion. Direct support workers can wied a great dea of power over peope with needs for that support, so poicy must aow peope to act as needed to avoid negative consequences in the short run. For exampe, someone may be asked to sign a frauduent timesheet, and fees they must wait unti the next worker comes on duty to report the matter in a timey fashion to their case manager. A consumer cannot be expected to directy confront someone on whom they are dependent. Those consumers who report such events and seek appropriate hep in a timey manner, and who are not wiing participants in fraud or misuse of funds, are considered in compiance with requirements and are not subject to invountary exit. Unreported Fraud If, however, the consumer faied to report an incident as described above in a timey manner, the incident woud be considered unreported fraud and woud be cause for invountary exit. Restrictions Under Primary Care Utiization Committee Decisions CDCS services are not avaiabe to an individua or their representative who has at any time been restricted by the Primary Care Utiization Review (PCUR) Committee for fraud or abuse of pubic funds. Information about such restriction wi be found in the Recipient Primary Care Utiization Review (RPCR) screen in MMIS. An edit wi aso post when a screening document is entered or updated that wi contain information about past and future restrictions by PCUR. If a person is paced on such restriction after CDCS is impemented, an invountary exit from CDCS woud aso occur. 75

80 Section 13: Paying Parent or Appendix D Spouse Under CDCS Consumer Directed Community Supports Lead Agency Operations Manua Appendix D Consumer Directed Community Supports (CDCS) Notice of Technica Assistance and/or Support The Required Case Manager shoud compete this form to document a need for additiona technica assistance and/or support that is beyond reasonabe efforts. The consumer or their ega representative shoud sign the form and be given a copy. The origina wi be kept in the consumer s fie. Consumer name: Case manager s name: County: Date of this notice of technica assistance and/or support: Number of documented notices in this service pan year and date of each notice: * Identification of the probem (describe what caused the need for technica assistance and/or support): Corrective action needed (describe what action needs to occur to correct the probem): Timeine to accompish the corrective action (give a timeine for the CDCS recipient to compete the corrective action): Consumer or ega representative signature (indicates receipt of this notice): *On the 4th occurrence of technica assistance and/or support beyond reasonabe efforts, the Notice of Action (DHS 2828) wi be sent immediatey. The CDCS recipient wi be exited from CDCS as of the effective date on the form. 76

81 Consumer Directed Community Supports Lead Agency Operations Manua Section 13: Paying Parent or Spouse Under CDCS 13.1 Purchasing Persona Assistance Services (PAS) from a Spouse or Parent A person can eect to use CDCS funding to purchase persona assistance from a parent or spouse. The intent of this option is to maximize the avaiabe persona assistance resources within the home and community-based service system, and to provide consumers with the comfort and assurance of receiving care from famiiar and trusted individuas. Generay, consumers rate services from quaified and capabe reatives as high quaity with a high eve of satisfaction. Persona assistance service is the ony support for which a parent of a minor chid age 18 years or younger or spouse may be paid using CDCS funding. Whie a parent or spouse may aso function in other supportive roes such those performed by a FCM or managing empoyer, they may NOT receive payment for serving in these other roes or performing other supportive functions. A parent who is a quaified nurse and who wishes to provide skied services for payment using CDCS funding must provide this service under the Persona Assistance Service category AND under the payment imitation governing payment to parents and spouses (i.e. the state maximum PCA rate) Criteria for Paying Spouse or Parent for PAS Certain requirements must be met to approve CDCS payment to a spouse or bioogica or adoptive parent of recipients under 18. For the parent of a minor chid or spouse to receive payment for performing Persona Assistance Service, a of the foowing criteria must be met: The type of assistance or support to be provided fas within the description and aowabe costs of Persona Assistance Service. Persona Assistance Services are specified in the Community Support Pan. The care for which a parent or spouse is reimbursed is directy reated to functiona dependency of the recipient. See the next page for more information about determination of ADL dependencies. The parent or spouse meets the quaifications for Persona Assistance Service as outined in the Community Support Pan. The number of hours for which a parent or spouse is to receive payment is addressed in the pan which records the assessed need, such as hep with dressing, and incudes the frequency of deivery, the payment rate, and units per week. The service must NOT be an activity that the parent or spouse woud ordinariy perform, or is responsibe to perform. These activities woud incude, but are not imited to, supervision or transportation of chidren, for exampe, or househod maintenance such as house ceaning, mea preparation, or aundry. 77

82 Section 13: Paying Parent or Spouse Under CDCS Consumer Directed Community Supports Lead Agency Operations Manua 13.3 Determination of ADL Dependency As noted in the previous section, in order to pay a spouse or parent for Persona Assistance Service, the consumer must be assessed as being dependent in at east one Activity of Daiy Living (ADL). This determination wi be based on use of the ADL items contained in the LTCC Assessment Form, DHS 3428 or 3428A for aduts, and as determined under DHS Form 3428C for minors age 18 or under. Whie the MRRC assessment team does not need to compete the entire LTCC assessment, they must aso use DHS Form 3428 or 3428C to determine dependencies. ADULTS: For aduts, dependent means that the eve of need for assistance or supervision is scored for purposes of case mix determination as foows for the 8 case mix ADLs : Activity of Daiy Living Items on 3428 or 3428A Score(s) Indicating Dependent Dressing 2-4 Notes Grooming 2-3 Bathing 4-5 Eating 2-4 Bed Mobiity 2-3 Transferring 2-4 Waking 2-4 Toieting 1-6 CHILDREN: A parent is egay responsibe to meet the needs of a minor chid, incuding the need for assistance and supervision typicay required for chidren at various stages of growth and deveopment. A parent can, however, receive payment for Persona Assistance Service when this support goes beyond what woud be expected to be performed in the usua course of parenting, and when needed support exceeds what is typicay required for a chid of the same age. For persons under age 18, the eve of independence expected in activities of daiy iving increases as chidren get oder. Younger chidren are typicay dependent on parents, and the definitions used to indicate dependency represent a eve of need that is not typica for chidren at various ages. DHS Form 3428C identifies those eves of need considered dependent reative to the chid s age. See Appendix D for a copy of the items contained in 3428C and the determination of dependency based on age. 78

83 Consumer Directed Community Supports Lead Agency Operations Manua Section 13: Paying Parent or Spouse Under CDCS 13.4 Financia Considerations There may be financia consequences to consider in a famiy s decision to receive payment for services: If a parent or spouse wi be a paid staff, how wi the payment affect the empoyee/famiy s eigibiity for other programs? Does the famiy understand that this is rea income that is taxabe, and that it may affect their eigibiity for other programs? How wi this income affect eigibiity for specific programs? Tax Consequences: Payment made to a spouse or parent of a minor is considered income to the empoyee, and must be treated as such for purposes of state and federa taxes, incuding FICA, SUTA, and FUTA. Consequences for Other Program Eigibiity: CDCS income may affect eigibiity for programs with income-based eigibiity guideines. The consumer or famiy shoud discuss these consequences with other program managers before making a decision about empoyment through CDCS. CDCS payments made to a spouse or custodia parent of a minor chid coud affect: The famiy s eigibiity for Medicaid: CDCS payments are considered income and deemed as such when determining MA eigibiity The chid s eigibiity for SSI The spouse s eigibiity for other programs or assistance when income is part of eigibiity criteria for those programs or services The TEFRA parenta fee: CDCS income is considered in the TEFRA parenta fee cacuation The famiy s eigibiity for MFIP: CDCS payments can be used to meet MFIP work requirements for the famiy member-empoyee Food Stamp eigibiity is determined by househod income. If the tota househod income increases, this may affect the Food Stamp aotment 79

84 Section 13: Paying Parent or Spouse Under CDCS Consumer Directed Community Supports Lead Agency Operations Manua 13.5 Limitations on Payment to Spouse or Parent A spouse or parent may not receive payment for more than 40 hours of Persona Assistance Service in a seven-day period. No more than 40 hours per week can be paid to one or both parents, regardess of the number of chidren in the househod receiving CDCS waivered services, or the actua number of hours of care being provided by the parent(s). The spouse or parent must compete time reports and other required documentation, such as reporting on tasks performed during paid working hours. The negotiated payment rate, incuding wages and payro-reated taxes, may not exceed the pubic pay fee-for-service rate estabished by the Department for persona care services (PCA) during the same fisca year in which services are deivered. The Community Support Pan must specify the frequency, duration, units, and payment rate negotiated for the Persona Assistance Service to be provided by the spouse or parent separatey from others who may be hired to provide Persona Assistance Services as we. 80

85 Consumer Directed Community Supports Lead Agency Operations Manua Section 13: Paying Parent or Spouse Under CDCS 13.6 Lead Agency Monitoring Requirements When Parent or Spouse is Paid for Persona Assistance Service In addition to the consumer s or their ega representative s pan to manage and monitor service deivery, incuding quaity and outcome indicators, the ead agency has monitoring requirements when the parent or spouse is serving in the roe of a paid empoyee. The ead agency case manager must: Conduct quartery reviews of expenditures and services provided, and the heath, safety and we-being of the consumer and the caregiver. Conduct in-home face-to-face visits twice a year with the consumer. 81

86 Appendix Section 13: E Paying Parent or Spouse Under CDCS Consumer Directed Community Supports Lead Agency Operations Manua Appendix E : Determining ADL Dependency in Chidren Age 18 and Under Dressing Assessor s Score Independent 00 Intermittent supervision or reminders. May need 01 physica assistance with fasteners, shoes or aying out cothes Constant supervision, but no physica assistance. *02 (N/A 0-48 months) Physica assistance or presence of another at a *03 times, but chid is abe to physicay participate. (N/A 0-36 months) Totay dependent on another for a dressing. *04 Chid is unabe to physicay participate. (N/A 0-12 months) Grooming Independent 00 Intermittent supervision or reminders 01 Hep of another to compete task, but chid is *02 physicay abe to participate. (N/A 0-48 months) Totay dependent on another for a grooming *03 needs. Chid is physicay unabe to participate. (N/A 0-24 months) Bathing Independent 00 Intermittent supervision or reminders 01 Needs hep in and out of tub 02 Constant supervision, but chid does not need *03 physica assistance. (N/A 0-60 months) Physica assistance of another, but chid is *04 physicay abe to participate. (N/A 0-48 months) Totay dependent on another for a bathing. *05 Chid is physicay unabe to participate. (N/A 0-12 months) Eating Independent 00 Intermittent supervision or reminders 01 Needs constant supervision and/or assistance in 02 setting up meas, i.e. cutting meat, pouring fuids. (N/A 0-60 months) Needs physica assistance. Chid can partiay feed *03 sef. (N/A 0-24 months) Needs and receives tota ora feeding from another. *04 Chid is physicay unabe to participate. (N/A 0-12 months) Receives tube feeding.* Chid has documented *05 incidents of choking or refux on a weeky basis or more that is reated to diagnosis or disabiity. Transfers Assessor s Score Independent 00 Needs intermittent supervision or reminders, i.e. cuing or guidance ony. 01 Needs physica assistance, but chid is abe to *02 participate. Excudes carseat, highchair, crib for todder age chid. (N/A 0-30 months) Needs tota assistance of another, and chid is *03 physicay unabe to participate. (N/A 0-18 months) Must be transferred using a mechanica device, i.e. *04 Hoyer ift. Mobiity (waking) Independent. Ambuatory without device. 00 Can mobiize with the assist of a device, but does 01 not need persona assistance. Intermittent physica assistance of another. *02 (N/A 0-24 months) (This does not incude supervision for safety of a chid under age 5.) Needs constant physica assistance of another. *03 Incudes chid who remains bedfast. (N/A 0-12 months) Positioning (bed mobiity) Independent. Ambuatory without device. 00 Needs occasiona assistance from another person or 01 device to change position ess than daiy. Needs intermittent assistance of another on a daiy *02 basis to change position. Chid is physicay abe to participate. Needs tota assistance in turning and positioning. *03 Chid is unabe to participate. (N/A 0-9 months) Toieting Independent 00 Intermittent supervision, cuing or minor physica *01 assistance such as cothes adjustment or hygiene. No incontinence. (N/A 0-60 months) Usuay continent of bowe and badder, but has *02 occasiona accidents requiring physica assistance. (N/A 0-60 months) Usuay continent of bowe and badder, but needs *03 physica assistance or constant supervision for a parts of the task. (N/A 0-60 months) Incontinent of bowe and badder. Diapered. *04 (N/A 0-48 months) Needs assistance with bowe and badder programs, *05 or appiances (i.e. ostomies or urinary catheters). * Dependency is signaed by a score asterisked and boded. 82

87 Consumer Directed Community Supports Lead Agency Operations Manua Section 14: CDCS Authorizations & MMIS Activity:>65 Edery Waiver and Aternative Care 14.1 CDCS Budget Amount on the Pan The CDCS budget amounts wi be issued annuay by the Department. For persons aged 65 and oder participating in the Edery Waiver or Aternative Care Program, budget amounts wi foow the community-based case mix structure, and wi b e cacuated according to historica expenditures of each popuation. The caps contained in Appendix E are the budget maximums for FY05, and wi be updated each fisca year. The amount isted under each case mix category represents the tota doars avaiabe to purchase services over one service pan year for a services except Required Case Management and background checks requested by the consumer. The ead agency professiona conducting the LTCC assessment or reassessment process wi inform the consumer of their avaiabe budget amounts for both CDCS and conventiona EW or AC services panning as part of the information presented about CDCS and other service options when a person is determined eigibe for the program, and at reassessment. The ead agency has 60 days after the date of assessment/reassessment to impement CDCS. The individua receiving CDCS must be given 30 days to deveop their pan. This timeine may require the ead agency to prorate the adjustment depending on when the change occurs in reation to the individua s pan year. For the purposes of panning, the ead agency can appy a formua by: For EW and AC the budget is based on a case mix The person-centered Community Support Pan can incude costs for aowabe services up to the annua CDCS budget amount. The consumer and the ead agency case manager must compare the proposed cost of impementing the CDCS service pan to the tota CDCS budget amount avaiabe to evauate cost effectiveness, and the ikey success of the proposed pan. Like any other type of service budget maximum, the cap represents an up to amount avaiabe to purchase service. The amount actuay approved for services wi be based on projected cost of services needed to address assessed needs, and may be ess than the CDCS budget cap. The Department wi cacuate the tota doars avaiabe for CDCS services as a monthy maximum. Whie there is not a monthy imit to spending, services pans deveoped for ess than 12 months wi have a prorated maximum budget appied to the Service Agreement. For exampe, if the CDCS monthy maximum amount is $1,000, and the CDCS service pan is for nine months, the pan budget wi be $9,000 for the nine month period. The amount the consumer pans to spend each month can be more or ess than $1,000 but cannot exceed the tota avaiabe. Unexpended CDCS budget amounts cannot be carried over to subsequent service pan years. 83

88 Section 14: CDCS Authorizations & MMIS Activity:>65 Consumer Directed Community Supports Lead Agency Operations Manua 14.2 Authorizations and Payments Under CDCS : EW and AC The process for authorizing and paying for services when CDCS is seected and a pan is approved is the same as that foowed for any person receiving AC or EW services. A Long Term Care Screening Document is entered into MMIS. Information from the SDOC is refected on the Service Agreement. Providers submit caims. Screening Document edits are appied and the document is approved in MMIS. The Screening Document records assessment information, program seection, and support pan information. It aso estabishes a from-through program eigibiity span. This span documents a period of time in which the person wi remain eigibe for the program that cannot exceed 365 days. Annua reassessment re-estabishes eigibiity for the program. There are different Service Agreement types for different programs. Information from the Screening Document (program type, case mix) determines the maximum doar amount and set of services that can be authorized. Service Agreement edits are appied, and the Service Agreement is approved in MMIS. The Service Agreement identifies approved providers, services, rates, ength of approva, and tota doars authorized. Consumers receive copies of their authorizations as a Service Agreement etter generated by MMIS. Caims edits are appied, incuding checks against recipient information, authorized providers, and services, dates of service, and rates. Caims are paid or denied. Payments are decreased from tota doars authorized. Providers receive summaries of caims submitted and paid. Changes were made to each of these support processes and toos to support CDCS impementation in the EW and AC programs as outined in the next subsections. 84

89 Consumer Directed Community Supports Lead Agency Operations Manua Section 14: CDCS Authorizations & MMIS Activity:> Summary of Changes to the Long Term Care Screening Document: EW & AC New fieds were added to the LTC Screening Document to: Indicate whether CDCS is seected as a service option (Fied # 94) This fied must aways be competed when entering a LTC Screening Document for a community assessment. The choice is coded as Y or N. Show the CDCS monthy budget cap based on case mix cassification (Fied # 95) This amount wi aways appear on the LTC Screening Document and is based on case mix cassification, the program type, and the Assessment Resut Date. New vaues for existing fieds were created to: Record any changes between CDCS and non-cdcs services in a service pan year, to re-estabish budget maximums for that service pan year (New Assessment Resut Codes 36= Edery, eected CDCS from non-cdcs, and 37 = Edery, eected non-cdcs from CDCS). Because the CDCS and non-cdcs monthy budget amounts are different, when a person changes between CDCS and non-cdcs in the same service pan year, MMIS wi cacuate the amount avaiabe for the remainder of that service pan year. Record Support Pan information (New Service Pan Summary codes, 40= CDCS, 41=Parent/Spouse Paid CDCS), if appicabe Record reasons for exiting CDCS using Fied 75 Reasons for Continuing Institutiona Stay (Vaue 02 now reads Case Mix/CDCS Cap Doesn t Meet Needs, and new vaue 11 Invountary Exit from CDCS ). Any of the other reasons can aso be coded. New LTC Screening Document edits were created to post when: The CDCS = Y or N fied is eft bank or an invaid code is entered (Edit # 441) The information coded for changes between CDCS and non-cdcs (Assessment Resut Codes) doesn t match the CDCS = Y or N information (Edits # 448 and 449) A person eaves CDCS and a Reason Code is not entered in Fied 75 (Edit # 644). The Department wants to evauate why peope forego the service after eection. CDCS is eected by a person who cannot access this service because of Primary Care Utiization Review information in the Recipient Fie (see the RPCR Screen in the Recipient Fie) in MMIS (Edit # 442) 85

90 Section 14: CDCS Authorizations & MMIS Activity:>65 Consumer Directed Community Supports Lead Agency Operations Manua 14.4 Service Agreement Changes for CDCS Under EW & AC: Procedure Codes New Procedure Codes were added to authorize CDCS funding and services under AC and EW. There are three new procedure codes: T2028 is to be used to authorize a CDCS services. It incudes the foowing service categories as defined in Sections 5 and 6 of this manua: Persona Assistance; Treatment and Training; Environmenta Modifications and Provisions; and Sef-directed Support Activities. It wi aso be used to authorize a conventiona waiver or AC services eected by the person as part of their support pan. T2040 wi be used to authorize payment for Background Checks. T2041 incudes a activities bied under Required Case Management. If a paraprofessiona performs any aowed deegated tasks, the amount bied must refect the paraprofessiona rate. 86

91 Consumer Directed Community Supports Lead Agency Operations Manua Section 14: CDCS Authorizations & MMIS Activity:> Service Agreement Changes for CDCS Under EW and AC: Edits Goa/Assurance Edit Number Edit Text & Notes CDCS is authorized on the LTC screening document prior to entering the ine items on the Service Agreement. Ony specific services are authorized when CDCS is eected. The tota amount authorized for CDCS services is kept under the CDCS budget cap. Required Case Management is incuded ony on a CDCS Service Agreement. The tota amount authorized for Required Case Management is kept under a cap amount for Required Case Management. Fisca Support Entity is the enroed provider under CDCS. Ony the Fisca Support Entity (FSE) provider number may be used on the ine item for T2028. FSE must be recertified periodicay to continue to provide service. 443 ( CDCS Not Authorized ) wi post when the T2028 code is added to a Service Agreement and the LTC Screening Document indicates CDCS=N. If the CDCS fied on the ast approved LTC screening document was mistakeny vaued as an N, that document wi need to be deeted and a new document entered with the correct vaue. 445 ( Service Not Aowed with CDCS ) wi post if other services are entered on a ine item that are not aowed in combination with CDCS on the Service Agreement. See 14.6 for a ist of the procedure codes that ARE aowabe in combination with CDCS. 672 ( Tota Authorized Amount Exceeded ) wi post if the tota authorized amounts of the combined ine items (except for Background Checks) exceed the CDCS budget cap. You must reduce one or more ine item units or tota amounts. 447 RCM Without CDCS wi post if 1) an approved ine item for T2028 is not on the same service agreement as T2041, or 2) T2028 is on the Service Agreement but not T2041, or 3) one of the ine items is in a denied status. That is, this case management code is to be used ony in combination with CDCS. 452 RCM Cap Exceeded wi post if the tota sum of a ine items for T2041 exceed the RCM budget cap. Reduce the ine item(s) so the tota amount does not exceed these maximums. This aowabe tota is incuded in Appendix E. 412 The Category of Service Does Not Match the Procedure Requested There wi be an ending date on the category of service for this provider. The provider must re-enro with DHS Provider Enroment Unit on a biannua basis. If the service agreement ine item for T2028 exceeds this ending date, you wi receive Edit 412. View the PCOS Screen in the Provider Subsystem for this provider number for the ending date. The ine item end date must be changed so it does not exceed this date. 87

92 Section 14: CDCS Authorizations & MMIS Activity:>65 Consumer Directed Community Supports Lead Agency Operations Manua 14.6 Other Procedure Codes That Can Be Authorized in Combination with CDCS Services: Edery Waiver and Aternative Care Programs For AC and EW: Other services that can be authorized in combination with T2028 (the CDCS Service code) are: T2040 (Background Checks) T2041 (Required Case Management) For EW Ony: The person may have incuded state pan home care services as part of their pan. For this provider type ony, the foowing services can be authorized separatey on the Service Agreement, and the agency can bi directy. For AC Ony: X5609 (PMAP) if the person is enroed in Managed Care and receiving state pan services T1021 (Home Heath Aide) T1003 with or without modifiers TT or TG (LPN) T1002 with or without modifiers TT or TG (RN) T1030 (Skied Nursing) T1030 with modifier GT (Teehomecare) T1019 (Persona Care Assistant) X4037 (RN Supervision of PCA) Home care services under an approved AC support pan address ony chronic, ong term care needs. When authorized in accordance with AC requirements, they are considered to be extended home care in nature and, as such, shoud be authorized under ine item costs for T2028. Note: MA-covered services are not covered services under the AC program. 88

93 Consumer Directed Community Supports Lead Agency Operations Manua Section 14: CDCS Authorizations & MMIS Activity:> Caim Payments: EW and AC As noted, the Fisca Support Entity (FSE) wi be the enroed provider and the ony entity that can bi for service costs under the CDCS service code T2028. When the FSE submits caims, the charges for services must contain information about which category of CDCS service was provided during the biing period. Services provided under T2028 wi be identified on the caim form by using modifiers. The caim form ine items must incude one of the foowing four modifiers: T2028 with modifier U1 for Persona Assistance T2028 with modifier U2 for Treatment and Training T2028 with modifier U3 for Environmenta Modifications and Provisions T2028 with modifier U4 for Sef-directed Support Activities (incudes the FSE and FCM fees, and empoyer reated expenses for benefits such as heath insurance, as approved in the pan). T2028 U8 Fexibe Case Management These modifiers are NOT used on the Service Agreement. Payments from these ine items wi decrement against the Service Agreement ine item for T2028. To bi for Background Checks (T2040), use T2040 on the caim form. To bi for Required Case Management (T2041), use T2041 on the caim form. County or triba agencies wi be aowed to bi MMIS directy (i.e. caims are not submitted by the FSE). Specia Income Standard-Edery Waiver (SIS-EW): Payments for a three procedure codes (T2028, T2040, and T2041) wi be appied toward the SIS/EW waiver obigation. See Section 16.A for more information about spenddown and waiver obigation. Use of Caim Modifier 76 Caim Modifier 76 was deveoped to aow payment for mutipe services provided on the same date or date span. When competing a caim for CDCS using procedure code T2028 when there wi be more than one caim for the same date(s), use modifier U1 - U4 and/or U8 (as needed) in the MOD 1 fied of the caim ine item aong with modifier 76 in the MOD2 fied of the caim ine item. By using modifier 76, the new caim(s) wi not be considered a dupicate of the initia caim. 89

94 Section 14: CDCS Authorizations & MMIS Activity:>65 Consumer Directed Community Supports Lead Agency Operations Manua 14.8 Consumer Scenario: Initia Opening Seects CDCS The person is not currenty on the EW or AC program and seects CDCS at initia opening to the program. Enter a LTC Screening Document using: Enter a new Service Agreement using: Edits You Might Receive: Activity Type 02 or 04 Assessment Resut 01 or 28 (use 11 ony if the same program type was used in the past) Program Type 03, 04, 09, 10, or 22 CDCS Fied = Y, and CDCS is marked in the Service Pan Summary, and Paid CDCS Parent/ Spouse if appicabe. The case mix amount for non-cdcs and CDCS wi appear on the approved LTC Screening Document based on the person s case mix, program, and Assessment Resut Date (used by MMIS to find the right rate year). The EW or AC eigibiity span is deveoped. The corresponding service agreement type to match the program type. The header amount wi be the CDCS amount isted from the LTC Screening Document, mutipied by the number of months in the header (service pan) period. One ine item for CDCS that represents the tota of a CDCS approved services and goods; For EW, one ine item each for any MA state pan service that the person has eected to receive from a conventiona home care agency, or one ine item for x5609 if the person is enroed in Managed Care and home care is part of their pan One ine item for Required Case Management, and One ine item for Background Checks (if appicabe) For AC, one ine item each for CDCS, Required Case Management, Background Checks Exception: One ine item each for AC home care services if the person is program type 22 Temp. AC New edit 445 Services Not Aowed with CDCS wi post if any other procedure code is incuded Edit 672 Tota Authorized Greater Than Cap wi post if the tota authorized amount exceeds the header amount. New edit 452 RCM Cap Exceeded wi post if the tota amount authorized for T2041 exceeds the maximum imit. Edit 412 The Category of Service Does Not Match the Procedure Requested wi post if the ine item end date for T2028 exceeds the ending date for the FSE s provider number. 90

95 Consumer Directed Community Supports Lead Agency Operations Manua Section 14: CDCS Authorizations & MMIS Activity:> Consumer Scenario: Person Who Has Been Using CDCS Wants to Discontinue that Service If the person eects to end CDCS and switch to non-cdcs services: Cose the Service Agreement to the ast day CDCS wi be used and Use reason code 987 CDCS services no onger authorized for this person on the ASA2 Screen of the service agreement to expain to the providers that a funding change was made. Enter a LTC Screening Document using: Activity Type 07 if there are no significant changes in the person s needs and the change represents a service change ony Assessment Resut 37 Eected Edery Non-CDCS Services From CDCS Do not change the program type. Change the CDCS fied to N. Note: Edit 449 CDCS Fied Equas Y wi post if there is a Y in this fied and the Assessment Resut is 37. Enter fied 75 Reason(s) for Continued or Long-term Institution Stay and Deete the CDCS vaue from the Service Summary Section. Note: When using Activity Type 07, the eigibiity span is not extended, nor can the case mix be changed. The amount of money that wi show up on the new Screening Document wi represent the non-cdcs monthy amount times the number of months eft in the eigibiity span. Reassessment: If there has been a significant change in need, or the decision to opt out of CDCS occurs at or near the time a reassessment woud occur, the case manager can compete the reassessment using Activity Type 06 instead of 07. In this case, a new eigibiity span wi be created, using the Assessment Resut Date as the start date for the new span, and the new Service Agreement wi refect a 12 month budget. Enter a new Service Agreement using: MA state pan services pus EW extended home care, waiver services, and/or x5609 as appicabe, or AC services, depending on the program type. 91

96 Section 14: CDCS Authorizations & MMIS Activity:>65 Consumer Directed Community Supports Lead Agency Operations Manua Consumer Scenario: A Person Currenty Open to EW or AC Decides to Change to CDCS If the person is currenty receiving non-cdcs services and eects to use CDCS: Cose the EW or AC service agreement. You may add a message to the Provider and Recipient Comment Screens indicating that a new service agreement for CDCS services wi be deveoped. Compete a LTC Screening Document using: Activity Type 07 if the change is in services ony Assessment Resut 36 Eected Edery CDCS Do not change the program type. Change the CDCS fied to Y. Note: edit 448 CDCS Fied Equas N wi post if there is a N in this fied and the Assessment Resut is 36, and Indicate the CDCS vaue from the Service Summary Section, and Paid CDCS Parent/ Spouse if appicabe. Enter a new Service Agreement using: The corresponding service agreement type to match the program type One ine item for CDCS For EW, one ine item each for MA state pan service, or one ine item for x5609 if the person is enroed in Managed Care One ine item for Required Case Management and One ine item for Background Checks (if appicabe) For AC, one ine item each for CDCS and Required Case Management, and Background Checks, if appicabe Exception: One ine item each for AC home care services if the person is program type 22 Temporary AC. 92

97 Consumer Directed Community Supports Lead Agency Operations Manua Section 14: CDCS Authorizations & MMIS Activity:> Consumer Scenario: Renewa of CDCS The person remains with CDCS services at time of the annua reassessment. Enter a LTC Screening Document using: Activity Type 06 Assessment Resut 13 Do not change the program type and Do not change the CDCS fied. The EW or AC eigibiity span is extended. Enter a new Service Agreement using: The corresponding service agreement type to match the program type One ine item for CDCS For EW, one ine item each for MA state pan service, or one ine item for x5609 if the person is enroed in Managed Care One ine item for Required Case Management and One ine item for Background Checks (if appicabe) For AC, one ine item each for CDCS, Required Case Management, and Background Checks Exception: One ine item each for AC home care services if the person is program type 22 - Temporary AC. If the Person Lives in an Institution. For a person who is eigibe for Medica Assistance, community services panning that occurs whie the person is in the institution, incuding panning to utiize CDCS as the service option to return to the community, shoud be bied under Reocation Service Coordination (RSC). See Buetins and its repacement, , for compete information about provision and payment for Reocation Services Coordination. A person determined to be eigibe for AC can access AC conversion case management to assist in panning whie residing in a nursing faciity as we. Use X5476 for diversion-type Service Agreements or T1016 for conversion-type Service Agreements. 93

98 Section 14: CDCS Authorizations & Appendix MMIS Activity:>65 F Consumer Directed Community Supports Lead Agency Operations Manua Appendix F FY05 CDCS Budgets EW The CDCS budgets for FY05, the first year of impementation, for Edery Waiver participants are based on the average actua expenditures for FY03. 1 In addition, the case mix weights were appied to the FY03 amounts when the FY03 budget amount based on actua FY03 expenditures was ower than the amount expected given the case mix weight. The weight was appied to adjust case mix categories that had very few peope in them during the periods anayzed. The tabe on the next page shows average CDCS budget amounts per month by case mix cap for Edery Waiver participants. The annua amount, which aso appears on the tabe, is used for authorization and projected spending caps. The pan and Service Agreement authorization is not imited by the average monthy amounts shown here, but wi refect proposed services and negotiated rates, and projected use of services over a period of time. The annua service budget amount cannot be exceeded, and represents an up to amount avaiabe over the year to purchase needed, approved services, incuding Fisca Support Entity service as specified in the pan, and Fexibe Case Management service if the person chooses this optiona case management service. Required Case Management amounts are aso presented as a monthy average amount and an annua maximum amount. The average amount of case management expenditures during FY03 ranged from between $ to $ per person per month. 2 The annua maximum amount isted cannot be exceeded. Required Case Management biing must refect the units of service provided in a given bied period, the use of case aide versus case management service, and the ead agency s usua and customary charge for waiver case management service. Background checks, which can be requested by a person but not required, can be authorized using up to $20 per check requested. Biing for this service must be based on actua cost of the check. The cost for background checks is not incuded in the cap appearing in Coumn 6 beow. 1 Aging and Adut Services Division staff examined authorized and actua Edery Waiver expenditures for FY02 and FY03 by case mix cassification. The anaysis incuded case management and home care (both FFS and PMAP) authorizations and expenditures, and excuded foster care, residentia care and assisted iving service costs. These costs were excuded because peope iving in these settings cannot access CDCS as a service option. 2 The division used 8 units per month at the state-wide maximum rate for case management to cacuate an annua maximum amount that wi support a range of required case management activity, incuding the provision of additiona technica assistance prior to invountary exit from CDCS service. 94

99 Consumer Directed Community Supports Lead Agency Operations Manua Section 14: CDCS Authorizations & MMIS Activity:>65 Appendix F 1. Case Mix 2. CDCS Monthy Amount 3. Annua Maximum CDCS Service Budget Amount Tabe 1: FY 05 CDCS Budget EW 4. Required Case Management Monthy Amount 5. Required Case Management Annua Maximum Amount 6. Tota: CDCS Service Cap + Required Case Management 7. Background Check(s) Maximum Payment A $691 $8,292 $ $2, $10, $20/check B $1,035 $12,420 $ $2, $14, $20/check C $1,229 $14,748 $ $2, $16, $20/check D $1,337 $16,044 $ $2, $18, $20/check E $1,729 $20,748 $ $2, $22, $20/check F $1,775 $21,300 $ $2, $23, $20/check G $1,789 $21,468 $ $2, $23, $20/check H $2,343 $28,116 $ $2, $30, $20/check I $2,748 $32,976 $ $2, $35, $20/check J $2,815 $33,780 $ $2, $35, $20/check K $2,901 $34,812 $ $2, $36, $20/check Lead agencies wi receive revised budget maximums information each Fisca Year. 95

100 Section 15: CDCS Service Appendix Authorizations F.1 & MMIS Activity:<65 Consumer Directed Community Supports Lead Agency Operations Manua 1. Case Mix 2. CDCS Monthy Amount Tabe 2. AC Budgets for CDCS FY Annua Maximum CDCS Service Budget Amount 1 4. Required Case Management: 8 units X $22.67 average monthy units 5. Required Case Management Annua Maximum Amount 6. Tota: CDCS Service Cap + Required Case 7. Background Check(s) Maximum Payment A $683 $8,196 $ $2, $10, $20/check B $923 $11,076 $ $2, $13, $20/check C $1,074 $12,888 $ $2, $15, $20/check D $1,226 $14,712 $ $2, $16, $20/check E $1,444 $17,328 $ $2, $19, $20/check F $1,534 $18,408 $ $2, $20, $20/check G $1,623 $19,476 $ $2, $21, $20/check H $2,000 $24,000 $ $2, $26, $20/check I $2,108 $25,296 $ $2, $27, $20/check J $2,216 $26,592 $ $2, $28, $20/check K $2,520 $30,240 $ $2, $32, $20/check These amounts wi be updated annuay and repubished for ead agency and consumer use. 96

101 Consumer Directed Community Supports Lead Agency Operations Manua Section 15: CDCS Service Authorizations & MMIS Activity:< CDCS Service Authorizations & MMIS Activity: Persons under Age 65 in CAC, CADI, MR/RC, and TBI Waiver Programs As of October 1st, 2004, CDCS became avaiabe to persons who are enroed in or eigibe for the foowing programs: CAC waiver (Community Aternative Care), CADI waiver (Community Aternatives for Disabed Individuas), TBI waiver (Traumatic Brain Injury), and MR/RC waiver (Menta Retardation or Reated Condition) The CDCS budget amounts wi be issued annuay by the Department of Human Services, and cacuated according to historica expenditures of each popuation, except for MR/RC waiver, where budget is based on the individua screening document. The amount authorized represents the tota doars avaiabe to purchase services over one service pan year for a services except Required Case Management, background checks requested by the consumer, and the cost of approved modifications or assistive technoogy that exceeds $5, The ead agency has 60 days after the date of assessment/reassessment to impement CDCS. The individua receiving CDCS must be given 30 days to deveop their pan. This timeine may require the ead agency to prorate the adjustment depending on when the change occurs in reation to the individua s pan year. For the purposes of panning, the ead agency can appy a formua by: For potentia recipients and reassessments for the MR/RC waiver the ead agency can use the MR/RC Waiver CDCS Budget Formua: disabiities/documents/pub/dhs_id_ pdf For current MR/RC, CAC, CADI and TBI waiver recipients, the CDCS budget is ocated on the Waiver Management Systems For potentia recipients for the CAC/CADI/TBI waivers the ead agency can take the individua s initia waiver resource amount derived from the CCT waiver management system and use this formua: resource amount -2.9 x.70 For reassessments for the CAC/CADI/TBI waivers the ead agency can compete a manua entry on the CCT waiver management system The ead agency professiona (county case manager, triba entity or heath pan representative) conducting the assessment or reassessment process wi inform the consumer of services avaiabe in the waiver when a person is determined eigibe for a waiver program, and at reassessment. This information wi incude avaiabe budget amounts for CDCS. Like any other type of service budget maximum, the cap represents an up to amount avaiabe to purchase services. The amount actuay approved for services wi be based on projected cost of services needed to address assessed needs, and may be ess than the CDCS budget cap. The personcentered Community Support Pan can ony incude costs for aowabe services up to the annua CDCS budget amount. The consumer and the ead agency must compare the proposed cost of 97

102 Section 15: CDCS Service Authorizations & MMIS Activity:<65 Consumer Directed Community Supports Lead Agency Operations Manua impementing the CDCS service pan to the tota CDCS budget amount avaiabe to evauate cost effectiveness, and the ikey success of the proposed pan, taking into consideration the heath and safety of the individua. A person who is currenty receiving non-cdcs services can eect to use CDCS. The CDCS budget avaiabe woud be prorated to refect remaining months in a waiver year span. The CDCS service agreement date spans coud not exceed the waiver span. If a person enters a fu-team screening to begin CDCS, that fu team screening extends the waiver span. Aso if a reassessment is done and there is a change in services, there woud then be a change in the service agreement. Unexpended CDCS budget amounts cannot be carried over to subsequent service pan years Consumer Scenarios: Choosing CDCS Scenario 1: Initia opening person seects CDCS The person is not currenty on CAC, CADI, or TBI waiver and seects CDCS at the initia opening to the program. Enter a LTC screening document using activity type 02, 04, or 07 (if within 60 days of a face to face assessment) Use assessment resut 01,10,11,28 Enter a Y in the CDCS fied Note: this wi create a waiver span for this person. The person is not currenty on the MR/RC waiver and seects CDCS at the initia opening to the program. Enter a fu team screening document using activity type 01 Enter a waiver-in screening document, activity type 04 and enter the CDCS code, 48 in Fied 41 (Current Services) Scenario 2: At reassessment: a person aready on a waiver decides to change to CDCS If the individua is currenty receiving non-cdcs services and eects at his/her reassessment to use CDCS. 98 For CAC, CADI, or TBI: Enter a LTC screening document using activity type 06 Use assessment resut 13 Enter a Y in the CDCS fied Note: This wi extend the waiver span for person. For MR/RC: Enter an Annua Review screening document using activity type 02 and enter the CDCS code, 48 in Fied 41 (Current Services)

103 Consumer Directed Community Supports Lead Agency Operations Manua Section 15: CDCS Service Authorizations & MMIS Activity:<65 Scenario 3: A person is aready on a waiver and chooses CDCS, but NOT at reassessment. If this individua is currenty receiving non-cdcs services and eects to use CDCS immediatey without waiting for his/her reassessment. Enter a LTC screening document using activity type 07 Use assessment resut 98 Enter a Y in the CDCS fied. Note: This wi not extend the waiver span for the person. For MR/RC: Enter a service change screening document, using activity type 03 and enter the CDCS code 48 in Fied 41 (Current Services) 15.3 Consumer Scenarios: Discontinuing CDCS Scenario 1: A person who has been using CDCS chooses to discontinue that service at the time of his/her reassessment. If this person wants to discontinue CDCS, and switch to non-cdcs services at the time of his/her reassessment. For CAC, CADI, TBI: Enter a LTC Screening Document using activity type 06 Use assessment resut 13 Enter an N in the CDCS fied Note: This wi extend the waiver span for the person. For MR/RC: Enter and Annua Review screening document, activity type 02 and remove the CDCS code, 48 from Fied 41 Scenario 2: Person who has been using CDCS on a waiver chooses to discontinue that service at any time other than reassessment. If this person eects to end CDCS anytime before his/her reassessment, and switch to non-cdcs services immediatey without having to wait for his/her reassessment. For CAC, CADI, or TBI: Enter a LTC screening document using activity type 07 Use assessment resut 98 Enter an N in the CDCS fied Note: This wi not extend the waiver span for the person. 99

104 Section 15: CDCS Service Authorizations & MMIS Activity:<65 Consumer Directed Community Supports Lead Agency Operations Manua For MR/RC: Enter a service change screening document, activity type 03 and remove the CDCS code, 48 from Fied 41 (Current Services) 15.4 Service Agreements: CAC, CADI, MR/RC, TBI In order to authorize CDCS on a Service Agreement: The LTCC Screening Document must indicate a Y in the CDCS fied, OR The DD Screening Document Current Service Code is 48 CDCS is authorized as one service agreement ine item for CAC, CADI, TBI and MR/RC waivers. Enter the dates of the service span Use CDCS code T2028 (no modifier) Enter the individua s county authorized budget amount as the requested tota amount. (no unit or rate) This amount can not exceed the State set resource. This information is aso on the Waiver Management System. Other Services aowed as separate ine items on the service agreement. Not incuded in the individua s CDCS service budget T2040 background checks X5476 case management X5491 case management aide X5671 assistive technoogy that exceeds $5000, if the county has chosen to fund the difference within their aggregate poo S5165 the cost of approved modifications that exceeds $5000, if the county has chosen to fund the difference within their aggregate poo Incuded under the CDCS budget X5609 PPHP services (Prepaid heath pan services) X4037 supervision of PCA T1019 PCA T1030 skied nurse visit T1020 home heath aide T1002 PDN-RN T1003 PDN-LPN Extended home care services are authorized as and incuded in the CDCS budget under the T2028 code. Home Modifications/Assistive Technoogy A note about authorizing home modification and assistive technoogy that wi cost more than $5000. In addition to state pan home care, CDCS service, background checks, and Required Case Management, home modifications and assistive technoogy costs of more than $5000 approved by the ead agency are authorized on the Service Agreement separatey if the ead agency decides to fund the cost within their aggregate poo. 100

105 Consumer Directed Community Supports Lead Agency Operations Manua Section 15: CDCS Service Authorizations & MMIS Activity:<65 Using S5165 procedure code for modifications and 5671 for assistive technoogy, authorize the amount exceeding $5000 approved by the ead agency which wi be funded by the ead agency s aggregate poo. Amounts up to $5000 are incuded under T2028 (CDCS) and come out of the individua s CDCS budget. Amounts that exceed $5000 that are paid for out of the individua s CDCS budget woud aso be incuded under T Screening Document Edits: Edit 441 CDCS Fied is bank or invaid LTC Screening Document. If the Program Type is CAC, CADI, or TBI, then the CDCS fied must be popuated. Edit 442 CDCS not aowed for PCUR (Primary Care Utiization Review) If DD screening document has current service 48 (CDCS) or LTC SD has CDCS fied Y then Recipient cannot have a current or past PCUR begin date. Service Agreement Edits: Edit 440 Excuded time fied is bank or invaid. If procedure code T2028 is entered, the Excuded Time must be popuated. Edit 568 Procedure code/current service mismatch For procedure code T2028 The DD screening document must incude Current Service Code - 48 (CDCS) Edit 443 CDCS NOT ALLOWED (CAC, CADI, & TBI) For procedure code T2028 or T2040 The LTC screening document CDCS fied must be Y. Edit 363 Procedure/Modifier Confict Procedure code T2028 cannot be entered on an SA with a modifier Edit 444 CDCS/Other Service Confict Procedure code T2028 conficts with another service on the SA. 101

106 Section 15: CDCS Service Authorizations & MMIS Activity:<65 Consumer Directed Community Supports Lead Agency Operations Manua 15.6 Biing Cdcs Services CDCS is authorized on the SA using procedure code T2028 (with no modifier) CDCS is bied on the CMS 1500 using an appropriate modifier. T2028 U1 CDCS Persona Assistance T2028 U2 CDCS - Treatment and Training T2028 U3 CDCS Environmenta Modifications and Provisions T2028 U4 CDCS Sef Direction Support Activities T2028 U8 Fexibe Case Management Use of these codes for biing wi decrement the SA ine item T2028. Use of Caim Modifier 76 Caim Modifier 76 was deveoped to aow payment for mutipe services provided on the same date or date span. When competing a caim for CDCS using procedure code T2028 when there wi be more than one caim for the same date(s), use modifier U1 - U4 and/or U8 (as needed) in the MOD 1 fied of the caim ine item aong with modifier 76 in the MOD2 fied of the caim ine item. By using modifier 76, the new caim(s) wi not be considered a dupicate of the initia caim. 102

107 Consumer Directed Community Supports Lead Agency Operations Manua Section Section 16: CDCS 16A: Spenddowns, Notes for Peope Waiver Enroed in Obigations MSHO & and MnDHO CDCS 16.1 CDCS & Enroment in Managed Care MSHO, MnDHO, PMAP, or CBP When a county or tribe receives a request from a person to receive CDCS, DHS recommends counties ca the DHS Eigibiity Verification System (EVS) to verify Minnesota Heath Programs eigibiity. Minnesota Senior Heath Option (MSHO) and Minnesota Disabiity Heath Option (MnDHO) enroees receiving services on a waiver may be eigibe to choose CDCS as a service, and the county or tribe shoud refer the person to their heath pan to access the CDCS service. The heath pan or the heath pan s designee (usuay the care coordinator) who is responsibe for the heath coordination or case management functions wi estabish an individua s waiver budget. Costs reated to required case management and crimina background studies wi be excuded from that budget and are paid as a service expense through the heath pan. The cost for MSHO and MnDHO enroees who choose to have additiona fexibe case management support beyond that provided by their heath pan coordinator for deveopment and impementation of their Community Support Pan wi be incuded in their individua service budget. Recipients or their representatives have the right to seect and work with providers in their heath pan s network. To use an out-of-network provider, recipients must foow procedures deineated in the heath pan s Certificate of Coverage. If EVS indicates the person is an enroee of the Prepaid Medica Assistance Program (PMAP) or County-Based Purchasing (CBP), the county or tribe shoud administer the CDCS waiver service when it administers a other waiver services. The county or tribe must continue to coordinate their activities with the appropriate heath pan to insure continuity of care and that efforts and services are not dupicated. FY05 Note: During the first quarter of 2005, changes wi be made to the entity administering the Edery Waiver in some counties. CBP counties who are aso MOU counties (there are five- Freeborn, Steee, Brown, Goodhue and Itasca) wi begin to administer a waiver services, incuding CDCS, through the CBP organization. In addition, some non-cbp MOU counties (unnamed at this time) may be seected to participate in a managed partnership pan in which the managed care provider wi manage both state pan and waiver services, incuding CDCS. Expansion of this deivery system mode is expected to occur throughout Detais of these changes wi be shared with counties as they become avaiabe. 103

108 Section 16A: 16: CDCS Spenddowns, Notes Waiver for Peope Enroed Obigations in MSHO and & MnDHO CDCS Consumer Directed Community Supports Lead Agency Operations Manua 16A.1 Medica Assistance Spenddowns When Choosing CDCS The Financia Assistance unit of the ead agency is responsibe for determining the financia obigation of a medica assistance participant to contribute toward medica costs. The financia worker informs the consumer if they are responsibe for payments under a spenddown. Aso see Minnesota Heath Care Manua, documents/pub/dhs_id_ hcsp#p109_2243, Chapter 0913, for more detaied information about premiums and spenddowns. Under CDCS, a spenddown obigation works the same way as it woud under conventiona HCBS waiver programs. MA spenddown may be met with any combination of expenditures from State Pan services, pharmacy, or waiver services. MA spenddowns are to be met each month. The information beow outines consumer options for paying determined spenddown amounts. 1. Prepay DHS a Spenddown Consumers can choose to prepay their spenddown to DHS. This process is Cient Option Spenddown. The Financia Assistance unit wi determine if a person is eigibe to use this option. Consumers must sign DHS Form 3081 DHS Agreement to Prepay MA Spenddown. When this option is chosen, MMIS sends a bi directy to the cient No Designated Provider A spenddown can be met in a pot uck order. If the first caim that is submitted is from the Fisca Support Entity (FSE) who is the enroed CDCS service provider, then the FSE woud be responsibe for the coection of the spenddown from the cient. If the first caim that is submitted is from the County or Tribe for Required Case Management and/or background checks then they woud be responsibe to coect the spenddown from the cient. If the first caim that is submitted is from any other State Pan service or pharmacy provider, then that provider woud be responsibe to coect the spenddown from the cient. If the first caim does not satisfy the entire spenddown, then the next caim submitted wi determine who woud be responsibe for the coection of any remaining spenddown. Each caim submitted in the order it is processed in MMIS wi be used to decrement the spenddown unti the spenddown is satisfied. Each provider submitting the bis woud be responsibe for coecting the spenddown from the cient 1 Cients who have a Waiver Obigation cannot use this option. See the next section for information about CDCS and waiver obigation under the Specia Income Standard Edery Waiver program. 104

109 Consumer Directed Community Supports Lead Agency Operations Manua Section Section 16: CDCS 16A: Spenddowns, Notes for Peope Waiver Enroed in Obigations MSHO & and MnDHO CDCS 3. Designate a Provider It is vountary for a recipient to use a designated provider. A consumer can designate one provider to whom they wi pay their spenddown each month. The recipient with a spenddown can use a designated provider if: The recipient has a one month automated spenddown, and The recipient is the ony member of the MA/GAMC househod with a spenddown, and The provider they choose can meet the entire spenddown amount each month. If the cient chooses the designated provider option, the financia worker needs to be notified and the cient must sign DHS-3161 Agreement to Use a Designated Provider. The financia worker aso wi need the provider number of the designated provider to be entered into MMIS. A note on Designated Providers Providers cannot refuse to be a designated provider. MMIS sends a notice to the designated provider and the amount to be coected from the cient. The cient can choose which provider they want to be the designated provider. The designated provider can be a State Pan home heath care provider, (if one is incuded in the pan), another State Pan provider, the RCM, or the FSE provider. The person determines who the designated provider wi be, if any. Designated Provider Under CDCS If the FSE is chosen as the designated provider, then the spenddown wi be appied against a caims that are submitted through the FSE unti spenddown amount is met each month. The FSE woud aways be responsibe to coect the spenddown from the consumer. Payments to the FSE woud be decremented against unti the spenddown was met, no matter if other caims are submitted, nor in what order a the other caims are submitted. Any other provider can be chosen as the designated provider, as ong as a the criteria outined above can be met. The designated provider is aways responsibe to coect the spenddown unti it is fuy met. 105

110 Section 16A: 16: CDCS Spenddowns, Notes Waiver for Peope Enroed Obigations in MSHO and & MnDHO CDCS Consumer Directed Community Supports Lead Agency Operations Manua 16A.2 Specia Income Standard Edery Waiver and Waiver Obigation There are two income imits for individuas who are eigibe for the Edery Waiver Program. Under one imit, referred to as the Specia Income Standard, or the SIS-EW program, the consumer wi be responsibe to pay a waiver obigation. This obigation ony appies to their waiver services, not any other medica assistance covered services such as home care. 2 Go to Minnesota Heath Care Manua, documents/pub/dhs_id_ hcsp#p2661_191589, Chapter 0907, for information about eigibiity for Specia Income Standard Edery Waiver, incuding waiver obigations. Consumers who have a waiver obigation can aso use the designated provider option but must choose a waivered service provider as the designated provider. SIS-EW Waiver Obigation Since ony waiver services caims can be used to meet waiver obigation amounts, no other medica assistance provider caims wi be affected by waiver obigation amounts. 1. No Designated Waiver Provider The waiver obigation woud be met in a pot uck order. If the first caim that is submitted is from the Fisca Support Entity (FSE) who is the enroed CDCS service provider, then the FSE woud be responsibe for the coection of the waiver obigation from the cient. If the first caim that is submitted is from the County or Tribe for Required Case Management and/or background checks, then they woud be responsibe to coect the waiver obigation from the cient. If the first caim does not satisfy the entire waiver obigation, then the next caim submitted wi determine who woud be responsibe for the coection of the remaining waiver obigation. Each caim submitted by a waiver provider, in the order it is processed in MMIS, wi be used to decrement against the waiver obigation unti the obigation is satisfied. 2. Designated Provider For a CDCS cient, the designated provider can be the FSE or the ead agency for Required Case Management. The waiver obigation woud be met with the bis submitted through the FSE or ead agency. The designated provider woud be responsibe for coecting the waiver obigation from the cient. 2 For a other EW cients, some may have a medica assistance spenddown, and some wi not, depending on their financia and marita situation. 106

111 Consumer Directed Community Supports Lead Agency Operations Manua Section Section 16: CDCS 16A: Spenddowns, Notes for Peope Waiver Enroed in Obigations MSHO & and MnDHO CDCS If the FSE is designated, and the county or tribe bis for case management and/or background checks, these caims woud not be decremented for the waiver obigation no matter what order they were submitted. The FSE woud aways be responsibe to coect the waiver obigation. If the cient chooses the designated provider option the financia worker needs to be notified and the cient must sign DHS-3161 Agreement to Use a Designated Provider. The financia worker aso wi need the provider number of the FSE or ead agency to be entered into MMIS. 107

112 Section 16A: 16: CDCS Spenddowns, Notes Waiver for Peope Enroed Obigations in MSHO & and MnDHO CDCS Consumer Directed Community Supports Lead Agency Operations Manua 16A.3 Non payment of Waiver Obigation or Spenddown Whie Using CDCS Under the Federa Waiver amendment, one criterion for invountary exit from CDCS is inabiity to impement the approved support pan or compy with CDCS requirements despite efforts to provide additiona technica assistance. Faiure to impement the pan woud incude faiure to meet responsibiity for Edery Waiver obigations and Medica Assistance spenddowns. An unpaid waiver obigation or spenddown after the cient receives services is considered to be unpaid debt and the provider is not required to continue to serve recipients with outstanding debt. The provider must give sufficient notice to the cient which gives opportunity to repay the debt. If the recipient does not pay, the provider can refuse to provide care and the consumer can seek out services from other providers. If the cient does not pay the designated or pot uck provider after receiving services, the provider is to give sufficient notice to the cient concerning their obigation and reasonabe opportunity to pay the debt. The provider shoud aso inform the ead agency, who needs to provide Additiona Assistance and Technica Support. The ead agency wi provide some invovement to resove the non-payment issues. The ead agency shoud document a reasonabe efforts to provide the need for technica assistance. The documentation must incude: Identification of the probem Corrective action needed A timeine to accompish the action or payment of debt. Each discovery of non-compiance with the community support pan (non payment of waiver obigation or spenddown for services received) that requires a corrective action woud cause a CDCS Notice of Technica Assistance and Support to be sent to the consumer and a copy retained in the ead agency fie. When three documented efforts that do meet the forma definition of Technica Assistance and Support are fied and a fourth occurrence of need for corrective action occurs because of non-payment of waiver obigation or spenddown for services that have been deivered, the CDCS option can be terminated and cause an invountary exit from the CDCS program. The recipient woud sti be eigibe to receive other waiver services. 16A.4 Spenddowns and Waiver Obigations under MnDHO & MSHO MnDHO coects the spenddown and invoices the enroees monthy. Designated providers are not used for peope in the community. Cient Option spenddowns are used for these recipients. The same corrective action and a CDCS notice of TA woud be used for this program as we. MSHO instructions wi be added on how the participating pans coect waiver obigations and spenddowns. 108

113 Consumer Directed Community Supports Lead Agency Operations Manua Section 17: Notes About CDCS under AC 17.1 Notes About CDCS Under the Aternative Care Program (A buetin wi be pubished outining AC requirements reated to the addition of CDCS as a service option to this program. The buetin content wi aso be pubished and added to this manua at a ater date.) 109

114 Section 18: Caregiver Supports Consumer Directed Community Supports Lead Agency Operations Manua 18.1 CDCS and Unpaid Caregiver Supports Caregiver supports are intended to: Buid greater capacity for famiy or other informa caregivers to provide quaity care to the person supported under CDCS Extend the duration over which informa caregivers can provide support to that person Decrease caregiver burden by providing training, coaching, support counseing, and respite. DHS assessment and support panning forms contain a section for caregiver assessment and support panning. Both DHS Forms used for Community Support Panning, Form 4166 and 2925, contain a section that can be used to outine proposed caregiver support services. In order to approve proposed caregiver support services under CDCS, the proposed caregiver support services must be intended to accompish the goas isted above, and meet certain service criteria. For exampe, training for a caregiver must address specific needs of the person participating in a waiver or AC program. 110

115 Consumer Directed Community Supports Lead Agency Operations Manua Section 18: Caregiver Supports 18.2 Types of Caregiver Support Services Respite: The primary purpose of respite services is to give reief to the unpaid (typicay famiy) caregiver aowing a break from or decreasing the intensity of the caregiving responsibiities and routine. Respite services provide substitute caregiving at the eve of care and supervision necessary to ensure the heath and safety of the person. Respite can be an essentia service for caregivers provided on an intermittent, occasiona or emergency basis. Respite is provided to an informa caregiver whose support or care is an ongoing, dependabe, substantia part of the person s Community Support Pan. Under CDCS, respite or reief for a primary unpaid caregiver may be an important part of the person s support pan. Respite is the repacement of care or support provided to the recipient by the caregiver. Respite service woud be categorized as Persona Assistance Service if provided by a neighbor or friend or a PCA provider. Respite panned to be deivered in an institution woud be categorized as Treatment and Training, as woud in-home respite that wi be provided by a certified or icensed professiona staff. Famiy and Caregiver Training and Education is training and education provided to an informa caregiver who provides direct and ongoing services to a recipient. Training can incude instruction about treatment regimens, disease management, caregiver roes, or use of equipment as specified in the pan, for exampes. Education can incude caregiver counseing, incuding coaching, guidance or instruction directy reated to providing care to the person supported by a waiver or AC program. Approved coasts for training and education shoud be imited to the cost of the training or counseing (e.g. paying professiona or course or conference registration fess). Costs reated to transportation, odging and trave are not covered. Go to for information about provider standards for famiy and caregiver trainers and educators as defined for the Edery Waiver. Whie CDCS is intended to aow sef-design of provider standards where noted in this manua, approved caregiver training and education proposas shoud refect the use of trainers and/or educators who meet community standards and demonstrate competency in the training or education subject matter. Training must address a specific assessed need of the recipient and be intended to improve the quaity of care provided, increase the caregiver s knowedge about providing care, or assure caregiver heath and safety. 111

116 Section 19: Assurances for CDCS Consumer Directed Community Supports Lead Agency Operations Manua 19.1 HCBS Quaity Framework: Organizing Quaity Management Around Seven Quaity Focus Areas A states participating in 1915(c) (Medicaid) waiver programs must provide assurances concerning the quaity of care and services provided through these programs as a condition of federa approva of the state waiver pan. The Centers for Medicare/Medicaid Services (CMS) has reformatted the former federa assurances into a Quaity Framework that focuses attention on participant-centered desired outcomes aong seven dimensions. If you want to review the Quaity Focus Areas contained in the federa matrix, pease go to: The outcomes isted beow are those desired for a waiver participants, regardess of the type of service seected. Participant Access: Individuas have access to home and community-based services and supports in their communities. Participant-Centered Service Panning and Deivery: Services and supports are panned and effectivey impemented in accordance with each participant s unique needs, expressed preferences and decisions concerning his/her ife in the community. Provider Capacity and Capabiities: There are sufficient HCBS providers and they possess and demonstrate the capabiity to effectivey serve participants. Participant Safeguards: Participants are safe and secure in their homes and communities, taking into account their informed and expressed choices. Participant Rights and Responsibiities: Participants receive support to exercise their rights and in accepting persona responsibiities. Participant Outcomes and Satisfaction: Participants are satisfied with their services and achieve desired outcomes. System Performance: The system supports participants efficienty and effectivey and constanty strives to improve quaity. 112

117 Consumer Directed Community Supports Lead Agency Operations Manua Section 19: Assurances for CDCS 19.2 The HCBS QA/QI Pan - Loca Agency HCBS Quaity Assurance & Improvement Responsibiities Each county or triba agency or heath pan administering home and community waiver services programs, Long Term Care Consutation, or the Aternative Care programs must deveop and impement a pan for quaity assurance in Home and Community-Based programs (HCBS QA/QI Pan). The pan is forwarded to DHS biannuay to demonstrate that the agency: Is impementing programs according to statute Is carrying out deegated quaity assurance, monitoring, and assessment activities necessary to achieve desired program outcomes, and Has poicies and practices in pace to ensure the heath and safety and participation and choice-making of consumers participating in these programs. Under this pan, the ead agency addresses both state and federa quaity assurance and improvement requirements for the Long Term Care Consutation and Aternative Care programs, as we as the Edery Waiver, Community Aternatives for Disabed Individuas Waiver, MR/RC Waiver, Traumatic Brain Injury Waiver, and Community Aternative Care Waiver programs. The most recent pan submitted at the time of the pubication of this manua was that for , forwarded by the ead agency in fa 2004 via web-based survey. To see a worksheet version of the pan, go to 113

118 Section 19: Assurances for CDCS Consumer Directed Community Supports Lead Agency Operations Manua 19.3 Appying the Quaity Framework to CDCS Here is a brief ist of requirements reevant to CDCS, organized around the quaity focus areas or domains. These are requirements in addition to those that are appicabe to HCBS in genera. Access to CDCS: Individuas have compete information about CDCS, incuding budget amounts Individuas have access to CDCS in their community Individuas have access to supports and resources to make CDCS a viabe aternative. Participant-Centered CDCS Services Panning and Deivery: Services are panned by consumers using person-centered panning toos and approaches Services are directed by consumers Lead agencies approve CDCS pans by appying required criteria. Provider Capacity & Capabiity: There are sufficient Fisca Support Entities and Fexibe Case Management providers to ensure choice CDCS staff possess and demonstrate the capabiity to effectivey serve participants. Participant Safeguards: Community support pans incude persona risk management, emergency back up, and crisis services pans Support staff, FCM, and FSE understand their roe as mandated reporters of suspected vunerabe adut or chid abuse, negect, or expoitation County Adut and Chid Protection agencies provide appropriate interventions, incuding support services, to ensure heath and safety and an individua s right to manage risk. Participant Rights and Responsibiities: Participants understand their roe as empoyer and other responsibiities Participants have access to support, toos, and other resources to effectivey carry out their responsibiities Participants receive information about their right to appea ead agency decisions reated to their support pan and choices in service deivery, training requirements outined, or any other condition of their CDCS or waiver approva by the ead agency Participants receive support to exercise their rights. 114

119 Consumer Directed Community Supports Lead Agency Operations Manua Section 19: Assurances for CDCS Participant Outcomes and Satisfaction: Participants deveop individuaized CDCS outcomes or desired resuts Participants are satisfied with their services and achieve desired outcomes. System Performance: Reports and Monitoring Requirements Approved CDCS pans support participants efficienty and effectivey Approved pans incude quaity monitoring roes and schedues The ead agency meets monitoring and reporting requirements. Appendix G incudes a Sef-Assessment for each ead agency to use to review those practices and poicies identified as being necessary to achieve the program and individua outcomes for CDCS isted above. 115

120 Appendix G Consumer Directed Community Supports Lead Agency Operations Manua Appendix G: CDCS Quaity Assurance and Improvement Activity: Lead Agency Sef-assessment The ead agency: Yes No Provides information about CDCS as a service option to a waiver appicants Yes Yes Yes Yes Yes 116 No Provides each person at assessment and reassessment with the consumer CDCS Brochure (DHS-4124) No Has a compete CDCS Too Kit avaiabe for review and use by potentia CDCS users No Carries out pubic education activity reated to the avaiabiity of CDCS No Provides information about budget amounts to hep peope choose the service options that best meet their needs and preferences No Expains Fexibe Case Management service as an option to hep the person access and continue to use CDCS Participant-centered CDCS Services Panning and Deivery: Person-centered panning is centra to using CDCS services and supports. A supports are expressy panned and effectivey impemented and directed by each participant. The pan wi refect the person s unique needs, expressed preferences, and decisions concerning his/her ife in the community. The ead agency: Yes No Offers the consumer a choice in person-centered panning toos and eve of invovement Ensures that pans submitted for approva by CDCS consumers: Yes No Incude the frequency, source, rate, and duration of support or service from a sources. Yes Yes Yes Yes No Incude frequency, payment rate, and description of Fexibe Case Management service. No Outine training or other requirements for persona assistance, and pans to verify training is competed/adequatey. No Identify background checks requested by consumer and how findings wi be incorporated into or affect pan approva. No Appropriatey address/incude services recommended by other professionas, incuding physicians, invoved in assessment/panning.

121 Consumer Directed Community Supports Lead Agency Operations Manua Appendix G Yes Yes No Incude communication pans to accommodate changes in the person s condition, preferred services, or desired outcomes. No Incorporate the individua s personay deveoped outcome and quaity indicators and monitoring roe and schedue. Provider Capacity There are sufficient FSE and FCM providers. CDCS staff possess and demonstrate the capabiity to effectivey serve participants. The ead agency: Yes Yes Yes Yes No Has poicies and practices that ensure that FSE providers meets appicabe state and federa standards No Has poicies and practices that ensure that FCM providers meets appicabe state and federa standards No Provides ists to consumers of a quaified FSE and FCM No Reviews provider records on a periodic basis to ensure that the provider is adequatey documenting the deivery of services to conform with the individua s support pan. This shoud incude review of individua fies and invoices. The ead agency may carry out activity to increase choice between FSE and FCM providers. Yes No Recruits FSE providers Yes Yes Yes Yes No Recruits cuturay competent providers No Assesses the need for service providers with specia knowedge, ski or background to provide support to peope with dua diagnosis or communication imitations, etc. No Provides equa consideration to a providers who meet appicabe standards No Maintains a directory of a quaified service providers for the CDCS consumer who wants to combine non-cdcs and CDCS. 117

122 Appendix G Consumer Directed Community Supports Lead Agency Operations Manua Participant Safeguards Participants are safe and secure in their homes and communities, taking into account their informed and expressed choices. The ead agency: Yes No Has poicies and procedures for monitoring the heath and safety of the person at east annuay Yes No Has poicies for evauating unsafe home conditions Yes No Has poicies for evauating need for supervision Yes No Incorporates persona risk management in support panning Yes No Reviews LTCC staff competion of Environmenta Safety section of the Community Assessment Form (DHS-3428) or equivaent Yes No Required Case Manager has face-to-face contact with the person as indicated in the community support or care pan, and as required under various programs. Yes No Has poicies in pace for the CDCS participant, FCM, or persona assistant to foow if probems arise concerning the person Yes No Ensures the person has a contingency pan for emergencies when the ack of immediate care woud pose a serious threat to heath and wefare. This assurance is directed at community-wide emergencies such as those posed by incement weather. Yes No Ensures the person has a pan for backup assistance when providers aren t avaiabe and ack of immediate care woud pose a serious threat to heath and wefare. This assurance is intended to be in pace at the individua cient eve and to refect individuaized panning. Vunerabe Adut & Chid Protection: The ead agency has poicies and practices that address: Yes No The prevention of abuse, negect and expoitation Yes No Screening for abuse, negect, and expoitation Yes No Identification of abuse, negect, and expoitation Yes No Investigation of abuse, negect, and expoitation Yes No Reporting abuse, negect, and expoitation Yes No Actions to be taken when the heath or safety of a person has not been safeguarded Yes No Does the ead agency have poicies/procedures that address training directy reated to abuse, negect, and expoitation Yes No Has the ead agency deveoped communication processes that create an appropriate, efficient feedback oop between adut or chid protection and case manager. 118

123 Consumer Directed Community Supports Lead Agency Operations Manua Appendix G Participant Rights and Responsibiities Participants receive support to exercise their rights and in accepting persona responsibiities. The ead agency ensures: Yes No The person receives information about data privacy Yes Yes Yes Yes No About their rights to appea county decisions regarding CDCS services and/or access to programs, incuding denia of expenditures and faiure to approve the support pan No The ead agency provides the person with information regarding Ombudsman services. No The ead agency ensures the person aways receives a copy of service agreements or prior authorizations that incudes information about appeaing those decisions No The ead agency has poicies and procedures in pace to ensure peope have access to guardianship or conservator services. Participant Outcomes and Satisfaction Participants are satisfied with their services and achieve desired outcomes. Does the ead agency conduct consumer satisfaction surveys reated to the provision of CDCS? Yes No System Performance: Reports and Monitoring Requirements The system supports participants efficienty and effectivey and constanty strives to improve quaity. A. Consumer Monitoring and Reporting: Support pans incude monitoring schedues, roes, what inputs and outcomes wi be monitored. Consumer has a method and format for monitoring. B. FSE Monitoring and Reporting FSE provides monthy standardized reports to famiy members and counties as required to maintain certification. Reports incude monthy expenditure and baances information to consumer. Reports incude identification of persons with over or underspending. 119

124 Appendix G Consumer Directed Community Supports Lead Agency Operations Manua C. Lead Agency Monitoring and Reporting Lead agency submits required reports to DHS. Reports incude measures of satisfaction Reports incude utiization, budget and discharge information. Conducts additiona reviews and monitoring activity required when a spouse or parent is a paid persona assistant. D. Required Case Management: Reassessment Reassessments of waiver eigibiity occurs at east annuay. Support pan is reviewed for continuing adequacy, appropriateness. 120