PLANNING FOR TRANSITION:

Transcription

1 PLANNING FOR TRANSITION: Habilitation Supports Waiver vs. MI Choice Waiver Elizabeth Gallagher, Manager, Home & Community Based Services Section, MDCH Belinda Hawks, Federal Compliance Manager, Division of Quality Management and Planning, BHDDA, MDCH November 19, 2014 Michigan Department of Community Health 1

2 TODAY S FOCUS The special issues for people who will be turning age 21 and no longer eligible for Private Duty Nursing (PDN) through the Medicaid State Plan. More emphasis on the MI Choice Waiver since this audience is familiar with the Habilitation Supports Waiver (HSW). Michigan Department of Community Health 2

3 MEDICAID STATE PLAN Until age 21, every Medicaid beneficiary who meets medical necessity for PDN is eligible to receive the State Plan service called Private Duty Nursing. Michigan Department of Community Health 3

4 HOW DOES SOMEONE GET PDN IF THEY ARE AGE 21 OR OLDER? PRIVATE DUTY NURSING FOR BENEFICIARIES AGES 21+ Habilitation Supports Waiver Program by PIHP/CMHSP MI Choice Waiver Program by waiver agency NOTE: PDN may be provided to a person living in a licensed setting, such as an adult foster care home, as long as he/she does not need a nurse to either provide care or direct the care of other staff 24-hrs a day. Michigan Department of Community Health 4

5 TRIGGER FOR TRANSITION PLANNING Aging off PDN state plan services on 21 st birthday Michigan Department of Community Health 5

6 WHEN SHOULD TRANSITION PLANNING BEGIN? The first transition planning meeting should be at least 6 months prior to the 21 st birthday. Transition planning is a series of activities that is finished only when the person enrolls in the program that best meets his or her needs. Michigan Department of Community Health 6

7 WHO SHOULD BE INVOLVED? Initial Meeting: the person, family or friends as identified by the person, guardian if applicable, the CM/SC, and others identified by the person or family Transition Planning Conference Call: Same as listed above Subsequent Communication (may be in-person or by phone): Those listed above plus representatives of potential programs or providers. How often: As often as necessary to make sure the person can make an informed decision about which program in which to enroll. Michigan Department of Community Health 7

8 STEPS IN THE TRANSITION PROCESS 1. Identification of Needs 2. Making Informed Choice 3. Pursue Referral for Assessment of Eligibility & Services/Supports 4. Provide close follow-up with family until decision has been made and enrollment has been completed. NOTE: A person cannot be enrolled in both the MI Choice Waiver and HSW. This is because there are two different LOC alternatives. Michigan Department of Community Health 8

9 TRANSITION PLANNING CONFERENCE CALL About 6 months before the 21 st birthday, MDCH will facilitate a conference call. Participants: Person and Family HSW representative (Belinda Hawks) MI Choice representative (Elizabeth or Carol Hansen) CSHCS representative (Anthony Spagnuolo and Public Health Nurse PIHP representative (HSW Coordinator, SC) MI Choice representative (Waiver Director, Supervisor or Supports Coordinator) Michigan Department of Community Health 9

10 TRANSITION PLANNING CONFERENCE CALL Purpose of the call Make sure all parties are familiar with both MI Choice and HSW and have the same information Let the family know about the transition process Address any concerns the family may have with the transition Answer questions from any of the parties Enable the family to make an informed choice once they understand the options they have. The family may decide during the call which program they want to apply for or might ask that both programs complete an initial assessment before deciding. Michigan Department of Community Health 10

11 TRANSITION PLANNING CONFERENCE CALL The purpose of this initial conference call is to provide information and to determine a course of action for the family. The conference call DOES NOT: Determine which program the person will choose (in most cases) Determine the plan of care after the age of 21 Force the family to make an immediate decision Michigan Department of Community Health 11

12 WHAT DO WE NEED TO KNOW ABOUT THE DIFFERENT PROGRAMS? WHERE DO WE GO TO ASK FOR SERVICES? Michigan Department of Community Health 12

13 OVERVIEW OF MI CHOICE The MI Choice Waiver is designed to enable the elderly and younger disabled adults (age 18 & older) to remain at home and to participate in their communities. The waiver serves approximately 14,000 adults each year. Michigan Department of Community Health 13

14 REFERRAL TO MI CHOICE Persons interested in enrolling in MI Choice must work with a waiver agent that serves their county of residence. Michigan Department of Community Health 14

15 REFERRAL TO MI CHOICE To find a local waiver agent or for more information on the MI Choice Waiver: Click on Health care coverage. Click on Services for seniors. Click on Choices for older or disabled persons who may need help caring for themselves. Michigan Department of Community Health 15

16 REFERRAL TO MI CHOICE (cont d) Ask for an assessment of eligibility for MI Choice waiver services. An intake specialist will conduct a pre-screen over the phone If applicant passes the pre-screen, the specialist will schedule an inperson assessment. OFTEN THIS IS AVOIDED WHEN MI CHOICE AGENT PARTICIPATES IN THE ORIGINAL CONFERENCE CALL. Michigan Department of Community Health 16

17 WAITING LISTS Waiting lists are managed with four priority categories as listed below in descending priority: 1. Adults aging off of Medicaid State Plan Private Duty Nursing whose services are authorized by Medicaid Program Review Division 2. Nursing Facility residents 3. Persons with active Adult Protective Services cases or Persons at imminent risk of nursing facility placement 4. All other applicants by date of inquiry Michigan Department of Community Health 17

18 MI CHOICE ASSESSMENT Once an applicant is at the top of the waiting list the following happens: A supports coordination team comprised of a Registered Nurse (RN) and licensed Social Worker (SW) will meet with the applicant in their home to complete an assessment. During the assessment, the team will determine likelihood of eligibility Will start person-centered planning Will start development of a plan of care if likely eligible Michigan Department of Community Health 18

19 NFLOC Nursing Facility Level of Care To be eligible for the MI Choice Waiver, applicants must meet the NFLOC. This is a set of functional and medical criteria one must meet to qualify for a Medicaid-funded nursing facility stay. Applicants for the MI Choice Waiver must demonstrate they meet this same criteria. Most applicants qualify by needing assistance with their ADLs. Home and Community Based Waivers enable states to provide services to Medicaid beneficiaries in the community who would otherwise need institutional level of care. The MI Choice Waiver has NFLOC as the alternative institutional level of care. Michigan Department of Community Health 19

20 MI CHOICE ELIGIBILITY REQUIREMENTS Must meet nursing facility level of care (NFLOC) MI Choice waiver agents must apply the Michigan Medicaid Nursing Facility Level of Care Determination tool to persons applying for enrollment in the program Applicants must pass through one of the seven doors Michigan Department of Community Health 20

21 FINANCIAL ELIGIBILITY FOR MI CHOICE WAIVER Must be eligible for Medicaid Maximum income is 300% SSI ($2,163/mo. GROSS in calendar year 2014, $2,199/mo. GROSS in calendar year 2015) Spousal protections apply Waiver participants are considered a group of one Waiver participants do not have a spend-down (Medicaid Deductible) Michigan Department of Community Health 21

22 SERVICE NEED REQUIREMENTS Applicant must demonstrate, through the assessment process, the need for at least one MI Choice waiver service Waiver participants must receive at least one MI Choice service (in addition to supports coordination) on a regular basis to maintain program eligibility. Michigan Department of Community Health 22

23 MI CHOICE AVAILABLE SERVICES Adult Day Health Chore Services Community Living Supports Community Transition Services Counseling Environmental Accessibility Adaptations Fiscal Intermediary Goods and Services Home Delivered Meals Non-Medical Transportation Nursing Services Personal Emergency Response Systems Private Duty Nursing Respite Specialized Medical Equipment & Supplies Supports Coordination Training Michigan Department of Community Health 23 23

24 MI CHOICE ENROLLMENT If PDN State Plan age out, usually on 21 st birthday, may be sooner if need MI Choice services other than PDN Cannot enroll before date of initial assessment by waiver agent Can still receive all State Plan Services including mental health services through the PIHP, but careful coordination must occur so there is no duplication of services. Must use MI Choice Community Living Supports for ADL/IADL needs Cannot use both MI Choice and Home Help program for personal care services. Michigan Department of Community Health 24

25 MI CHOICE & PDN AGE-OUTS The MI Choice waiver agent participates in the conference call and will be familiar with the participant/family Often the waiver agent will provide the family a direct number to call to schedule an assessment. In-home assessment should be completed by the waiver agent within 7 days of contact If waiver agent has waiting list, this may take longer CSHCS age-outs should not have to wait. If problems, contact Elizabeth Gallagher at or GallagherE@michigan.gov Michigan Department of Community Health 25

26 MI CHOICE ENROLLMENT Two Options for Service Delivery Traditional/Agency Based All workers must be employed by an agency in the waiver agent s provider network. Self-Determination Can choose own workers Workers cannot be legally responsible for participant (i.e. spouse or guardian) Participants can use a mixture of Traditional and Self-Determined services Michigan Department of Community Health 26

27 MI CHOICE POLICY MI Choice Chapter in Medicaid Policy Manual can be found at: Michigan Department of Community Health 27

28 APPLICANT S RIGHT TO APPEAL Waiver agent must inform applicant of their right to appeal throughout the process If applicant put on waiting list If applicant does not pass telephone screen If applicant does not meet NFLOC If applicant does not meet other enrollment criteria If applicant requests services that are not authorized Michigan Department of Community Health 28

29 OVERVIEW of The Habilitation Supports Waiver (HSW) The purpose of the HSW is to enable people of any age who have an intellectual disability to live and participate as productive members of their communities instead of living in institutions. This waiver serves approximately 8,000 people each year. Michigan Department of Community Health 29

30 ICF/IID Intermediate Care Facility for Individuals with Intellectual Disabilities To be eligible for the HSW, an individual must require the LOC provided by an ICF/IID if not for waiver services. This means an individual with a DD/ID would otherwise need an active treatment program of specialized and/or generic training, treatment, health and related services directed toward the acquisition of behaviors necessary to function with as much selfdetermination and independence as possible. Home and Community Based Waivers enable states to provide services to Medicaid beneficiaries in the community who would other need institutional level of care. The HSW has ICF/IID as the alternative institutional level of care. Michigan Department of Community Health 30

31 ELIGIBILITY REQUIREMENTS FOR HSW Must have a I/DD Must be living in the community while receiving HSW services Without HSW services, would otherwise require level of care services in an institution (ICF/IID) Must be eligible for Medicaid Must receive at least one HSW service each month Michigan Department of Community Health 31

32 ADDITIONAL INFORMATION FOR HSW Part of the managed care mental health system First priority for enrollment given equally to young adults aging off CWP and individuals discharged from ICF/IID. We do also try to prioritize people aging off state plan PDN if they are eligible to enroll in & choose HSW. PDN providers must be enrolled in the PIHP network if the person will be receiving PDN services through the HSW. Michigan Department of Community Health 32

33 REFERRAL TO HSW The person or his/her legal representative contacts the Access Center through the PIHP or local CMHSP Request an intake assessment to determine eligibility for DD services PIHP initiates assessment within 14 days of request If eligible for DD services, PIHP completes an individual plan of services to determine amount, scope and duration of services to be provided PIHP submits an application for HSW enrollment If not eligible, the PIHP notifies the person of his/her right to fair hearing Michigan Department of Community Health 33

34 RESOURCES FOR HSW Go to the Medicaid Provider Manual on the internet at: al.pdf Click on the Mental Health and Substance Abuse Chapter, Section 15. Michigan Department of Community Health 34

35 HOW DO WE HELP THE FAMILY CHOOSE THE BEST PROGRAM Decision which program to enroll in must: consider the unique needs and desired outcomes of the individual and family; use the person-centered planning process; be based on clear, comprehensive, accurate information about both programs and the services each can offer so the individual and family can make an informed choice; include timely assessments, determine eligibility and medical necessity for the services; and for HSW, determine whether the person needs and wants to participate in at least one habilitative service in addition to receiving PDN. Michigan Department of Community Health 35

36 COMPARISON OF MI CHOICE AND HSW PDN MI Choice Available for qualified participants aged 21+ HSW LOC Nursing Facility ICF/IID Available for adults with DD age 21+ (or younger without PDN) MA Hlth Plans Services PC Other Exempt Must receive at least one MI Choice service/month and SC Obtained thru MI Choice as CLS, not Home Help Once enrolled, no spend-down Offers services not in HSW Exempt Must participate in one habilitative waiver service in addition to PDN/mo. Must use Home Help (thru DHS) Offers services not in MI Choice Michigan Department of Community Health 36

37 Providing the person and family with information about the different features of each program and assisting with securing the necessary assessments or other intake requirements, the person can find the set of supports and services that is the best fit to meet his or her needs and help to achieve future goals. Michigan Department of Community Health 37

38 QUESTIONS ABOUT TRANSITION PLANNING IN THE REAL WORLD? Michigan Department of Community Health 38

39 CONTACT INFORMATION Elizabeth Gallagher, Manager, HCBS Section or Belinda Hawks, Manager, Federal Compliance Section, Division of Quality Management and Planning or Michigan Department of Community Health 39