Understanding the New Fee for Service System: An Overview for Individuals and Families New Jersey Department of Human Services Division of Developmental Disabilities October 21, 2014 Elizabeth M. Shea Assistant Commissioner Thomas Papa Chief of Staff
Fee for Service Shift: Part of a Larger Reform Effort Shifting to a Life Course model Promoting full community participation Moving from institutional to community-based support Moving to a Supportive Housing model Creating consistency to ensure equity across the system Maximizing federal reimbursement to serve more individuals Establishing a two-waiver system 2
What is a Fee for Service (FFS) System? A change in the way providers are reimbursed OLD Annual contracts between DDD and providers (payment prior to service) Slot -based/ Program -based NEW: FFS Providers submit claims for payment after service Billable service unit by individual Multiple rates for similar services Standard rates for standardized services 3
What is a Fee for Service (FFS) System? In some cases, shift from contract-based programs to combination of discreet services FOR EXAMPLE: Day Program (Old Model)* Day Habilitation Services: 18 hours/week Prevocational Training: 6 hours/week Speech Therapy: 1 hours/week *Based on a 25 hour/week day program. PLEASE NOTE: FFS system reforms include an increase in the maximum # of Day Habilitation service hours to 30 per week. 4
Standardized Rates Rate Study Comprehensive rate study January 2013 July 2014 Resulted in Final Rate Report and Rate Schedule available at: www.nj.gov/humanservices/ddd/programs/ffs_implementation.html Standard Rates for Standard Services Needs-based assessment tied to individual Services tied to needs-based assessment Rates tied to standardized services 5
REMINDER: FFS System is Built on a Medicaid Platform Individual served must be enrolled on Medicaid Enrolled on either the Supports Program or Community Care Waiver (CCW) Enrolled at the time of service delivery (Medicaid eligibility must be maintained) Transitioning to Fee for Service moves funding from a program basis to each individual for each discreet service 6
REMINDER: FFS System is Built on a Medicaid Platform Provider must be an approved Medicaid/DDD provider for each separate service Must meet all qualifications for the service Must produce all necessary documentation Must complete the Combined Application (Medicaid/DDD) 7
REMINDER: FFS System is Built on a Medicaid Platform Service must be a Medicaid Waiver service Community Care Waiver or Supports Program (Comprehensive Waiver) Become familiar with the service definitions Setting must be Home and Community Based Implications of CMS Final Rule? Service must be documented in the Individual Service Plan (ISP) 8
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Fee for Service Rate Schedule: Quick Reference Guide Types of Rates Single Unit, Single Person Rates per person rate per unit of service (Ex: Career Planning) Tiered Rates- per person rate is determined by an individual s assigned tier level, documented in ISP (Ex: Day Habilitation) Stepped Rates per person rate is determined by actual staffing ratio (Ex: Physical Therapy) Negotiated Rates services with no standard rate (Ex: Assistive Technology) Rates still being analyzed Supports Brokerage, Transportation 12
How do the Standard Rates Apply to Self Hires? Some services in the FFS System may be delivered by self hires individuals chosen by, and managed by, a consumer/family member as opposed to a provider agency. Self hires will use the same standard rate schedule for each applicable service; however the rate for self hires like all other providers must cover all cost components (i.e. benefits, employment taxes, administrative costs for the fiscal intermediary, etc.). 13
What Services will be Available in the FFS System? In most cases, the same services individuals receive today will be available, however: The way providers are reimbursed is changing; and Programs will have to be unbundled and differentiated into discreet services Familiarity with the available services is key to understanding: How your current services are potentially changing; and What new service options may be available 14
Services Available Supports Program Assistive Technology (B) Environmental Modifications (B) Prevocational Training (B) Behavioral Management (B) Financial Management Services FI (SP) Respite (B) Career Planning (B) Goods and Services (SP) Speech, Language and Hearing Therapy (B) Case Management (CCW) Individual Supports (CCW) Support Coordination (B) Cognitive Rehabilitation (SP) Interpreter Services (SP) Supported Employment Individual (B) Community Based Supports (SP) Natural Supports Training (SP) Supported Employment Small Group (B) Community Inclusion Services (SP) Occupational Therapy (B) Supports Brokerage (SP) Community Transition Services (CCW) Personal Emergency Response System (B) Transportation (B) Day Habilitation (B) Physical Therapy (B) Vehicle Modifications (B) SP=Supports Program CCW=Community Care Waiver B=Both 15
Services Available Community Care Waiver* Assistive Technology (B) Environmental Modifications (B) Prevocational Training (B) Behavioral Management (B) Financial Management Services FI (SP) Respite (B) Career Planning (B) Goods and Services (SP) Speech, Language and Hearing Therapy (B) Case Management (CCW) Individual Supports (CCW) Support Coordination (B) Cognitive Rehabilitation (SP) Interpreter Services (SP) Supported Employment Individual (B) Community Based Supports (SP) Natural Supports Training (SP) Supported Employment Small Group (B) Community Inclusion Services (SP) Occupational Therapy (B) Supports Brokerage (SP) Community Transition Services (CCW) Personal Emergency Response System (B) Transportation (B) Day Habilitation (B) Physical Therapy (B) Vehicle Modifications (B) *DRAFT only, pending final CMS approval SP=Supports Program CCW=Community Care Waiver B=Both 16
Services Available Employment Assistive Technology (B) Environmental Modifications (B) Prevocational Training (B) Behavioral Management (B) Financial Management Services FI (SP) Respite (B) Career Planning (B) Goods and Services (SP) Speech, Language and Hearing Therapy (B) Case Management (CCW) Individual Supports (CCW) Support Coordination (B) Cognitive Rehabilitation (SP) Interpreter Services (SP) Supported Employment Individual (B) Community Based Supports (SP) Natural Supports Training (SP) Supported Employment Small Group (B) Community Inclusion Services (SP) Occupational Therapy (B) Supports Brokerage (SP) Community Transition Services (CCW) Personal Emergency Response System (B) Transportation (B) Day Habilitation (B) Physical Therapy (B) Vehicle Modifications (B) SP=Supports Program CCW=Community Care Waiver B=Both 17
Services Available Day Services Assistive Technology (B) Environmental Modifications (B) Prevocational Training (B) Behavioral Management (B) Financial Management Services FI (SP) Respite (B) Career Planning (B) Goods and Services (SP) Speech, Language and Hearing Therapy (B) Case Management (CCW) Individual Supports (CCW) Support Coordination (B) Cognitive Rehabilitation (SP) Interpreter Services (SP) Supported Employment Individual (B) Community Based Supports (SP) Natural Supports Training (SP) Supported Employment Small Group (B) Community Inclusion Services (SP) Occupational Therapy (B) Supports Brokerage (SP) Community Transition Services (CCW) Personal Emergency Response System (B) Transportation (B) Day Habilitation (B) Physical Therapy (B) Vehicle Modifications (B) SP=Supports Program CCW=Community Care Waiver B=Both 18
Services Available Personal Care & Staff Supports Assistive Technology (B) Environmental Modifications (B) Prevocational Training (B) Behavioral Management (B) Financial Management Services FI (SP) Respite (B) Career Planning (B) Goods and Services (SP) Speech, Language and Hearing Therapy (B) Case Management (CCW) Individual Supports (CCW) Support Coordination (B) Cognitive Rehabilitation (SP) Interpreter Services (SP) Supported Employment Individual (B) Community Based Supports (SP) Natural Supports Training (SP) Supported Employment Small Group (B) Community Inclusion Services (SP) Occupational Therapy (B) Supports Brokerage (SP) Community Transition Services (CCW) Personal Emergency Response System (B) Transportation (B) Day Habilitation (B) Physical Therapy (B) Vehicle Modifications (B) SP=Supports Program CCW=Community Care Waiver B=Both 19
Services Available Therapies & Related Assistive Technology (B) Environmental Modifications (B) Prevocational Training (B) Behavioral Management (B) Financial Management Services FI (SP) Respite (B) Career Planning (B) Goods and Services (SP) Speech, Language and Hearing Therapy (B) Case Management (CCW) Individual Supports (CCW) Support Coordination (B) Cognitive Rehabilitation (SP) Interpreter Services (SP) Supported Employment Individual (B) Community Based Supports (SP) Natural Supports Training (SP) Supported Employment Small Group (B) Community Inclusion Services (SP) Occupational Therapy (B) Supports Brokerage (SP) Community Transition Services (CCW) Personal Emergency Response System (B) Transportation (B) Day Habilitation (B) Physical Therapy (B) Vehicle Modifications (B) SP=Supports Program CCW=Community Care Waiver B=Both 20
Services Available Care Coordination Assistive Technology (B) Environmental Modifications (B) Prevocational Training (B) Behavioral Management (B) Financial Management Services FI (SP) Respite (B) Career Planning (B) Goods and Services (SP) Speech, Language and Hearing Therapy (B) Case Management (CCW) Individual Supports (CCW) Support Coordination (B) Cognitive Rehabilitation (SP) Interpreter Services (SP) Supported Employment Individual (B) Community Based Supports (SP) Natural Supports Training (SP) Supported Employment Small Group (B) Community Inclusion Services (SP) Occupational Therapy (B) Supports Brokerage (SP) Community Transition Services (CCW) Personal Emergency Response System (B) Transportation (B) Day Habilitation (B) Physical Therapy (B) Vehicle Modifications (B) SP=Supports Program CCW=Community Care Waiver B=Both 21
Services Available Accessibility & Related Assistive Technology (B) Environmental Modifications (B) Prevocational Training (B) Behavioral Management (B) Financial Management Services FI (SP) Respite (B) Career Planning (B) Goods and Services (SP) Speech, Language and Hearing Therapy (B) Case Management (CCW) Individual Supports (CCW) Support Coordination (B) Cognitive Rehabilitation (SP) Interpreter Services (SP) Supported Employment Individual (B) Community Based Supports (SP) Natural Supports Training (SP) Supported Employment Small Group (B) Community Inclusion Services (SP) Occupational Therapy (B) Supports Brokerage (SP) Community Transition Services (CCW) Personal Emergency Response System (B) Transportation (B) Day Habilitation (B) Physical Therapy (B) Vehicle Modifications (B) SP=Supports Program CCW=Community Care Waiver B=Both 22
What Does this Change Mean for Individuals and Families? Increased flexibility Services billed in smaller units Unbundling of transportation Unbundling of programs Increased choice Enhanced services More providers to choose from Increased quality Open, competitive market Division s enhanced quality monitoring (including disenrollment of providers delivering sub-standard services) 23
How will the new FFS System work? NJ Comprehensive Assessment Tool (NJ CAT) Support Coordination model for all participants Individualized Service Plan (ISP) Person Centered Planning Tool (PCPT) Prior authorization of services Provider claims and gets paid after service is rendered Amended as needed throughout the year, re-done annually Quality Monitoring Provider qualifications and approval Provider and individual outcome monitoring Provider disenrollment if needed Support Coordination quality monitoring 24
Checklist: What Can Individuals/Families Do to Prepare? Ensure and maintain Medicaid eligibility Become familiar with new services and draft service definitions www.nj.gov/humanservices/ddd/programs/ffs_implementation.html Research Support Coordination Boggs Center Guide Selecting a Support Coordination Agency: Making Choices, Becoming Empowered http://rwjms.rutgers.edu/boggscenter/projects/infopeopleandfamilies.html 25
Checklist: What Can Individuals/Families Do to Prepare? Talk to your provider What are their plans? Will they continue to offer the same services? Are they familiar with the new services and service definitions? Review/understand new Individualized Service Plan (ISP) Person Centered Planning Tool (PCPT) Employment-related outcome 26
Fee for Service Resources FFS Implementation Timeline Additional Frequently Asked Questions & Webinars Fee for Service Implementation web page: www.nj.gov/humanservices/ddd/programs/ffs_implementation.html Fee for Service Helpdesk email: DDD.FeeforService@dhs.state.nj.us 27
Q & A 28