Innovations Waiver Update - Alliance Health · 9/3/14 through 10/27/14 – individuals with I/DD...
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Innovations Waiver Update (effective November 1, 2016)
Transcript of Innovations Waiver Update - Alliance Health · 9/3/14 through 10/27/14 – individuals with I/DD...
Innovations Waiver Update(effective November 1, 2016)
Training Overview
• Disclaimer
• How we arrived here
• Supports Intensity Scale (SIS)
• Resource Allocation
• Information on services-new and changed
Stakeholder Engagement
• Consumer, advocate and provider input through listening sessions which were held across the state from 9/3/14 through 10/27/14 – individuals with I/DD and their families, providers, MCO staff and advocacy groups.
• IDD State Stakeholder Group met on a regular basis from August 2014 through October 2015. Included Service recipients, family members, State and local CFACs, providers, provider associations and advocacy organizations.
Stakeholder Engagement
• Resource Allocation is a way that policymakers can make disciplined fiscal choices that are fair, make the best use of available money, but also are consistent with driving system principles.
• Resources are allocated to people based on their assessed level of need, so that each person receives what they need – no more and no less.
• The resulting model is a “best fit” solution so care must also be taken to accommodate individuals with extraordinary needs.
Resource Allocation
Resource Allocation
Terminology:
SIS
Individual Budget Tool
Base Budget
Base Budget Services
Non-base Budget Services
Resource AllocationThe Supports Intensity Scale (SIS) is an assessment tool to measure the supports an individual needs to live a meaningful life in the community. It is used to inform supports planning and also resource allocation.
People are asked questions about their specific level of need for support in several areas.
*For information on SIS reliability, validity & use by states go to:
http://www.siswebsite.org/
Resource AllocationSupports Intensity Scale:
• Section 1 asks about the individual’s support needs for home living, community living, lifelong learning, employment, health & safety and social activities.
• Section 2 asks about the individual’s support needs for speaking up for him/her self and others (advocacy), managing money, making choices and staying safe.
• Section 3 asks about the individual’s support needs for medical and behavioral challenges.
Resource Allocation
There are 4 SIS supplemental questions that identify those with the highest level of medical and/or behavioral support needs:
• Severe medical risk
• Severe community safety risk (convicted)
• Severe community safety risk (not convicted)
• Severe risk of injury to self
Resource Allocation
The Individual Budget Tool is the model that is based on:
• Living Arrangement-determines category
• Age-determines category
• Assessment of need (SIS)-determines level
Resource Allocation
The individual’s base budget is a guideline!
• All services covered under the Innovations waiver, including Residential Supports and Supported Living, should be requested to the full extent of the individual’s level of medical necessity, regardless of the individual’s budgeting category.
• Services may be authorized in excess of the individual budget.
Resource Allocation
SIS®
Age
Living Arrangement
Base Budget
Resource Allocation
• Living Arrangement breaks the population into:
(1) Individuals receiving Residential/Supported Living
(2) Individuals NOT in Residential/Supported Living.
• Age* breaks the population into:
(1) Individuals under age 22
(2) Individuals 22 and over
*will be determined by school-status regardless of age
Resource AllocationThe Four Categories are:1. Non-Residential Child (under 22 years old and living in
a private home).
2. Residential/Supported Living Child (under 22 years old and living in a group home, an Alternative Family Living (“AFL”) setting or a Supported Living setting).
3. Non-Residential Adult (age 22 and over and living in a private home).
4. Residential/Supported Living Adult (age 22 and over and living in a group home, an AFL or Supported Living setting).
Resource Allocation
• Each of the Four Categories has Seven Levels
• The Seven Levels are clinical descriptions representative of groupings of Individuals who have similar support needs and have budgets attached.
Living situation and Age/School status
CategoriesChild Non-Residential
Child Residential
Adult Non-Residential
Adult Residential
Levels
ABCDEFG
ABCDEFG
ABCDEFG
ABCDEFG
SIS
Resource Allocation
There are 7 Levels of Support, A through G:
Level A: Minimal ADL support needs
Level B: Moderate ADL support needs
Level C: Minimal/moderate ADL supports needs with behavioral support overlay
Level D: Moderate/high ADL supports needs
Resource Allocation
Level E: High ADL support needs
Level F: Some ADL support needs with extraordinary medical support overlay
Level G: Some ADL support needs with extraordinary behavioral support overlay
Resource Allocation
How are levels determined?
1. Each individual will be assigned a support level based on his/her support needs.
2. The support needs are indicated by the SIS which assigns the individual to a level.
3. Levels for base budget services were developed through a detailed process.
How are Levels Assigned?
• The Human Services Research Institute (HSRI) will assign the Individual Budgets using the Individual Budget Tool
• How will this happen?- The MCOs conduct the Supports Intensity Scale (SIS)- The MCOs upload the SIS data to SIS Online- HSRI accesses SIS Online and applies an algorithm based on
age, SIS, and Residential Setting•This generates a Level of Support and individual base budget
- The MCO accesses the Individual Budgets/Levels and generates the Individual Base Budget Letter.
Base Budget Services
Community Living and Supports
Community Networking Services
Day Supports
Respite
Supported Employment
Non-Base Budget Services (Add-on)
Assistive Technology Equipment and Supplies
Community Navigator
Community Transition Services
Crisis Services
Home Modifications/Van Modifications
Individual Goods and Services
Natural Supports Education
Specialized Consultation Services
Non-Base Budget Services
Financial Support Services-do not count towards base budget or annual budget maximum.
Residential Supports & Supported Living services-do not count towards base budget, but do count towards annual budget maximum
Resource Allocation
The individual’s base budget is a guideline!
• All services covered under the Innovations waiver, including Residential Supports and Supported Living, should be requested to the full extent of the individual’s level of medical necessity, regardless of the individual’s budgeting category.
• Services may be authorized in excess of the individual budget.
Questions
Innovations Waiver Amendment
Implementation
• The Centers for Medicare and Medicaid Services (CMS) have approved the Technical Amendment of the NC Innovations Waiver (0423).
• The effective date of the waiver is November 1, 2016.
• This will include a phase-in of individual budgets with a time-line of up to two years.
Implementation
• Josh is a 10 year old child who is still in school. In his previous plan year, his base budget services cost $50,000.
• This amount is 130% of what Josh’s annual base budget should be based on Josh’s living arrangement, age and SIS.
• His anticipated cost of base budget services should be $38,461.
Implementation
ISP Year Base Budget Amount
Previous Year $50,000 (130% of base budget)
Year 1 $46,153 (120% of base budget)
Year 2 $42,307 (110% of base budget)
Year 3 $38,461 (at base budget)
Implementation
• Mary is a 52 year old individual living in her family home. In her previous plan year, her base budget services cost $20,000.
• This amount is 80% of what Mary’s annual base budget should be based on her living arrangement, age and SIS.
• Her anticipated cost of base budget services should be $25,000.
Implementation
ISP Year Base Budget Amount
Previous Year $20,000 (80% of base budget)
Year 1 $22,500 (90% of base budget)
Year 2 $25,000 (at base budget)
Implementation
• A Permanent Change is a change in support needs expected to last longer than six (6) months.- Examples of a Permanent Change are changes in
living arrangement and changes from the child to adult category
- This process will be coordinated with HSRI
• A Temporary Change is an unexpected need that is expected to resolve in six (6) months or less.
Implementation
• Intensive Review is a process that occurs when a person’s needs cannot be met within her/his current base budget.
• There will be a internal committee established to review these situations. This committee will meet routinely.
• An Intensive Review will be based on the unique needs of the individual that puts them in excess of their base budget (based on medical and behavioral support needs).
Important ChangesIncrease flexibility of services
• Community Living and Supports– a new service which blends personal care and habilitation
• Supported Living – a new service for individuals who choose to rent or own their own home and receive services for up to 24 hours/day
• Day Supports – hourly unit• Residential Supports – updated cost assumptions• Respite – making available to individuals residing in
alternative family living situations (AFLs)
Important Changes
Relative as Provider:
It is recommended that a relative residing in the home of the beneficiary provide no more than 40 hours per week of service to the person. This must be reported, but does not require prior approval.
If more than 40 hours are requested, prior approval must be obtained. Justification must be provided:
• Why there is no other qualified provider
• Assurances of provider choice
• Isolation is not occurring
Important Changes
Relative as Provider:
Relatives who are providing more than 56 hours per week of service to a waiver beneficiary may continue to provide services at their current hours as long as there are:
• no health and safety concerns, including isolation• the services continue to be medically necessary, and • the beneficiary still wishes for them to provide the
service.
New requests will be limited to 56 hours per week.
Important Changes
Relative as Provider:
The only service that can be provided by a RAP is Community Living & Supports.
Note: If the relative is also the legal guardian for the waiver participant, he/she must be legally able to provide services as defined in HB543
http://www.ncleg.net/Sessions/2013/Bills/House/PDF/H543v4.pdf
Important Changes
Services in the home of a Direct Service Employee:
• Eligible only for Community Living and Supports, Respite
• Provider Agency, EOR or AWC is required to complete the Health & Safety Checklist prior to AND every six months afterwards, as long as the service continues to be provided in that location.
Other Changes
Service Breaks:
• The requirement that Level 1 incidents for NC Innovations participants include reporting of failure to provide back-up staffing has been removed.
• Breaks in service are to be documented by the provider and monitored by the Care Coordinator.
Other Changes
Progress Summary
• The requirement for Service Providers, Agencies with Choice and Employers of Record to complete progress summaries for habilitative services has been removed.
Questions
Service Definitions
New Services
• Community Living and Supports
• Supported Living
• Community Navigator
Community Living and Supports
• New Blended Service
• Combines current Personal Care, In-Home Skill Building and In-Home Intensive services
• This more comprehensive category will allow for habilitation, supervision and support, and will be more flexible
Community Living and Supports
• There is no wrong amount of either habilitation or personal care
• Only service that relatives as providers can provide.
Community Living and Supports
SCOPE/INTENT• To support successful living with family and/or other
natural supports in a private home
• To support the person in community activities with family and/or friends
Community Living and Supports
COVERABLE ACTIVITIES/TASKS• Support in learning new skills and/or improvement of
existing skills
• Provide for supervision and assistance for themember to complete activities to his/her level of independence
• Incidental technical assistance to unpaid supports who live in the home of the member as requested/suggested by the planning team
Community Living and Supports
COVERABLE ACTIVITIES/TASK• Meet exceptional, short-term situations where the
member requires more than 12 hours per day of services
• Provides technical assistance to unpaid supports who live in the home of the member to assist the member to maintain the skills they have learned
Community Living and Supports
EXCLUSIONS• May not be provided at the same time as Community
Networking, Day Supports, Respite, Supported Employment, or one of the state plan Medicaid services that works directly with the individual.
• Does not provide transportation to/from school.
Community Living and Supports
LIMITS• Subject to Limits on Sets of Services
• Typically 12 hours per day maximum – may receive 16 hours per day with prior approval for 90 to 180 day periods dependent upon circumstances
Supported Living
• New Service
• Flexible, daily service for individuals who live in their own home without licensure-up to 3 people
• May include a Live-in Caregiver. If a live-in caregiver is needed, only 2 individuals may live in the home.
• The house or apartment is not to be owned or rented by the provider
• Includes a Special Needs adjustment
Supported LivingSCOPE/INTENT• To support successful community living in unlicensed
residences owned or leased by the member
COVERED ACTIVITIES/TASKS• Provides a flexible partnership that enables the member
to live in his/her own home with support from an agency that provides individualized assistance in a home that is under the control and responsibility of the member
Supported LivingCOVERED ACTIVITIES/TASKS
• Provides direct assistance as needed with activities of daily living, household chores essential to the health and safety of the member, budget management, attending appointments and interpersonal and social skills building to enable the member to live in a home in the community.
• Provide transportation to/from activities when not reimbursed through another funding source (i.e. medical appointments covered through State Plan Medicaid)
Supported Living
COVERED ACTIVITIES/TASKS• Provider must develop an individualized staffing plan and
schedule based on the member’s preference and on the assessment and ISP process, including risk assessment
• The ISP must ensure staffing is adequate to protect the health and safety of the member and to carry out all activities required to meet the outcomes and goals identified in the ISP
• The plan must address staff coverage for back-up and relief staff
* 24 hour per day availability includes back-up, relief staff and primary crisis response
Supported Living
COVERED ACTIVITIES/TASKS• Provides for training activities, supervision and assistance
may be provided to allow the person to participate in home life or community activities
• Includes assistance with monitoring health status and physical condition, and assistance with transferring, ambulation and use of special mobility devices
• Provides for 24 hour per day availability at an individualized level of supports determined during the assessment process and clearly outlined in the ISP
Supported Living
COVERED ACTIVITIES/TASKS• Members may be able to have unsupervised periods of
time based on the assessment process. In these situations a specific plan for addressing health and safety needs must be included in the ISP and the provider must have staffing available in the case of emergency or crisis
• Requirements for the member’s safety in the absence of a staff person shall be addressed and may include use of tele-care options
• When assessed to be appropriate ATES elements may be utilized in lieu of direct care staff
Supported LivingSupported Living levels are determined by clinical and supports assessments which includes, but is not limited to, the supports Intensity Scale®, the “clinical description”, and person centered planning.
• Level 1
• Level 2
• Level 3
• Special needs adjustment (for time-limited periods of higher needs; transitions, need of roommate, medical or behavioral needs)
Supported Living
EXCLUSIONS/LIMITS• Not available to those under 18
• Subject to Limits on Sets of Services and Individual Budgeting
• Cannot be self-directed
• Cannot be provided by a relative
Community Navigator
• New Service (Formerly Community Guide)• Annual Informational Session on Self Direction and Self
Determination• Promotes Self Determinations• Promotes Self-Direction• Develops Community Connections
Community Navigator
SCOPE/INTENT• To promote self-determination
• To support beneficiary in making life choices, planning for the future and identifying opportunities for community integration
• To facilitate less reliance on paid supports
• To provide advocacy
Community Navigator
COVERABLE ACTIVITIES/TASKS Self-Determination:
• Encouraging exploration of possibilities related to life goals, defining what those are and the steps that they need to take in order to have those met
• Supporting the member to make decisions that are important to them
• Promote choice making to support the member’s strengths and interests
Community Navigator
COVERABLE ACTIVITIES/TASKSSelf-Determination:• Provide education on decision making, risk taking and
natural consequences• Provide education which guides the member in problem
solving, decision making and navigating multiple state systems
• Promote advocacy and collaborating with other individuals and organization on behalf of the individual
• Guidance with managing their individual budget
Community Navigator
COVERABLE ACTIVITIES/TASKSSelf-Determination:• Supporting the person in preparing, participating in and
implementing plans of any type including IEPs, ISPs or other service plans outside NC Innovations.
• Support the person in the person-centered planning process (i.e. development of ELP, MAPs, Circles, etc.)
• Assistance with guardianship, restoration of rights, supplemental security income issues, disability determination issues, Department of Social Services issues, financial/legal planning
Community NavigatorCOVERABLE ACTIVITIES/TASKSSelf-Determination:
• Assistance with locating and furnishing residences for the member to rent or own
• Provide education about appropriate accommodation needs
• Supports the Individual in negotiating roommate agreements
• Assistance with development of life related emergency plans
Community Navigator
COVERABLE ACTIVITIES/TASKSCommunity Connections:• Support in identifying community resources that offer
opportunities for the member, expand social relationships and build connections with the individual’s community through unpaid supports
• Assistance with locating and accessing non-Medicaid community supports and resources that are related to achieving the individual’s life goals
Community Navigator
COVERABLE ACTIVITIES/TASKSSelf-Direction:• Provide training, information/technical assistance on the
Individual and Family Directed Supports Options • Agency With Choice• Employer of Record
Community Navigator
EXCLUSIONS• This service does not duplication Care Coordination
and/or Care Coordination functions
Questions
Definitions with Changes
Assistive Technology Equipment and Supplies
• Removed exhaustive lists
• Added broad categories
• Allows for the repair of equipment
• Allows for connectivity and smart home technology
• Cost Limit: $50,000 over the life of the waiver (combination of ATES and Home Modifications)
Community Networking
• Clarification that Community Networking can link an individual to a volunteer setting if the individual requires paid supports to participate once connected with the activity.
• Added language around volunteering: may not be done at locations that would not typically have volunteers or in positions that would be paid positions if performed by an individual that was not on the waiver.
Community Networking
• Added payment for memberships when the individual will be participating in an integrated class
• There is not a requirement for a fading plan, but the service is intended to fade as community connections are gained.
Community TransitionIncreased flexibility:
• Community Transition can now be used more than once by a waiver beneficiary (changed to lifetime of the waiver).
• The cost has a limit of $5000.00 per Waiver period (changed from a lifetime limit for the individual).
• Allows for individuals to access Community Transition when stepping down from unlicensed AFLs, PRTFs and family homes when moving to a home of their own.
Crisis Services
Crisis Consultation:
• Added language to promote/allow for the prevention of crisis through Crisis Consultation.
• Staffing requirement changes allow the use of Qualified Professionals (with crisis experience and appropriate supervision).
Crisis ServicesCrisis Consultation may be used to:
1. Facilitate up-to monthly treatment team meetings• discuss clinical findings and recent crises
regarding the individual• evaluate the refinement of the crisis plan and
communicate changes to the to the crisis plan to the Care Coordinator
Crisis Services
2. Train, educate and provide ongoing technical assistance to natural supports and direct support professionals on crisis interventions and strategies.
3. Develop and implement strategies to aid the person in returning home after an out of home crisis stay or hospitalization.
4. Make referrals for medications evaluations if needed.
Crisis Services
• Crisis services are immediately available 24/7.
• Service authorization can be granted verbally or planned through the ISP to meet the needs of the individual.
• Following service authorization, any needed modifications to the ISP and the individual budget will occur within 5 working days of the date of verbal service authorization.
Crisis Services
• Out of Home Crisis may be authorized in increments up to 30 calendar days.
• Previously the maximum was 14 days.
Day Supports
• Day Supports is a group, facility based service.
• Individual Day Supports are available to meet specific and well documented needs.
• Facility-Based means that the individuals who receive this service are often in a licensed Day Supports provider facility that serves those with I/DD.
• Day Supports can start or end in the community, but it is expected that the individual will physically attend the facility once per week.
Day Supports
• Emphasizes inclusion and independence
• Individuals 16 or older, or new to the service will receive education on other types of meaningful day activities during the planning meeting.
• Day Supports is billed in 1 hour increments; an individual must receive Day Supports 15 minutes before the 1 hour unit may be billed.
Home Modifications
• Removed exhaustive list
• Cost Limit: $50,000 over the life of the waiver (combination of ATES and Home Modifications)
Residential Supports
• Residential Supports levels are determined by the Individual Budgeting Table Category (no longer the NC SNAP)
• Primary AFL staff who provide Residential Supports should not provide other waiver services to the beneficiary.
Residential Supports
• Respite (per diem) may be used to provide relief to individuals who reside in Licensed and Unlicensed AFLs.
• Respite and Residential Supports may not be billed on the same day.
• For non-AFL residential settings, payment for relief staff is included in the residential rate.
Respite
• For those receiving Residential Supports, Respite may only be used by individuals in AFLs.
• This service is not available to beneficiaries who reside in a facility licensed as 5600C or 5600B
• In AFL situations, per diem respite will be billed on admission. Per diem respite may not be billed on the same day as Residential Supports.
Respite continued
• Respite is not provided by any person who resides in the individual’s primary place of residence.
• Added language to allow for the person receiving services to have relief from the primary care-giver at his/her choice.
Specialized Consultative Services
• This service may be used for evaluations for adults when the State Plan limits have been exceeded.
Supported Employment
• Added language to include providing technical support to potential employers regarding Federal ADA accommodations and requirements.
• Improved access to Supported Employment service by removing three-year experience requirement for staff.
Supported Employment
• Provides clarification regarding Long Term Follow-up component: must occur at least monthly face-to-face to include activities such as monitoring, supervision, maintaining needed skills for the job, work adjustment training and counseling.
• Allows for transportation of the individual to and from the job site when the individual's job does not require staffing support.
Vehicle Modifications
• Allows for lifting and/or lowering devices.
• Removed exclusion for beneficiaries receiving Residential Supports: Vehicle Modifications may be accessed when the vehicle belongs to the individual and can transition to other settings with the individual.
Questions
