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OPWDD 1915(c) Home and Community-Based Services (HCBS)

Waiver Respite RedesignEffective July 1, 2017

Kate Marlay, OPWDD, Division of Person-Centered Supports, Deputy DirectorAbiba Kindo, Associate Deputy Commissioner, Regional Offices

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May 8, 2017 & May 10, 2017

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Purpose of Today’s Session

• Explain the details related to the redesign of HCBS Waiver Respite services effective July 1, 2017.

• Discuss the changes to the Respite Services proposal.

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Today’s Agenda• Materials• Changes to Proposal• Applicability of Respite Changes• Overview of Five Respite Categories• Respite Fee Schedule• Billing Guidance• Authorization Processes• Service Documentation• Next Steps

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Materials• Handout # 1 – PowerPoint• Handout #2 – Questions & Answers • Handout #3 – Service Documentation • Handout #3A – Checklist/Respite Documentation

Record – Individual Summary • Handout #4 – Draft Regulations• Handout #5 – Intensive Respite Approval Form• Handout #6 – Respite Transportation Units Form

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Changes to Respite Proposal• Elimination of School-Age category• Clarification regarding the difference between Site-

Based and Recreational Respite• Higher Daily Limit (10 hours)• Increased reimbursement for Intensive Respite

services• Increase to all Respite fees – Minimum Wage and

Cost of Living Adjustments• Overnight limit

– Full reimbursement rate for 42 days in a 180-day period– Any continued overnight billing will be limited to the

regional average daily rate paid for Supervised IRA Residential Habilitation services.

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Applicability• Who do the Respite changes apply to?

– Individuals enrolled in the OPWDD HCBS Waiver and non-waiver enrolled individuals who receive Respite services including Provider Directed or Agency Supported Self-Directed Respite.

• Respite changes do not impact:– Individuals who self-direct and self-hire Respite

staff.– Individuals receiving Respite services via a

Family Support Services (FSS) contract

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Respite Categories• Effective July 1, 2017, Respite

services will be delivered as the following types of service categories:1. In-Home 2. Camp3. Recreational 4. Site-Based5. Intensive

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In-Home Respite

• Takes place in Family Home or in other non-certified home, such as a neighbor’s home (Guest Respite).

• May include staff accompanying to person into the community.

• Does not take place in certified settings.

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Camp Respite

• Delivered at site based locations that possess a permit under Subpart 7 of the NYS Sanitary Code.

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Site-Based Respite• Takes place in:

– Free Standing Respite site (must have operating certificate)

– Certified Residence– Community Setting that the provider owns,

rents or pays property costs (e.g., stays in a hotel, or usage fee paid to YMCA)

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Recreational Respite• Typically provided in any community-based

setting that is not owned, rented or leased by the Respite provider.

• No fixed location of service.• Routine travel to an outing or event may be

involved.• Activities taking place in a public site(s) where

there is no overhead/rental cost for the property where services are provided. – (i.e., mall, movie outings)

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Intensive Respite• Two types: High Behavioral and High Medical • Must be authorized by DDRO• High Behavioral: must have Plan written by a

licensed professional (psychologist, LCSW, BIS, START Clinical Team Member)

• High Medical: must have Plan of Nursing Services (PONS) written by RN

• Intensive Respite “follows the individual” and can be delivered in any Respite setting (i.e., In-Home, Site Based, Camp, Recreational)

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Service Limits• Overnight: Only in Camp, Site-Based and In-Home

(including Intensive) Respite services – Limited to 42 days within a 180-day period per

individual.– After the 42 days, any continued overnight billing will

be limited to the regional average daily rate paid for Supervised IRA Residential Habilitation services.

– Overnight Camp Respite services is limited to 14 nights/year (applies against 42 day limit)

• Daily: All categories except In-Home – Up to 10 hours per day unless associated with

overnight stays– In-Home daily services are not limited

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Service Limits - Overnight• Overnight limits of 42 days in 180-day

period apply when a person receives Respite services on two (2) consecutive days and Respite staff are providing oversight to a person during nighttime hours.

• The 180-day timeframes are as follows:– July 1 – December 31– January 1 – June 30

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PROPOSED RESPITE FEE SCHEDULE

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Proposed Respite Fee Schedule

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DOH Region

UNIT OF SERVICE Camp Recreation Intensive In-

Home Site-Based

1 Hourly* $25.89 $22.52 $34.74 $25.39 $24.98

2 Hourly* $24.65 $21.57 $34.40 $24.05 $24.98

3 Hourly* $24.30 $21.36 $33.01 $23.84 $22.99

4 Hourly* $22.71 $20.86 $32.32 $23.43 $22.90

*Billed and paid in Quarter Hour Units

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BILLING GUIDANCE

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Billing Respite Services

• Respite services require in-person or “face-to-face” service provision by Respite staff.

• Respite remains an hourly service which will be continue to be billed in 15-minute increments for all categories.

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Billing Respite Services• Respite services are not always provided for a

continuous time period on a given day. For example, an individual may receive Respite services from 8:00 a.m. to 9:00 a.m., leaves to attend a Day Habilitation program, then, later in the evening returns to Respite setting from 7 p.m. to 9 p.m.

• In this case, the total billable duration for Respite services would be twelve 15-minute billing units (for 3 service hours).

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Billing Respite Services• An individual may receive multiple types of

Respite during any given day. For example, an individual may receive Respite Services at a Free-Standing Respite Site from 10:00 a.m. to 11:30 a.m. and then receive two hours of In-Home Respite services in the afternoon from 3:00 p.m. to 5:00 p.m.

• The total billable duration for Site-Based Respite Services would be six 15-minute billing units and the total billable duration for In-Home Respite Services would be eight 15-minute billing units.

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Transportation• To-From Transportation Time is included as

Billable Time.• The provider must retain documentation

associated with the start and stop times of Respite services including any time for transportation that is billed.

• At the time the staff person (staff person, transporter or contracted vendor) becomes responsible for the individual and the primary caregiver is relieved, Respite billing can begin.

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BILLING RESPITE SERVICESCentral Operations

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Respite Rate Codes

Rate Code Description7421 In-Home7422 Site-Based7423 Recreation7424 Camp7425 Intensive

These Rate Codes go into effect 7/1/17 

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Respite Rate Codes Continued

Self-Direction Respite Rate Codes• The self-hired respite rate code is not changing so it is not listed below.• Agency Supported Self-Direction can only be done through In-Home

Respite.

Rate Code Description7426 In-Home Agency Supported Self-Direction7427 Intensive In-Home Agency Supported Self-Direction

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Respite Rate Codes ContinuedPer Diem Rate Codes• The DOH Regional Supervised IRA rate.• Used when an individual has received 42 days of overnight

respite services across all respite categories in 180 days.• Providers are expected to track provision of overnight services

and bill accordingly based on these established rules.

Rate Code Description7428 In-Home Per Diem7429 Site-Based Per Diem

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State-Paid Respite Services• Providers will continue to submit billing through the

Services Recording Application for individuals who are authorized for Respite Services but are not enrolled in the HCBS Waiver.

• The Services Recording Application will be updated to reflect the respite changes taking effect July 1, 2017.

• A User’s Guide will be available for providers who use the Web-Based Application.

• Technical assistance will be available from Central Operations to assist providers with the use of the updated Services Recording Application.

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AUTHORIZATION PROCESSES

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Site-Based, Recreational, In-Home and Camp Respite Authorization

• An individual will receive authorization by the DDRO for Respite and the Respite Units may be used for Site-Based, Recreational, In-Home and Camp Respite based on the needs of the person.

• It is the responsibility of the provider to ensure that the appropriate fee is billed for the category of Respite delivered.

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Intensive Respite Authorization(see “Intensive Respite Approval Form” Handout #5)

• To request authorization for Intensive Respite services, provider agencies must submit a “Intensive Respite Approval Form” to their local OPWDD Regional Office for review.

• Authorization will be made by OPWDD Regional Offices based upon an individual’s behavioral support and/or medical support needs and the Plan utilized for the delivery of Respite services.

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Intensive Respite Authorization(see “Intensive Respite Approval Form” Handout #5)

• For individuals with high behavioral needs, the Plan must be developed by a licensed psychologist, licensed clinical social worker, Behavioral Intervention Specialist (BIS) or START Clinical Team Member.

• For individuals with high medical needs, the Plan of Nursing Services (PONS) must be developed by a Registered Nurse.

• The Plan or PONS must be created and implemented prior to Intensive Respite service delivery.

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Intensive Respite Authorization(see “Intensive Respite Approval Form” Handout #5)

• Provider agencies must meet the criteria described in the service categories and limits of each Respite service section in order to deliver and bill Intensive Respite services.

• For example, a Camp provider must possess a permit under Subpart 7 of the NYS Sanitary Code in order to bill Intensive Camp Respite services and may only deliver 10 hours of Intensive Camp Respite per day per individual for non-overnight Camp programs.

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TABS Authorization• Individuals will continue to be enrolled in

either hourly or Free-Standing Respite (FSR) for all 5 categories of Respite services.

• Individuals who attend a Site-Based program at a Free-Standing Respite Center, will continue to be enrolled in Free-Standing Respite in TABS.

• New program classifications for each category will not be created.

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Intensive Respite TABS Authorization

• Once an individual has been approved for Intensive Respite, a marker will be established in an individual’s profile in TABS.

• If an individual does not have the Intensive Respite marker in TABS, the individual is not authorized and the agency should not bill Intensive Respite.

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SERVICE DOCUMENTATION

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Individualized Service Plan (ISP)/Life Plan (LP)

• The Respite provider must have a copy of the individual’s current Individualized Service Plan (ISP) or Life Plan (LP) on file.

• The ISP/LP must include the following elements related to the Respite service:– Name of Provider: Agency Name– Type of Service: Respite– Frequency: Hourly– Duration: Ongoing– Effective Date: This date must be on or before the

first day of service that your agency bills for Respite services.

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Service Documentation Requirements(See Handouts #3 & 3A)

1. Individual’s name and if applicable, the Medicaid ID (CIN).

2. Identification of the category of waiver service provided, in this case, “Respite.”

3. Identification of the category of Respite service, i.e. In-Home, Camp, Site-Based, Recreational, or Intensive Respite.

4. Name of the agency providing the Respite service.

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Service Documentation Requirements(See Handouts #3 & 3A)

5. The date the service was provided.

6. The start time and stop time for each continuous period of Respite service.

7. Verification of service provision by the Respite staff person who delivered the service. Initials are permitted if a “key” is provided, which identifies the title, signature, and full name associated with the staff initials.

8. The date the service was documented (the date must be “contemporaneous” with service provision).

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Respite Documentation Record(See Handouts #3 & 3A)

• Provider’s responsibility to ensure that the appropriate fee is billed for the category of Respite delivered.

• Providers must maintain service documentation that supports the category of Respite billed. This documentation must indicate the appropriate billing category

• Providers may develop a checklist/documentation or use the Respite Documentation Record – Individual Summary checklist template which will be attached to the Respite ADM.

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NEXT STEPS

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Next Steps

• CMS Approval of “Amendment 01”

• Finalize and Post: – Respite Regulations – Respite Administrative Memorandum (ADM)– Respite Documentation Record – Individual

Summary form

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Contact Us

PeopleFirstWaiver@opwdd.ny.gov

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