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1 Medicaid State Plan, Waivers & Quality Assurance Presented by: Dana Hittle, Darlene O’Keeffe and Chris Pascual Department of Human Services Aging and.

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Presentation on theme: "1 Medicaid State Plan, Waivers & Quality Assurance Presented by: Dana Hittle, Darlene O’Keeffe and Chris Pascual Department of Human Services Aging and."— Presentation transcript:

1 1 Medicaid State Plan, Waivers & Quality Assurance Presented by: Dana Hittle, Darlene O’Keeffe and Chris Pascual Department of Human Services Aging and People with Disabilities Waiver and State Plan Unit

2 2 What is Medicaid? Joint Federal and state program to assist states in furnishing medical assistance to eligible needy persons. Federal law concerning the Medicaid program is located in Title XIX of the Social Security Act. Within broad national guidelines established by Federal statutes, regulations, and policies, each state: establishes its own eligibility standards; determines the type, amount, duration, and scope of services; sets the rate of payment for services; and administers its own program.

3 3 Federal and State Funding

4 4 Regulations Hierarchy

5 5 Medicaid State Plan Details requirements established by the State. Historically referred to as an individual’s “Medical Card”. Oregon Health Authority, Division of Medical Assistance Programs (DMAP) manages Oregon’s State Plan.

6 6 Who May Be Eligible for Oregon’s Medicaid State Plan? The Categorically Needy and the Categorically Eligible: Families who meet states’ Aid to Families with Dependent Children eligibility requirements in effect on 07/16/96. Pregnant women & kids under age 6 whose family income is at or below 133 % of the Federal Poverty Level (FPL) Kids aged 6 to 19 with family income up to 100% of the FPL. Caretakers (relatives or legal guardians who care for children under age 18 (or 19 if still in high school)). Supplemental Security Income (SSI) recipients. Aged, Blind, Disabled (per Social Security Administration’s definition). Individuals and couples who are living in medical institutions (Hospital, NF, ICF/IDD) and have monthly income up to 300% of the SSI income standard (Federal benefit rate). Other Identified Special Groups.

7 7 Oregon’s Medicaid State Plan Services Options: Federally Mandated Services: o Inpatient Hospital (non-Institutions for Mental Disease) o Outpatient Hospital o Federally Qualified Health Centers o Laboratory and X-Ray o Nursing Facility for adults over 21 o *Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) for children under 21 o Family planning services and supplies o Physician’s Services o Home Health Services o Pregnancy-related services o Nurse Midwife/Practitioner Services

8 8 Oregon’s Medicaid State Plan Services Options: Optional Services: o Med/Remedial - Licensed Practitioners o Private Duty Nursing o Clinic o Dental o Physical Therapy, Occupational Therapy, and Speech/Hearing/ Language o Drugs, Dentures, Prostheses, Glasses o Rehabilitative Services o Services for adults >65 in Institutions for Mental Disease (IMD) (ex: OSH Gero, EOPC) o ICF/IDD Services o Other NF o IMD <21 (ex: OSH Children’s Program) o *Personal Care o Primary Care Case Management (OHP) o Respiratory Care: Ventilator-Dependent

9 9 State Plan Personal Care otherwise known as “PC20” Developmentally-appropriate assistance provided to individuals with disabilities and chronic conditions of all ages which enables them to accomplish certain tasks. Assistance may be in the form of hands-on assistance or cueing. Needs assessments are performed on all clients prior to receiving personal care services. Available to all qualifying Medicaid-eligible individuals. Need for institutional level of care is not required. Must be provided by a qualified provider as identified in the State Plan.

10 10 Activities of Daily Living (ADL) Personal Care assistance with: Eating Bathing Dressing Toileting Transferring Maintaining continence

11 11 Instrumental Activities of Daily Living (IADL) Personal Care assistance with: Personal Hygiene Light Housework Laundry Meal Preparation Transportation Grocery Shopping Using the Telephone Medication Management Money Management

12 12 Delegated Nursing Tasks Dressing Changes Oxygen Administration Pulse Oximeter Placement and Monitoring Apnea Monitoring Tracheotomy Care Oral Suctioning Ventilator Care Continuous Positive Airway Pressure (CPAP) Injections (subcutaneous) Blood Glucose Testing

13 13 Oregon’s CMS-Approved State Plan HCBS Options 1915(i) HCBS State Plan Option- Targets individuals with chronic mental illness (CMI) receiving assistance through OHA, Addictions and Mental Health Division. Provides home-based habilitation, HCBS behavioral habilitation, HCBS psycho- social rehabilitation for persons with CMI. Individuals require daily assistance of at least 1 hour per day to perform at least two personal care services. Individuals do not meet criteria established for 1915(c) waivers. Services are provided in independent living situations, supported housing, adult foster homes, residential treatment facilities or the individual’s own home. Home Based Habilitation is based individual assessment and an individual to deliver a combination of the following services: Assistance with ADL/IADL needs Staff as needed to support the individual’s recovery Assistance in obtaining Non-Medical Transportation Skill development (ADLs, cooking, home maintenance, recreation, community mobility, money management, shopping, community survival skills, educational support) Services may be delivered in the community, adult foster home, residential treatment home or residential treatment facilities that are not considered secured.

14 14 Oregon’s CMS-Approved State Plan HCBS Options 1915(j) Self-Directed Personal Assistance Services- Targets individuals who are aged or physically disabled. Provides ADL/IADL services to individuals who reside in their own home and who are eligible for the Aged and Physically Disabled Waiver #0185. Individuals receive a monthly cash benefit to purchase services and supports. Individuals self-direct their personal assistance services and are responsible for hiring, directing, paying and dismissing providers, and purchasing other goods and services.

15 15 Oregon’s Proposed State Plan HCBS Option – 1915(k) Community First Choice Allows states to provide attendant services and supports in any home and community- based setting to all Medicaid-eligible individuals who meet an institutional level of care. States receive a 6% increase in federal match for the provision of CFC services and supports. Services: Participating states must: Cover assistance and maintenance with ADL/IADL needs and health- related tasks; Ensure continuity of services and supports; Provide voluntary training on how to select, manage and dismiss staff. Services can be provided through an agency or self-directed model. Participating states may choose to cover: Transition costs; Expenditures related to participant’s independence and services, or supports linked to an assessed need or goal.

16 16 Oregon’s Proposed State Plan HCBS Option – 1915(k) Community First Choice Additional requirements: CFC services must be provided without regard to the individual’s age, type or nature of disability, severity of disability, or the form of home and community-based attendant services and supports the individual requires to lead an independent life. Individuals must be determined to need an institutional level of care to be eligible for CFC services. CFC does not create a new Medicaid Eligibility Group. States cannot waive: Statewideness; Comparability; Freedom of choice of services or qualified providers.

17 17 Title XIX (TXIX) Waivers TXIX of the Social Security Act allows states to use Medicaid funds to provide home and community-based services (HCBS) to individuals who would require the level of care in an institution if not for the provision of HCBS.

18 18 Waiver Eligibility Must meet the need for institutional level of care during initial application and annually thereafter. Must meet initial and ongoing financial eligibility requirements. Meet other waiver requirements, if applicable (e.g.: DD eligible). Must be enrolled in and receiving a waivered service at least monthly.

19 19 Institutions Intermediate Care Facilities for individuals with Intellectual & Developmental Disabilities (ICF/IDD), formerly known as ICF/MR Nursing Facilities Hospitals (Non-IMD)

20 20 Oregon’s Waivers, Populations, and Institutional LOC: Comprehensive Residential Waiver #0117 – ID/DD; ICF/IDD Support Services Waiver #0375 – ID/DD; ICF/IDD Behavioral Model Waiver #40194– ID/DD; ICF/IDD Hospital Model Waiver (Medically Fragile Children) #40193– Physically Disabled; Hospital Medically Involved Children’s Waiver #0565 – Physically Disabled; Nursing Facility Aged and Physically Disabled Waiver #0185– Aged and Physically Disabled; Nursing Facility

21 21 Waiver Assurances The commitment by a state to operate a HCBS waiver program in accordance with statutory requirements (42 CFR § ).

22 22 Level of Care (LOC) Determination The specification of the minimum amount of assistance that an individual must require in order to receive services in an institutional setting under the State plan. Sub-assurances: An evaluation for LOC is provided to all applicants for whom there is reasonable indication that services may be needed in the future. The LOC of enrolled participants are reevaluated at least annually or as specified in the approved waiver. The processes and instruments described in the approved waiver are applied appropriately and according to the approved description to determine participant LOC.

23 23 Service Plan Written document that specifies the waiver and other services (regardless of funding source) along with any informal supports that are furnished to meet the needs of and to assist a waiver participant to remain in the community. The service plan must contain, at a minimum: the types of services to be furnished; the amount, the frequency and duration of each service; and the type of provider to furnish each service. Federal Financial Participation (FFP) may only be claimed for the waiver services that are furnished to a waiver participant when they have been authorized in the service plan.

24 24 Service Plan Sub-assurances: Service plans address all participants’ assessed needs (including health and safety risk factors) and personal goals, either by waiver services or through other means. The state monitors service plan development in accordance with its policies and procedures. Service plans are updated/revised at least annually or when warranted by changes in the waiver participant’s needs. Services are delivered in accordance with the service plan, including in the type, scope, amount, duration, and frequency specified in the service plan. Participants are afforded choice: Between waiver services and institutional care; and Between/among waiver services and providers.

25 25 Qualified Providers Standards established by the state that specify the education, training, skills, competencies and attributes that an individual or provider agency must possess in order to furnish services to waiver participants. Sub-assurances: The state verifies that providers initially and continually meet required licensure and/or certification standards and adhere to other standards prior to their furnishing waiver services. The state monitors non-licensed/non-certified providers to assure adherence to waiver requirements. The state implements its policies and procedures for verifying that provider training is conducted in accordance with state requirements and the approved waiver.

26 26 Health and Welfare A waiver’s design must provide for continuously and effectively assuring the health and welfare of waiver participants. Sub-assurance: The state, on an on-going basis, identifies, addresses, and seeks to prevent the occurrence of abuse, neglect and exploitation.

27 27 Administrative Authority The Medicaid Agency (Oregon Health Authority) retains ultimate administrative authority and responsibility for the operation of the waiver program by exercising oversight of the performance of waiver functions by other state and local/regional non-state agencies (if appropriate) and contracted entities.

28 28 Financial Accountability The assurance by a state that its claims for Federal financial participation in the costs of waiver services are: based on state payments for waiver services that have been rendered to waiver participants; authorized in the service plan; and properly billed by qualified waiver providers in accordance with the approved waiver. Sub-assurance: State financial oversight exists to assure that claims are coded and paid for in accordance with the reimbursement methodology specified in the approved waiver.

29 29 Oregon’s Tools for Assuring Quality Well-trained and empowered Services Coordinators and Personal Agents HCBS Waiver Review Checklist CDDP Site Reviews Brokerage Site Reviews Consumer Satisfaction Surveys Contract Reviews and Renewal Licensing Reviews and Actions SERT, County Reviews and Abuse Investigations

30 30 Questions?

31 31 Waiver, State Plan and Quality Assurance Unit Contacts Dana Hittle, , Darlene O’Keeffe, , Chris Pascual, ,


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