Presentation on theme: "Technology Assisted Waiver"— Presentation transcript:
1 Technology Assisted Waiver Department of Medical Assistance ServicesTechnology Assisted WaiverDepartment of Medical Assistance ServicesDivision of Long-Term Care2008 (with 2013 updates)1
2 Department of Medical Assistance Services Waivers in General2
3 Home and Community-Based Services Waivers -1915(c) Allow States flexibility to develop and implement alternatives to institutionalization care;Home- and community-based waiver services enable the participant to remain at home and in the community rather than being placed in an institution;Cost to Medicaid in the community can’t be higher than the cost to Medicaid in acute care hospitals and or specialized care nursing facilities stays and
4 1915(c) Waivers (cont) Can waive comparability of services Can waive rules that require States to provide services, on an equal basis, to all people in the StateMay be provided statewide or limited to specific geographic areas
5 1915(c) Waivers (cont)The State must assure CMS that there are safeguards to protect the health and welfare of recipientsThe state must assure the individual has the choice of settings for health care delivery.
6 1915(c) Waivers (cont)Waivers can be targeted to specific groups or any subgroup of:aged or disabled, or bothIntellectually disabled or developmentally disabled, or bothmentally ill
7 Virginia has Six 1915(c) Waivers Elderly or Disabled Waiver with Consumer Direction (EDCD)Intellectual Disabilities (ID)Technology Assisted (TECH)Day Support (DS)Individual and Family Developmental Disabilities Support (DD)Alzheimer’s Assisted Living Waiver
8 What is the Technology Assisted Waiver? Tech waiver is provided under the administration of DMASRequires the level of care provided as if the technology assisted participants are in hospitals (for individuals under 21) or specialized care nursing facilities (for those over 21).
9 What is the Technology Assisted Waiver? Objective of the waiver is to provide for medically appropriate and cost-effective coverage of services necessary to maintain these individuals in the community.
10 Financial Eligibility Requirements The income level used for the special home- and community-based waiver group at 42CFR is 300 percent of the current SSI payment standard for one person. Medically needy participants are eligible if they meet the medically needy financial requirements for income and resources.
11 Financial Eligibility Requirements (cont) When a participant has third-party payment for skilled private duty nursing, they are not eligible for waiver enrollment until the benefit is exhausted.When insurance has been voluntarily dropped in anticipation of waiver application, they are not eligible for enrollment into the Technology Assisted Waiver for a period of one year.Medicaid eligibility for children in the Tech waiver is based on the participant’s income and not the family income.
12 Tech Waiver Facts Waiver effective date: Dec. 12, 1988 No age limit to eligibilityRecipients served:FY 2012: 314 total212 Children102 Adults
13 Tech Waiver Target Population Participants who are:Chronically ill or severely impaired and need both a medical device to compensate for the loss of a vital body function and substantial and ongoing skilled nursing care to avert death or further disability and remain safely in the communityAdults- individuals who are 21 years of age or olderChildren- Individuals who are less than 21 years of age.
14 Who is Not Eligible for Tech Waiver? Services may not be furnished to persons:Who reside in a nursing facility;Intermediate care facility for the mentally retardedHospital;An assisted living facility licensed or certified by DSS orWho reside outside of the physical boundaries of the Commonwealth, with the exception of brief periods of time as approved by DMAS. Brief periods of time may include, but are not necessarily restricted to, vacation or illness.
15 Screenings and Enrollment Waiver CoordinationScreeningsandEnrollment15
16 Waiver ScreeningsDMAS coordinates UAI pre- admission screenings for TW enrollment with PAS Teams from the local Departments of Health and Department of Social Services in the community;Pre- Admission screenings are the same for the two waiver populations ( child and adult) except for age appropriate assessments and plans of care which are required beyond the UAI;
17 Waiver Enrollment Waiver enrollment is dependent on: Medicaid eligibility;If already Medicaid eligible, Medicaid eligibility re-determined must still occur when applying for waiver services;Physician signed and dated certification for the need for TW level of care and PDN;A complete PAS Team screening UAI packet;Completion of age appropriate referral forms;
18 Waiver Enrollment (cont) Being at risk for hospitalization;Receipt of final PDN authorization by DMAS;A safe and effective Plan of Care which meets the needs of the participant in a community setting;Assurance that the individual or legally responsible adult is afforded choice, andAssurance that Medicaid it the payers of last resort!
19 Technology Assisted Waiver Screening Process 19
20 Waiver Screening Process Pre-Screening is the process for:Evaluation- functional, nursing, and social supports of participants;Assisting- participants in determining what specific services the individuals need to include choice of services;Evaluation of availability of services or a combination of existing community services andReferral- to the appropriate provider for Medicaid-funded nursing facility or home and community-based care when those individuals meet nursing facility level of care.Choice shall be offered from the time a participant seeks waiver information or application and referral through discharge or termination.
21 Pre- Admission Screening Teams Who makes up the PAS Team?A registered nurse, social worker, and a physicianMay be from:Local Department of HealthLocal Department of Social ServicesHospital Discharge Screening Teams
22 Pre- Admission Screening Teams (cont) Regardless of who performs the pre- admission screenings, The DMAS Health Care Coordination Team makes the final decision for waiver criteria and eligibility determinations for all enrollments into the Technology Assisted Waiver.
23 Who completes the age appropriate referral forms? Regardless of age, as part of the referral process, the hospital or nursing facility discharge planner will complete the required scoring assessment forms and submit it to DMAS Health Care Coordinator for the final waiver criteria eligibility determination.Further screening information may be found in the Pre- Admission Screening https://www.virginiamedicaid.dmas.virginia.gov/wps/portal/ProviderManual
24 Pre- Admission Screenings when discharge is from a Long Stay Hospital Long Stay Hospitals include Lake Taylor Hospital (Norfolk) and Hospital for Sick Children (DC):Are the back up facility of choice for Tech Waiver;Are considered transfers and do not require the UAI assessment.Required documentation for transfer:A MD order for Tech Waiver enrollment;Medicaid eligibility determination;All required and completed Tech waiver referral forms including the DMAS 99T andAssurance that all skilled PDN third party benefits have been exhausted.
25 Pre- Admission Screening Pre- admission screenings are considered valid for the following time frames. Time frames apply to individuals who are screened but have not received services:0-6 months – no required updates6-12 months- update is required> 12 months- New PAS screening required
27 Waiver EligibilityParticipants can’t receive services from more than one Waiver at the same time.Participants may:Be on a waiting list for one Waiver and receive services in another Waiver if they meet the criteria for both Waivers;Be eligible for EPSDT nursing as long as they are Medicaid eligible individuals less than 21 years of age.Use Hospice benefit in conjunction with PDN and PC. Must bill Hospice first:PC (adults only)- Services will not be available to hospice recipients unless the hospice can document the provision of at least 21 hours per week of homemaker/home health aide services and that the recipient needs personal care-type services which exceed this amount.
28 Waiver Eligibility for Children Children are those participants who are younger than 21 years.Determined to need a medical device and substantial and ongoing skilled nursing care when the participant meets one or more of the following requirements:Dependent at least part of each day on mechanical ventilators orRequires prolonged intravenous administration of nutritional substances or drugs or ongoing peritoneal dialysis orHas daily dependence on other device-based respiratory or nutritional support, including tracheostomy tube care, oxygen support, or tube feeding andMust meet at least 50 points on the Pediatric Scoring Assessment form.
29 Waiver Eligibility for Adults Adults are those participants who are 21 years of age or older.Meets Medicaid specialized care criteria as determined to need a medical device when A or B of the following categories is met:A- Individuals depending at least part of each day on mechanical ventilators ORB- Individuals who meet all eight of the complex Tracheostomy criteria listed:1. Tracheostomy with the potential for weaning is unsuccessful;2. Nebulizer treatments or Nebulizer treatments followed by chest PT at least four times a day provided by a nurse and or respiratory therapist;
30 B. Complex Tracheostomy Criteria (cont) 3. Requires pulse oximetry at least every 8 hoursdue to unstable oxygen saturation levels;4. Requires Respiratory assessment by an RT or a nurse;5. MD order for Oxygen therapy with documented usage;6. Tracheostomy care at least daily;7. Tracheostomy suctioning PRN and as ordered by an MD and8. Deemed at risk to require subsequent mechanical ventilation.
31 Waiver Eligibility for Adults DMAS Technology Assisted Waiver Adult Referral form is required in order to qualify for enrollment;Criteria instructions and definitions can be found on the DMASAdult Medicaid-eligible participants who entered this waiver service prior to their 21st birthday shall be required to conform to the same medical needs and individual cost-effectiveness standards as specified for all other adults.
32 Interruption in Waiver Service Delivery Waiver termination occurs when:Skilled PDN services are interrupted for greater than 30 days;Admission to a nursing or specialized care facility;Participant no longer meets waiver criteria;Participant is no longer a resident of Virginia andParticipant is no longer Medicaid eligible.**Individuals admitted to any type of medical care facility for less than 30 days shall again be eligible for waiver services upon discharge so long as all enrollment criteria continues to be met**.
33 Intake Enrollment Initial Home Assessment Visit Waiver EnrollmentIntakeEnrollmentInitial Home Assessment Visit33
34 DMAS IntakeIntake begins with the receipt of a complete UAI screening packet at DMASA complete screening/ referral packet contains:12 page Uniform Assessment Instrument (UAI);MI/MR Assessments (DMAS 95);DMAS 96- Medicaid Funded Long Term Care Service Authorization form;
35 DMAS IntakeDMAS 97- Recipient Choice-Institutional Care or Waiver Services formAge appropriate TW referral form:DMAS 108-TW Adult Referral FormDMAS 109-TW Pediatric Referral FormLetter of determination from The Department of Health (DOH) when the screening is performed in the community;All supporting medical documentation;
36 DMAS Intake (cont)The DMAS Assessment for waiver enrollment includes a complete review of all screening documents and supporting documentation to assure:DMAS is the payer of last resort;There are no duplication of services;TW referral criteria has been met;MD orders for all waiver consideration;
37 DMAS Intake (cont)Diagnosis relates to the skilled technology;Family/ caregiver training is complete andThere is a safe and effective plan of careChoice shall be offered from the time a participant seeks waiver information or application and referral through discharge or termination and includes:Institutionalization verses community based care;Provider andService.
38 EnrollmentOnce waiver criteria and enrollment is determined DMAS will:Work with community resources & family to secure services from a provider agencyAssure all DME equipment has been ordered;Review the provider agency admission assessment (within 48 hours of admission) as the final determination for authorization of PDN;Determine the start of care date for PDN;Enroll and create Prior Authorization in the MMIS system to allow for provider reimbursement andNotify the provider and waiver participant of PDN authorization.
39 Enrollment (cont)Medicaid shall not reimburse for any PDN hours provided prior to the DMAS authorization on the Technology Assisted Waiver Skilled Private Duty Nursing Authorization Form (DMAS 102);Medicaid shall not reimburse for any home- and community-based care services delivered prior to:The participant establishing Medicaid eligibility;The date of the preadmission screening orThe physician signature on DMAS 96- the designated Medicaid-funded long-term care services authorization form.NOTE: The provider agency MUST notify DMAS when the first skilled nursing shift is worked.
40 Enrollment (cont)Once the individual is determined to meet waiver criteria, DMAS notifies the Department of Social Services of waiver enrollment in order to initiate Medicaid eligibility determination and determine the patient pay;The patient pay amount is the individual’s contribution toward his/her care received in a calendar month;
41 Enrollment (cont)If the amount of services received in a calendar month is equal to or less than the patient pay amount, only the amount for the services rendered should be collected, and DMAS should not be billed for that month;When more than one provider agency is providing services, the agency billing the greatest number of hours is responsible for collecting the patient pay andThe provider cannot bill DMAS for the patient pay amount.
42 DMAS Initial Assessment Visit The home assessment visit is performed by DMAS within 14 days of the first day of Private Duty Nursing and includes:An explanation of the program to the primary caregiver and waiver participant;Completion of the DMAS Tech Waiver Rights and Responsibilities form;
43 DMAS Initial Assessment Visit (cont) Assurance of MD orders and certification for home based care;Assurance the medical care that the participant is to receive in the home is agreed to by the legally responsible adult and all others involved in the assessment process andAssurance of quality care, safety and that the home is appropriate for the medical equipment and services being provided.
44 DMAS Home VisitsThe annual and semi- annual assessment visits are performed by DMAS:Semi-annual assessment visit- is completed every 180 days. The purpose is:Review the service plan for the level, amount, type, scope, and quality of services provided;Ensure appropriateness of services andMonitoring the cost-effectiveness of the participant’s care in the community.
45 DMAS Home VisitsAnnual assessment visit is- completed once every 365 days.The purpose is:Assure medical necessity of waiver services;Annual level of care eligibility re-determination andAssure that the participant continues to be safe in the community.Regardless of the type of assessment, the HCC review includes:Last three months of provider supervisory notes;Participant satisfaction and choice, andHealth, safety, welfare, or risk of the waiver participants.
46 Physician Certification for Home and Community Based Waiver Services CMS 485CertificationRe- CertificationVerbal Orders46
47 Physician Oversight and Certification Participants of Tech waiver PDN services, PDNRespite or Personal Care must be under thedirect care of a physician who is legallyauthorized to practice and act within the scope of his or her licensure.
48 Physician Certification A complete initial Home Health Certification and Plan of Care (CMS-485) shall include all required documentation and must be signed and dated by the attending physician;The provider agency may not bill Medicaid for waiver services until the recertification is signed and dated by the MD. MD signature must include the name and the professional title.
49 Physician Certification (cont) The certification/recertification service plan must:Be on a form designated by DMAS which includes but is not limited to:All MD orders at the initial waiver enrollment;Orders obtained as a result of modifications to the previous service plan, which remain in effect andAll updated goals and time frames for goal achievement for all services ordered.
50 Physician Certification (cont) When the provider agency chooses to use a form other than the Home Health Certification and Plan of Care (CMS 485), the alternate document MUST include all components of the 485 (see slide 54,55 &56) and must include the statement of physician certification with a signature and date and must be authorized by DMAS.Shall be kept in the participant’s medical record;
51 Physician Certification (cont) In order to assure that all of the care needs for the Tech Waiver participant are met, the most recent 485 or DMAS-designated service plan shall be kept in the participant’s home at all times and shall assist the nurse in case of emergencies, substitution, or when there is more than one nurse providing care;Modifications to the plan of care may occur in the form of a verbal order and must be received/ signed and dated by the RN and MD and must be included on the next re-certification 485.
52 Physician Certification (cont) In order to assure the 485 is renewed every 60 days, the renewal shall be submitted to the primary care MD at least 14 days prior to the certification end date. A 5 day (from certification end date on the current 485) grace period is allowed for MD signatures (i.e., between and including days 60-65).
53 Physician Certification (cont) The Plan of care shall include:Identification of the primary care physician in the community who has agreed to manage the medical care of the participant in the community;The name and current address of the participant;The participant’s date of birth, Social Security Number, Medicaid number, and any private insurance;Certification of the TW participant's need for licensed Skilled PDN care;All waiver services and treatments to include type, amount , duration, scope, and frequency of services;
54 Physician Certification (cont) Diagnosis to support waiver services;All current medications and allergies;A list of all DME equipment and supplies;Any new orders obtained since the last certification;Goals for care and services andThe dated MD and RN signatures completing the form;
55 Physician Certification (cont) Identification of the type, amount, and frequency of services that the family or informal caregiver will provide, including who will perform services and when; andOther referrals for assessment for services, as needed and appropriate, to include, but not be limited to:School system andEarly and Periodic Screening, Diagnosis and Treatment Program (EPSDT) services.
56 Physician Certification (cont) In order to assure that quality, risk, and safety are assessed, the provider agency shall submit the most updated 485 or DMAS-designated service plan and monthly supervisor report to the DMAS health care coordinator by the sixth day of the following month in which the visit occurred.
58 Waiver services shall be provided only to participants when services are available inthe scope and amount to meet the needs ofthe participant and when the needs areconsistent with the service description of therequested services.
61 Skilled Private Duty Nursing Provided to participants with serious medical conditions and complex health care needs;PDN requires specific skilled nursing services not provided by non- licensed staff on a regular or intermittent need basis;May include consultation and training of other care providers andRN/LPN shall have signed physician orders specifically identifying skilled tasks to be performed for the participant;All orders must be updated every 60 days on the CMS 485.
62 Skilled PDN Documentation Requirements Skilled PDN Nursing Visit notes must be completed each day and kept in the participants' home at all times;The nurse will keep the medical records in a designated place in the home and assure confidentiality is maintained in accordance with all HIPAA guidelines;
63 Skilled Private Duty Nursing (cont) Skilled Private Duty Nursing is the only stand alone service in the Tech waiver. No other service may be approved without the Tech waiver PDN authorization;The hours of private duty nursing (PDN) for adults shall be determined by medical necessity only and authorized up to a maximum of 16 hours per day in a 24 hour period per household.
64 Skilled Private Duty Nursing (cont) The PDN hours for children are determined by medical necessity and the total points / score on the Pediatric referral form (DMAS 109).PDN Scoring Categories:A points = Maximum of 10 PDN hours/dayB points = Maximum of 12 PDN hours/dayC 80 or more = Maximum of 16 PDN hours/day.
65 30 Day RuleTechnology Assisted waiver participants less than 21 years of age living separately or congregate, during the first 30 days of enrollment, may receive up to 24 hours of PDN when it is needed and appropriate to assist the family with adjustment to the care associated with the technology.All authorizations for 24 hour care MUST be approved by DMAS before reimbursement can occur.
66 Staff Requirements for PDN Must be licensed in the Commonwealth of Virginia:Registered NurseLicensed Practical Nurse under the direct supervision of the provider agency RN supervisorShall have at least 6 months of experience in the needs and care of the TW participant to include the care needs of children when the waiver participant is a child andShall be deemed competent and trained to care for TW clients with complex skilled needs such as ventilator dependency and those with a tracheostomy.
67 Skilled Nursing Visits There are three type of required skilled nursing visits:Initial Assessment visitPrivate Duty Nursing visitsSupervisory visitsInitial assessment visit- admission to Tech waiver PDN services, is performed by the provider agency RN supervisor and involves an assessment of all of the participants health care needs;DMAS 103- Tech Waiver Supervisory Monthly Summary;Must submit initial assessment to DMAS within 48 hours- prior authorization is dependant upon submission to DMAS.
68 RN Initial Assessment (cont) Coordination of services;Confirm and continue education and training of primary care giver in meeting nursing and related goals;Supervision of personnel involved in care delivery;Risk assessment andAssure Health, safety and welfare is maintained in the home environment at all times.
69 Skilled VisitsPDN visit – skilled PDN visits made by the provider agency RN or LPN in accordance to the Plan of Care. Visit includes all skilled hands on care ordered by the MD and complex health care.Supervisory visit - provider agency RN supervisor monthly visits. Responsible for the oversight for all TW services in the home. Visits are made in accordance to regulations and ensures all the health care needs are being met, participant satisfaction with waiver services, supervision of PDN Respite and Personal Care services and staff and all MD ordered medical needs are being provided.
70 PDN Documentation Requirements Documentation in the medical record shall follow the medical legal documentation requirements as defined by licensure and shall include the employees name, title, time of services performed and date of the entry.The PCG name and phone number is required as well as the name and phone number of the trained back up individual who is accepting responsibility for the oversight and care in case of emergency, illness or incapacitation of the PCG.The back up plan shall be in accordance to the provider agencies policy and procedures and all regulations.
71 PDN Documentation (cont) Supporting documentation must include and describe the following:The type of skilled procedures performed during the PDN visit;The complexity of steps needed to complete each procedure andAll services detailed and ordered in the MD certification/plan of care.
72 PDN Documentation Limits The monthly RN supervisory visit nurses notes can not be performed by the nurse making the daily PDN visitsDuring the initial assessment, when the RN supervisor determines that the participant is not appropriate for private duty nursing services because of safety, health, or welfare reasons or because the provider is unable to staff the case, the agency should not open the case to private duty nursing.If the provider agency decides not to accept the referral, the RN shall notify the participant and the DMAS Health Care Coordinator of this decision and the reason for the decision.
73 PDN Documentation (limits) The provider RN shall contact the DMAS HCC to discuss the situation and explore possible alternatives to provision of care.There must be a primary caregiver (PCG) who accepts responsibility for the health, safety and welfare of the waiver participant;The PCG must be trained in all aspects of care and assume responsibility for a minimum of 8 of the 24 hours of care and all care hours when no PDN is available;The Tech Waiver enrollee can not be left alone at any time and the PCG/ trained designated back up person must be in the home at all times when the personal care aide services are being utilized.
74 Skilled PDN (limits)PDN must be performed in the primary residence of the waiver participant. The provider agency is responsible for notifying DMAS when changes occur.PDN hours may be used to assist with medical appointments;When PDN hours are performed in schools, the nurse must be in the same room as the waiver participant;
75 Skilled PDN (limits)Waiver participants can’t receive services from more than one waiver program or Home Health program at the same time when the services duplicate any other care received.When more than one service is authorized at the same time such as PDN, Respite and Personal Care, those services can not be performed and billed for the same time frames.Medicaid reimbursement can not be made for skilled private duty nursing services:Performed by parents, spouses, or any other person living with the participant. ExceptionsPreauthorized by DMAS;Documentation must show multiple attempts made to staff and reason why exception needed to be made.
76 PDN Hours Shared by Two Providers When two waiver participants receive the same service from two different providers on the same day:The provider who submits the claim first will enter the HCPCS code and the claim will be paid.The second provider will submit the claim with the HCPCS code and the modifier 77 for the same dates of service. A denial will occur when a modifier is not included on the claims form.The system looks for the modifier to allow for same day billing.
77 Congregate Private Duty Nursing Waiver participants, regardless of age, may live with more than one waiver participant in the same household.The primary caregiver is shared and shall be responsible for providing all skilled nursing needs at a minimum of eights hours of care in a 24-hour time period in the absence of the skilled nurse.Likewise, one nurse shall perform the skilled nursing needs shared by both participants.** A group is defined as having greater than 3 waiver participants living in the same home. Tech waiver Medicaid reimbursement is not allowed in group home settings.***
78 Congregate Private Duty Nursing A combination of Congregate PDN hours and regular PDN hours are needed when the participants are not in the home at the same time such as school or medical appointments.These participants will have prior authorization for both types of PDN, but the agency must bill according to service delivery.On non school days, regardless of the reason, the congregate PDN rate will apply.Whenever congregate nursing applies, reimbursement will be made to one nurse.
79 PDN Service Units and Limits PDN hours are approved by DMAS on the TW Skilled PDN form- DMAS 102.The DMAS 102 is sent to the provider agency and the waiver participant on admission and when changes in service hours are made.The DMAS 102 is kept in the provider agency’s medical record.Prior authorization (PA) is entered into the MMIS system by DMAS upon enrollment and when changes occur.
80 PDN Service Units and Limits (cont) The begin date is the first date of service delivery and/ or change which can be billed.The recipient must be Medicaid eligible and enrolled in the Tech Waiver by DMAS in order to receive Medicaid reimbursement.The units are billed as monthly units
82 Waiver Services and HCPCS Codes T Personal Assistance (PC) - Adults OnlyAncillary Services:T Assistive TechnologyS Environmental ModificationsT Transition servicesPayment for services under the service plan shall not duplicate payments made to public agencies or private entities under other program authorities for this same purpose.
83 DMAS-225 Documentation Requirements The provider agency must notify DMAS and the Department of Social Services via the DMAS-225 when any of the following occurs:Death;Transfer;Hospitalization/ interruptions greater than 30 days ;Nursing or specialized care facility admission;Change in residence orNo longer a resident of Virginia.
84 Respite (PDN)Short-term relief of the unpaid primary caregiver (Does not have to live in the same home);360 hours is the maximum number of combined respite hours per calendar year;Must be requested by the primary caregiver;Provider agency can not use respite to “tack on” hours of care without caregiver permission andShall be provided by an RN or LPN under the direct supervision of an RN.
85 Documentation Guidelines for Respite (PDN) Documentation shall include the following:The reason for the respite care hours;Clearly states the PDN tasks performedTime and date of service delivery.PDN note must be clearly defined as Respite and maintained in a separate section of the medical record.Respite care hours must be billed separately from skilled PDN hours.
86 Respite PDNAll respite care shall be ordered by a physician on the 485;Services shall include assistance with ADL’S, administration of medication, skilled medical needs and monitoring of health and physical status;Shall not be provided simultaneously with PDNLicensed personnel providing Respite Care shall be under the supervision of a RN with documentation of monthly visits in the home of the waiver participant.
87 Personal CarePersonal care services (adults only) are ordered on the DMAS-designated service plan (DMAS 99T) by the provider agency’s RN supervisor prior to the initiation of PC;The RN Supervisor’s assessment visit shall note any special considerations for service provision and the support available to the participant.Each ADL category shall be totaled when time has been allotted to a particular category in the ADLs category.IADL time shall be limited as the primary caregiver is expected to perform this routine care. IADL is allowed for meal preparation, clean kitchen and areas used by the participate and make/ change beds.
88 Personal Care (cont)Long-term maintenance or support services necessary to enable the adult individual to remain at or return home rather than enter a nursing facilityMedicaid reimbursement shall not occur when ADL services are ordered and rendered to or for the convenience of other family members in the individual’s household (e.g., cleaning rooms used equally by all family members, cooking meals for the family, washing dishes, doing family laundry);
89 Personal Care (cont)Provided in the areas of activities of daily living, access to the community, monitoring of self-administered medications or other medical needs, and the monitoring of health status and physical conditionWhere the individual requires assistance with activities of daily living, and does not include supervisionMay be used to augment PDN when limited nursing hours are available and the individual needs assistance /PC.
90 Personal Care (cont)Not a stand alone service- must be receiving Private Duty NursingRendered by a Personal Care Aide (PCA) or Certified Nursing Aide from a DMAS approved training programProvider agency employs PCA and oversees the plan of care on behalf of the individual or primary caregiver
91 Personal Care Limits Agency-Directed Only: PCA and individual’s care are supervised by a RN employed or contracted by the provider agencyAn aide can’t render skilled services, therefore all skilled nursing needs must be met by the primary caregiver when personal care is being performed.The primary caregiver MUST be in the home at all times when personal care is performed.
92 Personal Care Aide- Limits Aides shall not be the parents of adult participants, the participant’s spouse, or the legally responsible adult.Payment shall not be made for services furnished by other family members living under the same roof as the participant; the exception may be made in rural areas where services are limited BUT there must be continuous objective written documentation as to why there are no other providers available to provide the service. This requires DMAS approval.Personal care services are limited to 8 hours in a 24 hour time frame.
93 Personal Care Aide Staffing Requirements DMAS requirements for aides:Registration as a certified nurse aide (CNA);Graduation from a DMAS-approved educational curriculum that offers certificates qualifying the student as a nursing aide, geriatric nursing assistant, or home health aide;Completion of a DMAS-approved provider-offered training that is consistent with the basic curriculum approved by DMAS; orCompletion of a minimum of 40 hours of training approved by DMAS.Must be able to read and write English.
94 Personal Care Interruption in Care Delivery When an aide is absent, the provider shall ensure all services continue to be provided to participants.The provider may either provide another aide or obtain a substitute aide from another provider.When the lapse in coverage is to be greater than two weeks in duration, the provider shall transfer the participant's services to another provider.When no other provider is available who can supply a substitute aide, the provider shall notify the participant, and the participant representative and DMAS.
95 Personal Care- Substitution During temporary, short-term lapses in coverage not to exceed two weeks in duration, the following procedures must apply:The preauthorized provider must provide the supervision for the substitute aide;The provider of the substitute aide must send a copy of the aide's daily documentation signed by the participant, and the participant representative, as appropriate, on the participant’s behalf and the aide to the provider having the authorization; and
96 Personal Care- Substitution (cont) The preauthorized provider must bill DMAS for services rendered by the substitute aide.If a provider secures a substitute aide, the provider entity is responsible for ensuring that all DMAS requirements continue to be met.Documentation of services rendered by the substitute aide must be completed.Documentation that the substitute aide's qualifications meet DMAS' requirements is required. The two providers involved are responsible for negotiating the financial arrangements of paying the substitute aide.
97 Personal Care Documentation Requirements Waiver service provider shall maintain documentation necessary to support services billed and include:All assessments, reassessments, and evaluationsService PlansProgress notesPrior- authorization decisionsDocumentation of services
98 Personal Care Documentation Requirements (cont) Skilled supervisor notesAide recordsDocumentation of choiceAll related correspondence which is related to the participant’s medical condition.Records of minors shall be kept for at least six years after such minor has reached the age of 18 years.
99 Environmental Modifications (EM) Physical adaptations to a house or place of residence when the modification exceeds reasonable accommodation requirements of the Americans with Disabilities Acts;Necessary to ensure participants’ health and safety;Or to enable functioning with greater independence.The adaptation can not be used to bring a substandard dwelling up to minimum habitation standards andMust be of direct medical or remedial benefit to participant.
100 EM (cont)Providers shall seek prior authorization from DMAS when the TW participant is ventilator-dependent for 24 hours per day and request environmental modification for the installation of a generator.EM requests shall be reviewed on an individual basis according to the specific needs of the waiver participant and must not: Duplicate modifications already paid for by Medicaid andExceed the $5,000 per recipient per calendar year limit.
101 EM (cont)Exclusions:Adaptations or improvements to the home which are of general utility and are not of direct medical or remedial benefit to the participant, such as carpeting, roof repairs, central air conditioning, etc.Adaptations which add to the total square footage of the home.All EM services shall be provided in the participant’s primary home in accordance with applicable state or local building codes.
102 EM (cont)EM service does not include the purchase of vehicles. Modifications may be made to a vehicle if it is the primary vehicle being used by the participant.Modifications shall be completed within the plan of care or the calendar year in which the modification was authorized, as appropriate to the waiver in which the participant is enrolled.Modifications shall not be used to bring a substandard dwelling up to minimum habitation standards.
103 EM (cont)Also excluded are modifications that are reasonable accommodation requirements of the ADA, the Virginians with Disabilities Act, and the Rehabilitation Act.
104 EM (cont)Provider must bill for the dates of service on the Prior authorization form from MMIS;Unit of services is 1;EM is not a stand alone service and can not be authorized unless PDN is authorized first.Cost shall not be carried over from one year to another.The agency RN supervisor shall confirm on the monthly visit that the modification was completed and the participant satisfaction with the work.
105 Assistive Technology (AT) Specialized medical equipment and supplies including those devices, controls, or appliances, specified in the plan of care but not available under the State Plan for Medical Assistance;Enables participants to increase their abilities to perform activities of daily living;Enable participants to perceive, control, or communicate with the environment in which they live orwhich are necessary to the proper functioning of such items.Must not duplicate AT items already reimbursed by Medicaid andshall not exceed the allocated $5,000 per recipient per calendar yearAT must not be used for educational purposes and must be of medical or remedial benefit.
106 AT (cont)AT is available to participants who are receiving at least one other waiver service;Costs for AT shall not be carried over from year to year and must be preauthorized each service plan year andAT shall not be approved for purposes of convenience of the caregiver or provider or restraint of the participant.An independent, professional consultation must be obtained from qualified professionals who are knowledgeable of that item for each AT request prior to approval by the prior authorization agent and
107 AT (cont)May include training on such AT by the qualified professional.All AT shall be prior authorized by the prior authorization agent prior to billing. Also excluded are modifications that are reasonable accommodation requirements of the ADA, the Virginians with Disabilities Act, and the Rehabilitation Act.The prior authorization agent is DMAS.
108 AT (cont)Equipment/supplies/technology not available as DME through the State Plan may be purchased and billed as AT as long as the request for equipment/supplies/technology is documented and justified in the participant's service plan, recommended by DMAS, and preauthorized by the designated agent.The RN supervisor shall document delivery of AT and customer satisfaction of the item on the monthly visit note.
109 Provider Responsibilities Quality of CareFree of AbuseChoiceFree from RestraintGrievancesAppealsParticipant Rights
110 Participant Rights and Responsibilities The waiver participant has the right to:Quality of care. Participants shall receive, and the provider and provider staff shall provide, the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and service plan.
111 Participant Rights and Responsibilities The waiver participant has the right to be free from :Verbal, sexual, physical, and mental abuse, physical abuse, neglect, exploitation, and misappropriation of property.The participant and the participant’s representative, as appropriate, shall be provided information by the provider, upon the beginning of services, regarding signs of abuse and how to report suspected abuse to the appropriate authorities.
112 Participant Rights and Responsibilities The waiver participant has the right to freedom of choice:The participant or the participant representative, as appropriate, shall be offered choice in all things and their choices respected, unless harmful.Each of these choices shall be documented in the participant’s record and shall include, but not be limited to, the freedom to:1. Choose whether the participant wishes to receive community-based care services or institutionalization in accordance with the assessment for services;2. If waiver services are chosen, choose between services and Choose the provider of services.
113 Participant Rights and Responsibilities The waiver participant has the right to freedom of choice (cont):Choice of a personal attending physician;Be fully informed in advance about care and treatment and of any changes in that care or treatment; andUnless adjudged incompetent or otherwise found to be incapacitated under the laws of the State, participate in the development of the service plan and services.
114 Participant Rights and Responsibilities The waiver participant has the right be free of restraints:Each participant has the right to be free from any physical or chemical restraints, of any form, used as a means of coercion, discipline, convenience, or retaliation and not required to treat the participant's medical symptoms.
115 Participant Rights and Responsibilities The waiver participant has the right to:Grievances:Voice grievances to the provider or provider staff without discrimination or reprisal. Such grievances include those with respect to treatment which has been furnished as well as that which has not been furnished;Prompt efforts by the provider to resolve any grievances the participant may have.Appeal:Participant appeals shall be considered pursuant to 12VAC et seq. and 12VAC
116 Participant Rights and Responsibilities A provider shall protect and promote the rights of eachparticipant, including each of the following rights:Free of interference, coercion, discrimination, and reprisal from the provider in exercising the participant’s rights;Personal privacy and confidentiality of his or her personal and clinical records;In the case of a participant adjudged incompetent under the laws of a State by a court of competent jurisdiction, the rights of the participant are exercised by the person appointed under State law to act on the participant's behalf;In the case of a participant who has not been adjudged incompetent by the State court, any legal-surrogate designated in accordance with State law may exercise the participant's rights to the extent provided by State law.
117 Participant Rights and Responsibilities A provider shall protect and promote the rights of each participant, including each of the following rights:To receive services from the provider with reasonable accommodation of participant needs and preferences, except when the health or safety of the participant or other participants would be endangered.The participant or the participant representative, as applicable, shall notify DMAS and the provider, as applicable, if the participant experiences a significant change in physical, mental, social, or economic circumstances. This includes, but is not limited to, the participant no longer meeting the criteria for the receipt of waiver services, is hospitalized, moves to another address, or receives an increase in income that could affect the participant’s Medicaid eligibility;
118 Participant Rights and Responsibilities A provider shall protect and promote the rights of each participant, including each of the following rights:The participant or the participant representative, as applicable, shall cooperate with any stated requirements regarding participant compliance in order to receive waiver services, unless good cause can be demonstrated, as described in 12VAC E ;Good cause for failure to cooperate with waiver services requirements shall be established when the participant or the participant representative, as applicable, demonstrates one or more of the following conditions:a. There was a serious illness or death of the participant or the participant representative, as applicable. (cont)
119 Participant Rights and Responsibilities b. There was an emergency or household disaster, such as fire, flood, or tornado.c. The participant or participant representative offers a good cause beyond the participant’s or participant representative’s, as applicable, control.d. There was a failure to receive DMAS' request for information or notification for a reason not attributable to participant or the participant representative.The participant or the participant representative shall not commit fraud in the receipt of DMAS waiver services. Cases of suspected misrepresentation or fraud shall be investigated according to DMAS's fraud prevention and control policies and any other applicable statutory provisions.
120 Money Follows the Person (MFP) The purpose of MFP is to identify participants living in institutions who desire to move back into the community and to assist them with initial moving expenses and the transition process;The MFP program is applicable to existing waiver services for select home and community-based Medicaid waivers.
121 Transition ServicesTransitional Services (TS) – a one-time, life-time $5,000 benefit for those participants transitioning from a qualified institution to a qualified community setting to assist with items and services needed for a successful transition;For the purposes of transition services, an institution means an ICF/IID, a nursing facility, or a specialized care facility/hospital as defined at 42 CFR Transition services do not apply to an acute care admission to a hospital.
122 Transition Services Allowable costs include, but are not limited to: Security deposits that are required to obtain a lease on an apartment or home;Essential household furnishings required to occupy and use a community domicile, including furniture, window coverings, food preparation items, and bed/bath linens;Set-up fees or deposits for utility or services access, including telephone, electricity, heating and water andServices necessary for the participant’s health, safety, and welfare such as pest eradication and one-time cleaning prior to occupancy
123 Interruption in Waiver Services DischargeTerminationTransfer123
124 Change in Service PlanChanges to a participant’s service plan (485) require authorization by DMAS or its designated agent, as appropriate. These changes include, but are not limited to:Decreases or increases in hours of service;Interruptions in service delivery;Discharge from waiver services or waiver enrollment termination.
125 Cessation of Technology/ Equipment A child or adult who no longer meets the qualifications of 12VAC C may be eligible for PDN for the number of hours previously approved in the service plan per 24-hour period not to exceed two weeks from the date the attending physician certifies the cessation of daily technology assistance but…When appropriate, it is the Provider RN Supervisor’s responsibility to coordinate with DMAS for a decrease in hours.
126 Discharge versus Termination Termination from the waiver is a DMAS function only.Discharge from an agency is performed by the agency and must include written notification to the individual with 14 days notice (plus 3 days to allow for mailing). This letter must include the reason for discharge, effective date and notify DMAS immediately..In an emergency when health and safety of the participant or agency personnel are endangered the written notification period is not required. DMAS must be notified by the agency RN Supervisor prior to the discharge or discontinuing PDN services. Adult Protective Services or Child Protective Services must be notified immediately when appropriate.
127 Discharges/ Termination (cont) The provider agency supervisor must assure all visits are according to regulation. When the waiver participant no longer meets criteria for the Tech Waiver or the Physician orders reflect the need to discontinue waiver services, the agency RN supervisor shall notify DMAS immediately.Upon admit to a nursing facility or Specialized Care Unit, waiver enrollment is automatically terminated.Upon re- enrollment, the provider will assure Medicaid eligibility, complete a new assessment and seek re-enrollment through DMAS. The pre- admission guidelines are followed for the UAI assessment.Upon discharge the pre- admission screening rules will apply.
128 Participant AppealIn accordance with 12VAC , when termination or other change in waiver services are proposed or made by DMAS or its designated agent, DMAS or its designated agent shall notify the participant or the participant representative, as appropriate, in writing of the right to appeal the decision or decisions to adversely affect, reduce, terminate, suspend, or deny services pursuant to DMAS client appeals regulations, 12VAC , et seq., including the process for submitting an appeal to DMAS.A request for appeal shall be filed by the participant within 30 days of the appellant's receipt of the notice of an adverse action described in 12VAC
129 Participant Appeal (cont) The written notice described in 12VAC shall include:a. What action the agency intends to take;b. The reasons for the intended action;c. The specific regulations that support or the change in law that requires the action;d. The right to request an evidentiary hearing, and the methods and time limits for doing so;
130 Participant Appeal (cont) e. The circumstances under which benefits are continued if a hearing is requested in accordance with 12VAC ); andf. The right to representation.A request for appeal shall be filed by the participant within 30 days of the appellant's receipt of the notice of an adverse action described in 12VAC
131 Termination from the Waiver Reasons for termination from the waiver:The home and community based care services are no longer the critical alternative to delay institutional placement;No longer Medicaid eligible;No longer meets nursing facility or specialized care criteria;Participant’s environment does not provide for his health, safety and welfare.DMAS or its designated agent shall have the final authority to approve or deny a requested change to the participant’s supporting documentation.
133 Provider Responsibility The provider shall assure background checks pursuant to 12VAC E shall be conducted for the owner, co-owner's), if applicable, any other person identified as having decision-making authority for the organization or agency, and all employees providing services to a waiver participant.Any person with a conviction in the criminal background check or any of the other registry searches or who cannot demonstrate a successful work history shall not be deemed fit to provide services to Medicaid participants.
134 Provider Responsibility Assure the participant’s freedom to reject medical care and treatment;Provide services and supplies to participants in full compliance of the same quality and in the same mode of delivery as is provided to all others served by the provider regardless of payer source, including reasonable access to services in a timely manner;The provider shall not attempt to collect from the participant or the participant’s representative any amount that exceeds the usual Medicaid allowance for the service rendered or any amount for services delivered. This includes not billing DMAS or participants or the participant representative, as applicable, for broken or missed appointments or collect monies up front for services to be delivered;
135 Provider Responsibility Medical Records- The provider will:Keep such records as DMAS determines necessary;Furnish DMAS (on request) information in the form requested regarding payments claimed for providing services under the State Plan and other documentation;Use only DMAS-designated forms for service documentation;Shall not alter the DMAS forms in any manner unless approval from DMAS is obtained prior to using the altered forms;Allow access to records, participants, and facilities by DMAS and its designated agents, the Attorney General of Virginia or his authorized representatives, the state Medicaid Fraud Control Unit, the State Long-Term Care Ombudsman, and any other authorized state and federal personnel shall be permitted upon reasonable request.The provider agrees to comply with the regulations of HIPAA of 1996, including the protection of confidentiality and integrity of DMAS information.
136 Provider Responsibility Agree to monitor and evaluate service quality and effectiveness on a systematic and ongoing basis. Input from participants receiving services or their authorized representatives about services used and participation in service planning shall be a part of the quality assurance system.Be in full compliance with all state and federal licensure and certification requirements to perform the act of service delivery.
137 Provider Responsibility Not engage in direct-marketing or improper direct solicitation of participants and shall announce services fairly and accurately in a manner which will aid the public in forming their own informed judgments, opinions and choices and which avoids fraud and misrepresentation through sensationalism, exaggeration or superficiality.The provider shall ensure that all employees are aware of the requirements to report suspected abuse, neglect, or exploitation immediately to APS or CPS, as appropriate.A civil penalty may be imposed on mandated reporters who do not report suspected abuse, neglect, or exploitation to VDSS as required.
138 Minimum qualifications of provider staff RNLPNAide138
139 Staff QualificationsThe provider shall assure that RN supervisory and aide staffs meet the qualifications detailed in Chapter II of the provider manual. All RNs who perform supervisory activities are expected to be knowledgeable of waiver services criteria, definitions for the completion of the functional status assessment and all program requirements, regardless of whether they perform these activities on a part-time basis.RNs providing waiver services shall be currently licensed to practice in the Commonwealth or hold a multi-state compact privilege and have at least two years of related clinical nursing experience that may include work in an acute care hospital, public health clinic, home health agency, rehabilitation hospital, NF, or as an LPN.LPNs providing waiver services shall be currently licensed to practice in the Commonwealth and be supervised by a RN.
140 Staff QualificationsThe provider shall be responsible for instructing all aides who provide personal care in the program requirements related to their performance of duties.Each staff person providing Medicaid-funded waiver services shall:Provide services in a manner that is in the best interest of the participant and does not endanger the participant’s health, safety, or welfare.Provide services only within the competency areas for which one is qualified by training or experience.Represent accurately one's competence, education, training and experience.Report to DMAS any unethical or incompetent practices by providers that jeopardize public safety or cause a risk of harm to waiver participants.
141 Background ChecksThe provider shall ensure that himself and all participants in his employ or under his supervision who are involved in providing services to participants receiving waiver services shall have a check of:a. Criminal history records through the Virginia State Police;b. The Virginia CPS Central Registry if providing services to children;c. The Virginia Nurse Aide Registry if certified as a nurse aide; andd. The Virginia Sex Offender Registry.
142 Background ChecksThe provider shall not employ or supervise persons who have:A record of committing barrier crimes such as those defined in the Code of Virginia, §A founded disposition in the Child Protective Services (CPS) Central Registry at VDSS.A finding entered into the State nurse aide registry maintained by the Virginia Department of Health Professions concerning abuse, neglect, mistreatment of participants, or misappropriation of their property.
143 Background ChecksA finding entered into the Virginia Sex Offender Public Registry, coordinated by the Virginia State Police.DMAS shall not reimburse the agency provider for any services provided by an employee who has committed a barrier crime, who has a finding in the CPS Registry, who is found in the Virginia Nurse Aide Registry, or is found in the Virginia Sex Offender Registry.
144 Medicaid Contracted Vendors for Waiver Services 144
145 Vendors (cont)KePROConducts prior-authorization for the following services:Environmental ModificationsAssistive TechnologyDurable Medical EquipmentPhysical Therapy/ Occupational Therapy and Speech Therapy
146 DMAS Health Care Coordinators Rebecca Stricklin, RNRoberta Matthews, RNLaura Epperly, RNGinny Tweel, RNDiane Gilbert, RNDMAS LONG TERM CARE DIVISION–FAX