1. NC Department of Health and Human Services DMA 1915 (c) Waiver Training January 2012 Andrea Misenheimer Medicaid Director – PBH Patti French Waiver Consultant

2. NC Department of Health and Human Services DMA Welcome to NC Innovations

3. NC Department of Health and Human Services DMA Used to implement a mandatory managed care program that includes HCBS waiver services in the managed care contract. The 1915(c) waiver allows a state to target eligibility and provide the HCBS services. The 1915 (b) waiver then allows a State to mandate enrollment in managed care plans that provide these HCBS services. States must apply for each waiver authority separately and comply with the statutory and regulatory requirements of each 1915 (b) (c) concurrent waivers

4. NC Department of Health and Human Services DMA A New Tool Kit for the 1915 (c ) waiver  Rate setting authority allows PIHP to adjust rates according to local conditions  Closed Network allows for competition and choice while rightsizing the marketplace; ensures health of providers  Utilization Management gives PIHP the tools to ensure consumers receive both the appropriate service and amount of treatment to meet their needs  Care Coordination is an important activity that directly intervenes to ensure consumers receive the care needed when it is needed in order to prevent use of higher cost services when appropriate treatment is delayed.

5. NC Department of Health and Human Services DMA Vision  NC Innovations is a tool to guide the I/DD service system  Goals for the Waiver: Value and Support of individuals as members of the community The ability to self direct services to the extent each individual chooses Offer choice in where people live, work and spend their day Promote promising practices Development of stronger natural support networks

6. NC Department of Health and Human Services DMA Slots and Prioritization Finite number of Slots for use in the waiver:  Each year of waiver operation, (January 1-December 31) the number of slots available is specified in the waiver  Slots are unduplicated  Slots are frozen once used and can not be filled until the following waiver year. ( A person may re-enter in the same waiver year)

7. NC Department of Health and Human Services DMA Prioritization Prioritization Prioritization  Individuals are determined potentially eligible through Access and wait on the Registry of Unmet (waitlist) needs until waiver slots are available, typically in January of every year  Screening for potential eligibility includes a clinical review (Risk Support Needs Assessment and the SIS) and review against the eligibility criteria Potentially eligible individuals are allocated waiver funding as follows: Non-Reserved Capacity Non-Reserved Capacity  First come, first serve  Based on date of application for services

8. NC Department of Health and Human Services DMA Prioritization Reserved Capacity  Emergency Process: A clinical team inclusive of 1 psychiatrist and a minimum of one developmental disability specialist determines the allocation of emergency slots as referrals are made  Emergency Criteria Significant imminent risk of serious harm due to primary caregiver /support system inability to meet the persons basic needs Protection from confirmed abuse, neglect or exploitation Meets all other waiver eligibility criteria  Emergency slots will be maintained at the state during the transition period.

9. NC Department of Health and Human Services DMA  Transition from CAP-MR/DD and Cardinal Innovations due to change in Medicaid county Due to Medicaid county change to the MCO area If there is no available slot, contact DMA for next steps  Transition from CAP-C when children age out and meet the eligibility criteria Due to aging out of CAP –C at age 21 If there is no available slot, contact DMA for next steps  Deinstitutionalization from an ICF-MR for children 0-17 Children moving from an ICF-MR ( state or community) If there is no available slot, contact DMA for next steps  Money Follows the Person Individuals who meet the MFP criteria If there is no available slot, contact DMA for next step  Military Transfers Individuals who transfer from other states into North Carolina and need continued waiver funding. Reserved Capacity

10. NC Department of Health and Human Services DMA Initial Level of Care Process Eligibility Criteria = ICF-MR Criteria DMA Clinical Coverage Policy No: 8  Referral disability is Mental Retardation (Intellectual Disability ) or a condition closely related to Mental Retardation : licensed psychologist or licensed psychological associate completes the assessment. The assessment includes a review of a psychological evaluation inclusive of an adaptive behavior assessment  Referral disability is medical in nature, epilepsy or cerebral palsy: A physician completes the assessment  The Level of Care evaluation is valid for 30 days once signed.

11. NC Department of Health and Human Services DMA Annual Reassessment of Level of Care  Reassessment of continued eligibility is completed by the Care Coordinator  Completed annually during or up to 30 days prior to the birth month  The annual assessment includes completion of the NC Innovations Risk Support Needs Assessment.  If the individual’s condition or needs have changed significantly during the past twelve months and continued eligibility is questionable, the individual is referred through the full evaluation to verify continued eligibility.

12. NC Department of Health and Human Services DMA Level of Care Form  Initial NC Innovations Level of Care Form  Level of Care Form is completed on all individuals screened for NC Innovations waiver funding  If the referral disability is medical in nature the Medical addendum can be used to support the eligibility.  Annual NC Innovations Level of Care Reassessment  LOC Reassessment is documented on the Signature Page of the ISP

13. NC Department of Health and Human Services DMA LOC and Transition  To ensure a smooth transition, the waiver eligibility determination by the CAP-MR/DD program will be accepted in the NC Innovations waiver until the next annual re- evaluation of eligibility in the individual’s birth month.

14. NC Department of Health and Human Services DMA Freedom of Choice Freedom of Choice is documented:  Initial when new to the waiver  Annually as a component of the ISP

15. NC Department of Health and Human Services DMA Individual Budgeting Individual Budgets: The budget is developed during the planning process to inform the person of the amount of funding available for them to plan within. Budget Authority: Individuals have the authority to make decisions about how to spend their waiver dollars.

16. NC Department of Health and Human Services DMA Building Budgets Each budget has two parts:  Base Budget Services- the services that are are the core habilitation and support services in the waiver.  Add On (Non Base) Budget Services – services which are provided to ensure prevention, education or enhanced independence.

17. NC Department of Health and Human Services DMA Base Budget services  Base Budget Services include: Community Networking Services Day Supports In-Home Skill Building In-Home Intensive Supports Personal Care Residential Supports Respite Supported Employment

18. NC Department of Health and Human Services DMA Add On (Non Base) Services Budget  Add On Budget Services include: Assistive Technology Equipment and Supplies Community Transition Services Crisis Services Individual Goods and Services Home Modifications Natural Supports Education Specialized Consultation Services Vehicle Modifications Community Guide

19. NC Department of Health and Human Services DMA Individual Budget  In combination the Base and Add On budgets may not total more than $135,000  If the individual decides to participate in Individual Family Direction, they will additionally have a Self Directed Budget  The current CAP-MR/DD cost summary will be accepted as the individual budget for the person.

20. NC Department of Health and Human Services DMA Limitations on Living Arrangement  Own Home/Private Family or  Residential Facility of: 6 beds or less 3 beds if newly constructed The facility bed requirement of 6 or fewer beds does not apply to individuals transitioning from CAP-I/DD on the date their LME transitions to NC Innovations.

21. NC Department of Health and Human Services DMA Role of Care Coordinator  Treatment Planning Case Management  Educating participant/family/providers about services, waiver requirements, options  Assessment of support needs (completing, arranging for, obtaining)  Linkage to needed MH/DD/SA resources (includes ensuring provider choice)  Facilitation of Planning / Plan Development  Monitoring plan implementation, including health and safety  Medicaid eligibility coordination

22. NC Department of Health and Human Services DMA Role of Community Guide  Advocacy Support  Linkage to community resources  Assistance obtaining medical care  Supporting Employers of Record in Individual and Family Directed Services option Care Coordinators do not perform functions of Community Guide

23. NC Department of Health and Human Services DMA ISP Development  The NC SNAP will be used until the Supports Intensity Scale is fully implemented.  Assessment is the first and most important step in developing an Individual Support Plan. The quality of the Person Centered Plan is directly tied to the quality of the Assessments.

24. NC Department of Health and Human Services DMA ISP Development  Obtaining/reviewing updated records/assessments relevant to the person’s interests and needs for support  The NCSNAP must be completed annually until such time as the SIS has been completely implemented.  Orientation to Individual and Family Direction

25. NC Department of Health and Human Services DMA Risk/Support Needs Assessment  Risk/Support Needs Assessment to determine supports needs and risks that need to be mitigated/addressed - Demographic Information - Material Supports - Physician Supports - Professional Supports - Medication Supports - Medical Treatment - Health and Wellness

26. NC Department of Health and Human Services DMA Planning Meeting  Review of assessment information/draft plan  Development of long range outcomes

27. NC Department of Health and Human Services DMA Plan Development  Individual Support Plan and Individual Budget developed by Care Coordinator, including Positive Behavior Support Plan as required or otherwise indicated  Care Coordinator reviews plan with participant/legally responsible person and obtain signatures (including Freedom of Choice for Innovations participants)  Plan (with all accompanying documents) submitted to Utilization Management per PIHP guidelines.

28. NC Department of Health and Human Services DMA Individual Support Plan – How It’s Different.  Based on an ELP model  Focus on the person’s voice  Demographics at the end  Summary of the Risks that need to be mitigated is in the plan  Requires a back-up support plan be documented

29. NC Department of Health and Human Services DMA Plan Implementation  Providers/Employers of Record develop short-range goals and accompanying interventions/strategies/ task analyses  Staff Training  Provision of service as outlined in plan  Documentation of the services provided  Monitoring of plan implementation by Care Coordinator

30. NC Department of Health and Human Services DMA Plan Implementation  ISP is updated/revised as needed Update to Individual Support Plan (most often includes update to Individual Budget) Demographic Information - Update Update to Crisis Prevention and Intervention

31. NC Department of Health and Human Services DMA Support Planning SIS™ Identifies/Measures support needs Identify desired life goals/experiences/choices using person centered tools Person Centered Planning Individual Support Plan (ISP) Risk/Support Needs Assessment / Other Other Assessments Natural and Funded Resources

32. NC Department of Health and Human Services DMA ISP and Transition  The CAP-MR/DD person centered plan will be accepted in the NC Innovations waiver until the next annual individual service plan (ISP) is developed in the individual’s birth month. The participant’s ISP will continue to be reviewed as needed due to changes in care needs and on an annual basis. The NC Innovations waiver includes services that crosswalk to the CAP-MR/DD waiver.

33. NC Department of Health and Human Services DMA Waiver Incident Reporting  Failure to provide Back Up Staff will require a Level 1 Incident Report  This applies to all Provider Directed and Employer Directed Services

34. NC Department of Health and Human Services DMA Service Options through Innovations  Traditional Provider Directed Option  Individual/Family Directed Option (Self Direction) - Agency with Choice  If the person tries an option and is not satisfied they can change  The person has the flexibility to direct only the services that they choose

35. NC Department of Health and Human Services DMA Individual Family Direction

36. NC Department of Health and Human Services DMA CMS Requirements  No other Model of Self-Direction except the model approved in the waiver  Payments may not be made directly to a waiver participant, or managing employer, either to reimburse for expenses incurred or to pay a service provider directly  No cost to the Participant or Managing Employer  Financial Manager or Agency With Choice manages funds  Self-direct one or more services  Service planning is led by the participant  Independent advocacy is available  Budget Authority to make decisions about how funding is used

37. NC Department of Health and Human Services DMA Services that can be Individual/Family Directed  In-Home Skill Building  Personal Care  In-Home Intensive Support  Natural Supports Education  Community Networking  Respite  Supported Employment  Community Guide  Individual Goods and Services

38. NC Department of Health and Human Services DMA Model of Individual/Family Directed Supports  Agency With Choice (Managing Employer)

39. NC Department of Health and Human Services DMA Representative The representative is someone who can assist the Managing Employer in performing some or all of their duties

40. NC Department of Health and Human Services DMA Individual If the individual is not the Managing Employer, they need to be as involved in the process as possible

41. NC Department of Health and Human Services DMA Managing Employer is…  Innovations Waiver Participant if they are 18 and do not have a legal guardian Or Or  Parent of a child under 18 Or Or  The legal guardian of an Innovations participant

42. NC Department of Health and Human Services DMA The Direct Support Worker  Works for the Agency With Choice.  Works when and where the Managing Employer choose.  Does what Managing Employer wants him or her to do.  In the Agency With Choice Model, decisions are shared with the Agency

43. NC Department of Health and Human Services DMA Community Guide  Empowers the employer to define and direct services  Understands employers needs and preferences  May not be the employer, representative or family may not be paid to provide service  Service can be mandated

44. NC Department of Health and Human Services DMA Community Guide functions in Individual Family Direction  Links to Resources  Role plays to teach skills  Connects to the community  Helps employer develop employee support agreements/supervision plans

45. NC Department of Health and Human Services DMA Community Guide will not….  Interview, hire, train or fire employees  Complete employment forms  Find back up employees  Obtain extra money for the employer if the budget is overspent  Make decisions for the employer  Do the Duties of the Care Coordinator

46. NC Department of Health and Human Services DMA Care Coordinator functions in Individual Family Direction  Completes the assessments  Completes the process for appointment of the representative, if needed  Completes referrals to the Agency With Choice and Community Guide  Completes the Individual and Family Supports Agreement  Completes the ISP/Update to ISP  Sends the ISP to UM for approval  Sends a copy of the approved ISP to team members including Community Guide, Managing Employer, Representative

47. NC Department of Health and Human Services DMA Annual Orientation to Individual Family Direction  Booklet  Fact Sheets

48. NC Department of Health and Human Services DMA Review of Agency with Choice Comparison Chart

49. NC Department of Health and Human Services DMA Step 1 Managing Employer  The Care Coordinator will determine who the Managing Employer will be  The Care Coordinator will ask the Managing Employer if they plan to use a representative  Managing Employer and Prospective Representative attend training provided by the Community Guide

50. NC Department of Health and Human Services DMA Step 2 Assessments  Individual and Family Supports/Community Guide Assessment  Representative Screening Questionnaire

51. NC Department of Health and Human Services DMA Step 3 Consider if a Representative Needs to be appointed  Representative is someone who can assist the Managing Employer in performing some or all of the Employer duties  Follow procedures for appointment of representative if Employer agrees.

52. NC Department of Health and Human Services DMA Step 4 Individual Support Plans  Determine staff qualifications and supervision requirements of staff  Document back up staffing plan  Consider emergency plans that need to be developed  Make sure the plan addresses how the participant will be involved in self directing services  Update the monitoring plan  Include Community Guide outcomes in the plan  Determine effective date

53. NC Department of Health and Human Services DMA Special Skills employees need to know….  Agency With Choice will ensure that staff meet the minimum qualifications to provide the NC Innovations services  Managing Employer needs to add to the ISP any additional skills they require for the staff related to services

54. NC Department of Health and Human Services DMA Back up Staffing  Two levels of back up staffing are required for each service  Emergency responses to severe weather and environmental emergencies  Immediate coverage if the participant can not be left alone  Who to call if the plan is not working  Ways to manage risk  Contact numbers  Unique to the participant  Immediately accessible and operational

55. NC Department of Health and Human Services DMA Care Coordinator Monitoring of Individual/Family Directed Services  Monthly Monitoring  Natural Supports can assist in monitoring

56. NC Department of Health and Human Services DMA Effective date of Individual/Family Direction  Allow time for plan submission  Allow time for Utilization Management review  Allow time for Agency With Choice start up  Allow time for staff to be hired  Allow time for staff training

57. NC Department of Health and Human Services DMA Recruiting  Managing Employer recruits the staff  Can request that an ad be run through the Agency With Choice  Community Guide trains the Managing Employer as needed on recruiting

58. NC Department of Health and Human Services DMA Agreements  Individual/Family Directed Supports Agreement  Agency With Choice Agreement  Employee Support Agreement/Supervision Plan

59. NC Department of Health and Human Services DMA Agency with Choice  Common Law Employer (agency is the employer of record with IRS)  Files claims for services, sets employee pay rates and determines benefits  Withholds taxes and unemployment insurance  Carries Worker Compensation Insurance on Employees  Administers benefits  Maintains accounts on participants funds  Conduct background checks  Purchases goods and services  Produces records for audit  Produces the quarterly financial reports for the Managing Employers

60. NC Department of Health and Human Services DMA What will the Agency with Choice do for the individual? In the Agency With Choice Model, the Agency With Choice:  Provides a toll free service line so that the Managing Employer can call the Agency With choice  Sends quarterly report to the Managing Employer and Care Coordinator describing services billed and Individual Goods and Services purchased  Answers questions about the report

61. NC Department of Health and Human Services DMA The Agency with Choice helps the Managing Employer by….  Paying employees  Providing Workers Compensation Insurance on employees  Informing Employers of how much funding they have used (Quarterly Report)  Filing tax forms for employees  Following state and federal rules about waiver funding

62. NC Department of Health and Human Services DMA Managing Employer Responsibilities  Participate in training and complete Self Assessment with Care Coordinator  Decide skills and training that employees need  Lead/participate in the development or Update of the ISP  Select an Agency With Choice to be the common law employer of the employees  Find out pay rates and benefits offered by the Agency With Choice  Decide job duties and schedules with Agency  Refer prospective Employees to the Agency With Choice

63. NC Department of Health and Human Services DMA Managing Employer Responsibilities  Assist Agency in obtaining new hire paperwork  Agency With Choice maintains Workers Compensation insurance on Employees  Work with Agency With Choice to make sure employees are trained  Resolve issues or recommend replacement of employees  Review quarterly reports from Agency and stay within the Individual/Family Budget  Make sure services are provided as written in the ISP  Ensure that the individual is healthy and safe

64. NC Department of Health and Human Services DMA Managing Staff: Agency with Choice Model Agency With Choice/Managing Employer work together to manage staff:  Provide or arrange training  Schedule employees  Evaluate employees  Replace as needed

65. NC Department of Health and Human Services DMA Agency With Choice: What is the Service Rate? This is the Medicaid Service rate that the Agency With Choice uses to pay for :  Employee Training and Supplies  Employment Advertisement  Employee Salary, benefits  Employer Taxes  Workers Compensation Insurance  Qualified Professional Supervision  Record Keeping and Retention

66. NC Department of Health and Human Services DMA Termination from Individual/Family Direction A Managing Employer may be removed from the Individual and Family Directed Supports involuntarily under the following circumstances: A Managing Employer may be removed from the Individual and Family Directed Supports involuntarily under the following circumstances:  Immediate health and safety concern, including mistreatment of the individual  Suspected fraud and abuse of funds or evidence of unreported fraud  No approved Representative available when the Managing Employer is determined to need one  Refusal to accept needed Community Guide Services  Refusal to allow Care Coordinator to monitor services  Non compliance with the Individual Family Supports, Agency with Choice, and /or Employee Support Agreements  Inability to implement the approved ISP or comply with Innovations requirements despite reasonable efforts by the MCO to provide additional technical assistance and support ( 4th event requiring additional technical assistance/corrective action plan in twelve months)

67. NC Department of Health and Human Services DMA Provider Responsibility o Treatment Team Participation o Responsible for the development and implementation of the short range goals o Responsible for the development and implementation of the strategies/task analysis o Ensure short-range goals and strategies/task analysis are in place prior to plan implementation

68. NC Department of Health and Human Services DMA Relative as Provider Policy Services may be provided by:  Legal guardians, parents of adult participants and other relatives who live in the home of the individual Waiver services that may be provided by relatives:  Community Networking, Day Supports, Personal Care, In-Home Skill Building, In-Home Intensive Support, Residential Supports Conditions where relative may be employed:  Other staff are not available to provide the service or  Other staff are only willing to provide the service at an extraordinarily higher cost than the fee or charge negotiated with the qualified family member or legal guardian.  Managing Employer may not direct a service that is subject to the managing employer’s direction  Typically no more than 40 hours per week of service or seven daily units per week, may be approved between all relatives who live in the same home as the individual.

69. NC Department of Health and Human Services DMA  Submit application to the Network Cross Functional Team  Part A application-New Employees  Part B application-Existing Employees  Part C application-Request to Exceed 40 hours  Part D application if removed and reapply  Applications must be renewed annually Relative as Direct Support Employee Process

70. NC Department of Health and Human Services DMA Review of Service Comparison Chart

71. NC Department of Health and Human Services DMA  Completed for Direct Service Employees  Checklist is valid for the location of service provision  The Provider Agency will make and document at a minimum a monthly site visit  H/S checklist is maintained at the agency and reviewed during QM onsite monitoring. Health and Safety Checklist

72. NC Department of Health and Human Services DMA  School Policy  Equipment and Supplies  Location of Service  Services in the Home of the Employee  Out of State  Provider Qualifications Additional Guidance and Waiver Policy

73. NC Department of Health and Human Services DMA  Services must be documented by all Medicaid providers and done so prior to service implementation  There should be follow-up documentation to reflect any service deviation.  All NC Innovations services require a daily or per service note or grid  Follow the procedures as noted in the Records Management and Documentation Manual 45-2 (Chapters 8 & 9). Documentation

74. NC Department of Health and Human Services DMA  Crisis Services  Community Guide  Individual/directed Goods and Services  Natural Supports Education  Specialized Consultative Services Service notes:

75. NC Department of Health and Human Services DMA  Community Networking  Day Supports  In-Home Intensive Supports  In-Home Skill Building  Residential Supports  Personal Care  Respite  Supported Employment Service Grids

76. NC Department of Health and Human Services DMA  Completed quarterly  Should be documented within 7 working days of close of the quarterly progress period  Considered a ‘late entry” if not completed within required timeframe Progress Summary

77. NC Department of Health and Human Services DMA o Progress summary requirements: o Individual’s name o Date of quarterly review and dates the review covers o Progress towards goals o Recommendations for continuation, revision or termination of goal o Signature of individual completing review Progress Summary

78. NC Department of Health and Human Services DMA  Required for the following services: Community Networking Supported Employment Residential Supports In-Home Skill building Personal Care Day Supports Progress Summary

79. NC Department of Health and Human Services DMA Absences, Terminations, and Transfers  Terminations  Transfer to and from CAP-I/DD  Transfers to and from other PIHPs  Transfers to and from Cardinal Innovations

80. NC Department of Health and Human Services DMA Performance Indicators  Used to demonstrate that waiver assurances and sub-assurances  Reported to CMS  PIHP will remediate

81. NC Department of Health and Human Services DMA Lessons Learned  Do things that are familiar  Use your managed care tools to increase felicity and quality of care  Look for opportunities to suggest to DMA less rules through better system management  Stay focused the Vision of the waiver in every system you implement and decision you make