Division of Medical Assistance Personal Care Services (PCS) Summit 2.0

1. Division of Medical AssistancePersonal Care Services (PCS) Summit 2.0 September 25, 2013 Sheraton Imperial Hotel 4700 Emperor Blvd Durham, NC 27703

2. Summit Mission • The mission of this event is to provide a forum for Personal Care Services (PCS) stakeholders to collaborate in effort to address and resolve issues around the implementation of the new PCS policy. • To improve and develop communication processes that supports the Department of Health and Human Services (DHHS) and the Division of Medical Assistance’s (DMA) goal for customer service excellence. • This event is convened as a follow-up meeting from a PCS stakeholder event convened in the spring.

3. Program Updates • Session Law 2013-306 • State Plan Amendment (SPA) • Policy • Independent Assessment Entity (IAE) Transition • Communication Plan • Timeline • Expedited Assessment

4. Session Law 2013-306 An Act To Direct The Department Of Health And Human Services To Adjust Medicaid Personal Care Services To Provide Additional Safeguards For Qualified Individuals. http://www.ncga.state.nc.us/Sessions/2013/Bills/House/PDF/H492v7.pdf

5. Session Law 2013-306 • A Medicaid recipient who meets each of the following criteria is eligible for up to 80 hours of personal care services: • The recipient has a medical condition, disability, or cognitive impairment and demonstrates unmet needs for, at a minimum, • (i) three of the five qualifying activities of daily living (ADLs) with limited hands-on assistance; (ii) two ADLs, one of which requires extensive assistance; or (iii) two ADLs, one of which requires assistance at the full dependence level.

6. Session Law 2013-306 • The recipient shall meet each of the criteria below to be eligible for up to 50 additional hours of PCS: • The recipient requires an increased level of supervision. b. The recipient requires caregivers with training or experience in caring for individuals who have a degenerative disease, characterized by irreversible memory dysfunction, that attacks the brain and results in impaired memory, thinking, and behavior, including gradual memory loss, impaired judgment, disorientation, personality change, difficulty in learning, and the loss of language skills.

7. Session Law 2013-306 c. Regardless of setting, the recipient requires a physical environment that includes modifications and safety measures to safeguard the recipient because of the recipient's gradual memory loss, impaired judgment, disorientation, personality change, difficulty in learning, and the loss of language skills. d. The recipient has a history of safety concerns related to inappropriate wandering, ingestion, aggressive behavior, and an increased incidence of falls.

8. Session Law 2013-306 • Physician attestation • A recipient must have a physician's attestation that the recipient meets each of the above criteria (a. through d.) • Independent assessment • Based on the physician's attestation • Independent assessment conducted by an IAE

9. State Plan Amendment • SPA 13-009 Personal Care Services • Effective October 1, 2013, payment for PCS shall be reimbursed to providers, who are allowed to bill PCS in fifteen (15) minute increments of care at a rate of $3.28 per unit. http://www.ncdhhs.gov/dma/plan/Public_Notice_SPA13009.pdf

10. 3L-Clinical Coverage Policy Approval Process • Physician Advisory Group (PAG)-9/26/13 • 45-day public comment • Effective upon approval of SPA by the Centers for Medicare and Medicaid Services (CMS)

11. IAE Transition • Stakeholder Involvement • DMA convenes weekly PCS Transition Meetings with Contractors • The Carolinas Center for Medical Excellence (CCME), DMA, & Liberty Healthcare-NC, VieBridge, Public Consulting Group (PCH), Office of Administrative Hearings, and others as needed

12. IAE Transition • Communication Plan • Bi-monthly Meetings with Intra-departmental stakeholders • Weekly update provided during the Thursday PCS Stakeholder Calls • Special Medicaid Bulletins • Liberty Health Care Stakeholder Focus Group

13. IAE Transition Milestones:

14. Beneficiaries By Setting With Processed Assessments PCS Assessments Processed to Notification January 1 through September 13, 2013-The Carolinas Center for Medical Excellence (CCME)

15. Assessment Types for Beneficiaries PCS Assessments Processed to Notification Through January 1 through September 13, 2013-The CCME

16. Expedited Assessment • The PCS expedited process determines beneficiary provisional eligibility and authorized service level pending the completion of the full independent assessment conducted by IAE Assessors. The expedited process must be requested by: • a hospital discharge planner; • Adult Protective Services (APS) Worker; or • Nursing Home Discharge Planner

17. Expedited Assessment • To qualify for the expedited process the beneficiary must be : • medically stable, • eligible for Medicaid or pending Medicaid eligibility, • have a PASRR* number and be • in process of being discharged from the hospital following a qualifying stay, or • under the care of an APS.

18. Expedited Assessment • PCS approval through the expedited process is provisional and subject to the standard PCS independent assessment process. • Maximum prior approval (PA) is limited to one 60 day preliminary period. *ACH Referrals ONLY

19. Expedited Assessment • An expedited assessment is conducted over the phone to determine eligibility. • A provider must be identified and the hospital or nursing home discharge planner or APS must communicate selected provider and date of admission to the IAE. • Provisional PA will not exceed 60 hours of services during the preliminary period. Subsequent eligibility will be determined during the full independent assessment.

20. For Additional Information • Consolidated PCS: • http://www.ncdhhs.gov/dma/pcs/pas.html • DMA Website: • http://www.ncdhhs.gov/dma/index.htm • Liberty Healthcare Corporation-NC: • http://www.nc-pcs.com/