Spring 2019 Q & A Your Questions Answered Gayla Harken, IACP Outreach Director

1. Spring 2019Q & AYour Questions AnsweredGayla Harken, IACP Outreach Director

2. What we’ll cover • IME Related Questions • MCO Information (including ITC updates) • State and Federal Rule Updates • Informational Letters • General Information as Requested by Providers….

3. General

4. What’s the best way to ask a TA question? We have a new form to use! https://docs.google.com/forms/d/e/1FAIpQLSdq0oTuTnTeJ_1bpVxEtkkTdVlvrnQn2tUJLyBJ3yrHTlreow/viewform Look for the link on the IACP homepage

5. Is IME moving? Yes! The move should be completed April 5th. New Address: Iowa Medicaid Enterprise 611 5th Avenue Des Moines, IA 50309

6. How does IME tell us about changes made to the Provider agreement? 5.10 Amendment. The Department may amend this Agreement from time to time by posting an updated version on the Provider Services website at:http://www.ime.state.ia.us/Providers/index.htmland providing notice of the amended Agreement to the Provider by issuing a bulletin/informational letter. effective upon receipt of such notice.

7. Final Rule: Heightened Scrutiny update https://www.medicaid.gov/federal-policy-guidance/downloads/smd19001.pdf March 22, 2019 CMS is issuing this guidance in keeping with a letter from CMS Administrator Seema Verma to the nation’s Governors on March 14, 2017, indicating the intention to provide additional flexibility to states and to streamline implementation efforts associated with the home and community-based settings regulation.

8. Q: Has medication manager training changed? April 30 meeting scheduled. To date, we know there have been proposed changes that have Not been adopted by DIA. The standards have not been changed at this time.

9. DOL Changes….. • DOL Overtime Rule Comment Period Open Through May 21, 2019 -  On Thursday, March 7, The Department of Labor released its Notice of Proposed Rule Making (NPRM) for the Overtime Rule, which proposes to increase the salary threshold from the current $455 per week ($23,660 per year) to $679 per week ($35,308 per year).  The comment period for these rules is open through May 21, 2019.  Click here to access comment instructions and to read more about the proposed rule.

10. New Tiered ID SCL Daily rates? https://dhs.iowa.gov/sites/default/files/1992-MC-FFS_New_Tiered_Rates_Reminder.pdf?032520191653 Went into effect March 15, 2019

11. Is there a standardized way to do the Off-Year SIS Assessments? According to IME, there is no standardized approach to how off-years are done. Either way is acceptable as long as the appropriate information is being collected for consideration. It is the responsibility of the case manager or community-based case manager to assure the assessment is initiated as required to complete the CSR.

12. Are we going to have to bill electronically? https://secureapp.dhs.state.ia.us/IMPA/Information/ViewDocument.aspx?viewdocument=203a00e0-3c14-4afc-98f1-f4988e0fb573

13. Can Subacute and Crisis Stabilization Residential Services be done in an IMD? https://secureapp.dhs.state.ia.us/IMPA/Information/ViewDocument.aspx?viewdocument=f1758589-045f-40d4-a2f3-749bd2d6b9e6

14. Please explain how some providers can implement blanket rights restrictions like no drinking, bed time, visitors, etc. This should not be happening! • Rights Restrictions are specific to an individual • Agreed upon by the team • Have a plan to restore right • Reviewed at least quarterly

15. Right’s Restriction new rules…. There was a change in rule that went into effect August 8, 2018 that required all HCBS waivers to match the requirement that has been in Habilitation to review existing rights restrictions at least quarterly. https://www.legis.iowa.gov/docs/ACO/chapter/441.77.pdf

16. Right’s Restrictions The case manager has to have all the rights restrictions in their plan, but the provider also must have those rights restrictions that apply to their environment.

17. Right’s Restrictions Quarterly Reviews: There are no set rules as to how to do this, but you must do this! • You must document that your team has reviewed the RR quarterly and determined if it still is applicable and necessary. • If behavioral then progress, lack of progress, etc. should be documented and the determination to keep or change the RR should be supported by how effective the intervention has been.

18. Right’s Restrictions • Some restrictions will be on going (ie, due to physical limitation, the member must have assistance toileting) and a note that physical health has not changed would work, but you still need to review it

19. MCOs are wanting reports for things as Major Incidents that we don’t think qualify. What is a Major Incident? Here is where you find the definitions for all the HCBS services: • Habilitation Services- 77.25 (1) • Health & Disability (HD) Waiver- 77.30 (18) • Elderly Waiver- 77.33 (22) • AIDS/HIV Waiver- 77.34 (14) • Intellectual Disability (ID) Waiver- 77.37 (8) • Brain Injury (BI) Waiver- 77.39 (6) • Physical Disability Waiver- 77.41 (12) • Children’s Mental Health (CMH) Waiver- 77.46 (1)

20. Incident Reports: What is a major report? An occurrence involving a member enrolled in waiver (or Habilitation) services: 1. Results in a physical injury to or by the consumer that requires a physician’s treatment or admission to a hospital; 2. Results in the death of the member; 3. Requires emergency mental health treatment for the member; 4. Requires the intervention of law enforcement;

21. Incident Reports: What is a major report? 77.25(1) con’t: 5. Results in a report of child abuse pursuant to Iowa Code section 232.69 or a report of dependent adult abuse pursuant to Iowa Code section 235B.3; 6. Constitutes a prescription medication error or a pattern of medication errors that leads to the outcome in paragraph “1,” “2,” or “3”; or “5” 7. Involves a member’s location being unknown by provider staff who are assigned protective oversight. (This is when services or supervision by staff is to be provided or is scheduled)

22. Do you have to notify a guardian of major/minor incidents? Yes. 77.37(8) Incident management and reporting. c. Reporting procedure for major incidents. When a major incident occurs or a staff member becomes aware of a major incident: (1) The staff member involved shall notify the following persons of theincident by the end of the next calendar day after the incident: 1. The staff consumer’s supervisor.

23. Do you have to notify a guardian of major/minor incidents? 2. The consumer or the consumer’s legal guardian. EXCEPTION: Notification to the consumer is required only if the incident took place outside of the provider’s service provision. Notification to the guardian, if any, is always required. 3. The consumer’s case manager.

24. Do you have to have Individual Releases of Information or can you use a multi entity release? Shannon Miller from HCBS says: A provider is not required to keep individual ROIs on file for members, although as best practice many providers just automatically do and update these annually. Providers are however required to have a process for notification of privacy practices and to utilize an authorization for release of information should the situation arise where one is needed. Provider policy and privacy practices should align with CFR 45 § 164.508. Thank you, Shannon Miller

25. Are checklists allowed in documentation? How should they be used? • Checklists may be used in addition to service note documentation it does not replace it. • Checklists may be used to document the ongoing supports provided during the course of service provision. i.e. personal care supports, range of motion, routine daily tasks

26. With everything changing, how do we know our documentation is up to par? Our best advice is to continue to follow 79.3 (2) a(3) • Document the specific procedure or treatments given that are approved in the person’s plan • Include date, time of service, and location • Document how the intervention went • Sign with your credentials (if any)

27. With everything changing, how do we know our documentation is up to par? and….. 5. Be sure to document in a way that substantiates the time you have billed.

28. UHC says we need to show progress on goals. How often are they expecting to see goals run in a daily site? A lot of the time, we only have time for Supports and there's no way to work on a goal each shift of the day at a daily site (house). (answer on next slide) (Answer next slide)

29. Answer to previous question: UHC is stating everything need to be tied to a goal: They are stating this and this helps to prove the medical necessity of the services. This should allow for goals to be worked on every shift as some goals are more supportive in nature, for example: Goal: I want to be safe in my home. Barrier: Due to Gayla's intellectual disability she is unable to understand basic safety concepts, such when it is cold out - you need to wear a jacket or how to adjust water temperature while bathing. Your goals should answer the question - Why is this service necessary?

30. Can we provide only Supports during an SCL hourly service? Yes you can. These should be tied to a support type goal that identifies why the service is necessary. They need to be specifically identified in the person's service plan and based on an identified need.

31. If we are responsible for administering medications, is it required that the med pass is documented in the notes? It will already be on the MAR. Typically you would include at least a statement in the narrative documentation that you administered the person's medications - the details - dosage, route, etc would be on the MAR.

32. For SCL Daily services - Do we need to show a break in the time entries if the consumer is only out of site for a few minutes? ie: blood draw, a walk around the block, etc. Yes you do need to record anytime the person is not in your service. In a daily service this could be put in the narrative: Karen left at 9:32 am to go for a walk and return at 9:45 am. or Karen left with her sister to get her blood drawn at 8:00 am and returned at 8:15 am.

33. If an agency has taken over another agency and have their member documents, can they destroy those documents after 5 IME or 7 MCO 7 years? IME suggests keeping these records if you are still serving the member.

34. If a person needs to meet a training requirement within a certain amount of time and they fail to do so, but provide service anyway, is the whole time they did the work recoupable? Yes, the entire time the person did the work is recoupable. The time that is given to accomplish the training is not a “grace” period. It is intended to give the provider time to meet the guideline.

35. Are there rules that say if a person is in SCL daily, they cannot have home health services such as skilled nursing? 78.41 that pertain to this - they should be billable as long as they fall into these scopes and are authorized in the person's services plan: 78.41(5) Nursing services. Nursing services are individualized in-home medical services provided by licensed nurses. Services shall exceed the Medicaid state plan services and be included in the consumer’s individual comprehensive plan. a. A unit of service is one hour. b. A maximum of ten units are available per week.

36. Are there rules that say if a person is in SCL daily, they cannot have home health services such as skilled nursing? (Con’t) 78.41(6) Home health aide services. Home health aide services are personal or direct care services provided to the member which are not payable under Medicaid as set forth in rule 441—78.9(249A). Services shall include unskilled medical services and shall exceed those services provided under HCBS intellectual disability waiver supported community living. Instruction, supervision, support or assistance in personal hygiene, bathing, and daily living shall be provided under supported community living. a. Services shall be included in the member’s service plan. b. A unit is one hour. c. A maximum of 14 units are available per week

37. A guardian got married, do we have to have them fill out all new paperwork for the member’s file? No, According to Gary Jones, you just need proof that the person is married and have that in the file to explain the name changes.

38. Cannabidiol--What are the rules? From the Department of Inspections and Appeals: -There is currently no provision in state law for a "facility caregiver". Only the patient and/or a designated caregiver would be able to pick up the medication from the dispensary. - There are no rules/requirements regarding who could "administer" the cannabidiol as long as it was a patient or designated caregiver (no specific licensure or certification required, e.g., RN, CMA, etc.). However, since cannabidiol is a Schedule I drug, the applicable storage and handling requirements would apply. That is, only the resident and the designated caregiver would be able to store, access and administer the drug. Facility staff could not do so. - Iowa law does NOT prohibit a physician from writing an order for medical cannabidiol, However, physicians may be unlikely to do so. Many physicians are reluctant to provide the certification required, let alone write an "order" for the use of cannabidiol. - The use of medical cannabidiol in regulated entities would be extremely difficult to implement within the current law. Changes will possibly occur that will change the landscape in the future.

39. Who has to pay for interpreters? https://dhs.iowa.gov/sites/default/files/Comm501.pdf?021920192028 The cost of interpreters is a Medicaid covered expense. Work with your case manager/MCO to access the service

40. If a medicaid member dies and has no family, what happens to anything they have (estate) The State generally is the beneficiary of a Medicaid recipient’s estate. This FAQ explains this: https://dhs.iowa.gov/sites/default/files/Estate Recovery_FAQ_FINAL_0.pdf?022620192025

41. How soon do CMs have to have a social history done on a member? Legal reference: 441 IAC 90.5(1)“a”441—90.5(249A) Service provision. 90.5(1) Covered services. The following shall be included in the assistance that case managers provide to members in obtaining services: a. Assessment. The case manager shall perform a comprehensive assessment and periodic reassessment of the member’s individual needs using Form 470-4694, Comprehensive Assessment, to determine the need for any medical, social, educational, housing, transportation, vocational or other services.

42. How soon do CMs have to have a social history done on a member? (con’t) The comprehensive assessment shall address all of the member’s areas of need, strengths, preferences, and risk factors, considering the member’s physical and social environment. A face-to-face reassessment must be conducted at a minimum annually and more frequently if changes occur in the member’s condition. The assessment and reassessment activities include the following: (1) Taking the member’s history, including current and past information and social history in accordance with 441—subrule 24.4(1), and updating the history annually

43. DirectCourse funding IME will not be contracting with IACP starting July 1, 2019. IACP has discounted funding for DC IACP members. Non-members may purchase at the rack rate of $129 per learner

44. Employment Services

45. What are the rounding rules for SE? https://dhs.iowa.gov/ime/members/medicaid-a-to-z/hcbs/waivers Hourly services should be rounded as follows: Add all the minutes provided for a day • When the total minutes for the day is less than 60, round up to one (1) whole unit • When the total minutes for the day is more than 60, divide the total by 60 to get the number of hours for the day. This should be rounded to the nearest whole unit, by rounding down for 1-30 minutes, and rounding up for 31-59 minutes

46. What are the rounding rules for SE? https://dhs.iowa.gov/ime/members/medicaid-a-to-z/hcbs/waivers For the month... The Tier is based on the average hours worked over the course of a calendar month. The member remains in Tier 3 (H2025 U5) for the entire month. If the average hours over the course of the month fall below the 9 hour threshold and that is the new “ average” for the person then the Tier would be changed to Tier 2 for the following month. The provider would bill for the Tier authorized for the current month and would then bill at the new Tier for the following month.

47. Can providers use Relias as part of the employment training requirement? Yes! LeAnn Moskowitz says: The Department will accept the RELIAS Continuing Education Platform courses for Community Employment to meet the 9.5 hours of employment service training and to meet the 4 hours of annual continuing education requirement for both Prevocational and Supported Employment services. The Department intends to promulgate rules to formalize the change (2-25-18).

48. If a member has a job in the community and is placed on the abuse registry, do they have to tell their employer? Our legal council says the employee has to follow their employer’s policies regarding self reporting.

49. Can the VR webinars be used for meeting the continuing education for Job Coaches? Yes, they can. You can use any training as long as it directly relates to providing employment services.

50. Where can you access these trainings? IVRS is hosting a series of informational webinars. IVRS partners are welcome to join by clicking on the zoom link below. We anticipate ongoing training as outlined: (First Monday of the month at 10 am) • May- Specific Industry-Federal Resume • June-VIDEO RESUMES • July through December - TBD https://zoom.us/j/5154146800