Proposed Changes to MaineCare Personal Care Services

1. Maine Department of Health and Human Services Proposed Changes to MaineCare Personal Care Services Bonnie Smith – Deputy Commissioner for Programs Patty Dushuttle – Strategic Initiatives Coordinator November 20, 2012

2. Details of Proposed Model • Simplification and consolidation of reimbursement for Personal Care Services (PCS). • Reimbursement for medically eligible members regardless of setting. • Member choice for in-home PCS. • Self-directed • PCS Agency • Adult Family Care Homes or PCS Homes • Services provided by the licensed agency operating the residence. • Licensing regulation changes will be necessary.

3. Personal Care Services Model

4. Covered Personal Care Services • 42 CFR § 440.167   Personal care services • Unless defined differently by a State agency for purposes of a waiver granted under part 441, subpart G of this chapter— • (a) Personal care services means services furnished to an individual who is not an inpatient or resident of a hospital, nursing facility, intermediate care facility for individuals with intellectual disabilities, or institution for mental disease that are— • (1) Authorized for the individual by a physician in accordance with a plan of treatment or (at the option of the State) otherwise authorized for the individual in accordance with a service plan approved by the State; • (2) Provided by an individual who is qualified to provide such services and who is not a member of the individual's family; and • (3) Furnished in a home, and at the State's option, in another location. • (b) For purposes of this section, family member means a legally responsible relative.

5. Covered Personal Care Services • Activities of Daily Living (ADL): • Bed mobility, transfer and locomotion activities to get in and out of bed, wheelchair or motor vehicle • Using the toilet and maintaining continence • Health maintenance activities • Bathing and Personal hygiene • Dressing • Eating and clean up • Assistance • Cueing • Supervising • Provide limited or extensive physical assistance

6. Covered Personal Care Services • Instrumental Activities of Daily Living (ADL) • Grocery andprepared food shopping • Assistance with obtaining medications • Routine housework • Laundry • Money management, • Meal preparation and clean up • Assistance • Cueing • Supervising • Provide limited or extensive physical assistance

7. Proposed Medical Eligibility for PCS Determined by Standardized Independent Assessment

8. Personal Care Services and Consumer Choice

9. Current Guidance for Consumer Directed Personal Care Services

10. Proposed Time/Task for “Average” Adult Family Care Home or PCS Homes

11. Proposed PCS Staffing Requirements • Minimum staffing qualifications for all Personal Care Services. • May require DLRS and MaineCare rule changes. • Requirements: • Be authorized to work in the United States • Contracted with the Medicaid Agency or its Designated Agent • Have a Medicaid Agency criminal background check • Department certification - Personal Support Specialist (PSS) • The Department may approve licensed health care staff whose training or licensure exceeds these certifications. (CNA, CRMA, HHA) • Medication administration must be done by qualified staff • CRMA cannot administer medications outside of a facility and without nursing supervision

12. Rates for In-Home Personal Care Services • Current: • Consumer Directed Services (Section 12) for Personal Support Specialists • $10.44 per hour (15 minute units @ $2.61 per unit) • Staff are not typically agency employed • Agency providers under Personal Care Services/Private Duty Nursing • $15 per hour (billed in 15 minute units @ $3.75 per unit) • Allows for added agency licensing requirements. • Proposed: • $10.44 per hour for Independent and/or Consumer Directed providers • $15 per hour for Licensed PCS Agency providers

13. Adult Family Care Home Proposal • Group setting allows 24/7 supervision without MaineCare reimbursement • Grouping assessed and approved by Independent Assessor • Current Per Diem Resource Grouping reimbursement maintained • Base rate increased to be consistent with Independent Rate of $10.44/hr. • Resource Groupings estimate “average” member unable to live alone requires 5 hours PCS • Independent Provider rate applied to daily per diem base rate • $10.44 x 5hrs = $52.20

14. Proposed Rates for Adult Family Care Home • Licensed Adult Family Care Home Rates: Group Case Mix Current Proposed Rate • 1 1.657 $71.68 $86.50 • 2 1.21 $52.34 $63.17 • 3 1.36 $58.83 $71.00 • 4 1.027 $44.43 $53.61 • 5 0.924 $39.97 $48.24 • 6 0.804 $34.78 $41.97 • 7 0.551 $23.84 $28.77 • 8 0.551 $23.84 $28.77

15. Proposed for PCS Homes • Group setting allows 24/7 supervision without additional MaineCare reimbursement • Grouping assessed and approved by Independent Assessor • Current Per Diem Resource Grouping reimbursement maintained • Base rate increased to be consistent with Licensed PCS Agency rate $15/hr. • Resource Groupings estimate “average” member unable to live alone requires 5 hours of PCS • Licensed Agency rate applied to daily per diem base rate • $15 x5 hours = $75

16. Proposed Rates for PCS Homes

17. Additional Considerations • Service Plans and documentation • Provider responsibility • Elimination of DHHS Audits • R&B negotiated between PCH and resident • Staffing Impact • Training and certification may be necessary for some staff • Medication Administration • Billed separately (currently $6.32 per administration) • Subject to staffing requirements

18. Projected Fiscal Impact Fiscal Impact assumes utilization is stable, which may need recalculation as eligibility changes

19. Thank You • Patricia.Dushuttle@maine.gov • Bonnie.Smith@maine.gov