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2003 1915(b) WAIVER RENEWAL APPLICATION

2003 1915(b) WAIVER RENEWAL APPLICATION. CMS opinion: states may not use Section (a)(1)(A) of the Social Security Act to offer alternative services covered by Medicaid States may use Section 1915(b)(3) to offer additional services out of Medicaid “savings”

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2003 1915(b) WAIVER RENEWAL APPLICATION

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  1. 2003 1915(b) WAIVER RENEWAL APPLICATION • CMS opinion: states may not use Section (a)(1)(A) of the Social Security Act to offer alternative services covered by Medicaid • States may use Section 1915(b)(3) to offer additional services out of Medicaid “savings” • CMS offered Michigan a one-time-only opportunity to count the expenditures for alternatives as expenditures for (b)(3) and use them as part of the cost effectiveness calculation

  2. ADDITIONAL OR (b)(3) SERVICES • Retains the set of flexible services that enable beneficiaries to move from more traditional services and restrictive settings to supports for living and participating in the community • Tradeoff: more tracking by PIHPs and MDCH of use of and expenditures for (b)(3)s

  3. ADDITIONAL OR (b)(3) SERVICES • Consolidates three lists of services into two: • One set for MI/DD • One set for SA • Provides new opportunities such as for MI beneficiaries to use supports coordination and DD to use peer-delivered • Tradeoff: potential risk of exceeding (b)(3) caps when additional beneficiaries have access to new services

  4. ADDITIONAL OR (b)(3) SERVICES • CMS interpretation: (b)(3)s are entitlements and carry with them the full rights to Medicaid fair hearing when the services are denied, reduced, suspended or terminated • Settles the “Sullivan” issue • Tradeoff: Amount, scope and duration and medical necessity limits must be imposed in order to manage to the cap

  5. ADDITIONAL OR (b)(3) SERVICES • Revised the definitions of the alternatives in the contract • Revised the definition of medical necessity to include services for developmental disabilities • Obtained input from consumers, advocates, and MACMHB • Submitted to CMS for approval* • Expect to publish Chapter III Bulletin with changes mid-June

  6. (b)(3) Definitions • Established criteria for their use • Individual must have goals of community inclusion and participation, independence, and/or productivity • Support or service is expected to achieve one or more of the goals • Support or service must meet medical necessity criteria • Special criteria for some services

  7. ENCOUNTER DATA REPORTING • Need for tracking the utilization and expenditures for services in each of the three buckets: • State plan • (b)(3)s • Habilitation Supports Waiver • Only the HSW needs a modifier for every (HSW) service provided

  8. ENCOUNTER DATA REPORTING • In order to show Medicaid expenditures for specialized residential, day program, and supported independent housing need to: • “un-bundle” the per diem rates • Report Medicaid and GF-funded services that were purchased: • Personal care • Community living supports • Clinic services

  9. ENCOUNTER DATA REPORTING • In order to provide information to actuaries who will develop the 1915(b) 2005 per/member/per/month rates based on current utilization and expenditures need to: • Report the cost of each unit of service for each person • Compromise: report “allowed” amount

  10. ENCOUNTER DATA REPORTING • In order to provide information to actuaries who will establish an administrative rate need to: • Report the amount of Medicaid funds spent on administrative functions • Using Medicaid sub-element cost report due in December

  11. ENCOUNTER DATA REPORTING • MDCH thanks PIHP members of EDIT who worked hard to help develop: • Definition of allowed amount • Definition of Medicaid administration • Costing methodology for each Medicaid and GF support/service • Procedure code (HCPCs & CPT) lists

  12. ENCOUNTER DATA REPORTING • Next steps: • Encounter data corrective action plan submitted to CMS* • Hold HIPAA liaison meeting May 21st to ID remaining problems and concerns • MDCH staff are monitoring data that is submitted to warehouse and will begin site visits to validate data this summer*

  13. ENCOUNTER DATA REPORTING • More next steps: • Establish EDIT, II to assist MDCH in interpreting the data, and advise on strategies to improve it • Distribute updated compendium of documents (Administrative functions, costing methods, specialized residential unbundling, etc) that assist encounter data reporting

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