An Introduction to Consumer Rights in the Family Care & IRIS Programs

1. An Introduction toConsumer Rights in the Family Care & IRIS Programs 2013

2. Plan for Today Introduction to Family Care & IRIS Programs Plan Development Grievances & Appeals Q&A

3. Adult LTC System Overview Entry Point: Aging and Disability Resource Center Determines functional eligibility for adult LTC programs (and facilitates financial eligibility determination for Medicaid with Income Maintenance Consortium) IF ELIGIBLE, THEN A PROGRAM IS SELECTED FAMILY CARE— Managed Care Organization (includes Family Care, Partnership or PACE) Include, Respect, I Self-direct (IRIS)— Self-Directed Services • Interdisciplinary Team determines “outcomes” • Interdisciplinary Team manages care • Provider Network • Self-directed services (SDS) can be used • No pre-determined budget amount for services • Participant (with IRIS Consultant) determines “outcomes” • IRIS Consultant Agency (ICA) and Fiscal Services Agency (FSA) provide assistance • Participant selects service providers and manages service plan • Allocation (based on functional screen results) provides an estimate for cost of services (maximum)

4. Functional Eligibility:The Adult LTC Functional Screen Adult Long-Term Care Functional Screen determines functional eligibility Different from the children’s LTCFS Inventory of activities people need to do every day Gathers information about whether help is needed and if so, how much Looks at individual’s ability to do: “ADLs” and “IADLs”

5. Activities of Daily Living (ADLs) Bathing Dressing Eating Mobility in the home Toileting Transferring

6. Instrumental Activities of Daily Living (IADLs) Meal preparation Money management Medication management and administration Laundry and other chores Ability to use the telephone Arrange and use transportation Ability to function at a job site

7. Other Components of LTCFS Living situation Supports (natural/formal) Behavior Risk Factors Not all questions affect eligibility

8. Financial Eligibility Similar rules as Medical Assistance Low income and low assets Spousal Impoverishment rules apply Married people may have access to higher asset limits Cost-share, if any, calculated by Income Maintenance agency Do not assume you are or are not eligible without talking with an expert.

9. Cost-effective AND effective Member-centered Flexible Comprehensive services Provide “self-directed supports” End waiting lists Goals of Family Care & IRIS “The right services in the right amount at the right time for the right cost.” Kitty Rhoades, Deputy Secretary of Department of Health Services (stated in presentation on Family Care to Assembly Committee on Aging and Long Term Care, March 10, 2011)

10. Differences Between FC and IRIS Family Care is “managed care” The MCO builds relationships and negotiates and contracts with providers The MCO manages the services and the cost and quality of those services MCO receives a capitated rate and a portion of that is used to pay for services Member has Interdisciplinary Team • IRIS is “self directed supports” • Participant builds relationships and negotiates and contracts with providers • Participant has Budget Authority and Employer Authority • Participant uses an allocation derived from “fee for service” Medicaid funds • Participant has help from IRIS Consultant Agency (ICA) and Financial Services Agency FSA)

12. Family Care: Member-Centered Plans

13. MCO’s Comprehensive Assessment First step in developing Member Centered Plan (MCP) Looks at member’s: Needs – Builds on the LTCFS Strengths Resources Preferences Conducted in-person May include others Includes a discussion about the options for self-direction Is the start of ongoing discussions about member’s outcomes

14. “Outcomes” What is important to you? What do you want from life?

15. 12 Outcome Areas 1. I decide where and with whom I live 2. I make my own decisions regarding my supports and services 3. I work or do other activities that are important to me 4. I have relationships with family and friends I care about 5. I decide how I spend my day

16. 12 Outcome Areas (continued) 6. I am involved in my community 7. My life is stable 8. I am respected and treated fairly 9. I have privacy 10. I have the best possible health 11. I feel safe 12. I am free from abuse and neglect

17. Outcomes are Individual Each member’s outcomes are unique Each member’s services will depend on each member’s outcomes Different outcomes → Different supports

18. The Member-Centered Plan Comprehensive Assessment + Outcomes + “Resource Allocation Decision” (RAD) Method

19. Individual Service Decisions:The RAD Method Service authorization policy developed by DHS and adopted by MCOs Helps to identify cost-effective ways to meet outcomes Creatively looks at options, including natural/informal supports DOES NOT EQUAL “cheapest” Should be cost-effective AND effective.

20. Individual Service Decisions:The RAD Method (continued) Completed by the Interdisciplinary Team: Member + anyone that the member chooses to participate in the discussion Care Manager Nurse Begins with the outcome, goal or problem and asks a series of questions to help identify the most appropriate option Available on DHS’ website

21. The RAD Method Six Questions: What is the need, goal, or problem? Does it relate to member’s assessment, service plan, and desired outcome? How could the need be met? Are there policy guidelines to guide the choice of option? Which option does the member (and/or family) prefer? Which option is most effective and cost-effective in meeting desired outcome(s)?

22. Member Centered Plan (MCP) A record that documents a process by which the member and the IDT staff further identify, define and prioritize the member’s outcomes initially identified in the comprehensive assessment. Identifies the services and supports, paid or unpaid, provided or arranged by the MCO including frequency and duration of each service (e.g. start & stop date) provider(s) that will furnish each service.

23. Member Centered Plan (MCP) (continued) Identifies clinical and functional needs of the member identified by the IDT staff which the member may not want to receive assistance with at this time, but for health and safety reasons, the IDT staff need to recognize and attempt to mitigate. Includes the plan for coordinating services outside the benefit package received by the member. Members should be given a copy of their MCP by their Family Care team.

24. IRIS: Individualized Supports and Services Plan

25. IRIS: ISSP Plan Development OC helps participant identify outcomes Using outcomes, OC helps develop first plan Helps participant determine immediate needs for services and supports Helps write initial plan (helps develop budget) Makes sure plan is within allocation and is compliant with definition standards** Helps initiate separate budget for personal care services if participant chooses to self-direct that service Submits plan to ICA for approval **also need to meet criteria for “Customized Goods and Services” when that is used

26. IRIS: ISSP Plan Development (continued) Once plan is in place, IC makes regular connection with participant Further explores outcomes and develops plan Helps participant consider who or what providers can offer services, through paid or unpaid supports Helps trouble shoot difficulties participant is having with plan Helps update plan for any changes needed and submits it to ICA for approval FSA sends monthly reports showing budget usage Participants uses monthly report to ensure they are staying within approved budget

27. IRIS: ISSP Plan Development (continued) • Allocation Adjustment • Requests for an increase in IRIS allocation • This is a request to increase the “ceiling” when the participant cannot meet needs with given allocation • Exceptional Expense • Requests for time-specific and/or one-time expenses

28. IRIS: ISSP Plan Development (continued) Allocation Adjustment (AA)** If allocation is substantially insufficient to provide necessary supports and services, OC or IC can help participant prepare and submit a request to increase allocation to meet needs The AA is submitted to the ICA, where the AA Specialist reviews for completeness The AA is submitted to DHS, which brings it to the AA/EE Committee for approval, denial or partial denial **An AA is not permitted in certain circumstances, usually related to residential setting

29. IRIS: ISSP Plan Development (continued) • Requests NOT reviewed by AA/EE Committee • Requests for funding for an individual not yet determined eligible for IRIS** • Requests that may be paid through Medicaid Card or other payer • Requests not submitted by IC **However, committee may review requests from an individual who is eligible and considering IRIS prior to enrollment

30. Member Rights: Grievances & Appeals

31. Appeal A decision was made that you don’t agree with Usually an action taken to a plan (termination or reduction) or denial to a request, or a change in Level of Care determination You want a reconsideration of that decision Grievance There is something you are having a problem with (not a decision that was made) Maybe you don’t like how your care team communicates with you Maybe you don’t feel safe with the transportation provider You want help resolving that problem You can grieve a decision, rather than go through an appeal. What are Grievances & Appeals?

32. Family Care Grievances & Appeals

33. Right to receive written notice of MCO decisions about denials, terminations, or reductions of services (called a “Notice of Action”) and denials for requests for payment. Terminations or reductions of services Must receive Notice of Action (NOA) at least 10 days before the effective date of the action Denials of requests for services MCO must authorize service or provide NOA within 14 days of the request MCO may ask for additional 14 days to consider request Family Care Grievances & Appeals

34. Family Care Grievances & Appeals • Effective date • Description • Reasons • Any applicable laws • Right to appeal • How to file an appeal • Right to appear in person at MCO appeal • Assistance with filing an appeal • Free copies of records relevant to appeal • Right to continuing benefits if MCO intends to terminate or reduce services • Notice of Action Requirements

35. Appealing MCO Decisions If a member disagrees with a MCO’s decision, member has the right to appeal the decision Members may also appeal decisions made by Income Maintenance agencies  If a member disagrees with an Income Maintenance agency’s decision, member has the right to appeal by requesting a State Fair Hearing—Examples: Financial eligibility Cost share amounts Family Care Grievances & Appeals

36. Right to continuing benefits Should request continuing benefits when you submit your appeal Must request appeal on or before the effective date of the intended action to obtain continuing benefits MCO must grant all timely requests Member may be liable for cost of continuing benefits if appeal ends in adverse decision Family Care Grievances & Appeals

37. Appeal options in Family Care MCO Appeal Committee A committee is arranged by the MCO. Includes at least one person eligible for the Family Care benefit Can file for State Fair Hearing if decision is adverse State Fair Hearing An Administrative Law Judge (ALJ) presides over a hearing Decision is final (can’t file for MCO Appeal if adverse) Case review option in Family Care DHS Review MetaStar does a record review and makes recommendations No ruling or decision is made Family Care Grievances & Appeals

38. MCO Grievance & Appeals Committee Committee made up of individuals selected by MCO and include: no MCO employee involved in earlier decision at least one person (or guardian of a person) who is functionally eligible for one of the target groups Individuals with appropriate medical or clinical expertise for this member’s issue Member may bring advocate, friend/family member, witnesses, and evidence Decision can be appealed through State Fair Hearing Family Care Grievances & Appeals

39. State Fair Hearing May file an appeal with the State—the “Division of Hearings and Appeals” (DHA) Held in front of an Administrative Law Judge (ALJ) May bring advocate, friend/family member, witnesses, and evidence Decision is final Family Care Grievances & Appeals

40. MCO Member Rights Specialist Can assist with: problem solving resolving grievances obtaining records filing appeals Will not represent member in appeal Will not gather evidence to support member’s case Family Care Grievances & Appeals

41. Right to request Department of Health Services review MetaStar is DHS’s external quality review organization Attempts to resolve concerns informally Cannot require MCO to change decision But, MetaStar can make recommendation to DHS, and DHS can instruct MCO to change its decision Automatically reviews requests for State Fair Hearings Family Care Grievances & Appeals

42. Do not have to appeal to the MCO Committee or request review by MetaStar in order to request a State Fair Hearing But if member wants to appeal to the MCO Committee, he/she must do so prior to State Fair Hearing (though an appeal can be initiated with both at the same time) Review by MetaStar will happen automatically if member requests a State Fair Hearing Family Care Grievances & Appeals

43. Deadline to file appeals File as soon as possible File no later than 45 calendar days from receipt of the Notice of Action To request continuing benefits, must file appeal before effective date of intended action Family Care Grievances & Appeals

44. IRIS: Grievances & Appeals

45. Right to receive written notice of IRIS decisions about terminations or reductions of services (called a “Notice of Action”) and denials for requests not already on plan (letter of denial). Terminations or reductions of existing services Must receive Notice of Action (NOA) at least 10 days before the effective date of the action Denials for requests not already on plan Letter of denial outlines grievance rights If not satisfied with results of grievance, can file an appeal IRIS Grievances & Appeals

46. IRIS Grievances & Appeals • Effective date • Description • Reasons • Any applicable laws • Right to appeal • How to file an appeal • Assistance with filing an appeal • Free copies of records relevant to appeal • Right to continuing benefits if IRIS intends to terminate, reduce or suspend services • Notice of Action Requirements

47. Appeal options in IRIS State Fair Hearing AA/EE denials other appeals Grievance options in IRIS All grievances are first submitted to ICA If they involve issues with the ICA, they are taken care of by the ICA If they involve issues with the FSA, a form is completed by the ICA and sent to the FSA IRIS Grievances & Appeals

48. Right to continuing benefits Should request continuing benefits when you submit your appeal Must request appeal on or before the effective date of the intended action to obtain continuing benefits IRIS must grant all timely requests Participant may be liable for cost of continuing benefits if appeal ends in adverse decision IRIS Grievances & Appeals

49. IRIS Participant Services Specialists Can assist with: problem solving resolving grievances obtaining records filing appeals Will not represent participant in appeal Will not gather evidence to support participant’s case IRIS Grievances & Appeals

50. Appealing decisions based on Functional Screen ADRC conducts initial screen to determine functional eligibility. Disputes with results of initial screen are appealed to the ADRC ICA conducts annual rescreens and changes in condition thereafter If found no longer eligible will receive NOA and can appeal to the ICA Appealing decisions based on Financial Screen Financial Screen is conducted annually by Income Maintenance Disputes with results (eligibility or cost share) can be appealed through a State Fair Hearing IRIS Grievances & Appeals