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THE CHILDREN’S WAIVER PROGRAM AN OVERVIEW November 2011

THE CHILDREN’S WAIVER PROGRAM AN OVERVIEW November 2011. Legal authority Funding Eligibility Prescreens Application process Plan development Decision guides. Services Provider qualifications PDN Budgets Administrative hearings Choice Voucher Quality assurance.

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THE CHILDREN’S WAIVER PROGRAM AN OVERVIEW November 2011

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  1. THE CHILDREN’S WAIVER PROGRAM AN OVERVIEWNovember 2011

  2. Legal authority Funding Eligibility Prescreens Application process Plan development Decision guides Services Provider qualifications PDN Budgets Administrative hearings Choice Voucher Quality assurance What Will We Cover Today?

  3. Legal Authority • Authorized under Section 1915(c) of the Social Security Act • Allows states to waive parental assets and income and make a child eligible for Medicaid as a “family of one” • Provides additional services specific to, and limited to, the waiver population

  4. State Funding • An appropriation controlled by the Michigan Legislature • Matched with federal funds • Limited to the number of children it can support on the CWP

  5. Up to age 18 Meets financial eligibility for Medicaid as a “family of one” Resides w/parent(s)or guardian (relative) Receives at least one waiver service per month At risk of out of home placement Has a Developmental Disability as defined in the mental health code AND meets criteria for an ICF/MR CWP Eligibility Requirements

  6. Intermediate Care Facility for the Mentally Retarded (ICF/MR ) An individual must have the need for an active treatment program of specialized and generic training, treatment, health and related services directed toward the acquisition of behaviors necessary to function with as much self-determination and independence as possible.

  7. When Considering a CWP Pre-Screen • Is the child currently Medicaid eligible? If so, CMH is responsible to provide medically necessary supports and services & cannot place the child on a waiting list. • Is the child developmentally disabled? • Does the child meet criteria for ICF/MR, including needing “active treatment”? • Is the child at risk due to health and/or safety conditions? • What service needs have been identified? • Can services be provided through CMHSP and other community sources?

  8. Priority Weighing Criteria • Factor 10: Home Care Supports Other Than the CWP • Factor 9: Health and Safety • Factor 8: At Risk of Out-of-Home Placement • Factor 7: Other Minor Children Residing in the Home • Factor 6: Family Stress and/or Physical Health Problems • Factor 5: Other Children with Special Needs • Factor 4: Child Presently in a Nursing Home • Factor 3: Child Presently Resides in a ICF/MR Facility • Factor 2: For Future Use • Factor 1: The Child is Presently in Foster Care and Needs Support

  9. CWP Pre-screen Updates • Annual update is required • An update within the past six months is necessary for an invitation to apply • If a child no longer qualifies for the CWP, or if the family no longer wants waiver services, the child’s name will be removed from the Weighing List

  10. When Waiver Slots Become Available Case manager contacts the child’s parent(s) to confirm: • Child’s service needs • Current residence • Medicaid status • Family still wants waiver services

  11. Initial Application Process • Due within 30 days from invitation to apply • Waiver Certification Form and Demographic Intake Form

  12. CWP Clinical Review Team (CRT) reviews waiver application for clinical eligibility Approval notification is sent to: Case manager (CRT) DHS (MDCH MA Liaison) Family (MDCH MA Liaison) Approval Process

  13. After Initial Approval • CMHSP should: • Establish the child’s Individual Plan Of Service (IPOS) • Train CLS and respite staff in the IPOS and assure staff meet all other training/provider requirements before providing services • Submit final application documents

  14. Final Application Documents • Within 45 days, CMHSP submits: • CWP budget • Revised Waiver Certification form (if necessary) • DHS 49 • Date the child got the first WAIVERservice

  15. Final Application Documents For Children Eligible For PDN • PDN eligibility worksheet • Health care plan • Copy of physician’s order for PDN • IPOS

  16. Budget Details • Waiver budget must reflect • Only services identified in IPOS • Amount of service to be provided • Procedure code for service

  17. Annual Renewal • October 1st of each year, the case manager must submit an annual budget to MDCH • Annual Recertification form must be submitted within 365 days of initial certification • Copy of the Medical Examination Form (DHS-49) must be submitted within 365 days of the prior physical exam

  18. What is a Decision Guide ? It is a tool to: • Assist the child’s team in determining the amount of publicly supported CLS hourly care • Ensure consistency across the state of Michigan • Review the care needs of the child and the resources available to the family

  19. Assessment of Need • Type of behaviors identified • Frequency, intensity and duration of the identified behaviors • How recently serious behaviors occurred • Specific effects of the behavior on persons in the family and property

  20. Categories of Care • Demonstrates mildlevel behaviors that may interfere with the daily routine of the family. • Demonstrates a daily pattern of medium level behaviors including self-injurious, physically aggressive or assaultive behaviors that have not resulted in hospitalization or emergency room treatment for injuries in the past year, or has engaged in occasional, significant property destruction that is not life-threatening. • Demonstrates a daily pattern ofmoderateself-injurious, physically aggressive or assaultive behavior when medical intervention, or hospital emergency room treatment has been required for treatment of injuries in the past year without resulting hospitalization, or if the child has engaged in frequent,significant property destruction that is not life-threatening. • Demonstrates a pattern of severeself-injurious, physically aggressive or assaultive behavior, or life threatening property destruction that has occurred one or more times in the past year. Documented evidence of additional behavioral problems on a frequent basis each day supports a need for one-to-one intensive behavioral treatment.

  21. COC Documented Narrative • Additional Resources • # of caregivers • Health of Caregivers • Dependent Children • Children w/special needs • Night Interventions • School schedule • Assessment of Need • Type of behaviors • Frequency, intensity and duration of behaviors • How recently behaviors occurred • Effects of behavior on family & property

  22. Services Available to Children on the CWP • All mental health services included in the CWP Services database when: • Used to address a need • Identified in the IPOS • Services include: • “State plan” mental health services, and • “Waiver” services

  23. Community Living Supports (CLS) Enhanced Transportation Respite Services Home Care Training, Family Specialty Services Home Care Training, Non-Family Specialized Medical Equipment & Supplies Environmental Accessibility Adaptations Fiscal Intermediary Waiver Services

  24. Private Duty Nursing Occupational Therapy Physical Therapy Speech Therapy Targeted Case Management Durable Medical Equipment Professional Evaluations & Testing Treatment Planning Health Assessments Medication Review etc. Medicaid State Plan Services

  25. Community Living Supports • H2015 - Community Living Supports; per 15 minutes • Must be trained in: • IPOS • Recipient Rights • Basic First Aid, CPR • Emergency Procedures

  26. Enhanced Transportation Enhanced Transportation • S0215 - Non-Emergency Transportation; mileage (per mile) • CLS costs include transportation • Transportation may be billed when provided by staff other than CLS • Limited to resident’s county or surrounding county • Is identified in the IPOS

  27. Respite Care • T1005 - Respite Care, per 15 minutes • Can be provided in: child’s home, licensed foster home, licensed respite care facility, licensed camp • “Vacation” respite eliminated effective 1/1/12 & means no: “per diem” codes; 96 hr/mo. cap; reduction in CLS or PDN if respite used in 24-hour increment • New respite limits: 864 hours (3456 units) Jan. 1 – Sept. 30, 2012; 1152 hours (4608 units) per fiscal year beginning Oct. 1, 2012

  28. Family Training • S5111 - Home Care Training, Family; per session • Provided by MSW, LLP or QMRP • Includes: • Instruction about treatment regimens & use of equipment specified in the IPOS • A counseling service to families

  29. Specialty Services • G0176 for: • Music Therapies • Recreation Therapies • Art Therapies • 97124 for: • Massage Therapy • Limit of 4 sessions per month per type of specialty service

  30. Non-Family Training • S5116 - Home Care Training, Non-Family; per session • Provided by an MSW, LLP or QMRP to CLS and/or respite staff

  31. Specialized Medical Equipment & Supplies • Must be: • medically necessary, and beyond what is ordinarily found in the home • specified in the IPOS • Includes devices, controls and appliances not covered under Medicaid State Plan

  32. Environmental Accessibility Adaptations • S5165 - Home Modifications must be: • prior authorized by MDCH • specified in the IPOS • necessary to ensure the health, welfare and safety of the child

  33. Fiscal Management Services(FI) • New CWP waiver service effective 10/1/2010 • The fiscal intermediary must meet requirements as identified in the “MDCH/CMHSP Managed Mental Health Supports and Services Contract – Attachment C3.4.4 Medicaid Managed Specialty Supports and Services Concurrent 1915(b)(c) Waiver Program FY12 – Attachment P3 4.4” • Monthly all-inclusive code – T2025

  34. Prior Authorization • Yours (locally authorized) • Adaptive toys: T1999 • ADL aids: S5199 • Allergy control supplies: T2028 • Ours (CRT authorized) • Enhanced hours (CLS & PDN) • Environmental safety & control devices: T2029 • Repair or non-routine service for DME: K0739 • Vehicle modifications: T2039 • Environmental accessibility adaptations: S5165 • Durable medical equipment, misc.: E1399 • Therapeutic items; assistive technology; other DME for sensory, communication, mobility needs; generators; window air conditioners

  35. Administrative Hearing • A notice of action: • Must be sent whenever a Medicaid covered service is denied, suspended, reduced or terminated • Provides consumer with the opportunity to request an Administrative Hearing, held by an Administrative Law Judge (ALJ)

  36. The Choice Voucher System • Must be made available for children enrolled in CWP • Provides parents of minor children a method to control and direct how their child’s IPOS is implemented and who are the providers • Participation by families is voluntary

  37. Family & CMHSP, using the PCP process, develop child’s IPOS identifying needed services and supports A CWP budget is developed based on the IPOS Parent implements arrangements through the Choice Voucher System A Choice Voucher Agreement between the CMHSP and Parent is signed The funds in the CWP budget are lodged with a fiscal intermediary How the System Works

  38. Quality Assurance & Improvement • Recent renewal requires changes to quality assurance and improvement strategies: • bi-annual site-reviews (QMP & CWP); we must review more records; CWP site review protocol & Department-level processes revised to align with “CWP Performance Measures”; plans of correction still required; we must report “remediation” of problems to the consumer-level

  39. For Additional Information • Medicaid Provider Manual-Mental Health/Substance Abuse/Section 14 • Audrey Craft • 517.241.5757 - crafta@michigan.gov • Joan Deschamps • 517.241-5754 -deschampsj@michigan.gov • Sandy McDiarmid • 517.241.5768 - mcdiarmids@michigan.gov

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