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Medicaid Personal Assistance Services

Medicaid Personal Assistance Services. Program Overview. What is Personal Assistance. Often referred to as home care, home health care or personal care . . . The goal of the personal assistance program:

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Medicaid Personal Assistance Services

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  1. Medicaid Personal Assistance Services Program Overview

  2. What is Personal Assistance Often referred to as home care, home health care or personal care . . . The goal of the personal assistance program: Prevent or delay institutionalization by providing medically necessarymaintenance or supportive care in the home.

  3. List of Covered Services Activities of Daily Living Bathing, dressing, grooming, toileting, transferring, positioning, meal preparation, eating (including GI tube feeding, exercise, medication assistance) Housekeeping Tasks (HT) to insure a safe environment Changing bed sheets, light housekeeping, cleaning medical equipment, laundry, washing dishes Escort to medical appointments Going with and assisting a person to medical appointments paid for by Medicaid

  4. Program Options • Agency-Based Option (PAS or ABPAS) • Nurse Supervision • Agency responsible for hiring, scheduling and training attendants • Self-Direct Option (SDPAS) • Agency Oversight • Consumer or personal representative (PR) responsible for hiring, scheduling and training attendants

  5. PAS Principles:Risk – Choice - Environment Right to self determination; Right to Fail; Right to maintain the environment of their choice; Right to be informed of the consequences of their choices It’s a lifestyle choice Right to take risks.

  6. Working through a Consumer Example • Introducing Connie Fused • Our Consumer for the Day • Refer to Connie Fused paperwork throughout the Power Point • The Power Point slide that is connected to the Connie Fused handout will be indicated by Connie’s initials and the handout # (CF #)

  7. Referral Process Opening the Door to Services

  8. Eligibility for Services PAS/SDPAS 401 ABPAS 1-3SDPAS 1-5 1) health condition that limits ability to perform activities of daily living, 2) participate in the screening process through Mountain Pacific Quality Health (MPQH) 3) be financially eligible for Full Medicaid. 4) consumer/personal representative must pass a capacity assessment (MPQH) and 5) have health care professional approval form

  9. Referrals (CF 1) (PAS/SDPAS 503 and CSB 1007) • Referrals can be made by anyone: consumer, family member, doctor, discharge planners, friend or agency • Referrals are sent via telephone to MPQH at 1-800-268-1145 ext. 5830 • Referrals can be faxed to MPQH at 1-800-268-5767 • Faxed referrals from PAS agencies, use the SLTC 154 pg 1

  10. Referral Process Cont. On the referral form make sure to include: • Indicate the Preferred Option (i.e. SDPAS or ABPAS) • Medicaid ID, name, address, Phone • Contact, when appropriate for PAS • Note: if a contact name is listed MPQH must call this person instead of the consumer • Personal Representative is contact if SDPAS • Directions to home (including traveling from) Very helpful in rural settings

  11. Referral Cont. • Personal Care Needs- Focus on Diagnosis (Dx) or Impairment and ADL’s as the Homemaker Tasks (HT) are very limited • Health Care Professional (HCP) and telephone number are very helpful • Referral Dx may not be the Overview Dx which is obtained when onsite • Referral Source- the name of the person completing the form • High Risk- Include date services were started

  12. Beginning Services Initial Authorization Process and Paperwork

  13. Initial Authorization Process An agency cannot bill for services unless a consumer is authorized for those services. In a typical case this means the consumer chart must contain the following records: • MPQH Prescreen and/or Overview and Profile (SLCT-155 and 156) • Agency On-Site Intake Visit (SLTC-150 or 164) • Health Care Professional Authorization and Consumer Agreement- SDPAS only Note: We will discuss the high risk process at a later time

  14. Initial MPQH Authorization: Prescreen and Onsite (CF 2&3)(PAS/SDPAS 411, 502) The MPQH Nurse coordinator must do an on-site visit to complete the Overview and Profile (SLTC-154 and 155) The on-site must be done within 10 working days of receiving the referral If the MPQH nurse cannot make an onsite in those 10 days a pre-screen over the phone is done within 10 working days of receiving the referral. If a telephone pre-screen is done, onsite must then be made within 30 working days from the referral

  15. Authorizing Process Assess each person in his/her own environment Conversation to Determine Authorization What assistance is used other than Medicaid State Plan (family, social supports, other services) Provide the agency a complete picture Authorize according to Need Profile establishes service limit based on tasks and frequency of those tasks Provide the agency a complete picture Partnership with Agencies to make it work

  16. During the Initial MPQH Authorization On-Site Visit A list of providers by county and ABPAS or SDPAS is maintained by Mountain-Pacific At the end of each visit the consumer is asked if they have decided what agency they have selected If they are unsure, the above mentioned list is provided They are instructed to call the MPQH toll-free number when they have made a decision. If we do not hear in one week, we call the consumer

  17. Agency Intake Visit (CF 4) (PAS/SDPAS 702 and 905) Department Requirements: • Must be in person, on-site • Must include agency generated forms • Must include review of profile and authorization • Must complete the intake visit, SLTC nurse supervision or oversight form (SLTC-150 or 164) • Complete the agency intake visit prior to beginning services, regardless of whether it is high risk or a normal admit

  18. Agency Intake Form: SLTC-163 (CF 5)(PAS/SDPAS 908) • This form is NOT the form that is used for the intake visit (SLTC-150 or 164) • You must complete the form and indicate the date that the attendant began providing services • The date services began is NOT the date that you conducted the on-site intake visit • Fax the form to MPQH Note: Agency must institute services within 10 working days of receiving profile

  19. Agency Unable to Admit Form: SLTC-158 (CF 6)(PAS/SDPAS 907) • If the agency receives the referral and is unable to serve the consumer the agency must complete STLC-158 • Indicate the reason the admit was unable to be processed • Fax the form to MPQH

  20. Continuing Services Ongoing Authorization Process and Paperwork

  21. Ongoing Authorization To provide ongoing services your agency must ensure the following authorizations are in place: • Recertification Visit – current within last 180 days (SLTC 150 or 164) • Current Authorization from MPQH • Date span indicated on upper right corner of profile, (SLTC-155)

  22. Recertification Visit/ 180 day (CF 8)(PAS/SDPAS 702, 703) This is not the same as the MPQH annual authorization Visit Requirements: • Must be an in-person visit in the consumer’s home • Must be completed during the month the 180th day falls or if significant changes occur • If not able to occur, must document reason for the delay • Prior to visit, review time sheets and chart notes and provide follow-up, as necessary • Use the SLTC-150 or 164 to document the visit- be specific and thorough

  23. MPQH Annual Reviews Monthly, Mountain-Pacific produces a list of consumers whose authorized span is ending. The list is faxed to the provider agency The agency needs to verify the phone number and address and fax back to Mountain-Pacific within 10 working days or be out of compliance

  24. Annual Reviews…continued After the annual review, Mountain-Pacific faxes the Consumer Overview and profile to the agency no later than the last working day of the month (our goal 80% by the 21st) Wrong phone number, no answer, out of town (discussion) The agency determines if a follow up home visit is necessary The agency will adjust the consumer’s schedule to accommodate any changes in hours within ten working days of receiving the fax

  25. Questions about the review? If the agency and the consumer disagree with the annual authorization of services then the agency may request a change in authorization via a Nurse Supervision/Oversight form Use the same form if the consumer does not want to utilize an increase in hours If it appears there is a data entry error, fax a note or call 457-5830 or 1-800-268-1145 ext. 5830 and we will be happy to check entry and get back with you

  26. What if? Information gathered during review DOES NOT MATCH Information provided by Agency Gather more information, call consumer, family, provider or Health Care Professional GET A CLEAR PICTURE OF SITUATION AND MAKE DETERMINATION, based on Rules

  27. Discharge/Readmit Saying Goodbye . . . maybe

  28. Discharges (CF 14) PAS/SDPAS 705, 907 The following situations require consumer discharge Temporary Absence: If a consumer . . . Hospitalized or placed in a nursing home for a period of 45 days Has an extended absence from MT longer than 45 days without utilizing PAS/SDPAS services Other reasons a 45 day break in services has occurred Situations where consumer will be permanently off services

  29. Discharge Process • Complete form Discharge Form SLTC-158 • Fax form to the MPQH • Don’t forget to fill the form out completely • Please provide some narrative

  30. Re-admissions (PAS/SDPAS 411) If you discharge a consumer and need to re-instate services: Send a new referral to MPQH Agency must have current authorization to re-instate services SLTC 150 or 164 MPQH Profile (SLTC 154 and 155) If authorization paperwork is not current you must process as a new intake

  31. Authorizing Services What Can and Can’t Be Authorized?

  32. Department Policies Affecting Authorization of Services (PAS/SDPAS 403) Covered Service and Limits • Services are available only to consumers who reside at home or under certain circumstances in a licensed foster or group home. (acute, short-term) • 40 hours a week limit. In special cases if consumer has short-term acute needs can go beyond 40 hours, but needs to be authorized by Mountain-Pacific (not to exceed 90 days).

  33. Household Tasks (HT) (PAS/SDPAS 403) Household tasks include assistance with activities related to housekeeping that are essential to maintaining the consumer’s health and safety in the home. Housecleaning Laundry Shopping Household tasks shall not include basic homemaking services that maintain an entire household or family. Household tasks may not exceed one-third of the total personal assistance/HMA hours or a total of three hours per week.

  34. Meal prep shall be limited to those meals when the significant party is not available or when the consumer’s special diet requires preparation that is significantly different and separate from the household. Shopping for groceries and DME or pharmaceuticals may be allowed when it is not convenient for the family to do in conjunction with any household shopping. Other Service Limits: Meals and Shopping (PAS/SDPAS 403, 710)

  35. Services to Children under the age of 21 (PAS/SDPAS 403,404, 712) Services to children are not available to relieve a parent of their child caring or other legal responsibilities. In authorizing services to disabled children, the age-appropriateness of parental assistance is considered. Children under the legal age for driving are not authorized for medical escort If 18-21 and in college, can get services

  36. Live-in Attendants, Family and Significant Others (PAS/SDPAS 710, 403) The PAS program is designed to provide support to caregivers, but not replace them entirely. When a consumer resides with family members (including significant others) or their attendant, it is expected that they will provide the majority of household support tasks, including shopping for groceries.

  37. Exclusions cont. The program does not cover tasks such as yard work, household repairs, major cleaning, shopping for non-essential items, escort to non-medical services, pet care or general transportation. (Area Agencies on Aging for folks over the age of 60 and HCBS programs are 2 examples of where folks can get these needs met)!

  38. More Exclusions(PAS403 SDPAS 404) Reimbursement for Personal assistance services is not available to: Husband or wife Legal guardian Conservator Natural parent of a minor child (less than 18 years old) Adoptive parent of a minor child Step parent of a minor child Foster parent of a minor child

  39. Special Circumstances Agency Role in Making Things Happen

  40. Temporary Authorization For situations when agency needs to temporarily authorize services

  41. Temporary AuthorizationSLTC-161 or 165 (CF 9) (PAS/SDPAS 417, 903) Provides agency with the ability to temporarily authorize services • Document current authorization and utilization based on medical need for service • Identify specific tasks • Identify days per week and time per day to complete tasks

  42. Four Situations to Use the Form • Admitting someone for 20 days or less • High Risk referral • Use in Conjunction with the Referral Form • Change from profile will be 20 days or less • Change from profile will be over 20 days • Use form in conjunction with the Amendment Form

  43. Situation 1: Temporary Admit • Admitting Someone for 20 Days or Less • Rarely happens • Complete TA Form • Complete the necessary intake forms • No need to submit the referral to MPQH or admit as high risk

  44. Situation 2: High Risk Intake (PAS/SDPAS 414) What do you do when the consumer needs services immediately and you can’t wait for the MPQH authorization? . . . Consider implementing a high risk intake If you implement a high risk intake you can begin providing services prior to receiving the MPQH authorization

  45. High Risk Intake Authorization Process (CF-7) Consumer Criteria Agency Requirements The agency must perform the following prior to beginning services: Document high risk on the bottom of the referral form(SLTC-154) and fax to MPQH Complete intake visit (SLTC-150 or 164), must be on-site and in person Develop a temporary service plan (SLTC-161 or 165) The consumer must fall into one of two criteria: • Services are necessary to prevent institutionalization or • Services are necessary to resolve a hazardous home situation that places the consumer at high risk or

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