New Choices Waiver Adult Residential Provider Training

1. New Choices WaiverAdult Residential Provider Training Presented By: The New Choices Waiver Program Office Division of Medicaid and Health Financing

2. Purpose of today’s training session: Inform providers of new regulations and policy changes. Inform providers of upcoming projects. Offer an opportunity for questions. Provide tools and resources to take with you. COMMUNICATE!

3. New Choices Waiver - 2015 in a nutshell.

4. QUESTIONS

5. Adult Residential Services Description During the waiver renewal process, the New Choices Waiver program office identified many areas of the old implementation plan that needed to be better defined and clarified. As a result, NCW has updated several service descriptions with clarifying language, including the service description for Adult Residential Services. “Adult Residential Services” is the catch-all title which encompasses all residential types of settings available through the NCW program.

6. Adult Residential Services Description • NCW Adult Residential Services setting types include: • Certified Independent Living Facilities • Licensed Small Health Care (Type N) Facilities • Licensed Assisted Living Facilities (Type I and II) • Licensed Assisted Living Facilities (Memory Care) • Licensed Community Residential Treatment Facilities • Even though all of these types of settings fall under the overarching umbrella title of “Adult Residential Services,” each of them have a specific set of licensing or certification requirements and each of them are limited in which HCPCS code they can bill through NCW.

7. Adult Residential Services Description • Facility types with applicable NCW HCPCS code: • Certified Independent Living Facilities = H0043 • Licensed Small Health Care (Type N) Facilities = T2031 • Licensed Assisted Living Facilities (Type I and II) = T2031 • Licensed Assisted Living Facilities (Memory Care) = T2016 • Licensed Community Residential Treatment Facilities = T2033 • Adult Residential Services providers will receive a Service Authorization Form from each client’s assigned waiver case management agency. This Service Authorization Form will list the appropriate HCPCS code that can be billed to Medicaid. • (We will talk more about Service Authorization Forms later.)

8. Adult Residential Services Description • The following general service definition applies to ALL Adult Residential Services setting types: • “Supportive services provided in an approved community-based adult residential facility. Supportive services are expected to meet scheduled and unpredictable participant needs and to provide supervision, safety and security in conjunction with residing in a homelike, non-institutional setting.” • Now let’s examine each setting type’s description and HCPCS separately in the next few slides:

9. Licensed Assisted Living Facilities & Small Health Care Facilities Adult Residential Services in licensed assisted living facilities (type I and type II) and licensed small health care (type N) facilities: NCW HCPCS Code: T2031 “Includes homemaking services, chore services, 24-hour on-site response capability, attendant care services, meal preparation, medication assistance/oversight, social/recreational programming, and nursing/skilled therapy services that are incidental rather than integral to the provision of Adult Residential Services.”

10. Licensed Assisted Living Facilites, Memory Care Adult Residential Services in licensed assisted living facilities, memory care: NCW HCPCS code T2016 “Includes homemaking services, chore services, 24-hour on-site response capability, attendant care services, meal preparation, medication assistance/oversight, social/recreational programming, memory care services, and nursing/skilled therapy services that are incidental rather than integral to the provision of Adult Residential Services.”

11. Licensed Community Residential Treatment Facilities • Adult Residential Services in licensed community residential facilities: • NCW HCPCS code T2033 • “Includes meal preparation, behavioral health services, 24-hour on-site response capability, homemaking services, chore services, and social/recreational programming.”

12. Certified Independent Living Facilities Adult Residential Services in certified independent living facilities: NCW HCPCS code H0043 “Includes homemaking services, meal preparation, 24-hour on-site response capability, formal safety plans and daily status checks (or more frequently as deemed appropriate in the comprehensive needs assessment).”

13. All Adult Residential Services Facilities “All Adult Residential Services no matter the setting includes 24 hour on-site response capability or other alternative emergency response arrangements determined appropriate to meet scheduled or unpredictable participant needs and to provide supervision, safety and security in conjunction with residing in a homelike, non-institutional setting.”

14. Adult Residential Services Limitations Service limits have also been expanded and include more detail: “Separate payment is not made for homemaker services furnished to a participant receiving adult residential services, since these services are integral to and inherent in the provision of adult residential services.”

15. Adult Residential Services Limitations • “Separate payment is not made for chore services unless an exceptional need is identified in the comprehensive needs assessment that is not specified in the formal lease agreement between the facility and the participant/family as being the responsibility of the facility. Example of an exceptional need: heavy cleaning resulting from hoarding behavior. Documentation of exceptional needs must be submitted with the care plan for approval. Exceptions will not be approved if the chore service is for the costs of general facility maintenance, upkeep or improvement.”

16. Adult Residential Services Limitations • “Separate payment is not made for attendant care services furnished when the participant is actively receiving care inside the facility or during activities provided by the facility off campus. Attendant care may be provided when a need is identified for participation in off-campus activities not associated with the facility. Examples: personal shopping or accompanying the participant to doctor appointments.. Exceptions to the attendant care limitation are made for individuals residing in licensed community residential facilities and independent living facilities because neither type of facility is licensed to perform hands-on assistance with activities of daily living.”

17. Adult Residential Services Limitations “Payment is not made for 24-hour skilled care or supervision. Federal financial participation is not available for room and board, for items of comfort or convenience, or the costs of facility maintenance, upkeep and improvement.”

18. QUESTIONS

19. Admission Policy Changes Changes were made to the admission policies effective July 1, 2015. Before describing the changes, let’s talk about the history of NCW leading up to present day.

20. General Waiver Characteristics • States develop waiver programs to provide HCBS to a limited, targeted groups of individuals. • Waivers are not an entitlement for all Medicaid recipients • People must meet additional eligibility criteria • Waiver services do not take the place of traditional Medicaid benefits. Waiver services are an additional benefit package. • States must assure that necessary safeguards are taken to protect the health and welfare of waiver clients. • Waiver programs must be cost neutral.

21. New Choices Waiver In 2007, the New Choices Waiver (NCW) program was developed and approved by CMS. NCW was designed as a deinstitutionalization program, not a nursing home diversion program. The original target group is people who are actively living in nursing homes, hospitals and other Utah medical institutions who wish to move out and reside in a community-based setting.

22. ALF Entry Route In 2012, a new entry route was implemented for people living in assisted living facilities (ALF). An initial estimate of 8-10 people per year were predicted to enter NCW through this pathway. Without limits in place, New Choices Waiver experienced tremendous growth in the number of people entering the program from ALF settings. (22 new clients per month.) The number of people enrolling from nursing facilities/hospitals did not change so NCW experienced growth beyond what was expected.

23. Enrollment Cap • NCW reached it’s maximum capacity in December 2014. • As a result, NCW experienced an enrollment freeze for six months until slots opened up again on July 1, 2015. • Attrition from prior year disenrollments • Additional slots were added • During the six month enrollment freeze time period, Medicaid met with stakeholders to redesign its admission policies with these goals in mind: • Ensure that residents of hospitals/nursing facilities continuously had an option for returning to the community • Maintain the ability to demonstrate cost savings

24. Admission Policy Revisions Effective July 1, 2015 • Admission policies were revised as follows: • The majority of available waiver capacity is reserved for people wishing to move out of hospital and nursing facility settings. • This group may apply anytime during the year. • Other eligibility criteria remains unchanged. • ALF residents may still apply to NCW, but limits now exist for this group as follows: • Length of stay requirement has increased to 365 days. • Three open application periods each year. • A limited number of applicants will be selected each open application period. • Preference is given to those with a longer length of stay.

25. Open Application Schedule • Open application periods for ALF residents are: July 1 – July 14 November 1 – November 14 March 1 – March 14 (This schedule does not apply to hospital/nursing facility residents.)

26. Open Application Data NCW has held two open application periods so far. This year, in each open application period NCW can enroll 27 people. July: 43 applications received 3 did not meet medical criteria 2 did not meet length of stay criteria 2 did not qualify for Medicaid 2 applications were not received timely Nov: 48 applications received 3 did not meet medical criteria 2 did not meet length of stay criteria 1 withdrew their application 2 applications were not received timely

27. Other Application Process Changes • NCW will no longer act as a go-between for Medicaid financial eligibility applications with the Department of Workforce Services. • NCW will not proceed with a New Choices Waiver application until confirming that DWS has received a Medicaid application. • The ALF application packet has been updated. • Evidence that documents the complete length of stay of 365 days must be provided with applications. • Lease agreements are the best form of evidence. • Letters are not considered acceptable evidence. • Since applicants are selected based on length of stay, it is very important to provide evidence to document prior facility stays as well.

28. O At-a-glace reference guide.

29. QUESTIONS

30. Medical Eligibility Screening Form • The New Choices Waiver (NCW) Medical Eligibility Screening form is a tool that is used by the NCW RN to determine if an applicant meets medical (level of care) eligibility. • The form must be completed by a physician or RN. • It is recommended that the caretakers assisting the applicant with their daily cares provide feedback to the medical professional completing the form.

31. Medical Eligibility Screening Form • Nursing facility level of care consists of the following 3 criteria: • Activities of daily living- Applicant requires substantial assistance above the level of verbal prompting, supervising, and setting up. The applicant must require physical hands on assistance with 2 or more ADL’s, 3 or more times a week. • Orientation to person, place, time and situation-Diagnosis of dementia or any other cognitive impairment. • Medical condition(s) and intensity of services indicate that the care needs of the applicant cannot be safely met in less structured setting without the services and supports of a Medicaid home and community based waiver program • The applicant must meet at least 2 of the 3 criteria above.

32. Medical Eligibility Screening Form This updated form was effective July 2015 and is included in all NCW application packets for ALF residents. The changes were made to make the form more intuitive for medical professionals who are not trained in the Nursing Facility Level of Care assessment process.

33. Medical Eligibility Screening Form • Activities of Daily Living (Criterion 1) • Incontinence and bed mobility have been added to the ADL section of the form. (i) This question was added when the form was updated. • Orientation (Criterion 2) • The question asking about a physician diagnoses and check box were added to the updated form. • a-f were changed to response categories of: • “N/A, Mild, Moderate, and Severe” • g-h were added to the updated form • Medical Conditions and Intensity of Services (Criterion 3) • This section of the form has remained the same

34. Medical Eligibility Screening Form • Common problems that often delay the application process or that sometimes result in a denial of the application: • Information provided on the Medical Eligibility Screening form should correlate with supportive documentation sent in with the NCW application: • Physical exam records, ALF service plan, medication logs, other medical records, etc. • Accurate documentation of the physical level of assistance needed. • If the assessor has not seen the applicant’s ability to complete the ADL and there is a question of the applicant’s ability it is recommended the assessor request the applicant to demonstrate their ability to do the ADL.

35. Medical Eligibility Screening Form • Common problems, continued: • When the “Yes” box is checked for criterion 2 (orientation), make sure there is a cognitive diagnoses listed in the blank space. • Complete section 3. Leaving this section blank is unacceptable unless the applicant truly has no medical conditions, treatments/therapies or medications to report. • Please document all pertinent medical information such as medical diagnosis, treatments and therapies.

36. QUESTIONS

37. Proposed ALF Rule Changes O The NCW Program Office met with Health Facility Licensing in August in an effort to resolve some difficulties experienced by NCW Clients residing in Assisted Living Facilities. The difficulties included: • Clients residing at type I facilities have not been permitted to receive physical help with more than one ADL if they are receiving medication administration assistance. • Clients residing in ALFs have been unable to self-administer their own injections and also have all other oral medications administered by the ALF staff.

38. Proposed ALF Rule Changes O Several solutions were discussed with Health Facility Licensing and the following changes have been proposed: • Clients residing in type one facilities may receive total assistance with two ADLs in addition to receiving medication assistance. • Clients residing in ALFs may independently administer their own personal insulin injections and continue to receive medication administration services by ALF staff for all other medications.

39. Proposed ALF Rule Changes O Health Facility Licensing has been open to the feedback and expressed a willingness to make changes to the administrative rule in the interest of improving public health care. Until the rule amendment is officially enacted, ALFs may submit variance requests to Health Facility Licensing to obtain special approval to allow clients to administer their own injections and also receive ALF staff assistance with administration of all other oral medications.

40. Proposed ALF Rule Changes O Health Facility Licensing has drafted an amendment to R432-270 and filed it with the Department of Administrative Services on December 1st. The amendment will be available for public viewing and comment beginning on December 15, 2015. http://www.rules.utah.gov/publicat/opencomment.htm Public comments will be accepted for 30 calendar days after the proposed rule change is posted.

41. QUESTIONS

42. Service Authorization Forms O It is important to remember that New Choices Waiver services cannot be provided or billed unless they have been authorized through the care planning process. DO NOT PROVIDE SERVICES TO A NEW CHOICES WAIVER CLIENT UNTIL YOU HAVE A SIGNED SERVICE AUTHORIZATION FORM IN HAND! If a New Choices Waiver client contacts you to begin services, ALWAYS ask who their case management agency is and call them to find out if services have been approved and to request a Service Authorization Form.

43. Service Authorization Forms O ALWAYSrefer to the approved NCW Service Authorization form to determine the date you can begin billing for services you provide. • Claims paid for waiver services outside of the date span listed on the Service Authorization will be recovered. • Claims paid for waiver services with a higher number of units or frequency than was authorized on the service authorization form will be recovered. • Claims paid for HCPCS codes not authorized will be recovered.

44. Service Authorization Forms O Do not assume a service has been authorized or will be authorized. Service Authorization Forms are only valid for a maximum of 1 year even if the “end date” is left blank. Once the service authorization has been signed, make sure the services on the adult residential service plan match those on the service authorization form. Communication with the case management agency is critical!

45. O

48. Service Authorization Forms O Approved Service Authorization Forms are not a guarantee of payment. Providers must verify their client’s Medicaid eligibility every month. There are two ways to verify client eligibility each month: • Call Access Now: 800-662-9651, option 1, option 1 • Use the eligibility look-up tool on the Medicaid website: https://medicaid.utah.gov/eligibility

49. Helpful Links and Contacts O New Choices Waiver Provider Manual http://health.utah.gov/ltc/NC/NCHome.htm Each NCW provider is responsible for reading this manual and understanding the policies and procedures it contains.

50. Medicaid Information Bulletin (MIB) O The Medicaid Information Bulletin (MIB) is published quarterly or more frequently as needed. It includes important policy and procedural updates and information regarding all Medicaid programs, including: • Updates to the NCW Provider manual • Changes to Medicaid billing procedures • Progress reports on Medicaid’s new billing system, PRISM, and more Each provider is responsible to check the MIB frequently for changes that will affect you, as a provider.