Consolidated Personal Care Services Webinar Training for Licensed Home Providers

1. Consolidated Personal Care Services Webinar Training for Licensed Home Providers Program Eligibility, Independent Assessments, and Recipient Notifications Talbatha Myatt, Division of Medical Assistance Robyn Reasor, The Carolinas Center for Medical Excellence July 26, 2012

2. Presentation Overview • Review: Recipient eligibility criteria, independent assessment (IA) requirements, and IA scheduling • Walk-through: IA tool and process • Preview: IA notification process

3. Consolidated PCS • January 1, 2013 program implementation • Comparable benefit for beneficiaries in private residences and licensed homes • Recipient eligibility criteria • Service definition • Reimbursement rate and methodology

5. Proposed Clinical Coverage Policy 3L

6. Eligible Beneficiaries Eating • Have a medical condition, disability, or cognitive impairment, and • Demonstrate unmet need for hands-on assistance with qualifying activities of daily living (ADLs).

8. Covered Services for Adults

9. Additional Services for Children

10. Eligibility Determinations for Current Licensed Home Residents • Medical attestation • Independent assessment (IA) conducted in recipient’s home by Carolinas Center for Medical Excellence (CCME) RN Assessor

11. Transition Planning Resources

15. Medical Attestation Form

17. Independent Assessments

18. Preliminary Projected Timeline

19. Preliminary Projected Timeline • Licensed care facilities with paid Medicaid PCS claims for Jan-May 2012 dates of service • Additional facilities use New Admission assessment request • New Admission request process to be announced and implemented this fall

20. Assessment Scheduling • CCME contacts facility in advance by phone to confirm dates and verify Medicaid resident list • Provider reports discharges and new admissions • CCME makes return visits this fall to assess new admissions since initial visit

22. The Independent Assessment

24. Cognitive/Mental Capacities to Participate in Assessment • Fully able– Resident is alert and oriented to person, place and time; can verbalize general information about conditions and medications appropriately. • Requires limited assistance– Resident alert and oriented greater than 50% of time with periods of confusion, but can be redirected easily; questions may need to be repeated, but resident verbalizes appropriate answers to basic questions. • Requires extensive assistance— Resident alert and oriented less than 50% of time; may need basic questions repeated several times; generally not able to answer complex questions appropriately. • Requires full assistance – Cognitive impairment prevents resident from participating in assessment.

26. Resident’s Ability to Self-Manage Medications • Totally able; no assistance required • Can do with set-up assistance only • Can do with verbal cueing and supervision only • Can do with set-up assistance and verbal cueing/supervision only • Can do with limited hands-on assistance with taking medications • Can do with extensive hands-on assistance with taking medications • Cannot do at all; full staff assistance required

29. Assessor’s Overall Self-Performance Capacity Rating • Totally able— Recipient able to self-perform 100% of activity, with or without aids or assistive devices and without supervision or set-up assistance • Needs verbal cueing or supervision only— Recipient able to self-perform 100% of activity, with or without aids or assistive devices, and requires supervision, monitoring, or set-up assistance. • Can do with limited hands-on assistance — Recipient able to self-perform more than 50% of activity, and requires hands-on assistance to complete remainder. • Can do with extensive hands-on assistance— Recipient able to self-perform less than 50% of activity, and requires hands-on assistance to complete remainder. • Cannot do at all— Recipient unable to perform any of the activity; activity must be completely performed for recipient.

39. INDEPENDENT ASSESSMENT Data Transmission Quality Review Assessment Processing Eligibility Determination Service Level Determination RECIPIENT NOTIFICATION

40. Recipient Notification • Recipient notified of assessment results and authorized service level in formal Decision Notice • Approval notices sent by U.S. mail • Adverse decision notices sent by trackable mail • Current provider receives notice copy • Notification timelines will be announced when finalized

41. Recipient Appeals and MOS • Adverse decision = service reduction or denial • Recipient may appeal adverse decision • Decision Notice includes appeal rights, appeal request form, and instructions • Providers may assist beneficiaries who wish to appeal • beneficiaries who appeal timely, within 30 days of decision, are entitled to Maintenance of Services (MOS) until appeal is resolved

42. Upcoming Provider Trainings

43. For More Information Consolidated Personal Care Services (PCS): http://www.ncdhhs.gov/dma/pcs/pas.html CCME Independent Assessment Help Line: 1-800-228-3365 CCME IA e-mail: PCSAssessment@thecarolinascenter.org (Do not include PHI.)