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Becoming A Medicaid HCBS Waiver Provider

Funding For Special Needs Child Care. Becoming A Medicaid HCBS Waiver Provider. Presented by:. Deborah VanderGaast, RN Owner - Tipton Adaptive Daycare Home Care Case Manager, Girling Health Home care services for adults and children with disabilities

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Becoming A Medicaid HCBS Waiver Provider

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  1. Funding For Special Needs Child Care Becoming A Medicaid HCBS Waiver Provider Iowa Department of Human Services. (2011). Chapter 80: Procedure and method of payment. Retrieved May 1, 2011, from http://www.dhs.state.ia.us/policyanalysis/PolicyManualPages/Manual_Documents/Rules/441-80.pdf

  2. Presented by: Deborah VanderGaast, RN • Owner - Tipton Adaptive Daycare • Home Care Case Manager, Girling Health • Home care services for adults and children with disabilities • Skilled nursing care for acute and chronic health care needs

  3. Tipton Adaptive Daycare Category B Family Daycare Home Medicaid Waiver Provider for IMMT & Respite Child Care Assistance Promise Jobs Protective Daycare Skilled Child Care for Children with Special Health Care Needs www.TiptonAdaptiveDaycare.com

  4. Special Needs Child Care Providing care for children with special needs in an inclusive environment with their typically-developing peers.

  5. Least Restrictive Environment The Individuals with Disabilities Education Act (IDEA) of 1975 requires that children with disabilities be provided education and services in the least restrictive environment. • Amended in 1997 to include specific guidelines for infants and toddlers • Guidelines state they should receive care and services in “natural environments”

  6. Natural Environments Defined as, “settings that are natural or normal for the child’s age peers with no disabilities”. Smith, Barbara J., & Rapport, Mary Jane K. (1999, September). IDEA and early childhood inclusion. Collaborative Planning Project. Retrieved July 15, 2009, from http://www.nectac.org/~pdfs/topics/inclusion/ideaec.pdf

  7. Special Health Care Needs Children and youth with special health care needs (CYSHCN) are defined by the Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB) as: • “Those who have or are at increased risk for a chronic physical, development, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally” McPherson, M., Arango, P., Fox, H., Lauver, C., McManus, M., Perrin, J. M., et al. (1998, July). A new definition of children with special health care needs. Pediatrics, 102(1), 137-141.

  8. Statistics: [1.]Looman, Wendy S., O'Conner-Von, Susan, & Lindeke, Linda L. (2008, July 11). Caring for children with special health care needs and their families: What advanced practice nurses need to know. The Journal for Nurse Practitioners, 4, 512-517. [2.] Kogan, Michael D., Strickland, Bonnie B., Blumberg, Stephen J., Singh, Gopal K., Perrin, James M., & van Dyck, Peter C. (2008, December). A national profile of the health care experiences and family impact of autism spectrum disorder among children in the United States, 2005-2006. Pediatrics, 122(6), e1149-e1158. • Approximately 20% of American households with children have one or more children with special health care needs (SHCN) [1.] • In 2008, there was an estimated 535,000 children with SHCN living in the United States [2.]

  9. Medicaid HCBS Waivers • The Medicaid Home and Community Based Services are designed to allow individuals with disabilities to receive the care they need to remain living in their homes.

  10. How the Waivers Were Created • The Medicaid Waivers started in 1981 with a 3-year-old girl in a hospital and the president who was angered when he learned that federal rules prevented her from going home. • Shapiro, J. (2010, November 8). Katie Beckett: Patient turned home-care advocate. National Public Radio. Retrieved April 2, 2011, from http://www.npr.org/templates/story/story.php?storyId=131145687

  11. Katie Beckett “Katie Becket, had contracted viral encephalitis, a brain infection, when she was just five months old. She'd gone into a coma for ten days, and when she came out she suffered a paralysis that left her unable to breathe without the help of a ventilator most of the day. After more than two years living in St. Luke's Methodist Hospital in Cedar Rapids, Iowa, the family reached the limit of what its private insurance would pay for Katie's care. Medicaid, the state and federal health insurance for the needy, started picking up the cost of that expensive breathing machine and other care. But Medicaid would pay only as long as the little girl lived in the pediatric intensive care unit at the hospital.” [1] • [1] Shapiro, J. (2010, November 8). Katie Beckett: Patient turned home-care advocate. National Public Radio. Retrieved April 2, 2011, from http://www.npr.org/templates/story/story.php?storyId=131145687

  12. “By what sense do we have a regulation in government that says we'll pay $6,000 a month to keep someone in a hospital that we believe would be better off at home, but the family cannot afford one-sixth that amount to keep them at home?” - President Ronald Reagan, Nov. 10, 1981 • Shapiro, J. (2010, November 8). Katie Beckett: Patient turned home-care advocate. National Public Radio. Retrieved April 2, 2011, from http://www.npr.org/templates/story/story.php?storyId=131145687

  13. Eligible Waivers Waivers that fund services that can be provided by day care centers and registered day care centers.

  14. HCBS Ill & Handicapped (IH) Waiver The IH waiver provides services for persons who are blind or disabled. An applicant must be less than 65 years of age. The following services are available: ● Adult Day Care ● Homemaker ● Consumer Directed ● Interim Medical Attendant Care Monitoring & Treatment ● Counseling ● Nursing ● Home & Vehicle ● Nutritional Counseling Modification ● Personal Emergency ● Home Delivered Meals Response ● Home Health Aide ● Respite • Iowa Department of Human Services. (2006, September). Are Home & Community Based Services Right for You? Retrieved April 1, 2011, from http://www.ime.state.ia.us/docs/HCBSbrochure102606.pdf

  15. HCBS Intellectual Disability (ID) Waiver The IDwaiver provides services for persons with a diagnosis of intellectual disability. The following services are available: ● Adult Day Care ● Personal Emergency ● Consumer Directed Response Attendant Care ● Prevocational ● Day Habilitation ● Respite ● Home & Vehicle ● Supported Community Modification Living ● Home Health Aide ● Supported Community ● Interim Medical Living-Residential Based Monitoring & Treatment ● Supported Employment ● Nursing ● Transportation • Iowa Department of Human Services. (2006, September). Are Home & Community Based Services Right for You?.Retrieved April 1, 2011, from http://www.ime.state.ia.us/docs/HCBSbrochure102606.pdf

  16. HCBS Brain Injury (BI) Waiver The BI waiver provides services for persons who have a brain injury diagnosis due to an accident or illness. An applicant must be at least one month of age but less than 65 years of age. The following services are available: ● Adult Day Care ● Behavioral Programming ● Case Management ● Consumer Directed Attendant Care ● Family Counseling & Training ● Home & Vehicle Modification ● Interim Medical Monitoring & Treatment ● Personal Emergency Response ● Prevocational Services ● Respite ● Specialized Medical Equipment ● Supported Community Living ● Supported Employment ● Transportation • Iowa Department of Human Services. (2006, September). Are Home & Community Based Services Right for You?.Retrieved April 1, 2011, from http://www.ime.state.ia.us/docs/HCBSbrochure102606.pdf

  17. B.I. Waiver Requirements: • Those wishing to provide services under the Brain Injury waiver need to submit documentation indicating training or experience with persons with brain injury. • Providers must demonstrate proficiency in delivery of the services included in a consumer’s service plan. Proficiency must be demonstrated through documentation of prior training and experience or a certificate of formal training. • Training classes are available through DHS. To receive training call (515) 281-8061. http://www.dhs.state.ia.us/policyanalysis/PolicyManualPages/Manual_Documents/Provman/ill.pdf

  18. Service Plan • All consumers will have a service plan developed by a DHS service worker or Medicaid case manager in cooperation with the consumer. • This plan must be completed prior to implementation of services. • The service plan for consumers aged 20 or under must be developed or reviewed taking into consideration those services that may be provided through the individual education plan (IEP) and EPSDT (Care For Kids) plan(s).

  19. Special Needs Child Care • The only Medicaid waiver service that can be accessed for child care while their parents are working is interim medical monitoring and treatment (IMMT) • Children with problem behaviors due to autism or intellectual disabilitiescannot use IMMT because their need for additional care and monitoring is a behavioral need and not a medical need.

  20. IMMT Services

  21. What is IMMT? • I = Interim • M = Medical • M = Monitoring • T = Treatment

  22. Legal Definition: • Interim medical monitoring and treatment services are monitoring and treatment of a medical nature requiring specially trained caregivers beyond what is normally available in a day care setting. Iowa Human Services Department. (2009, June 17) Medicaid waiver services, (ch.83). Retrieved July 11, 2009, from http://www.legis.state.ia.us/aspx/ACODocs/DOCS/6-17-2009.441.83.pdf

  23. IMMT Eligibility e. To be eligible for interim medical monitoring and treatment services the consumer must be: (1) Under the age of 21; (2) Currently receiving home health agency services under rule 441-78.9(249A) and require medical assessment, medical monitoring, and regular medical intervention or intervention in a medical emergency during those services; (3) Residing in the consumer’s family home or foster family home; (4) In need of interim medical monitoring and treatment as ordered by a physician. Iowa Human Services Department. (2009) Medicaid waiver services, (ch.83). Retrieved February 5, 2010, from http://www.legis.state.ia.us/aspx/ACODocs/DOCS/6-17-2009.441.83.pdf

  24. IMMT Services: ♦ Provide experiences for each member’s social, emotional, intellectual, and physical development. ♦ Include developmental care and any special services for a member with special needs. ♦ Include medical assessment, medical monitoring, and medical intervention as needed on a regular or emergency basis. ♦ May include supervision during transportation to and from school if not available through other sources. • Iowa Department of Human Services. (2011, March 18). Employees’ manual: Title 16, chapter K. Medicaid Waiver Services. Retrieved April 5, 2011, from http://www.dhs.state.ia.us/policyanalysis/policymanualpages/manual_documents/master/16-k.pdf

  25. Service Times: • The services must be needed to allow the consumer’s usual caregivers to be employed or, for a limited period of time, for academic or vocational training of a usual caregiver; due to the hospitalization, treatment for physical or mental illness, or death of a usual caregiver; or during a search for employment by a usual caregiver. • Iowa Human Services Department. (2009) Medicaid waiver services, (ch.83). Retrieved February 5, 2010, from http://www.legis.state.ia.us/aspx/ACODocs/DOCS/6-17-2009.441.83.pdf

  26. Service Locations: Services may not duplicate any regular Medicaid or waiver services provided under the state plan. They may be provided only: ♦ In the member’s home, ♦ In a registered child development home, ♦ In a licensed child care center, or ♦ During transportation to and from school. • Iowa Department of Human Services. (2011, March 18). Employees’ manual: Title 16, chapter K. Medicaid Waiver Services. Retrieved April 5, 2011, from http://www.dhs.state.ia.us/policyanalysis/policymanualpages/manual_documents/master/16-k.pdf

  27. Service Providers The following providers may provide IMMT services: ♦ Licensed child-care centers ♦ Registered child-care homes ♦ Home health agencies certified to participate in the Medicare program ♦ Supported community living providers under the ID waiver • Iowa Department of Human Services. (2011, March 18). Employees’ manual: Title 16, chapter K. Medicaid Waiver Services. Retrieved April 5, 2011, from http://www.dhs.state.ia.us/policyanalysis/policymanualpages/manual_documents/master/16-k.pdf

  28. Ratios and Billing Units: • The staff-to-member ratio shall not be less than one to six. • A unit of service is one hour. • A maximum of 12 one-hour units of service is available per day. • Iowa Department of Human Services. (2011, March 18). Employees’ manual: Title 16, chapter K. Medicaid Waiver Services. Retrieved April 5, 2011, from http://www.dhs.state.ia.us/policyanalysis/policymanualpages/manual_documents/master/16-k.pdf

  29. Respite Services

  30. Respite Care • Respite care services are services provided to the member that give temporary relief to the usual caregivers and provide all the necessary care that the usual caregiver would provide during that period. The purpose of respite care is to enable members to remain in their current living situation. • Iowa Department of Human Services. (2011, March 18). Employees’ manual: Title 16, chapter K. Medicaid Waiver Services. Retrieved April 5, 2011, from http://www.dhs.state.ia.us/policyanalysis/policymanualpages/manual_documents/master/16-k.pdf

  31. Usual Caregiver The “usual caregiver” is defined as a person or persons who reside with the member and are available on a 24-hour-per-day basis to assume responsibility for the care of the member. Respite care is not to be provided to members during the hours in which the member’s usual caregiver is employed, except when the provider is a camp. Iowa Department of Human Services. (2011, March 18). Employees’ manual: Title 16, chapter K. Medicaid Waiver Services. Retrieved April 5, 2011, from http://www.dhs.state.ia.us/policyanalysis/policymanualpages/manual_documents/master/16-k.pdf

  32. Respite Units of Service A unit of service is one hour for all respite services. A maximum of 14 consecutive days of 24-hour respite care may be reimbursed. When respite care is provided, the provision of or payment for other duplicative services under the waiver is precluded. Iowa Department of Human Services. (2011, March 18). Employees’ manual: Title 16, chapter K. Medicaid Waiver Services. Retrieved April 5, 2011, from http://www.dhs.state.ia.us/policyanalysis/policymanualpages/manual_documents/master/16-k.pdf

  33. Respite may be provided by: ♦ A camp certified by the American Camping Association ♦ A child development home registered with DHS ♦ A child-care center licensed by DHS ♦ A group living foster care facility for children licensed by DHS ♦ A home health agency certified to participate in Medicare ♦ A hospital enrolled in Medicaid ♦ A nursing facility enrolled in Medicaid ♦ A preschool ♦ A residential care facility for persons with mental retardation (RCF/MR) ♦ An adult day care provider certified by DIA ♦ An agency with a local public health services contract for similar services ♦ An assisted living program certified by DIA ♦ An intermediate care facility for the mentally retarded (ICF/MR) ♦ Any agency certified to provide care in a member’s home under the ID waiver Iowa Department of Human Services. (2011, March 18). Employees’ manual: Title 16, chapter K. Medicaid Waiver Services. Retrieved April 5, 2011, from http://www.dhs.state.ia.us/policyanalysis/policymanualpages/manual_documents/master/16-k.pdf

  34. Day Care vs. Home Care Private duty nurses meet the child’s medical needs and the child’s home is considered a natural environment. • The majority of time is often spent in front of the television rather than engaging in age-appropriate activities with other children. • May not be in compliance with the least restrictive environment requirement and may not be in the child’s best interest Etscheidt, Susan . (2006). Least restrictive and natural environments for young children with disabilities: A legal analysis of issues. Topics in Early Childhood Special Education, 26(3), 167-178.

  35. Applying to be a Medicaid Provider http://www.ime.state.ia.us/

  36. How to enroll as a Medicaid waiver provider The provider application and instructions can be found on Iowa Medicaid Enterprise’s (IME) web site. Any questions regarding the completion of the application can be directed to Iowa Medicaid Enterprise Provider Services 1-800-338-7909 or 515-725-1004 (from Des Moines). Iowa State University. (2007). Frequently Asked Questions from Service Providers. Child Welfare Research and Training Project for the Iowa Department of Human Services. Retrieved April 5, 2011, from http://www.dhs.state.ia.us/rts/Lib_Res/1FAQs.htm

  37. Iowa Department of Human Services. (2011). Chapter 80: Procedure and method of payment. Retrieved May 1, 2011, from http://www.dhs.state.ia.us/policyanalysis/PolicyManualPages/Manual_Documents/Rules/441-80.pdf

  38. Provider Handbook A Medicaid provider handbook that covers provider and member eligibility, waiver service policies, service rate information, and claim submission is available on the Internet either through the IME web site or through the Department’s Policy Analysis Web site at: http://www.dhs.iowa.gov/policyanalysis/PolicyManualPages/MedProvider.htm

  39. Provider Online Tools The IME provides you the opportunity to use the Web Portal through the Internet to Verify Member Eligibility (HIPAA Transaction 270), Check the Status of Your Claims (HIPAA Transaction 276), or submit a Request For Prior Authorization (HIPAA Transaction 278). You must register through EDISS Total Onboarding to use the Web Portal. http://www.ime.state.ia.us/Providers/OnlineTools.html

  40. Developing A Plan of Care

  41. Provider Qualifications: • The provider must be qualified by training or experience to provide medical intervention or intervention in a medical emergency necessary to carry out the member’s plan of care. • This must be determined by the usual caregivers and a licensed medical professional on the member’s interdisciplinary team and documented in the service plan. • Iowa Department of Human Services. (2011, March 18). Employees’ manual: Title 16, chapter K. Medicaid Waiver Services. Retrieved April 5, 2011, from http://www.dhs.state.ia.us/policyanalysis/policymanualpages/manual_documents/master/16-k.pdf

  42. Member’s Interdisciplinary Team “Depending on an individual's age and disability, the exact composition of the interdisciplinary team will vary. An interdisciplinary team consists of the family and professionals who are engaged in supporting the individual.” [1] • Primary Physician • Social Workers • Specialists & Therapists • Home Care Nurse • School Nurse • Physical, Occupational & Speech Therapists • Area Education Agency (AEA) • Home and Community-Based Service Providers • Direct Care Providers • Special Education Teachers • Child Care Provider ? [1] National Joint Committee for the Communication Needs of Persons with Severe Disabilities (NJC). (2011). Interdisciplinary teams; Communication services and supports for individuals with severe disabilities: FAQs. Retrieved April 20, 2011, from http://www.asha.org/NJC/faqs-i nterdisciplinary.htm#39

  43. Sample IMMT Daycare Plan • SERVICES PROVIDED AT DAYCARE IMMT services funded by the Ill and Handicap Waiver for a ##year-old female with cerebral palsy. Child is wheelchair bound and wears bilateral AFOs. She has a MIC-KEY Gastrostomy Feeding Tube for supplemental feeding QHS PRN for inadequate oral intake and medications. Daycare provider will provide safety supervision at all times, monitor and adjust positioning hourly, monitor oral intake daily, teach and assist with safe pivot transfer from wheelchair to toilet as needed, assist with toileting, hygiene and clothing adjustment as needed, perform stretching and passive range of motion to lower extremities daily, remove AFOs and provide floor time for at least one hour per day, reapply AFOs before returning to wheelchair, assess skin integrity daily, and report client's care and condition to client's mother daily. Provider will also encourage independent mobility, physical activity, and interactions with peers as appropriate to develop age-appropriate social and self-care skills.

  44. Sample Protective Daycare Plan • SERVICES PROVIDED AT DAYCARE Protective daycare services funded by the Department of Human Services for ## year-old female with risk for behavior disorders and risk for injury related to altered family process: mental illness. Child requires adult supervision at all times. Provider will provide continuous supervision, age appropriate activities, and homework supervision daily, homework assistance as needed, redirection to appropriate activities as needed, develop and implement behavior modification plans as needed for maladaptive behaviors, report absences to child's social worker immediately, communicate child's progress to parent as needed, give written or oral progress report to social worker monthly, and keep written record of incidents as needed.

  45. Required Documentation

  46. What are the basic documentation requirements that Waiver providers must meet? Information necessary to support each item of service reported on the Medicaid claim form.  For instance:1) Full name of child receiving service2)  Name of the service provided3) First and last name of the staff providing services4) Full date and time frames/duration of service delivery5) Signature of staff providing the service6)Activities during respite 7) Documentation of Medical Monitoring and Treatment on care plan Iowa State University. (2007). Frequently Asked Questions from Service Providers. Child Welfare Research and Training Project for the Iowa Department of Human Services. Retrieved April 5, 2011, from http://www.dhs.state.ia.us/rts/Lib_Res/1FAQs.htm

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