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Services and Processes

Department for Aging and Independent Living

275 East Main Street 3E-EFrankfort, KY 40621(502) 564-6390http://chfs.ky.gov/dail

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Outline

•Services – Definitions and Parameters

•Person Centered Service Plan

•Processing time and the Prior Authorization

•MWMA Timesheet preview

•New employee requirements

•New representative requirements DRAFT

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Participant Directed Coordination

•Service Advisor & Financial Management Services provided for each participant per month;

• Includes monthly visits;

• Timesheet processing;

•Reimbursed at $325 per month; and

•Can be provided by ADHC, HH, Centers for Independent Living, or AAAIL; however, agencies MUST have Fiscal Intermediary experience. DRAFT

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Services

•Must be Prior Authorized;

•Must be listed on the Person Centered Service Plan;

•Must be one-on-one;

•Must be accessed within 60 days of Prior Authorization;

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Services (continued)

•Cannot occur at the same time as another service, regardless of payer source▫May occur for routine physician appointments, or physical,

occupational, and/or speech therapy appointments.

Note: HCB services and Hospice services can be accessed in conjunction on the Person Centered Service Plan as long as neither source is providing the same type of service.▫ If under 21 years of age, can access any service in

HCB. ▫ If over 21 years of age, can access only Attendant

Care or Home Community Supports in HCB. DRAFT

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Services

•Home and Community Supports▫Replaces Personal Care and Homemaking;▫The equivalent to Attendant Care;▫May include any duties associated:

Personal hygiene and Homemaking; and Transportation and community outings.

▫Limited to $200 per day alone or in combination with attendant care;

▫Limited to $2.88 per unit before taxes and to 45 hours per week. Employee rate range is from $7.25 per hour to $11.52 per hour.

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Services

•Non-specialized Respite▫A primary caregiver must be identified in order to be

eligible; ▫Care needed must go beyond normal care sitting or

normal baby sitting;▫Rate maximum is $2.75 per 15 minute unit before taxes;

Employee rate ranges from $7.25 per hour to $11.00 per hour.

▫Limited to $4,000 per year alone, or in combination with specialized Respite; and

▫Limited to $200 per day alone, or in combination with specialized Respite. DRAFT

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Services

•Goods and Services▫Service description remains the same; ▫Must be individualized;▫Meet the needs of the participant;▫Must be able to reduce the need for personal care or

enhance independence in the community;▫Cannot include any restraints, or be experimental in

nature;▫Limited to $3,500 per LOC year.

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Goods and Services• Budget allows purchase of items such as incontinent supplies, nutritional

supplements, and personal care goods that are medically necessary;

• Add to the Person Centered Service Plan with three quotes from three separate vendors uploaded and medical necessity within comment section. A prescription is not required.

• If requesting Hearing, Vision or Dental then a Medical documentation must accompanied the quote from the Professional entity performing the service.

• Methods of purchase:▫ Direct purchase by participant and reimbursed through CM agency; or▫ CM agency may order through a vendor; and

Can be provided by ADHC, HH, AAAIL, or PDS vendors. DRAFT

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Environmental and Home Modifications

•Equipment used to create more stability for transfers and ambulation; or

•Altering space, or structures to create easier access, such as door widening, ramps, walk-in showers, or hand rails;

•Cannot add square footage to a dwelling;

•Must relate to the needs and disability of the participant; DRAFT

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Environmental and Home Modifications

•Can be provided by ADHC, HH, AAAIL, or PDS vendors;

• Three (3) quotes are required from separate contractors. Services must be completed by a licensed and insured provider qualified for the adaptation; The contractor must provide prior to work being initiated.

•A personal emergency response system may be considered for this service; and

•Maximum of $2,500 per LOC year.DRAFT

Create Draft Plan Section

View Plan Details Section

Goals Section

Service Details Section

Non-Waiver Program Section

Service Summary Section

Upload Documents Section

Submit Plan Section

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Obtaining authorization

•Once the Service Plan has been developed with services, employees, rates, time, and the FMA provider number for routing, the Service Advisor will submit the Plan to obtain Prior Authorization. This authorization will show the units you’ve requested for each service, the duration, and the total dollar figure designated for each service.

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Utilizing the Prior Authorization

•The Service Advisor informs the Person Centered Team about the limits of the authorization.

•Participants have flexibility in how the authorizations are spent; however the participant may not utilize over what limits are stated in a Prior Authorization.

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Utilizing the Prior Authorization

•Should additional hours or dollars be requested or required, and the request is within regulation limits, then Service Advisors will notify the RN Assessor to document on the Assessment form to illustrate need and then the Service Advisor will modify the Service Plan and submit for approval.

•As each participant transitions from CDO to PDS, utilization method shifts from dollars balanced over a period of 12 months (CDO budget), to units available and remaining in a given week, month, or year.

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Lack of Information correspondence

•Lack of Information (LOI) statements may be issued for various discrepancies. This may include but not be limited to: ▫Lack of statement for immediate family

member/guardian;▫Requests beyond the regulation limit for given

service; ▫Discrepancies in Service Plan goals;▫Inaccurate demographic information; or▫Additional verifications required for service requests.

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MWMA Timesheet Preview

•Upon participant transition into MWMA, employees, participants or representatives, and service advisors will have access to timesheet information.

•Service advisors will receive task notifications once the participant/representative has authorized the time submitted.

•Service advisor agencies will be responsible for entering time on behalf of those who do not access MWMA.

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Who can provide services?

• The individual and/or representative will recruit, hire, and supervise employees to provide services as approved in the Participant’s Person Centered Service Plan.

• Employees may include: ▫ Family▫ Friends▫Relatives▫Neighbors▫ Employees recruited by the participant▫ Personal Service agencies employed by the participant

Note that any a MAP 532 (Exemption form) must be submitted to DAIL for those are an immediate family member or guardian. An immediate family member is defined by KRS 205.8451 (3).

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MAP 532 Exemption Process:• The Service Advisor is responsible for providing assistance in

understanding and illustrating the questions posed in the Exemption form.

• Each question should be discussed in detail on how the applicant(s) meets the needs of the participant in ways that would be otherwise detrimental should other employees or agencies provide the requested service(s).

• Service Advisors may provide a copy of the Helpful Hints within the Participant Manual to the team members to further assist in this process.

• DAIL will respond and provide determinations within 14 business days.

• Participant may request appeals or reconsiderations of any denials; instructions will be provided with the determination issued. DRAFT

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MAP 532 Exemption process (cont.)

• Should a denial of at least one service be determined, the employee remains eligible for the denied service for 90 calendar days; this allows some time for a replacement to be found.

• If a reconsideration is submitted, the clock resets; if a denial is issued, the 90 day window restarts.

• If an appeal is filed, the employee remains eligible until a ruling can be provided by a hearing officer.

• If denial is upheld by a hearing officer, the employee remains eligible for 30 calendar days.

• Employees are not required to complete the PDS requirements during these timeframes.

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Employee Requirements:Employees must meet qualifications similar to an employee of a traditional direct service. This includes:

Application;I-9 verification form;W-4 and K-4 tax forms;PDS Contract illustrating services provided and agreed wages;

▫ Drug screening;▫ TB screening/test; ▫ Training components;▫ Background check requirements; and▫ Valid driver’s license if transporting the participant.

TB assessment/test must be completed within the first 30 days of services provided and annually thereafter; and

Participants are responsible for the costs associated with these requirements. DRAFT

Employee Requirements (cont.)

•Employees must be at 18 years old;•Be a citizen of the United States with a valid Social

Security Number, or possess a valid work permit if not a U.S. citizen;

•Be able to communicate effectively with the participant, representative, participant’s guardian, or family of the participant;

•Be able to understand and carry out instructions;•Be able to keep records as required by the

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Employee Requirements (cont.)

•Complete training on:▫Reporting of abuse, neglect, or exploitation in

accordance with KRS 209.030 or 620.030; ▫CPR/FA by a nationally accredited entity within 6 months

of starting employment; and ▫Receive DAIL attendant care certification training upon

hire and annually thereafter (July 2016); and▫Needs of the participant.

•Drug Screening▫Must be obtained before beginning employment; and▫Cannot test positive for illicit or prohibited drugs. DRAFT

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Employee Background Checks:

Each employee, upon hire, shall have the results of the following background checks: ▫ Administrative Office of the Courts (AOC), or out-of-state

equivalent if residing outside Kentucky in the last year;▫ Central Registry Check (CAN), or out-of-state equivalent if

resided outside Kentucky in the last year; ▫ Kentucky Board of Nursing nurse abuse registry check, or out-

of-state equivalent if resided outside Kentucky in the last year; and

▫ KY Caregiver Misconduct Registry.

• The AOC and Nurse Abuse Registry Check must be completed prior to employment. The CAN must be obtained within thirty (30) days from the start of employment. DRAFT

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Employee Background Checks:

• The Administrative Office of the Courts (AOC) has a $20 fee and may be completed online or through mail;

• For the AOC and Out-of-state equivalent, an employee may not have results showing a conviction of:▫Violent crime or sex crime as defined in KRS 17.165 (1) to

(3); ▫Any drug related conviction, plea bargain, or amended plea

bargain within the last 5 years;▫Any plea bargain, diversion, or conviction that has not been

completed; or ▫Abuse, neglect, or exploitation. ▫Medicaid fraud

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Employee Background Checks:

•The Central Registry Check is an abuse check processed by the Cabinet for Health and Family Services;

•The fee is $10.00; instructions for processing are provided on the form; and

•Expect the form to be returned with results within 14 business days.

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Employee Background Checks:

• The Nurse Aide Registry may be completed free of charge online at the KY Board of Nursing Website;

•Be sure to enter all known names of the employee (Refer to I-9, Employee application, and AOC request form);

•Print all known name results; a date completed date stamp should appear at the bottom of the page;

• ‘Validate Selected’ for all names in search results;•Should results reveal an employee’s name is on the

registry, follow up with KY Board of Nursing to ensure it is the same person as the applicant.

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Employee Background Checks:

•The Kentucky Caregiver Misconduct Registry may be conducted online free of charge;

•The user provides demographic information;

•Results are provided through Social Security Number; and

•Printed results should have date stamp at the bottom of the page.

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Employee Requirements:

• Service advisors shall maintain results of employee qualifications within participant files.

• Service advisors shall complete the Eligible Employee form to provide the FMA with verification of the employee’s qualification.

• Employees who do not complete the qualifications in the designated timeframes shall not be considered eligible for payment under the waiver until qualifications are completed; should employers continue to request employees to work, the employer shall be responsible for wages of those employees.

• Current PDS Employees will have three (3) months from recertification to transition to new service reimbursement rates. A new contract should be completed to reflect changes as well as service names. DRAFT

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Personal Service Agencies (PSA):• Service Advisors need to obtain a copy of the agency’s OIG

certification; this certification covers the criminal record check, Nurse Aide Registry check, drug screening, and TB assessment. PSAs are not required to conduct CAN checks as part of their certification, although some do perform them.

• Service Advisors should review the agency’s Policies and Procedures to determine if the Central Abuse Registry check and CPR/FA training is provided to each employee; each of these will be required within the specified timeframe if not covered by the PSA.

• PSA employees will be required to submit to the Caregiver Misconduct Registry.

• Once an employee has provided care, he/she will be required to complete training on the needs of the participant. DRAFT

What if a participant needs assistance to self-direct?

•A participant may appoint a Representative. The following applies to a representative role:

▫Cannot provide a paid service to same participant;

▫Must be at least 18 years of age;

▫Must submit to background checks from the Administrative Office of the Courts, Nurse Aide Abuse Registry; Caregiver Misconduct Registry; and the Central Abuse Neglect Registry and the out-of-state equivalents if resided or worked out of state within the last 12 months.

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Representative requirements (cont.)

▫Must not be convicted crimes as cited by PDS employees;

▫Must be available to attend Level of Care Assessments, Person Centered Service Plan meetings, and Face to Face meetings (at a minimum quarterly) as well as be available via phone for any indirect contact every monthly or as needed.

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Representative requirements (cont.)

• If a participant has a guardian or legal representative, the guardian or legal representative must either choose to be the Representative or they shall appoint a representative to act on the participant’s behalf.

• If a participant is under the age of 18, a legally responsible individual shall appoint a representative to act on the participant’s behalf.

•Must be part of the face-to-face visit at least every 3 months.

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Questions…