ln ltc EDCD

Elderly or Disabled with Consumer-Direction Services Waiver: 

Elderly or Disabled with Consumer-Direction Services Waiver Department of Medical Assistance Services www.dmas.virginia.gov

Outline of Presentation: 

Outline of Presentation Long Term Care Services and Eligibility What is Preadmission Screening Why is it done Case Examples How Does The New EDCD Waiver Affect Referrals Common problems that interfere with processing of UAI

Long-Term Care Services Defined: 

Long-Term Care Services Defined Institutional Services Nursing Facility Intermediate Care Facilities for the Mentally Retarded (ICF/MR) Community Based Services Waivers Program of All-Inclusive Care For the Elderly (PACE)

Eligibility for Long-Term Care Services: 

Eligibility for Long-Term Care Services To be eligible for Medicaid-funded long-term care services individuals must : Qualify for Medicaid; and Meet specified long-term care criteria according to a standardized long-term care assessment instrument Uniform Assessment Instrument (UAI) for nursing facility, PACE and Waiver level of care

Qualify for MedicaidDMAS -122: 

Qualify for Medicaid DMAS -122 The DMAS-122 is the service provider’s authorization to bill Medicaid for LTC services. DMAS-122 is to be sent by the Eligibility Worker no later than 45 days from date of application, and 30 days from the date of a reported change.

Qualify for MedicaidDMAS -122: 

Qualify for Medicaid DMAS -122 If the individual does not receive LTC services for 30 days, he must be referred to the Eligibility Worker for a determination of continued Medicaid eligibility.

Qualify for Medicaid: 

Qualify for Medicaid Individuals who are Medicaid eligible at the time of application for LTC services are not automatically eligible for LTC services if they meet the functional assessment. The local DSS must assess the individual’s eligibility for Medicaid (LTC) and calculate a patient pay. Everyone must have a calculation, not everyone has a patient pay.

What is Preadmission Screening: 

What is Preadmission Screening Evaluate whether a service or a combination of existing community services is available to meet the individual's needs; and to make sure those services are available.

What is Preadmission Screening: 

What is Preadmission Screening Evaluate the medical, nursing, developmental, psychological, and social needs when there is a reasonable indication that a recipient might need institutional services in a month or less unless he or she receives home and community based services (42 CFR 441.302(c)(1)) Analyze what specific services the individual needs;

What is Preadmission Screening: 

What is Preadmission Screening Determine the level of care required by the individual by applying existing criteria for nursing facility. The pre-admission screening process is designed to be a team process that includes the input of both medical and social work professionals.

What is Preadmission Screening: 

What is Preadmission Screening The screening team's assessment of the availability of community services depends upon: Whether the needed service exists in the community; • Whether eligibility for Medicaid coverage can be established; and • Whether the service can be delivered at the time and in the amount necessary to meet the individual's needs.

What is Preadmission Screening: 

What is Preadmission Screening The screening team explores alternative settings or services, or both, which might meet the identified needs of the individual. If nursing facility placement or a combination of other services is determined to be appropriate, the screening team initiates referrals for service.

What is Preadmission Screening?: 

What is Preadmission Screening? Community Based Care Services

What is Preadmission Screening: 

What is Preadmission Screening If Medicaid-funded home and community-based care services are determined to be necessary to delay or avoid nursing facility placement, the screening team is responsible for initiating referrals for service.

Preadmission Screening: 

Preadmission Screening In order to be eligible for a waiver individuals must be screened to determine if they meet the admission criteria. If in the community, the screening is done by a nurse from the local health department and a social worker from the local department of social services

Preadmission Screening: 

Preadmission Screening If in the hospital, the hospital does the screening.

Alternate Institutional Placement: 

The individual who is applying for a waiver must meet the same criteria that is used for admission to the institution. 42 C.F.R. 441.302 (c)(1); 42 C.F.R. 441.303 (c)(2) Alternate Institutional Placement To Receive Approval to Implement a Waiver Criteria for Admission to the Waiver Criteria for Admission to Institution

Nursing Facility, Waiver, and PACE Admission Criteria: 

Nursing Facility, Waiver, and PACE Admission Criteria Dependent in 2-4 ADLs, plus semi-dependent or dependent in behavior and orientation, plus semi-dependent in joint motion or semi-dependent in medication administration, OR Dependent in 5-7 ADLs plus dependent in Mobility, OR Semi-Dependent in 2-7 ADLs, plus dependent in mobility, plus dependent in behavior and orientation. AND Have Medical Nursing Needs

Activities of Daily Living (for purposes of Medicaid eligibility): 

Activities of Daily Living (for purposes of Medicaid eligibility) Bathing Dressing Transferring Toileting Bowel Function Bladder Function Eating/Feeding

Medical Nursing Needs: 

Medical Nursing Needs In addition to meeting functional criteria, in order for Medicaid to pay for nursing facility care, the individual must have medical or nursing supervision or care needs that are not primarily for the care and treatment of mental disease (Alzheimer’s and dementia are not considered mental diseases.)

Medical Nursing Needs: 

Medical Nursing Needs The individual’s medical condition requires observation and assessment to assure evaluation of the person’s needs due to the inability for self observation or evaluation; OR The individual has complex medical conditions which may be unstable or have the potential for instability; OR The individual requires at least one ongoing medical or nursing service.

Examples of Medical Nursing Needs: 

Examples of Medical Nursing Needs Routine care of colostomy or ileostomy or management of neurogenic bowel and bladder; Use of physical or chemical restraints; Routine skin care to prevent pressure ulcers for individuals who are immobile; Care of small uncomplicated pressure ulcers and local skin rashes; Management of those with sensory, metabolic, or circulatory impairment with demonstrated clinical evidence of medical instability; Infusion therapy; and Oxygen

Examples of Medical Nursing Needs: 

Examples of Medical Nursing Needs Application of aseptic dressings; Routine catheter care; Respiratory therapy; Therapeutic exercise and positioning; Chemotheraphy; Radiation; Dialysis; Suctioning; Supervision for adequate nutrition and hydration for individuals who show clinical evidence of malnourishment or dehydration or have a recent history of weight loss or inadequate hydration which, if not supervised, would be expected to result in malnourishment or dehydration;

Dependent in 2-4 ADLs, plus semi-dependent or dependent in behavior and orientation, plus semi-dependent in joint motion or semi-dependent in medication administration, and have medical nursing needs.: 

Dependent in 2-4 ADLs, plus semi-dependent or dependent in behavior and orientation, plus semi-dependent in joint motion or semi-dependent in medication administration, and have medical nursing needs. Mrs. Jones is a 76-year-old who had a stroke two years ago. She has non-insulin dependent diabetes. She needs someone to turn on the water taps so she can take a bath, needs for someone button and zip clothing, is incontinent of bladder and has a catheter.  Mrs. Jones usually has to be told the day and month, and sometimes does not recognize family members. Unless someone speaks directly to her, she sits passively and just stares out of the window. Mrs. Jones’ medications must be monitored since she cannot take them by herself. Mrs. Jones needs someone to take care of the catheter.

Dependent in 5 to 7 ADLs and dependent in mobility, and have a medical nursing need.: 

Dependent in 5 to 7 ADLs and dependent in mobility, and have a medical nursing need. Mrs. Smith is a 60-year-old female with a diagnosis of hypertension who recently suffered a stroke. She is partially paralyzed on the right side. Mrs. Smith needs someone to turn on the bath water taps, needs someone to help her dress and to button and zip clothing, needs to have her food cut up, needs help toileting, and needs help transferring from bed to chair and back. Mrs. Smith cannot walk without human support. She is oriented to all spheres all times and her behavior is appropriate. Mrs. Smith’s medications must be monitored and she needs to be closely monitored to make sure that she does not develop pressure ulcers.

Semi-Dependent in 2 to 7 ADLs, Plus dependent in behavior and orientation, and mobility, and have a medical nursing need.: 

Semi-Dependent in 2 to 7 ADLs, Plus dependent in behavior and orientation, and mobility, and have a medical nursing need.  Mr. Ford is a 37-year-old male with a diagnosis of a stroke with right sided weakness and dementia. He needs for someone to turn on the water taps so he can take a bath. He needs to be reminded to dress, eat, toilet, and transfer from the bed to a chair. Mr. Ford uses a walker, but must have supervision when he uses it. He is continent of both bowel and bladder. Mr. Ford does not know the day, or month, and frequently thinks he is a sixteen years old. He does not recognize family members. His behavior is aggressive or disruptive weekly or more. His medications must be monitored, and he will not take them without them being handed to him Mr. Ford forgets to eat and has a history of dehydration requiring his fluid intake to be closely monitored.

How Does The New EDCD Waiver Affect Referrals?: 

How Does The New EDCD Waiver Affect Referrals?

Referral Process EDCD: 

Referral Process EDCD The process for referral to services remains the same. If a recipient elects consumer -directed care service then you send them to a service facilitator that they have chosen. For other services refer to the provider of that service.

What Happens to the UAI? : 

What Happens to the UAI? Helpful tips for processing the UAI.

What Happens to the UAI?: 

What Happens to the UAI? Medical Nursing Needs Not documented Fill out and answer the questions. Evidence of Medical instability. Need for observation/assessment to prevent destabilization. Complexity created by multiple medical conditions. Why client’s condition requires either an agency or consumer directed care on a daily basis.

What Happens to the UAI?: 

What Happens to the UAI? Dependencies in Functional Behavior and Orientation Mobility Medication Administration Joint Motion

What Happens to the UAI?: 

What Happens to the UAI? Dependencies Not documented Fill out the questions fully, if no check no. Make your checks clear in each box. Make comments legible. Use appendix B of Preadmission Manual for examples.

What Happens to the UAI?: 

What Happens to the UAI? UAI missing information Not all questions answered Missing Information (name, dates, signatures) Not filling out No or Yes for questions Unable to read

What Happens to the UAI?: 

What Happens to the UAI? UAI information Copies of Copies hard to read. Make sure you get a good copy to send in for processing. Missing diagnosis Missing pages of UAI – assure all pages sent Sending in missing pages piece meal – can not match up.

What Happens to the UAI?: 

What Happens to the UAI? For Nursing Facility Placement not receiving all forms All 12 pages UAI Completed DMAS – 96 Completed DMAS – 95 MI/MR Level 1 If applicable Completed DMAS – 95 MI/MR Level 2 and Approval letter

What Happens to the UAI?: 

What Happens to the UAI? For Waiver Placement not receiving all forms All 12 pages UAI Completed DMAS – 96 Completed DMAS – 101 A If applicable Completed DMAS – 101 B and Approval letter

What Happens to the UAI?: 

What Happens to the UAI? For ALF Residential Placement not receiving all forms The first four pages of the UAI plus questions on Behavior, Orientation and Medication administration Completed DMAS – 96 Approval letter

What Happens to the UAI?: 

What Happens to the UAI? For ALF Residential Placement Annual Reassessment not receiving all forms The first four pages of the UAI plus questions on Behavior, Orientation and Medication administration Completed Eligibility Communication Document

What Happens to the UAI?: 

What Happens to the UAI? For Regular ALF Placement not receiving all forms All 12 pages UAI Completed DMAS – 96 Approval letter

What Happens to the UAI?: 

What Happens to the UAI? For Regular ALF Annual Reassessments All 12 pages UAI Completed Eligibility Communication Document

What Happens to the UAI?: 

What Happens to the UAI? Remember to evaluate each person individually and against the “norm”. For example a it is not the norm at the age of 10 to wear diapers. At any age it is not the norm to be short of breath Don’t lump all Diabetic, CHF, COPD, etc. patients into a category due to disease process. I.E. All COPD need Oxygen.

What is the EDCD Waiver?: 

What is the EDCD Waiver? Combines the Elderly & Disabled (E&D) and the Consumer-Directed Personal Attendant Services (CDPAS) Waivers

What will the EDCD Waiver look like?: 

What will the EDCD Waiver look like? CD-PAS: Consumer-directed personal care (42-hour per week limit) Decreased patient pay if working Elderly and Disabled: Agency Directed Personal Care Respite (including skilled respite) Adult Day Health Care Personal Emergency Response System EDCD Decreased patient pay if working Personal Care: Agency and Consumer-directed (no 42-hour per week limit) Personal Care Respite: agency and consumer-directed Skilled Respite – agency directed Adult Day Health Care Personal Emergency Response System (PERS)

Benefits of Combining the Waivers: 

Benefits of Combining the Waivers Individuals can receive either agency or consumer directed services, or both 720 hours of respite care per year for relief of unpaid caregivers, including skilled respite Access to PERS if it replaces supervision – Agency or Consumer Directed services Eliminated 42-hour per week limit for consumer-directed personal care

Considerations: 

Considerations Waiver must remain cost-effective All Waiver recipients must have a back-up plan in order to receive services

When Did This Waiver Become Effective?: 

When Did This Waiver Become Effective? February 1, 2005 Recipients who were in the E&D and CDPAS Waivers were automatically transferred into the EDCD Waiver effective February 1, 2005

Does a Provider Need a New Provider Number?: 

Does a Provider Need a New Provider Number? Providers will not be required to obtain a new provider agreement or provider number(s) to render the same type of service in the EDCD Waiver as they have in the E&D and CDPAS Waivers If Providers want to render a service for which they do not have a current agreement, a new provider agreement & number must be obtained for that service

E&D and CDPAS Waiver Recipients Transferred to the EDCD Waiver: 

E&D and CDPAS Waiver Recipients Transferred to the EDCD Waiver A recipient’s current amount of pre-authorized services remained the same A recipient’s pre-authorization numbers for billing remained the same for Personal Care, Adult Day Care, Respite, and PERS If a recipient was formerly in CDPAS, a new pre-authorization number will be mailed to the service facilitator

Assessment and Authorization Procedures for Services: 

Assessment and Authorization Procedures for Services

Pre-Authorization Process: 

Pre-Authorization Process Pre-authorization process remains the same for all services Exception: Currently if an individual is screened for the CDPAS and does not have a Medicaid ID, DMAS must review the screening and mail an eligibility letter to the SF to obtain a Medicaid ID from DSS…..but

Pre-Authorization Process: 

Pre-Authorization Process In the EDCD Waiver, if the individual does not have a Medicaid ID, the SF will: Conduct the initial comprehensive visit. If the individual meets the Waiver level of care criteria; Complete a DMAS-122 with the SOC date to the eligibility worker at DSS, who will complete a DMAS-122 with the patient pay amount (if applicable); Then submit the admission packet to WVMI for pre-authorization with the new DMAS-122

Pre-Authorization Process: 

Pre-Authorization Process To ensure timely authorization for reimbursement, enrollments must be submitted to WVMI within ten (10) business days of the initiation of services that require authorizations, or within ten (10) business days of notification of Medicaid eligibility,… OR Authorization begins when WVMI receives the admission packet

Pre-Authorization Process for Agency & Consumer Directed Services: 

Pre-Authorization Process for Agency & Consumer Directed Services If WVMI denies authorization for services: The provider will receive payment for the initial comprehensive visit; The CD personal care aide will be paid for services rendered; and WVMI will authorize services from the date of the initial assessment visit, or the date received at WVMI if received after the ten (10) day period, up to the date of the denial of services.

Nursing Facility to EDCD Waiver & Waiver to Waiver transfers: 

Nursing Facility to EDCD Waiver & Waiver to Waiver transfers If the individual has received services in a nursing facility or under the E&D, CDPAS, or HIV/AIDS Waivers, a new screening is not needed if EDCD Waiver services begin within 365 days of the discharge date If the individual is transferring from EDCD Waiver to one of these services, the same rule applies

Nursing Facility/Inpatient Rehab to EDCD Waiver: 

Nursing Facility/Inpatient Rehab to EDCD Waiver If the individual is transferring from the EDCD Waiver into a rehab facility and is returning to the EDCD Waiver, the following rules apply: If the date of admission into the rehab facility into the Waiver is less than 90 days, a new screening is not needed. The provider agency must update the appropriate forms as listed in the EDCD manual

Waiver Eligibility: 

Waiver Eligibility

Who is Eligible for EDCD?: 

Who is Eligible for EDCD? Under the EDCD Waiver, services may be furnished only to persons: Who meet the nursing facility criteria as determined by Pre-admission Screening Team; Who are eligible for Medicaid. If the individual is already Medicaid eligible, he/she must still have Medicaid eligibility re-determined when applying for Waiver services

Who is Eligible for EDCD?: 

Who is Eligible for EDCD? For whom an appropriate cost-effective plan of care can be established; Determining the cost-effectiveness is a part of the preauthorization process Who have no other or have insufficient community resources to meet the individual’s needs; Who are residents of the Commonwealth of Virginia

Who is Eligible for EDCD?: 

Who is Eligible for EDCD? Individuals cannot receive services from more than one Waiver at the same time However, individuals can be on a waiting list for one Waiver and receive services in another Waiver if they meet the criteria for both Waivers

Earned Income Allowance: 

Earned Income Allowance Individuals can keep earned income up to a total* of 300% of SSI income level if working 20 or more hours/week. They can keep earned income up to a total* of 200% of SSI income level if working 8-20 hours/week * total of earned and unearned income

Who is Not Eligible for EDCD?: 

Who is Not Eligible for EDCD? Services may not be furnished to persons: Who resides in a nursing facility, an ICF/MR, a hospital, an assisted living facility licensed by DSS or an Adult Foster Care provider certified by DSS, or a group home licensed by the Department of Mental Health & Mental Retardation & Substance Abuse Services (DMHMRSAS)

Patient Pay: 

Patient Pay The patient pay amount, as indicated by DSS on the Patient Information Form (DMAS-122), is to be collected by the service provider who is authorized for the most hours of care per month If the patient pay comes out of the CD services, the SF must send the DMAS-122 with the patient pay information to the CD Fiscal Agent (This will be covered in more detail in the session on CD Payroll)

Collecting the Patient Pay: Who & How: 

Collecting the Patient Pay: Who & How 1. All service providers (agency or consumer directed) must determine if the recipient is receiving multiple Waiver services This is obtained from the recipient, caregiver &/or family member Call WVMI, if unsure (other Waiver service(s), provider name, & phone #) 2. Each provider must obtain # of service hours authorized per month for each Waiver service being rendered from the other provider(s)

Collecting the Patient Pay: Who & How: 

Collecting the Patient Pay: Who & How 3. The service provider who is authorized to coordinate the most service hours per month needs to have the most recent DMAS-122 with the patient pay amount This provider must notify the eligibility worker at the local DSS office for future DMAS-122s

Collecting the Patient Pay: Who & How: 

Collecting the Patient Pay: Who & How 4. The provider who is receiving the DMAS-122 from DSS must send a copy to the other service providers 5. The multiple Waiver services and their providers must be noted on the revised DMAS-99 and/or DMAS-301 for ADHC each time the form is required to be completed 6. The DMAS-99 and/or DMAS-301 must also note which Waiver service the patient pay is being deducted from

EDCD Waiver Services: 

EDCD Waiver Services

Available Services: 

Available Services Adult Day Health Care Personal Care Agency Directed Personal Care Consumer-Directed Personal Care PERS and Medication Monitoring Available with Agency Directed & Consumer-Directed services

Available Services: 

Available Services Respite – two types: Agency-Directed Personal Care Aide Skilled (nurse) Facility Respite - A Medicaid-certified nursing facility Consumer-Directed Personal Care Aide Skilled respite is not available as CD

Available Services: 

Available Services Respite Care (Cont’) May be authorized to receive agency-directed AND consumer-directed respite Cannot receive agency-directed & consumer-directed respite simultaneously 720 hours is the maximum number of combined respite hours per calendar year, per individual

Available Services: 

Available Services Respite Care (Cont’) DMAS will pay for the first 720 billable respite hours submitted for payment DMAS/WVMI is unable to give an accurate up-to-date amount of respite hours that an individual has received

Available Services: 

Available Services Respite Care (Cont’) When an individual transfers to a new provider, the new provider is responsible for finding out how many respite care hours the individual has remaining for the current calendar year This includes transferring between agency-directed & consumer-directed respite This must be done through coordination with providers

Available Services: 

Available Services Service Facilitation This will covered more thoroughly in another training session later today

Personal Care - Supervision: 

Personal Care - Supervision Supervision is covered within the personal care plan of care when the purpose is to supervise or monitor those recipients who require the physical presence of the aide to ensure their safety during times when no other support system is available;

Personal Care - Supervision: 

Personal Care - Supervision The inclusion of supervision in the plan of care is appropriate only when the recipient cannot be left alone at any time due to mental or severe physical incapacitation This includes recipients who cannot use a telephone to call for help due to a disability

Personal Care - Supervision: 

Personal Care - Supervision A individual must be getting personal care in order to receive supervision Is available in agency-directed and consumer-directed services The provider agency must complete the Request for Supervision Hours in Personal Care (DMAS-100) and submit to WVMI for authorization

Increase in Hours on the Plan of Care: 

Increase in Hours on the Plan of Care Increases in the POC above the LOC category, which is currently authorized for a recipient, cannot be retroactive The agency or SF must obtain preauthorization from WVMI prior to initializing an increase in hours above the LOC category

Plan of Care with a Combination of Waiver Services: 

Plan of Care with a Combination of Waiver Services A recipient may receive a combination of any of the services once authorization is obtained by WVMI. Each plan of care will be reviewed along with the other services currently authorized for a combined total

Plan of Care with a Combination of Waiver Services: 

Plan of Care with a Combination of Waiver Services A request for additional services may or may not change the amount of services and/or # of hours authorized per week EX: John is authorized for 25 hrs. per week of agency-directed personal care services & wants CD services. Unless there is a need for an increase in hrs., the amount of total combined weekly hrs. will remain the same between the two services.

Plan of Care with a Combination of Waiver Services: 

Plan of Care with a Combination of Waiver Services If the recipient requests an increase in a service that will cause a decrease in another Waiver service currently being rendered, the provider who is initiating the change must notify the other service provider(s). WVMI will not decrease an authorized service unless that service provider submits a request for a decrease

Plan of Care with a Combination of Waiver Services: 

Plan of Care with a Combination of Waiver Services EX: John currently receives 25 hrs of agency-directed care and 10 hrs per week of CD. John contacts the SF and request an increase in CD services but does not want to change/decrease the 25 hrs of agency care that he is receiving.

Plan of Care with a Combination of Waiver Services: 

Plan of Care with a Combination of Waiver Services The SF will: (a) assess the needs of the recipient to determine if an increase is needed. If an increase is needed; (b) contact the agency-directed provider and request a copy of the current plan of care with the schedule of care being provided by the agency; (c) submit the request for authorization of CD services to WVMI, noting on the DMAS-98 that this is in addition to the agency-directed services; and (d) if WVMI approves the increase, the SF must notify the the agency-directed provider of the change in John’s CD services schedule.

Plan of Care with a Combination of Waiver Services: 

Plan of Care with a Combination of Waiver Services EX: John’s request for an increase in CD services is denied by WVMI. His current amount of services remains authorized unchanged. With only 25 hrs allowed, the SF will discuss with John the options of: (a) splitting the 25 hrs per week between agency-directed and consumer-directed services; or (b) use all 25 hrs in CD services; or (c) making no change in the current Waiver services

Plan of Care with a Combination of Waiver Services: 

Plan of Care with a Combination of Waiver Services If John requests to split the 25 hrs between the agency & consumer directed services, the SF will contact the other provider of the change in services and schedule of hrs per John’s request. (a) the agency-directed provider will need to submit the DMAS-98 and the DMAS-97A/B to WVMI with the decrease in hours to agency-directed services (b) the SF will need to submit the DMAS-98, and the DMAS-97A/B to WVMI for an increase

Plan of Care with a Combination of Waiver Services: 

Plan of Care with a Combination of Waiver Services EX: John is currently receiving agency-directed services and wants to also receive CD services in addition to the agency-directed service. John has never received CD services. John contacts a SF and requests CD services. The SF will: (a) contact the agency-directed provider and request a copy of the screening paperwork, current plan of care with a schedule of care being provided by the agency, & the DMAS-122; (b) conduct an initial comprehensive visit;

Plan of Care with a Combination of Waiver Services: 

Plan of Care with a Combination of Waiver Services (c) submit the request for authorization of CD services to WVMI, noting on the DMAS-98 that this is in addition to the agency-directed services; and (d) contact the agency-directed provider of John’s request; and (e) coordinate with the agency provider the schedule of hours between the two types of services.

Updated Forms: 

Updated Forms

Updated Forms: 

Updated Forms All forms are on the DMAS web site Agency-Directed & Consumer-Directed Plan of Care (DMAS-97A/B) Combines the DMAS-97A & DMAS-97B Community-Based Care Individual Assessment Report (DMAS-99) Combines the DMAS-99 & DMAS-99B

Updated Forms: 

Updated Forms DMAS-99 (cont’) More information is required on the form Ex: Under SUPPORT SYSTEM, the provider must list all Waiver services that the individual is receiving at the time of the assessment. The name of the service provider must also be listed Ex: The specific service provider responsible for collecting the patient pay must be noted There are other changes on the form

Updated Forms: 

Updated Forms Skilled Respite Record (DMAS-90A) Respite Care Needs Assessment Plan of Care (DMAS-300) For requesting respite care services Request for Supervision Hours in Personal Care (DMAS-100) Used for agency & consumer directed services

Updated Forms: 

Updated Forms Adult Day Health Care Interdisciplinary Plan of Care (DMAS-301) The provider must list all Waiver services that the individual is receiving at the time of the assessment. The name of the service provider must also be listed The specific service provider responsible for collecting the patient pay must be noted

Updated Forms: 

Updated Forms Request for Services Form (DMAS-98) Addition to the changes, this form must be filled out correctly and completely Request for PERS (Personal Emergency Response System) Form (DMAS-100A) To be used for agency & consumer directed services

New Form: 

New Form Consumer-Direction Services Management Questionnaire DMAS-95B Questions to consider if a family member is considering managing consumer directed (CD) services on behalf of a family member

As a Participating Provider You Must-: 

As a Participating Provider You Must- Determine the patient’s identity. Verify the patient’s age. Verify the patient’s eligibility. Accept, as payment in full, the amount paid by Virginia Medicaid. Bill any and all other third-party carriers.

Important Contacts: 

Important Contacts MediCall ARS- Web-Based Medicaid Eligibility Provider Call Center Customer Service Provider Enrollment Commonwealth Mailing Electronic Billing

MediCall/ARS- Information Available: 

MediCall/ARS- Information Available Medicaid client eligibility/benefit verification Service limit information Claim status Prior authorization Provider check log

MediCall: 

MediCall 800-884-9730 800-772-9996 804-965-9732 804-965-9733

Automated Response System- ARS: 

Automated Response System- ARS Web-based verification option Registration virginia.fhsc.com Questions concerning registration process 800-241-8726 Web Support Helpline

Slide102: 

DOB: 05/09/1964 F CARD# 00001 DEPARTMENT OF MEDICAL ASSISTANCE SERVICES COMMONWEALTH OF VIRGINIA V I RG I N I A J. R E C I P I E N T 9 9 9 9 9 9 9 9 9 9 9 9 002286

Provider Call Center: 

Provider Call Center Claims, covered services, billing inquiries: Department of Medical Assistance Services 600 East Broad Street, Suite 1300 Richmond, VA 23219 800-552-8627 804-786-6273

Customer Services: 

Customer Services Customer Services Department of Medical Assistance Services 600 East Broad Street, Suite 1300 Richmond, VA 23219

Provider Enrollment: 

Provider Enrollment New provider numbers or change of address: First Health – PEU P. O. Box 26803 Richmond, VA 23261 888-829-5373 804-270-5105 804-270-7027 - Fax

Requests for DMAS Forms and Manuals: : 

Requests for DMAS Forms and Manuals: DMAS Order Desk COMMONWEALTH MARTIN 1700 Venable Street Richmond, Virginia 23222 Phone: 1-804-780-0076 Email:dmas@cms-mpc.com

Electronic Billing: 

Electronic Billing Mailing Address EDI Coordinator-Virginia Operations First Health Services Coordinator 4300 Cox Road Richmond, VA 23060 E-mail: edivmap@fhsc.com Phone: (800) 924-6741 Fax: (804) 273-6797

Billing on the CMS-1500: 

Billing on the CMS-1500

MAIL HCFA-1500 FORMS TO:: 

MAIL HCFA-1500 FORMS TO: DEPARTMENT OF MEDICAL ASSISTANCE SERVICES PRACTITIONER P. O. Box 27444 Richmond, Virginia 23261

TIMELY FILING: 

TIMELY FILING ALL CLAIMS MUST BE SUBMITTED WITHIN ONE YEAR FROM THE DATE OF SERVICE EXCEPTIONS Retroactive Eligibility Delayed Eligibility Denied Claims NO EXCEPTIONS Accident Cases Other Primary Insurance

TIMELY FILING: 

TIMELY FILING Submit claims with documentation attached explaining the reason for delayed submission You must have the word “Attachment” in Locator 10d and use modifier “22” in Locator 24D

Slide112: 

MEDICAID (Medicaid #) Block 1: Check Medicaid CHAMPUS (Sponsor's SSN) 1. MEDICARE (Medicare #) CHECK MEDICAID BLOCK ONLY 2. PATIENT'S NAME (Last Name, First Name, Middle Initial) 17

Slide113: 

1a. INSURED'S I.D. NUMBER (FOR PROGRAM IN ITEM 1) Block 1a: Recipient ID Number (Be sure to include all 12 digits) 123456789 01 4 18

Slide114: 

Block 2: Patient's Name 2. PATIENT'S NAME (Last name, First Name, Middle Initial) Smith, Sam 5. PATIENT'S ADDRESS (No., Street) 19

Slide115: 

Block 10: Accident-Related 10. IS PATIENT'S CONDITION RELATED TO: a. EMPLOYMENT? (CURRENT OR PREVIOUS) b. AUTO ACCIDENT? c. OTHER ACCIDENT? YES NO PLACE (State) YES YES NO NO You MUST check YES or NO for a, b & c 20

Slide116: 

Block 10d You MUST use the word "ATTACHMENT" if you attach anything to the HCFA form. 10d. RESERVED FOR LOCAL USE ATTACHMENT 21

Slide117: 

Block 14: Conditional Use 14. DATE OF CURRENT ILLNESS (First symptom) OR INJURY (Accident) OR PREGNANCY (LMP) MM DD YY Corresponds to Block 7, Date Care Began, on DMAS-93 form (Required for Personal Care) 22

Slide118: 

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY 1. 2. 3. 4. 3441 Block 21: Diagnosis Codes May enter up to 4 codes Omit decimals 23 2963

Slide119: 

22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. Block 22: Adjustments and Voids 1032 xxxxxxxxxxxxxxxx Adjustment or Resubmission From original remittance Void Code (See HCFA instructions for list of codes) 24

Slide120: 

23. PRIOR AUTHORIZATION NUMBER Block 23: Prior Authorization Number - Conditional If service requires prior authorization, enter the nine digit PA number assigned by WVMI. 25

Slide121: 

24. A DATE(S) OF SERVICE From To MM DD YY MM DD YY Block 24A: Dates of Service 08 01 04 08 08 04 08 01 04 08 31 04 1 2 Both FROM and TO dates must be completed Dates must be within same calendar month 26

Slide122: 

B C Place of Service Service of Type Block 24B: Place of Service Block 24C: Type of Service 12 1 12-Patient's home 11-Office location 1- Medical Care 27

Slide123: 

D Block 24D: Procedure Codes PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circumstances) CPT/HCPCS MODIFIER H2000 22 28

Slide124: 

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY 1. 2. 3. 4. 34431 Block 24E: Diagnosis Code E DIAGNOSIS CODE 1 29 2963 1,2 Enter the entry identifier of the ICD-9-CM diagnosis code listed in Locator 21. To identify more than one diagnosis code, separate the indicators with a comma.

Slide125: 

F $ CHARGES Block 24 F: Charges Enter the usual and customary charges 30

Slide126: 

G DAYS OR UNITS Block 24G: Days or Units 1 Enter the number of times or hours the procedure, service, or item was provided during the service period. 31

Slide127: 

J K COB RESERVED FOR LOCAL USE 24J: COB Other Insurance 24K: $ Other Insurance Paid Attach denial from other carrier 33

24J: Use for Patient Pay24K: Enter the Patient Pay amount : 

24J: Use for Patient Pay 24K: Enter the Patient Pay amount Locator 24 J -Enter 3 Locator 24 K If this applies to the recipient, place the patient pay amount in 24K. The system will only calculate the patient pay when indicated on the claim. 34

Slide129: 

26. PATIENT ACCOUNT NUMBER Block 26: Patient’s Account Number (Optional) 12345678918765432 35

Slide130: 

Block 29: Amount Paid Personal Care Providers ONLY Enter patient pay amount 29. AMOUNT PAID $ 36

Slide131: 

31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse apply to this bill and are made a part thereof.) SIGNED DATE Block 31: Signature & Date If there is a signature waiver on file, you may stamp, print, or computer-generate the signature. 37

Slide132: 

PIN# GRP# 33. PHYSICIAN'S, SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE & PHONE # 123456789 Block 33: Provider ID # and Address Be sure to put the MEDICAID 9-digit ID number! 38

Slide133: 

22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. Block 22: Adjustments and Voids 1032 xxxxxxxxxxxxxxxx Adjustment or Resubmission From original remittance Void Code (See HCFA instructions for list of codes) 39

Special Billing Instructions: 

Special Billing Instructions

Northern Virginia Localities: 

Northern Virginia Localities Alexandria City Clarke County Fairfax City Falls Church City Fredericksburg City Loudon County Manassas Park City Spotsylvania County Warren County Arlington City Culpeper County Fairfax County Fauquier County King George County Manassas City Prince William County Stafford County

Personal Care: 

Personal Care T1019-Personal Care Northern Virginia $13.38 per/hr Rest of State $11.36 per/hr

Respite Care: 

Respite Care S9125-LPN/hr Northern Virginia $26.00/HR Rest of State $21.45/HR T1005-aide/hr Northern Virginia $13.38/HR Rest of State $11.36/HR

Personal/Respite Care: 

Personal/Respite Care Maximum hrs billed is amount on plan of care for personal care or authorized amount for respite care ONLY whole hours can be billed 30 extra minutes or more of care provided over a calendar month, the next highest hour can be billed Rounding up is for total monthly hours only

Adult Day Health Care: 

Adult Day Health Care S5102-ADHC Services Northern Virginia $47.25/per diem Rest of State $43.05/per diem A0120-ADHC Transportation Northern Virginia $2.00/per trip Rest of State $2.00/per trip *a trip is to and from the recipients residence

Adult Day Health Care: 

Adult Day Health Care A day is defined as 6 hours or more of attendance Less than six hours is considered a half day Half days may be added and rounded to the nearest whole day at the end of the month Transportation must be authorized by WVMI or the Screening Team

Personal Emergency Response System (PERS): 

Personal Emergency Response System (PERS) S5160-PERS Installation Northern Virginia $59.00 Rest of State $50.00 S5161-PERS Monitoring Northern Virginia $35.40/per month Rest of State $30.00/per month

PERS: 

PERS One time installation includes installation account activation recipient and caregiver instruction removal of equipment Monthly monitoring rate includes administrative costs time labor supplies Billed as one unit

Medication Monitoring: 

Medication Monitoring S5160/modifier U1- Installation Northern Virginia $88.50 Rest of State $75.00 S5185-Monthly Monitoring Northern Virginia $59.40/per month Rest of State $50.00/per month

Medication MonitoringNursing Visit: 

Medication Monitoring Nursing Visit H2021/modifier TD-RN visit Northern VA $15.00 Rest of State $12.25 H2021/modifier TE-LPN visit Northern VA $13.00 Rest of State $10.25 Nursing visits to fill medication monitors are reimbursed bimonthly

Service Facilitation Services: 

Service Facilitation Services H2000-Comprehensive Visit Northern Virginia $209.73 Rest of State $161.56 S5109-Consumer Training Northern Virginia $208.73 Rest of State $160.56 99509-Routine Visit Northern Virginia $65.23 Rest of State $50.18

Service Facilitator Services: 

Service Facilitator Services T1028-Reassessment Visit Northern Virginia $105.37 Rest of State $80.28 S5116-Management Training Northern Virginia $26.09 Rest of State $20.07 99199/modifier U1-Criminal record check Northern Virginia $15.00 Rest of State $15.00 Per check

Service Facilitation Services: 

Service Facilitation Services Registry Check-99199 Northern VA $5.00 Rest of State $5.00

Consumer Directed Personal Care Services: 

Consumer Directed Personal Care Services Personal Care and Respite Care Northern Virginia $10.10/hr Rest of State $7.80/hr

Patient Pay Amount and Collection: 

Patient Pay Amount and Collection There must be a completed DMAS-122 form in the clients file prior to billing DMAS For CD services, the service facilitator must also provide a copy to the fiscal agent Provider with the most authorized hours has total patient pay collection responsibility for the client in both personal care and ADHC

Patient Pay Amount and Collection: 

Patient Pay Amount and Collection If the amount of services received in a calendar month is equal to or less than the patient pay amount, only the amount for the services rendered should be collected from the recipient. DMAS should not be billed for that month

Patient Pay Amount and Collection: 

Patient Pay Amount and Collection If the amount of services rendered is greater than the amount of patient pay, an invoice should be submitted showing the total allowable charges and the patient pay amount. DMAS will reimburse to allowable charges less the patient pay amount

WVMI’S Role : 

WVMI’S Role Contracted by the Department of Medical Assistance Services (DMAS) to provide preauthorization for Elderly or Disabled with Consumer Direction Waiver Utilize DMAS criteria in the Provider Manuals, and VA Regulations

Preauthorization Overview: 

Preauthorization Overview All preauthorization requests to WVMI must be made using the REQUEST FOR SERVICES FORM (DMAS 98) Enrollments, changes, transfers and discharges This is a fax or mail process The DMAS 98 must accompany the Pre-Admission Screening Packet if the request is for a new enrollment WVMI will verify eligibility and enrollment

Preauthorization Overview: 

Preauthorization Overview WVMI will determine if the request meets DMAS Waiver criteria WVMI will render a decision Approval Partial Approval Pend Denial Reject Preauthorization Number Assigned Generated from the First Health System Will be included in correspondence generated from First Health

Request for Services Form (DMAS 98): 

Request for Services Form (DMAS 98) Sample DMAS 98 and Instructions Sheet DMAS 98 Form Review Type of Request New Request Pend Response Change to Approval Include the PA number Recipient and Provider Information Medicaid number (12 digits) Provider number Contact phone number

Request for Services Form (DMAS 98): 

Request for Services Form (DMAS 98) DMAS 98 Form Review (continued) Services Being Requested All fields must be completed Must be National Codes Units – indicate the hours requested for service based on the plan of care If the request is a change, indicate the total hours being requested Effective Date – the date services are to begin

Request for Services Form (DMAS 98): 

Request for Services Form (DMAS 98) DMAS 98 Form Review (continued) Services Being Requested (continued) Last date of service Complete when going from current waiver into either DD or MR waivers only Requires selection of DD or MR Effective Date is the current providers last date of service

Request for Services Form (DMAS 98): 

Request for Services Form (DMAS 98) DMAS 98 Form Review (continued) WVMI Tracking number 9 digits Recipient and Waiver specific Provides for quick identification Assigned to all decisions and entered on the original Request for Services Form (DMAS 98) Use on all correspondence with WVMI Provider Comments Can be used to communicate any special information regarding your request

Preauthorization Decisions: 

Preauthorization Decisions Reject If unable to process the request – no Medicaid ID number, DMAS 98, Provider information incomplete If a request is rejected, the entire packet of information must be resubmitted Pend Additional information is needed to render a decision A provider has a specified time frame to respond to a pend request

Preauthorization Decisions: 

Preauthorization Decisions Approval Services meet DMAS criteria and authorization is granted as requested Partial Approval Not all services and/or hours of services requested meet criteria Denial Services requested are not approved Decisions, with the exception of approvals, will be faxed or mailed to the requestor

Reconsiderations: 

Reconsiderations Denials only Requests may be mailed or faxed Include information that justifies your request Must be received within 30 days of the date of the denial Reconsideration decision will be made within 10 business days Written response will be faxed or mailed to provider

Appeals : 

Appeals If services have not been rendered, the Medicaid recipient may request an appeal within 30 days of the written notification of the denial If services have been rendered, the provider may appeal the adverse decision in writing within 30 days of the written notification of the denial Mail to: Director, Appeals Division Department of Medical Assistance Services 600 East Broad Street, Suite 1300 Richmond, Virginia 23219

WVMI Service Request Response: 

WVMI Service Request Response Most requests including enrollments, changes and transfers, will be reviewed within 10 business days or less Requests for supervision and increases above the cap will be reviewed within one business day PERS/PERS Medication Monitoring will be reviewed within 3 business days All voice mail messages will be returned within one business day

What to Expect With Preauthorization of EDCD Waiver Services 2/1/2005? : 

What to Expect With Preauthorization of EDCD Waiver Services 2/1/2005? The overall preauthorization process will change very little Beginning 2/1/2005 the same criteria will be used in reviewing preauthorization requests for all EDCD recipients The Plan of Care must support the need for requested services and units/hours of service

What to Expect With Preauthorization of EDCD Waiver Services 2/1/2005? : 

What to Expect With Preauthorization of EDCD Waiver Services 2/1/2005? Requests must be received within 10 business days of initiation of service or notification of Medicaid eligibility If the request is not received timely, service dates prior to the request receipt date will be denied therefore, providers may see an increase in partial approvals

What to Expect With Preauthorization of EDCD Waiver Services 2/1/2005? : 

What to Expect With Preauthorization of EDCD Waiver Services 2/1/2005? Former CD PAS recipients will receive new PA numbers All E&D and CDPAS Waiver recipients will receive new WVMI tracking numbers when EDCD services are reviewed WVMI will retain all history, all former PA numbers and tracking numbers which will be cross referenced and retrievable

What to Expect With Preauthorization of EDCD Waiver Services 2/1/2005? : 

What to Expect With Preauthorization of EDCD Waiver Services 2/1/2005? Obtaining information as to whether the recipient is receiving multiple waiver services Contact WVMI 804-648-3159 or 1-800-299-9864 Press 5 and then 4, if you leave a message, your call will be returned within one business day WVMI will provide name and contact number of other providers

Resource Materials: 

Resource Materials DMAS Website - www.dmas.virginia.gov DMAS Provider Manuals DMAS HELPLINE 804-786-6273 or 800-552-8627 WVMI Website - www.qiva.org Questions about a specific request Call WVMI CBC Inquiry Line 804-648-3159 or 1-800-299-9864, press Option 5 and then Option 4

Definition of Consumer-Directed Services: 

Definition of Consumer-Directed Services

Definition ofConsumer-Directed Services: 

Definition of Consumer-Directed Services Services for which the Waiver recipient or spouse, parent, adult child or guardian of the individual is responsible for hiring, training, supervising, and firing of the staff The individual must demonstrate a need for personal assistance in activities of daily living, community access, self-administration of medication, or other medical needs, or monitoring health status or physical condition

Consumer-Directed Eligibility Requirements: 

Consumer-Directed Eligibility Requirements Individuals must have the capability to hire and train their own personal care aides & supervise their performance; OR If an individual is unable to direct his own care or is under 18 years of age, a family member/caregiver may serve as the employer on behalf of the individual

Consumer-DirectedEligibility Requirements: 

Consumer-Directed Eligibility Requirements If a family/caregiver is managing the care on behalf of the individual, the caregiver will be the employer of CD services & be responsible for hiring, training, supervising, and firing care aides Ensure that the individual has a back-up plan in case the aide is not available

Consumer-Directed Eligibility Requirements: 

Consumer-Directed Eligibility Requirements Other employer duties include: Checking of references of personal care aides, determining that personal care aides meet basic qualifications, training care aides, supervising the care aide’s performance; and Submitting timesheets to the CD fiscal agent on a consistent and timely basis

Consumer-Directed Eligibility Requirements: 

Consumer-Directed Eligibility Requirements Individuals choosing consumer-directed services must receive support from a CD Service Facilitator The individual or family/caregiver must have a back-up plan for the provision of services in case the personal care aide does not show up for work as expected or terminates employment without prior notice

Inability to Obtain CD Personal Care Aide Services: 

Inability to Obtain CD Personal Care Aide Services The inability to obtain & retain personal care aides can be a serious threat to the safety & health of a individual who does not have a back-up support system If an individual is consistently unable to hire & retain the employment of an aide, the SF should discuss transferring the individual to agency-directed services

Consumer-Directed Service Facilitation: 

Consumer-Directed Service Facilitation

Definition of aService Facilitation (SF) Provider: 

Definition of a Service Facilitation (SF) Provider A participating consumer-directed (CD) service facilitator is a facility, agency, person, partnership, corporation, or association that meets the standards and requirements set forth by DMAS and has a current, signed participation agreement with DMAS

Responsibilities of the Service Facilitation Provider: 

Responsibilities of the Service Facilitation Provider The SF is responsible for monitoring the ongoing provision of services & the quality of care received by individuals in CD services. SF monitoring includes: The need for support in addition to the care provided by CD services. This includes an overall assessment of the individual’s safety and welfare in the home with CD services

Responsibilities of the Service Facilitation Provider: 

Responsibilities of the Service Facilitation Provider Availability: The CD Services Facilitator must be available by telephone to the individual receiving CD services while the individual is receiving services

Responsibilities of the Service Facilitation Provider: 

Responsibilities of the Service Facilitation Provider If a health and safety issue is noted by the CD Services Facilitator during a visit, he/she is obligated to report this to DSS (Child Protective Services/Adult Protective Services, as appropriate) and the Waiver Services Unit at DMAS (804-786-1465) Failure to make a report may put your DMAS provider agreement at risk of termination

Service Facilitation (SF) ProviderStaff Requirements: 

Service Facilitation (SF) Provider Staff Requirements The SF cannot be: The individual in the Waiver; The spouse of the recipient; The personal care aide rendering the care; The parent of the recipient who is a minor child; or A family/caregiver who is responsible for employing the personal care aide

ProviderStaff Requirements: 

Provider Staff Requirements It is preferred that the SF possess a minimum of an undergraduate degree in a human services field or be a registered nurse currently licensed to practice in Virginia In addition, it is preferred that the SF must have two years of satisfactory experience in the human services field working with persons with severe disabilities or the elderly

Provider Staff Requirements: 

Provider Staff Requirements If the SF employed by the provider is not a RN, the provider must have RN consulting services available, either by a staffing arrangement or through a contracted consulting arrangement The SF must have the knowledge, skills, and abilities set forth in Chapter II of the EDCD Manual

Service Facilitation Services: 

Service Facilitation Services

Comprehensive Visit: 

Comprehensive Visit The CD SF is responsible for initiating services with the individual upon accepting the referral of service from the Pre-Admission Screening Team This must be done before the personal care aide begins services

Comprehensive Visit: 

Comprehensive Visit It is done only once upon the individuals entry into CD services Unless the individual is terminated from CBC services and is being re-enrolled If the individual requests additional CD services, such as respite, another comprehensive visit is not necessary. The person has already been initially assessed for CD services

Comprehensive Visit: 

Comprehensive Visit If the individual changes service facilitation providers, the new provider must do a Reassessment Visit in lieu of a comprehensive visit. A new comprehensive visit will not be paid DMAS

Comprehensive Visit: 

Comprehensive Visit From the initial comprehensive visit the SF will: Assess the individual to determine Waiver eligibility using Community-Based Care Recipient Assessment Report (DMAS-99), Develop the Plan of Care on the DMAS-97A/B; and

Comprehensive Visit: 

Comprehensive Visit Ensure that the individual understands his/her rights and responsibilities in the program and sign all of the participation agreements found in the Employee Management Manual, (including those related to the Selection of Service, Fiscal Agent, and the consumer-directed services facilitator); and

Comprehensive Visit: 

Comprehensive Visit All forms must be completed, signed, and dated before the individual can begin employing a personal care aide in the program

Consumer Training: 

Consumer Training The SF must provide the individual with consumer training within seven days of the completion of the Comprehensive Visit The SF can complete the comprehensive visit and consumer training on the same day During the consumer training, the SF must train the individual, or caregiver, on his/her duties as an employer of CD services

Consumer Training : 

Consumer Training The SF must follow the Outline & Checklist for Consumer-Directed Recipient Training to ensure that the training content meets the minimum acceptable requirements The service facilitator must check each subject on the form after it has been covered, and have the required signatures and dates;

Consumer Training: 

Consumer Training The training check list must be maintained in the individual’s file and available for review by DMAS staff; and Regardless of the method of training, documentation must indicate that training was received prior to the individual’s employment of a personal care aide.

Routine Visits: 

Routine Visits After the comprehensive visit and consumer training, the SF must conduct two routine onsite visits within 60 days of the initiation of care (once per month) to monitor the individual’s Plan of Care and ensure both the quality and appropriateness of services

Routine Visits: 

Routine Visits Once the first two routine visits have been completed, the SF & the individual can decide how frequent the routine onsite visits occur All Routine Visits must be conducted at the individual’s residence, since the individual’s environment & support system is necessary to evaluate his/her needs

Routine Visits: 

Routine Visits The service facilitator’s documentation of the routine visit may be in the form of a progress note or a standardized form After the initial 90 days, the SF’s supervision of the plan of care will be performed in the individual’s home on an as-needed basis

Routine Visits: 

Routine Visits However, a face-to-face meeting with the individual must be conducted at least quarterly for personal care and every six months for respite care when it is provided as a sole service

Routine Visits: 

Routine Visits Routine visits are not to exceed a maximum of one visit every 30 days The SF must provide any necessary supervision to the individual and record all significant contacts in the individual’s file

Routine Visits: 

Routine Visits During routine visits, the SF: Must observe, evaluate, and document the adequacy and appropriateness of the personal care aide services; Will review the personal care aide’s time sheets, if available; Must discuss the individual’s satisfaction with the type and amount of service; and Other documentation as list in the Manual

Reassessment Visit: 

Reassessment Visit This must be documented on the Community-Based Care Recipient Assessment Report (DMAS-99), and must include: A complete review of the individual's needs & available supports, & a review of the Plan of Care

Reassessment Visit: 

Reassessment Visit Conducted every every six months or upon the use of 300 respite hours, whichever comes first. SF conducts a reassessment visit every six months or for individuals who are transferring from another CD SF or who requests a change in their CD services SF-A SF-B Reassessment Transfer

Management Training : 

Management Training There may be additional management training for the individual SF can provide up to four hours of management training to an individual within any six-month period Each hour of training is billed as one unit

Criminal Record Check: 

Criminal Record Check All personal care aides must submit to a criminal record check SF assist individuals by submitting the criminal record check forms to the Virginia State Police on behalf of the individual when the individual hires a new personal aide If the recipient is a minor, the aide must also be screened through the DSS Child Protective Services Registry

Annual Level of Care (LOC) Reviews: 

Annual Level of Care (LOC) Reviews The LOC review information is compiled on the Level of Care Review Instrument (DMAS-99C) The LOC assessment must be completed by a RN. If the SF does not have a RN on staff, the SF must contract with a RN to complete the assessment

CD Personal Care Aide Requirements & Duties: 

CD Personal Care Aide Requirements & Duties

Personal Care Aide Requirements: 

Personal Care Aide Requirements Must be 18 years of age or older Must possess basic math, reading and writing skills Must have the required skills to perform personal care duties as specified in the individual’s Plan of Care

Personal Care Aide Requirements: 

Personal Care Aide Requirements Must understand and agree to comply with the CD program requirements May be registered in a CD personal care aide registry, which will be maintained by CD service facilitators

Personal Care Aide Requirements: 

Personal Care Aide Requirements Receive periodic tuberculosis (TB) screening, cardiopulmonary resuscitation (CPR) training and an annual flu shot (unless medically contraindicated);

Personal Care Aide Requirements: 

Personal Care Aide Requirements May not be the parent of a minor, or spouse Payment may not be made for services furnished by other family/caregivers living under the same roof unless there is objective written documentation as to why there are no other aides available to provide the care

Personal Care Aide Requirements: 

Personal Care Aide Requirements Family members who are employed to provide CD services must meet all CD aide qualifications

Services Performed by CD Personal Care Aide: 

Services Performed by CD Personal Care Aide Services provided by CD personal care aides in the home include: Activities of Daily Living (ADLs): Assisting with care of the teeth and mouth; Assisting with grooming (including care of the hair, shaving, and ordinary nail care); Bathing- routine maintenance and care of external condom catheters is considered part of the bathing process;

Services Performed by CD Personal Care Aide: 

Services Performed by CD Personal Care Aide Activities of Daily Living (Cont’) Routine skin care- not to include applying topical medications or any type of product with an “active ingredient”; Dressing; Toileting; and Feeding.

Services Performed by CD Personal Care Aide: 

Services Performed by CD Personal Care Aide Turning and changing position, transferring, and ambulating; Self-administered medications and assuring the individual received medications at prescribed times not to include in any way determining the dosage of medication; and Checking the temperature, pulse, respiration, and blood pressure and recording and reporting as required.

Services Performed by CD Personal Care Aide: 

Services Performed by CD Personal Care Aide Home Maintenance Activities: Preparing and serving meals; Washing dishes and cleaning the kitchen; Making the bed and changing linens; Cleaning the individual’s bedroom, bathroom and rooms used primarily by the personal care individual;

Services Performed by CD Personal Care Aide: 

Services Performed by CD Personal Care Aide Shopping for necessary supplies for the individual if no one else is available to perform the service; and Washing the individual’s laundry if no other family member is available or able

Transportation : 

Transportation Transportation is not a covered service through this waiver Transportation to providers of Medicaid services can be arranged through the DMAS transportation broker. There are times that the aide may accompany the recipient to medical appointments or to other activities

Transportation : 

Transportation The total time required by the personal care aide for the day, including the time required to drive the individual, cannot exceed the individual’s authorized weekly hours. If the total time required exceeds daily hours, additional time may be deducted from another day as long as this does not jeopardize the individual’s health and safety

Transportation: 

Transportation In no case will DMAS pay, through this Waiver, for mileage or other costs associated with transportation

Transportation : 

Transportation As the aide is the employee of the individual receiving CD services, any arrangements for transportation not paid for by the Medicaid program are between the aide and the individual This includes transportation necessary to implement the CD services plan of care (for example, to permit community access and activities)

Transportation: 

Transportation Thus, it is permissible for the aide to transport the individual in the aide or individual/family’s vehicle if the following criteria are met: The vehicle is registered in the Commonwealth of Virginia; The aide has a valid Virginia driver’s license; and Current vehicle insurance that covers the following:

Transportation: 

Transportation The insurance should cover the driver and passenger(s); Against loss from any liability imposed by law for damages; Against damages for care and loss of services, because of bodily injury to or death of any person; Against injury to or destruction of property caused by accident and arising out of the ownership, use, or operation of such motor vehicle or motor vehicles within the Commonwealth, any other state in the United States, or Canada;

Transportation: 

Transportation The insurance should insure the insured or the other person; Subject to a limit of exclusive of interest and costs, with respect to each motor vehicle of $25,000 because of bodily injury to or death of one person in any one accident and, subject to the limit for one person, to a limit of $50,000 because of bodily injury to or death of two or more persons in any one accident; and Subject to a limit of $20,000 because of injury to or destruction of property of others in any one accident

Consumer-DirectedRespite Care: 

Consumer-Directed Respite Care

Respite Care Defined: 

Respite Care Defined Services designed to provide temporary but periodic or routine relief to the primary, unpaid caregiver Designed to relieve the physical and emotional burdens of the caregiver and, only secondarily, the needs of the individual Must aid in the prevention of individual or family, or both, breakdown and possible institutionalization of the individual

Consumer-Directed (CD) Respite: 

Consumer-Directed (CD) Respite CD respite can be rendered by the personal aide. Individuals receiving CD services may also receive agency-directed respite services, but not simultaneously. The maximum amount of combined respite services is 720 hours per calendar year.

Consumer-Directed (CD) Respite: 

Consumer-Directed (CD) Respite If the recipient is receiving a combination of agency-directed and consumer-directed respite, the service providers must coordinate services DMAS will pay for the first 720 billable respite hours submitted for payment DMAS is unable to give an accurate up-to-date amount of respite hours that an individual has received

Covered Services: 

Covered Services CD respite covers the same services as regular CD services The SF must create a plan of care on the DMAS-97A/B for CD respite services Use the Respite Care Needs Assessment Plan of Care (DMAS-300) to request authorization for respite services

Authorization of Services: 

Authorization of Services Authorization must be obtained from WVMI prior to beginning services. If respite services are requested, the WVMI Cover Sheet (DMAS-98) must be completed and sent to WVMI for authorization. This request must include the name of the primary caregiver requesting respite services, and it must also note whether the primary caregiver lives in the home with the individual.

Fiscal Agent (FA) Responsibilities: 

Fiscal Agent (FA) Responsibilities In a nutshell: to handle employment, payroll, and tax responsibilities on behalf of the recipient (employee of record) who is receiving consumer-directed services

FA Responsibilities: 

FA Responsibilities Includes: verifying the authorization of services for recipients ensuring proper completion of hire packets for assistants/companions receiving & processing time sheets

FA Responsibilities: 

FA Responsibilities Does Not Include obtaining waiver service authorizations determining the type or amount of services for recipients determining patient pay amounts discharges or admissions into the waiver

Hire Packet Forms: 

Hire Packet Forms Forms that need to be sent to the FA Personal Attendant Provider form Recipient Notification form Employee Agreement Signatory Authority form Employment Verification form (I‑9) Policies for Employees Have the employer use the Hire Packet Check List and make copies of all completed forms.

Hire Packet Reminders: 

Hire Packet Reminders The I-9 is the form that generates the most problems The Signatory Authority form must be completed for each employee Two photocopies of the two IDs used on the I-9 (Employment Verification form) can be included to expedite the process

Hire Packet Reminders: 

Hire Packet Reminders The FA must have the originals in the Hire Packet. (Signatory Authority form may be copied if noted a true copy of original and signed) “Recipient’s Name” = the Medicaid recipient’s name vs. the family member/caregiver name

Hire Packets (1281 Received Last Six Months): 

Hire Packets (1281 Received Last Six Months) (963) (44) (274)

Needing Corrections: 

Needing Corrections

Authorization Reminders: 

Authorization Reminders The attendant should not start services until the SF receives service authorization We can not process time sheets until we have received notice of authorization If the authorization is not retroactive, the employer will be responsible to pay the personal attendant

Time Sheet Reminders: 

Time Sheet Reminders Complete time sheets according to published schedule If two services are being provided (respite & attendant) then a separate time sheet needs to be completed for each service Print clearly When signing for another person, you must include the recipient’s name on the time sheet

Time Sheet Reminders: 

Time Sheet Reminders Time sheets MUST have time in / time out recorded. Must be signed by attendant and recipient or designee. Be for one service and one pay period. Have legible names.

Slide243: 

Select One Service Name signing for recipient's name

Payroll Time Line: 

Payroll Time Line FA receives Authorizations from DMHMRSAS and WVMI every Monday Hire Packets are received and processed daily FA receives DMAS-122s from SF for patient pay entries Pay periods are 14 days in length

Payroll Time Line: 

Payroll Time Line

Patient Pay: 

Patient Pay DMAS receives the 122 to determine if consumer direction services is the receiver of patient pay. Patient pay amount is paid by the recipient to the attendant when they receive their pay stub for the pay period that contains the first day of the month.

Patient Pay: 

Patient Pay If the recipient has more than one attendant then they MUST verify by reviewing the amount listed on the pay stub received from DMAS which attendant has had the patient pay amount deducted. If the attendant earned less than the patient pay amount, the recipient will not receive a pay stub from DMAS and will have a negative balance until they work enough hours to earn over the patient pay amount.

Tips For Success: 

Tips For Success The employer and employee should both keep a copy of the time sheet Mail time sheets when all the service for that payroll period has been provided

Tips For Success: 

Tips For Success Make sure that the FA has the employee’s current mailing address If an employee is terminated, the FA needs to be notified Send updated DMAS-122s to the FA

THANK YOU: 

THANK YOU