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Balancing Incentive Program – No Wrong DoorJanuary 27, 2014 1
Balancing Incentive Program
and LTSS ScreenJoyce Pohlman
Grants Coordinator
Community Access and Grants
DADS
Balancing Incentive Program – No Wrong DoorJanuary 27, 2014 2
Balancing Incentive
The Affordable Care Act created the Balancing Incentive Program (BIP), which helps states provide quality care in the most appropriate, least restrictive setting.
Balancing Incentive Program – No Wrong DoorJanuary 27, 2014 3
Balancing Incentive
Increases the Federal Matching Assistance Percentage (FMAP) to States that make structural reforms to increase nursing home diversions and access to non-institutional LTSS.
Enhanced matching payments are tied to the percentage of a State’s LTSS spending, with lower FMAP increases going to States that need to make fewer reforms.
Balancing Incentive Program – No Wrong DoorJanuary 27, 2014 4
BIP Mandated Requirements
Requires structural reforms to increase access to Medicaid community based long-term services and supports (LTSS).
Create a “no wrong door” to provide a single point of information and allow individuals to provide demographic information once.
Core standardized assessment instruments: ensure all assessment instruments cover mandated “domains”
Ensure “conflict-free” case management in all programs
All objectives must be met by September 30, 2015
Balancing Incentive Program – No Wrong DoorJanuary 27, 2014 5
LTSS Screen
A short, easy to complete process that directs individuals to long term services and supports (LTSS) for which they may be eligible.
Balancing Incentive Program – No Wrong DoorJanuary 27, 2014 6
LTSS Screen
BIP Requirements
Part of No Wrong Door Required by BIP - Level 1 Screen
Efficient, standardized approach to needs assessment
Refers people who are potentially eligible for Medicaid LTSS
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LTSS Screen
No Wrong Door
A common screen used in all major entry points to the LTSS system
Individuals have a uniform experience
Directs individuals to participating LTSS Doors
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LTSS Screen
Simple, concise, easy to complete
Individuals tell their story only once
Most will be completed via web or phone, but may be done in person
LTSS Screen
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Participating LTSS Doors
Aging and Disability Resources Centers (ADRC)
Area Agencies on Aging (AAA)
Local Authorities (LA)
DADS Regional Office (RO)
DADS Access and Intake Interest List (A&I IL)
Medicaid Managed Care Organization (MCO)
HHSC STAR+ Program Support Unit (PSU)
Local Mental Health Authorities (LMHA)
Outreach, Screening, Assessment, and Referral Centers (OSAR)
Balancing Incentive Program – No Wrong DoorJanuary 27, 2014 10
LTSS Screen
Advantages to Individuals
Receive assistance from programs for which they may be eligible
Find the right help more easily
Tell their story only once
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LTSS Screen
Advantages to intake workers
Less time gathering demographic information
More time providing personal assistance
System automatically produces referrals
Individual contact history is maintained
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LTSS Screen
Advantages to organizations (Doors)
Provides enrollment and referral information for the individual
Reduces need for in-depth understanding of other programs
Consistent evaluation of individual’s LTSS needs
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LTSS Screen
Process for Developing Screen:
Surveyed LTSS Doors Reviewed current intake forms Reviewed other states’ screens Developed and evaluated draft screens Met with representatives for each LTSS
Door
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LTSS Screen
Screen Questions - Demographic
Name Address where services will be delivered Date of birth Gender Race/ethnicity Social Security Number Caregiver information Military service Insurance information
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LTSS Screen
Screen Questions
Determination of LTSS need Need for benefits counseling Caregiver need Nursing facility risk Referral to programs with Interest
Lists Behavioral health Alcohol and drug abuse
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LTSS Screen
Tell us about the individual’s needs
a) Has an intellectual disability (IQ is less than 70).
b) Has an autism spectrum disorder.
c) Has dementia (not able to think clearly), Alzheimer's disease, a brain injury, or other cognitive impairment.
d) Needs help with daily living needs such as bathing, dressing, eating, shopping, laundry, or making meals.
e) Cares for someone with one or more of the conditions listed above (a. to d.) and doesn't get paid to give care.
f) Gets care from someone who: (1) helps with daily living needs such as bathing, dressing, eating, shopping, laundry, and making meals, and (2) doesn't get paid to give care.
g) Has or had a mental health diagnosis.
h) Lives alone or doesn't have anyone to call for help in case of emergency.
i) Has a physical disability (for example, can't walk, can't see, or can't hear) and needs help paying for items or services needed for medical reasons.
j) Has or had a diagnosis of alcoholism or drug abuse.
Balancing Incentive Program – No Wrong DoorJanuary 27, 2014 17
LTSS Screen
Do you have any questions about Medicare or private long-term care insurance?
Yes No No answer Have you dropped many activities and interests lately?
Yes No No answer Do you feel full of energy?
Yes No No answer
How many times in the past 12 months have you had 3 or more drinks of alcohol
in a single sitting? □ 0 □ 1 □ 2 □ 3 □ 4 □ 5 or more
If you can't get care at home, how likely are you to move into a nursing home? Very likely Likely Somewhat likely Not likely A nursing home is not an option that is being considered No answer
Balancing Incentive Program – No Wrong DoorJanuary 27, 2014 18
LTSS Screen
Does Homer think it is wonderful to be alive now?
Yes No No answer
During the past 30 days, has Homer taken any of the following? (check all that apply) □ Medicines for pain or problems like back pain, muscle pain, headaches, arthritis, or fibromyalgia. Don't count: (1) vitamins, (2) herbs, (3) natural remedies, or (4) over-the-counter medicines such as aspirin, ibuprofen, TYLENOL, Advil, or Aleve.
□ Medicine for diabetes.
□ Medicine to help with sleep. Don't count: (1) vitamins, (2) herbs, (3) natural remedies, or (4) over-the-counter medicines such as melatonin, Benadryl, TYLENOL PM, or Advil PM.
□ Medicine for anxiety, nerves, or emotional upset. Don't count (1) vitamins, (2) herbs, (3) natural remedies, or (4) over-the-counter medicines.
□ Medicine for heart disease or high blood pressure.
□ Alcohol - beer, wine, wine cooler, or hard liquor.
Balancing Incentive Program – No Wrong DoorJanuary 27, 2014 19
LTSS Screen Do you feel that your life is empty?
Yes No No answer
Programs you think might help.
Learn more about these programs at www.dads.state.tx.us. Most of these programs have an interest list. Check all that apply. If you're not sure about a program, check it anyway:Helps older adults and people age 21 and older with disabilities get support services in a home setting. (STAR+PLUS Waiver)
Helps people living in certain Texas areas get support services. See the list of areas. (Program for All-inclusive Care for the Elderly - PACE)
Helps people with developmental disabilities get support services. (Community Living Assistance and Support Services Waiver - CLASS)
Helps get support services for people who: (1) are deaf and blind, and (2) have another disability that keeps them from living on their own. (Deaf Blind with Multiple Disabilities Waiver - DBMD)
Helps get support services to families who are the main caregivers for children and young adults who need help with their medical care. Helps the child or young adult with: (1) moving from a nursing facility to a home setting or (2) staying in a home setting. (Medically Dependent Children Program - MDCP)
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LTSS Screen
You told us that you take care of someone. Could you use help? Help can include: (1) getting a short break - respite services, (2) helping you learn more about giving care, or (3) telling you about other support services.
Yes No No answer
The person you care for has: Dementia (can't think clearly), Alzheimer’s disease, brain injury, or other cognitive
impairment. Another disability.
Tell us more about the person you care for: Their age Their relationship to you Do they live with you?
Yes No No answer
Balancing Incentive Program – No Wrong DoorJanuary 27, 2014 21
Using the
LTSS ScreenDarshana Gore
Business Analyst
DADS IT Project Management Office
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Step One:Access the Screen
By phone
In person
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Step One:Access the Screen
Internet
By phone
In person
By Internet
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Step Two:Data Collection
Internet
By phone
In person
By Internet
DataCollection
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Step Three: Generate Referrals
System Generates Referrals
DataCollection
Balancing Incentive Program – No Wrong DoorJanuary 27, 2014 27
LTSS Screen
System Generates Referrals
ReferralManagement
AAAADRCA&I IL
LALMHA/OSAR
MCOPSURO
Data Collection
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Data Collection
Collected by Intake Demographic data Screen responses
Pulled from existing systems (automatically) Managed care enrollment Enrollment DADS LTSS programs and Interest List Medicaid eligibility
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System Generates Referrals
Individual consent Allows release of information to other Doors Can limit information shared Identifies organizations that can receive
information
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Referrals
What is on the referral? Date and time of Screen Access mode (web/phone/in-person) Who conducted the Screen Demographic data Current enrollment data Screen responses List of referrals generated and organization contact
information Comments
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Referrals
Referral to the Medicaid Managed Care Organization
(MCO)
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Referrals to MCO
ScenarioThe individual is receiving Medicaid andCurrently enrolled with MCO and Needs assistance
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Referrals
Referral to the
Program Support Unit
(PSU)
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Referrals to PSU
Scenario 1Individual is receiving MedicaidNOT enrolled with Medicaid Managed
Care Organization• Potential MCO enrollment
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Referrals to PSU
Scenario 2Individual is NOT receiving MedicaidIs at risk of moving to a nursing
facility
Scenario 3Individual is NOT receiving MedicaidExpresses interest in STAR+ Waiver
services
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Referrals to MCO or PSU
System Generates Referrals
ReferralManagement
MCO/PSU
Data Collection
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Referrals
Referral to the Regional Office (RO)
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Referrals to RO
Scenario 1Individual is a Texas resident and needs
help with at least one of the following:• Activities of Daily Living (ADL)• Instrumental Activities of Daily Living
(IADL)• Cognitive Impairment• Emergency Response Services• Has physical disability and needs
assistance purchasing medically necessary items or services
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Referrals to RO
System Generates Referrals
ReferralManagement
RO
Data Collection
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Referrals
Referral to the
Area Agency on Aging
(AAA)
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Referrals to AAA
Scenario 1Any Individual who has questions about
Medicare or Long-term Care Insurance
Scenario 2Individual or caregiver age 60 and over,
needing help or information
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Referrals to AAA
Scenario 3Caregiver caring for an individual (care
recipient) with Alzheimer’s Disease OR related disorders OR neurological/brain dysfunction
Scenario 4Caregiver over age 54, who is a relative
other than parent or spouse, living with and caring for an individual (care recipient) under age 19 or disabled
Balancing Incentive Program – No Wrong DoorJanuary 27, 2014 43
Referral to AAA
System Generates Referrals
ReferralManagement
AAA
Data Collection
Balancing Incentive Program – No Wrong DoorJanuary 27, 2014 44
Referrals
Referral to the Local Authority (LA)
Balancing Incentive Program – No Wrong DoorJanuary 27, 2014 45
Referrals to LA
Scenario 1Individual is receiving MedicaidCurrently enrolled with Medicaid Managed
Care Organization andEnrolled in one of the following:
• Home and Community-Based Services• Texas Home Living• Intermediate Care Facilities for Individuals with IDD
Balancing Incentive Program – No Wrong DoorJanuary 27, 2014 46
Referrals to LA
Scenario 2Individual has Autism Spectrum Disorder
Scenario 3Individual has an Intellectual Disability
Balancing Incentive Program – No Wrong DoorJanuary 27, 2014 47
Referrals to LA
System Generates Referrals
ReferralManagement
LA
Data Collection
Balancing Incentive Program – No Wrong DoorJanuary 27, 2014 48
Referrals
Referral to the Access and Intake Interest List (A&I IL)
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Referrals to A&I IL
Scenario 1An Individual is interested in learning more
about one of the following:• Community Living Assistance and Support
Services• Deaf-Blind with Multiple Disabilities• Medically Dependent Children Program
Balancing Incentive Program – No Wrong DoorJanuary 27, 2014 50
Referral to A&I IL
System Generates Referrals
ReferralManagement
A&I IL
Data Collection
Balancing Incentive Program – No Wrong DoorJanuary 27, 2014 51
Referrals
Referral to the Aging and Disability Resource Center
(ADRC)
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Referrals to ADRC
Scenario 1After a screening, an Individual does not
have a referral to any of the other Doors
Scenario 2Individual is a veteran
Scenario 3Individual at risk of placement to a nursing
facility
Balancing Incentive Program – No Wrong DoorJanuary 27, 2014 53
Referrals to ADRC
Scenario 4Individual needs caregiver support, but
does not qualify for AAA services
Scenario 5ADRC can be manually added to the list of
referrals
Balancing Incentive Program – No Wrong DoorJanuary 27, 2014 54
Referral to ADRC
System Generates Referrals
ReferralManagement
ADRC
Data Collection
Balancing Incentive Program – No Wrong DoorJanuary 27, 2014 55
Referrals to LMHA and OSAR
Referral to the LMHA and OSARExperts from these areas defined Referral
CriteriaBehavioral health questionsAlcohol and drug abuse
Balancing Incentive Program – No Wrong DoorJanuary 27, 2014 56
Referral Management
Receiving a referral
Acknowledge
Process
Forward, as necessary