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Home- and Community-Based Alternatives (HCBA) Waiver Solicitation for Application (SFA) October 20, 2017
Home- and Community-Based Alternatives (HCBA) Waiver
Solicitation for Application (SFA)October 20, 2017
Agenda
• HCBA Waiver Overview•
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Benefits of the Organized Health Care Delivery System (OHCDS) ModelSolicitation for Application (SFA)
TimelineContent
Questions & Resources2
HCBA Waiver Overview
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The HCBA Waiver is a Medicaid Home and Community-Based Services (HCBS) Waiver program authorized under §1915(c) of the Social Security Act1915(c) Waivers manage the provision of HCBS to eligible Medi-Cal beneficiaries who would otherwise receive care in a facility if not for the nursing and support services they receive in the community setting of their choice
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HCBA Waiver OverviewWhat does a Medi-Cal 1915 (c) Waiver do?
1915(c) Waivers allow states to provide services outside of the Medicaid State Plan by waiving one of three provisions of the Social Security Act:•
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Comparability - offer services to eligible waiver participants that are not provided to other Medicaid beneficiaries Statewideness - limit the operation of a waiver to specified geographic areas of the stateIncome and Resources for the Medically Needy – deem individuals eligible for Medicaid under the waiver who would otherwise only be eligible in an institutional setting
(often because of the income and resources of a spouse or parent)
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HCBA Waiver Overview•
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1915(c) Waivers are submitted to the Centers for Medicare and Medicaid Services (CMS) for re-authorization every 5 years Prior to submitting the most-recent HCBA Waiver* renewal application, DHCS underwent an extensive public engagement process to solicit input from participants, providers, and other stakeholdersUtilizing stakeholder input, DHCS submitted a significantly revised waiver renewal application to CMS, and CMS retro-actively authorized the HCBA Waiver back to Jan. 1, 2017
* The previous version of the HCBA Waiver expired on Dec. 31, 2016 and was known as the Nursing Facility/Acute Hospital (NF/AH) Waiver
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What does the HCBA Waiver Do?•
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The HCBA Waiver allows Medi-Cal beneficiaries with high-level care needs to continue to live at home or in the community by identifying and ensuring they receive services that will sustain their health and safety outside of an institution. Some of the services that may be provided to support Waiver participants in the community, include but are not limited to:
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– In-home nursing services– Waiver personal care services – Family/caregiver training– Home or facility respite – Habilitation services– Community transition services
– Environmental accessibility adaptation
– Medical equipment operating expenses
– Personal Emergency Response System (PERS) installation, testing, and operation
Changes to the Waiver
The most significant change made to the HCBA Waiver through the renewal process, is the shift of Waiver Administration from the State to selected local Waiver Agencies functioning as Organized Health Care Delivery Systems (OHCDS) for designated service areas.
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What is an OHCDS?42 CFR 447.10 defines OHCDSs as “…a public or private organization for delivering health services.” •
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An OHCDS must provide at least one Medicaid service directly (utilizing its own employees) and may contract with other qualified providers to furnish other waiver servicesWhen an OHCDS arrangement is used, the required Medicaid provider agreement is executed between the state and the OHCDSParticipants’ free choice of providers must be preserved and clearly communicated to eligible beneficiaries
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What is an OHCDS?(continued)
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When OHCDSs are used to provide Waiver services:
Subcontractors must meet the standards under the Waiver to provide Waiver services
The subcontract arrangement does not alter fundamental Waiver requirements with respect to provider qualifications or service standards
Payment is made directly to the OHCDS, and they, in turn, reimburses subcontractorsWaiver providers may not be required to subcontract with an OHCDS
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Who can be an OHCDS?
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OHCDSs may include, but are not limited to: Managed Care Health Plans Public HospitalsNon-profit Organizations For-profit Organizations Professional Corporations City/County Health and/or Social Services Departments
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New Model for WaiverAdministration and Implementation
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• The HCBA Waiver is approved as an OHCDS model
• DHCS will establish contracts with OHCDSs, which will be known as Waiver Agencies, to provide Waiver Administration and Comprehensive Care Management (CCM) services within a defined service area
• Contracted Waiver Agencies will receive per member, per month (PMPM) payments for providing Waiver Administration and CCM services
Role of a Waiver AgencyWaiver Administrative Services
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Develop and maintain a qualified provider network for the entire service areaConduct annual on-site provider performance monitoringPerform quality assurance and performance improvement activitiesAdjudicate provider claims, and billMedi-Cal Review Waiver applications, verify applicants’ eligibility for the Waiver, and coordinate the Waiver enrollment process with DHCSReview / authorize requests for Waiver servicesIssue Notices of Action (NOA) and participate in Fair Hearings, as required Utilization management
Comprehensive Care Management (CCM)Provided by a Care Management Team (CMT) comprised of a nurse and a social worker with at least a Master’s DegreeCoordinate / monitor medically necessary state plan and Waiver services, and other non Medi-Cal services available from across delivery systems, regardless of the funding sourceConduct assessments to determine participants’ Level of Care (LOC) Review / approve person-centered Plans of Treatment (POT) Conduct on-site home visits based on participants’ acuity levelsContact participants, in-person or by phone, at least once a monthReport / manage health and safety issues, and critical incidents 12
Anticipated Benefits ofImplementing the OHCDS Model
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Efficient delivery of services Address workload capacityGrowth of waiverEnhanced care management servicesImproved participant access to servicesImproved quality control
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Why it makes sense for an existing OHCDS to provide waiver services?
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Waiver services increase the number of options health care providers can present to members when discussing their long-term care preferences and goals, and reduces the need to provide more expensive care in an inpatient facility
Waiver Agencies will receive two per member, per month (PMPM) payments for:
Waiver Administration Services
Comprehensive Care Management Services
All direct Waiver services (e.g., in-home nursing, habilitation, respite, etc.) are paid through the Medi-Cal fee-for-service reimbursement system (except Waiver Personal Care Services, which is paid through CDSS)
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OHCDS are in the ideal position to maximize HCBA Waiver services in addition to the existing services they provide since they have the infrastructure and partnerships required to build a successful program at the local level, and can leverage the Waiver program to build efficiencies within the larger scope of the organization’s model of care
Becoming a Waiver Agency provides an OHCDS with:More options in managing the continuity of care of participants More control over the timeliness of service authorizationsDirect control over service quality monitoring and follow-up
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Why it makes sense for an existing OHCDS to provide waiver services?
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Implementation
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Who
• Organizations with experience providing case management and administrative functions for comparable populationsMCHP, Public Hospital, OHCDS, Non-profits, For-profits (i.e. Home Health Agencies), Professional Corporations, County/City entities, etc.
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How• DHCS has developed a Solicitation for Application (SFA) process to identify
qualified entitiesWaiver Agencies will be required to enter into a contract with DHCS •
When• DHCS will implement the Waiver Agency model effective April 1, 2018
DHCS will conduct training and readiness review functions for selected Waiver Agencies prior to implementation
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Solicitation for Application•
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DHCS is utilizing a Solicitation for Application (SFA) to select qualified organizations to provide HCBA Waiver services within defined service areasThe SFA is similar to a Request for Application (RFA) or Request for Proposal (RFP), but provides DHCS greater flexibility to:
Accept applications from MCHPs, Public Hospitals, OHCDS, Nonprofit Organizations (public or private), Commercial For-profit Entities, and Local GovernmentsMake awards for defined service areasBase award decisions on applicants’ qualifications and experience
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Application TimelineSFA Released October 4, 2017
Teleconference Questions Due(for questions to be addressed during the Teleconference)
October 18, 2017 5:00 p.m.
Voluntary Pre-Application TeleconferenceTo register, complete and submitSFA Attachment 10 to the HCBA Waiver Inbox at: [email protected] #: 888-847-7596 Passcode: 8196275
October 24, 2017 9:00 a.m.
Applications Due November 15, 2017 4:00 p.m.
Award Notices Released January 1, 2018
Proposed Contract Start Date April 1, 201818
SFA Content•••••••••••••
Purpose and objectives of the SFABackground on, and goals of, the HCBA WaiverProposed award scheduleHow to submit questionsApplicant eligibility criteriaRequired application format Required application content and documentationSubmission instructionsDescription of the evaluation and selection processContractual terms and conditionsSample ContractAppendices with resources for applicantsAttached forms for applicants to complete and submit as part of their application
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Application Content1. SFA Cover Page 13. Model of Care Narrative
2. SFA Checklist 14. Business Plan Narrative
3. Annual Agency Information Sheet 15. Organization Chart
4. Contractor Certification Clauses 16. Duty Statements
5. Payee Data Record 17. Proof of Current Licensure
6. Proof of Non-Profit Status (if applicable) 18. Proof of Insurance
7. Proof of Corporate Status (if applicable) 19. Financial Statements
8. Darfur Contracting Act Cert. 20. Proof of Insolvency Protection
9. Iran Contracting Cert. 21. Pro Forma
10. Attestations 22. Letters of Commitment (Network)
11. Conflict of Interest Compliance Cert. 23. Letters of Support (Community Partners/ Stakeholders)
12. Applicant Capacity Narrative 20
Applicant Capacity Narrative (Not to exceed 7 pages)
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Description of the applicant organizationCurrent and selected service areaOrganization’s mission, goals, and current workload and responsibilities Existing relationships with local service providersPast projects involving services similar to the Scope of Work in the SFA
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Model of Care Narrative(Not to exceed 20 pages in length)
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Describe applicant organization’s experience with, or plans for:
HCBA Waiver target populationEligibility determination, verification, & trackingCommunity outreach and educationProgram administrationLevel of Care assessment and oversightPlan of Care development and oversight
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Model of Care NarrativeContinued
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Other experience:Service authorizationProvider network development and oversightAdjudication and reimbursement of claimsComprehensive Care ManagementEnsuring health and safety of beneficiariesQuality monitoring and performance improvement
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Business Plan Narrative
(Not to exceed 5 pages)
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Staffing Plan Staff training and evaluationFinancial StabilityData Privacy ProtectionsReporting
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Resulting Contract Term
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Applicants selected to receive an award to contract as an OHCDS providing HCB Alternatives Waiver services will be known as “Waiver Agencies” and must always be in compliance with the waiverThe term of a resulting contract is expected to be 57 months, from April 1, 2018 through December 31, 2021, with two optional extensions of one year each at the discretion of DHCS
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Questions
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Immediately notify DHCS if you need clarification about the SOW attached to the SFA, or about the SFA and/or its accompanying materials, instructions, or requirements. Questions must be sent to the HCBA Waiver email inbox at: [email protected] with “SFA #17-10118 – Question” in the subject line of the email
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Resources
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For more information on the HCBA Wavier, go to: http://www.dhcs.ca.gov/services/ltc/Pages/Home-and-Community-Based-(HCB)-Alternatives-Waiver.aspxFor more information on the SFA, go to: http://www.dhcs.ca.gov/services/ltc/Pages/HCBA-Waiver-Solicitation-for-Application-(SFA).aspx
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