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NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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1915 (c) Waiver Training1915 (c) Waiver TrainingJanuary 2012January 2012
Andrea Misenheimer Andrea Misenheimer Medicaid Director – PBHMedicaid Director – PBH
Patti French Patti French
Waiver ConsultantWaiver Consultant
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Welcome to
NC Innovations
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Used to implement a mandatory managed care program that includes HCBS waiver services in the managed care contract.
The 1915(c) waiver allows a state to target eligibility and provide the HCBS services. The 1915 (b) waiver then allows a State to mandate enrollment in managed care plans that provide these HCBS services.
States must apply for each waiver authority separately and comply with the statutory and regulatory requirements of each
1915 (b) (c) concurrent waivers
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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A New Tool Kit for the 1915 (c ) waiver Rate setting authority allows PIHP to adjust rates according
to local conditions
Closed Network allows for competition and choice while rightsizing the marketplace; ensures health of providers
Utilization Management gives PIHP the tools to ensure consumers receive both the appropriate service and amount of treatment to meet their needs
Care Coordination is an important activity that directly intervenes to ensure consumers receive the care needed when it is needed in order to prevent use of higher cost services when appropriate treatment is delayed.
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Vision NC Innovations is a tool to guide the I/DD
service system
Goals for the Waiver: Value and Support of individuals as members
of the community The ability to self direct services to the extent
each individual chooses Offer choice in where people live, work and
spend their day Promote promising practices Development of stronger natural support
networks
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Slots and PrioritizationFinite number of Slots for use in Finite number of Slots for use in
the waiver:the waiver: Each year of waiver operation,
(January 1-December 31) the number of slots available is specified in the waiver
Slots are unduplicated Slots are frozen once used and can
not be filled until the following waiver year. ( A person may re-enter in the same waiver year)
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Prioritization PrioritizationPrioritization Individuals are determined potentially eligible through
Access and wait on the Registry of Unmet (waitlist) needs until waiver slots are available, typically in January of every year
Screening for potential eligibility includes a clinical review (Risk Support Needs Assessment and the SIS) and review against the eligibility criteria
Potentially eligible individuals are allocated waiver Potentially eligible individuals are allocated waiver funding as follows:funding as follows:
Non-Reserved CapacityNon-Reserved Capacity First come, first serve Based on date of application for services
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Prioritization Reserved Capacity Emergency Process:Emergency Process:
A clinical team inclusive of 1 psychiatrist and a minimum of one developmental disability specialist determines the allocation of emergency slots as referrals are made
Emergency CriteriaEmergency Criteria Significant imminent risk of serious harm due to primary
caregiver /support system inability to meet the persons basic needs
Protection from confirmed abuse, neglect or exploitation Meets all other waiver eligibility criteria
Emergency slots will be maintained at the state during the transition period.
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Transition from CAP-MR/DD and Cardinal Innovations due to change in Medicaid county
Due to Medicaid county change to the MCO area If there is no available slot, contact DMA for next steps
Transition from CAP-C when children age out and meet the eligibility criteria
Due to aging out of CAP –C at age 21 If there is no available slot, contact DMA for next steps
Deinstitutionalization from an ICF-MR for children 0-17 Children moving from an ICF-MR ( state or community) If there is no available slot, contact DMA for next steps
Money Follows the Person Individuals who meet the MFP criteriaIf there is no available slot, contact DMA for next step
Military Transfers Individuals who transfer from other states into North Carolina
and need continued waiver funding.
Reserved Capacity
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Initial Level of Care ProcessEligibility Criteria = ICF-MR Criteria DMA Clinical Eligibility Criteria = ICF-MR Criteria DMA Clinical
Coverage Policy No: 8Coverage Policy No: 8 Referral disability is Mental Retardation (Intellectual
Disability ) or a condition closely related to Mental Retardation :licensed psychologist or licensed psychological associate completes the assessment. The assessment includes a review of a psychological evaluation inclusive of an adaptive behavior assessment
Referral disability is medical in nature, epilepsy or cerebral palsy:A physician completes the assessment
The Level of Care evaluation is valid for 30 days once signed.
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Annual Reassessment of Level of Care Reassessment of continued eligibility is completed
by the Care Coordinator
Completed annually during or up to 30 days prior to the birth month
The annual assessment includes completion of the NC Innovations Risk Support Needs Assessment.
If the individual’s condition or needs have changed significantly during the past twelve months and continued eligibility is questionable, the individual is referred through the full evaluation to verify continued eligibility.
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Level of Care Form Initial NC Innovations Level of Care Form
Level of Care Form is completed on all individuals screened for NC Innovations waiver funding
If the referral disability is medical in nature the Medical addendum can be used to support the eligibility .
Annual NC Innovations Level of Care Reassessment
LOC Reassessment is documented on the Signature Page of the ISP
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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LOC and Transition To ensure a smooth transition, the
waiver eligibility determination by the CAP-MR/DD program will be accepted in the NC Innovations waiver until the next annual re-evaluation of eligibility in the individual’s birth month.
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Freedom of Choice
Freedom of Choice is documented:Freedom of Choice is documented: Initial when new to the waiver Annually as a component of the ISP
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Individual BudgetingIndividual Budgets: The budget is developed during the
planning process to inform the person of the amount of funding available for them to plan within.
Budget Authority: Individuals have the authority to make
decisions about how to spend their waiver dollars.
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Building BudgetsEach budget has two parts: Base Budget Services- the services that are are the core habilitation and
support services in the waiver. Add On (Non Base) Budget Services –
services which are provided to ensure prevention, education or enhanced independence.
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Base Budget services Base Budget Services include:
Community Networking Services Day Supports In-Home Skill Building In-Home Intensive Supports Personal Care Residential Supports Respite Supported Employment
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Add On (Non Base) Services Budget Add On Budget Services include:
Assistive Technology Equipment and Supplies Community Transition Services Crisis Services Individual Goods and Services Home Modifications Natural Supports Education Specialized Consultation Services Vehicle Modifications Community Guide
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Individual Budget In combination the Base and Add On budgets
may not total more than $135,000
If the individual decides to participate in Individual Family Direction, they will additionally have a Self Directed Budget
The current CAP-MR/DD cost summary will be accepted as the individual budget for the person.
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Limitations on Living Arrangement
Own Home/Private Family
or
Residential Facility of: 6 beds or less 3 beds if newly constructed The facility bed requirement of 6 or fewer beds
does not apply to individuals transitioning from CAP-I/DD on the date their LME transitions to NC Innovations.
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Role of Care Coordinator Treatment Planning Case Management Educating participant/family/providers about
services, waiver requirements, options Assessment of support needs (completing,
arranging for, obtaining) Linkage to needed MH/DD/SA resources
(includes ensuring provider choice) Facilitation of Planning / Plan Development Monitoring plan implementation, including
health and safety Medicaid eligibility coordination
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Role of Community Guide Advocacy Support
Linkage to community resources
Assistance obtaining medical care
Supporting Employers of Record in Individual and Family Directed Services option
Care Coordinators do not perform functions of Community Guide
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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ISP Development The NC SNAP will be used until the
Supports Intensity Scale is fully implemented.
Assessment is the first and most important step in developing an Individual Support Plan.
The quality of the Person Centered Plan is directly tied to the quality of the Assessments.
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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ISP Development Obtaining/reviewing updated
records/assessments relevant to the person’s interests and needs for support
The NCSNAP must be completed annually until such time as the SIS has been completely implemented.
Orientation to Individual and Family Direction
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Risk/Support Needs Assessment Risk/Support Needs Assessment to
determine supports needs and risks that need to be mitigated/addressed
- Demographic Information - Material Supports - Physician Supports - Professional Supports - Medication Supports - Medical Treatment - Health and Wellness
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Planning Meeting
Review of assessment information/draft plan
Development of long range outcomes
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Plan Development Individual Support Plan and Individual Budget
developed by Care Coordinator, including Positive Behavior Support Plan as required or otherwise indicated
Care Coordinator reviews plan with participant/legally responsible person and obtain signatures (including Freedom of Choice for Innovations participants)
Plan (with all accompanying documents) submitted toUtilization Management per PIHP guidelines.
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Individual Support Plan – How It’s Different.
Based on an ELP model Focus on the person’s voice Demographics at the end Summary of the Risks that need to
be mitigated is in the plan Requires a back-up support plan be
documented
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Plan Implementation Providers/Employers of Record develop short-range
goals and accompanying interventions/strategies/ task analyses
Staff Training
Provision of service as outlined in plan
Documentation of the services provided
Monitoring of plan implementation by Care Coordinator
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Plan Implementation ISP is updated/revised as needed
Update to Individual Support Plan (most often includes update to Individual Budget)Demographic Information - UpdateUpdate to Crisis Prevention and Intervention
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Support PlanningSIS™ Identifies/Measures
support needsIdentify desired life
goals/experiences/choices using person centered tools
Person Centered Planning IndividualSupport
Plan (ISP)
Risk/Support Needs Assessment / Other Other Assessments
Natural and FundedResources
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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ISP and Transition The CAP-MR/DD person centered plan will
be accepted in the NC Innovations waiver until the next annual individual service plan (ISP) is developed in the individual’s birth month. The participant’s ISP will continue to be reviewed as needed due to changes in care needs and on an annual basis. The NC Innovations waiver includes services that crosswalk to the CAP-MR/DD waiver.
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Waiver Incident Reporting
Failure to provide Back Up Staff will require a Level 1 Incident Report
This applies to all Provider Directed and Employer Directed Services
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Service Options through Innovations
Traditional Provider Directed Option Individual/Family Directed Option
(Self Direction) - Agency with Choice If the person tries an option and is not
satisfied they can change The person has the flexibility to direct
only the services that they choose
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Individual Family Direction
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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CMS RequirementsCMS Requirements No other Model of Self-Direction except the model approved No other Model of Self-Direction except the model approved
in the waiverin the waiver Payments may not be made directly to a waiver participant, Payments may not be made directly to a waiver participant,
or managing employer, either to reimburse for expenses or managing employer, either to reimburse for expenses incurred or to pay a service provider directlyincurred or to pay a service provider directly
No cost to the Participant or Managing EmployerNo cost to the Participant or Managing Employer Financial Manager or Agency With Choice manages funds Financial Manager or Agency With Choice manages funds Self-direct one or more servicesSelf-direct one or more services Service planning is led by the participantService planning is led by the participant Independent advocacy is availableIndependent advocacy is available Budget Authority to make decisions about how funding is Budget Authority to make decisions about how funding is
usedused
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Services that can be Individual/Family DirectedServices that can be Individual/Family Directed
In-Home Skill BuildingIn-Home Skill Building Personal CarePersonal Care In-Home Intensive SupportIn-Home Intensive Support Natural Supports EducationNatural Supports Education Community Networking Community Networking RespiteRespite Supported EmploymentSupported Employment Community Guide Community Guide Individual Goods and ServicesIndividual Goods and Services
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Model of Individual/Family Directed SupportsModel of Individual/Family Directed Supports
Agency With Choice (Managing Employer)
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Representative
The representative is someone who can assist The representative is someone who can assist the Managing Employer in performing some or the Managing Employer in performing some or all of their dutiesall of their duties
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Individual
If the individual is not the Managing If the individual is not the Managing Employer, they need to be as involved in Employer, they need to be as involved in the process as possiblethe process as possible
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Managing Employer is…Managing Employer is…
Innovations Waiver Participant if they are 18 and Innovations Waiver Participant if they are 18 and do not have a legal guardiando not have a legal guardian
OrOr Parent of a child under 18 Parent of a child under 18 OrOr The legal guardian of an Innovations participantThe legal guardian of an Innovations participant
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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The Direct Support Worker Works for the Agency With Choice.Works for the Agency With Choice.
Works when and where the Managing Employer Works when and where the Managing Employer choose.choose.
Does what Managing Employer wants him or her Does what Managing Employer wants him or her to do.to do.
In the Agency With Choice Model, decisions are In the Agency With Choice Model, decisions are shared with the Agencyshared with the Agency
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Community Guide
Empowers the employer to define and direct Empowers the employer to define and direct servicesservices
Understands employers needs and Understands employers needs and preferencespreferences
May not be the employer, representative or May not be the employer, representative or family may not be paid to provide servicefamily may not be paid to provide service
Service can be mandatedService can be mandated
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Community Guide functions in Individual Family Direction
Links to ResourcesLinks to Resources Role plays to teach skillsRole plays to teach skills Connects to the communityConnects to the community Helps employer develop employee support Helps employer develop employee support
agreements/supervision plansagreements/supervision plans
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Community Guide will not…. Interview, hire, train or fire employeesInterview, hire, train or fire employees Complete employment formsComplete employment forms Find back up employeesFind back up employees Obtain extra money for the employer if Obtain extra money for the employer if
the budget is overspentthe budget is overspent Make decisions for the employerMake decisions for the employer Do the Duties of the Care CoordinatorDo the Duties of the Care Coordinator
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Care Coordinator functions in Individual Family Direction
Completes the assessmentsCompletes the assessments Completes the process for appointment of the representative, if Completes the process for appointment of the representative, if
neededneeded Completes referrals to the Agency With Choice and Community Completes referrals to the Agency With Choice and Community
GuideGuide Completes the Individual and Family Supports AgreementCompletes the Individual and Family Supports Agreement Completes the ISP/Update to ISP Completes the ISP/Update to ISP Sends the ISP to UM for approvalSends the ISP to UM for approval Sends a copy of the approved ISP to team members including Sends a copy of the approved ISP to team members including
Community Guide, Managing Employer, RepresentativeCommunity Guide, Managing Employer, Representative
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Annual Orientation to Individual Family Direction
Booklet Fact Sheets
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Review of Agency with Choice Comparison Chart
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Step 1 Managing Employer
The Care Coordinator will determine who the Managing Employer will be
The Care Coordinator will ask the Managing Employer if they plan to use a representative
Managing Employer and Prospective Representative attend training provided by the Community Guide
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Step 2 Assessments
Individual and Family Supports/Community Guide Assessment
Representative Screening Questionnaire
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Step 3 Consider if a Representative Needs to be appointed
Representative is someone who can assist the Managing Employer in performing some or all of the Employer duties
Follow procedures for appointment of representative if Employer agrees.
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Step 4 Individual Support Plans Determine staff qualifications and supervision
requirements of staff Document back up staffing plan Consider emergency plans that need to be developed Make sure the plan addresses how the participant will
be involved in self directing services Update the monitoring plan Include Community Guide outcomes in the plan Determine effective date
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Special Skills employees need to know…. Agency With Choice will ensure that staff
meet the minimum qualifications to provide the NC Innovations services
Managing Employer needs to add to the
ISP any additional skills they require for the staff related to services
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Back up Staffing Two levels of back up staffing are required for
each service Emergency responses to severe weather and
environmental emergencies Immediate coverage if the participant can not be
left alone Who to call if the plan is not working Ways to manage risk Contact numbers Unique to the participant Immediately accessible and operational
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Care Coordinator Monitoring of Individual/Family Directed Services
Monthly Monitoring Natural Supports can assist in monitoring
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Effective date of Individual/Family Effective date of Individual/Family DirectionDirection
Allow time for plan submission Allow time for Utilization Management review Allow time for Agency With Choice start up Allow time for staff to be hired Allow time for staff training
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Recruiting Managing Employer recruits the staff Can request that an ad be run through the
Agency With Choice Community Guide trains the Managing
Employer as needed on recruiting
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Agreements Individual/Family Directed Supports
Agreement Agency With Choice Agreement Employee Support Agreement/Supervision
Plan
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Agency with Choice Common Law Employer (agency is the employer of
record with IRS) Files claims for services, sets employee pay rates
and determines benefits Withholds taxes and unemployment insurance Carries Worker Compensation Insurance on
Employees Administers benefits Maintains accounts on participants funds Conduct background checks Purchases goods and services Produces records for audit Produces the quarterly financial reports for the
Managing Employers
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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What will the Agency with Choice do for the individual?
In the Agency With Choice Model, the AgencyWith Choice: Provides a toll free service line so that the
Managing Employer can call the Agency With choice
Sends quarterly report to the Managing Employer and Care Coordinator describing services billed and Individual Goods and Services purchased
Answers questions about the report
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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The Agency with Choice helps the Managing Employer by…. Paying employeesPaying employees Providing Workers Compensation Insurance Providing Workers Compensation Insurance
on employeeson employees Informing Employers of how much funding Informing Employers of how much funding
they have used (Quarterly Report)they have used (Quarterly Report) Filing tax forms for employeesFiling tax forms for employees Following state and federal rules about Following state and federal rules about
waiver fundingwaiver funding
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Managing Employer Responsibilities Participate in training and complete Self Participate in training and complete Self
Assessment with Care CoordinatorAssessment with Care Coordinator Decide skills and training that employees needDecide skills and training that employees need Lead/participate in the development or Update of Lead/participate in the development or Update of
the ISP the ISP Select an Agency With Choice to be the common Select an Agency With Choice to be the common
law employer of the employees law employer of the employees Find out pay rates and benefits offered by the Find out pay rates and benefits offered by the
Agency With ChoiceAgency With Choice Decide job duties and schedules with AgencyDecide job duties and schedules with Agency Refer prospective Employees to the Agency With Refer prospective Employees to the Agency With
ChoiceChoice
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Managing Employer Responsibilities Assist Agency in obtaining new hire paperworkAssist Agency in obtaining new hire paperwork Agency With Choice maintains Workers Agency With Choice maintains Workers
Compensation insurance on EmployeesCompensation insurance on Employees Work with Agency With Choice to make sure Work with Agency With Choice to make sure
employees are trainedemployees are trained Resolve issues or recommend replacement of Resolve issues or recommend replacement of
employeesemployees Review quarterly reports from Agency and Review quarterly reports from Agency and
stay within the Individual/Family Budgetstay within the Individual/Family Budget Make sure services are provided as written in Make sure services are provided as written in
the ISPthe ISP Ensure that the individual is healthy and safeEnsure that the individual is healthy and safe
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Managing Staff: Agency with Choice Model
Agency With Choice/Managing Employer work together to manage staff:
Provide or arrange training Schedule employees Evaluate employees Replace as needed
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Agency With Choice: What is the Agency With Choice: What is the Service Rate?Service Rate?
This is the Medicaid Service rate that the Agency
With Choice uses to pay for : Employee Training and Supplies Employment Advertisement Employee Salary, benefits Employer Taxes Workers Compensation Insurance Qualified Professional Supervision Record Keeping and Retention
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Termination from Individual/Family Direction A Managing Employer may be removed from the Individual and A Managing Employer may be removed from the Individual and
Family Directed Supports involuntarily under the following Family Directed Supports involuntarily under the following circumstances:circumstances:
Immediate health and safety concern, including mistreatment Immediate health and safety concern, including mistreatment of the individual of the individual
Suspected fraud and abuse of funds or evidence of unreported Suspected fraud and abuse of funds or evidence of unreported fraudfraud
No approved Representative available when the Managing No approved Representative available when the Managing Employer is determined to need oneEmployer is determined to need one
Refusal to accept needed Community Guide ServicesRefusal to accept needed Community Guide Services Refusal to allow Care Coordinator to monitor servicesRefusal to allow Care Coordinator to monitor services Non compliance with the Individual Family Supports, Agency Non compliance with the Individual Family Supports, Agency
with Choice, and /or Employee Support Agreementswith Choice, and /or Employee Support Agreements Inability to implement the approved ISP or comply with Inability to implement the approved ISP or comply with
Innovations requirements despite reasonable efforts by the Innovations requirements despite reasonable efforts by the MCO to provide additional technical assistance and support MCO to provide additional technical assistance and support ( 4th event requiring additional technical assistance/corrective ( 4th event requiring additional technical assistance/corrective action plan in twelve months)action plan in twelve months)
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Provider Responsibilityo Treatment Team Participationo Responsible for the development and
implementation of the short range goalso Responsible for the development and
implementation of the strategies/task analysiso Ensure short-range goals and strategies/task
analysis are in place prior to plan implementation
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Relative as Provider PolicyServices may be provided by: Legal guardians, parents of adult participants and other relatives who live
in the home of the individual
Waiver services that may be provided by relatives: Community Networking, Day Supports, Personal Care, In-Home Skill
Building, In-Home Intensive Support, Residential Supports
Conditions where relative may be employed: Other staff are not available to provide the service or Other staff are only willing to provide the service at an extraordinarily
higher cost than the fee or charge negotiated with the qualified family member or legal guardian.
Managing Employer may not direct a service that is subject to the managing employer’s direction
Typically no more than 40 hours per week of service or seven daily units per week, may be approved between all relatives who live in the same home as the individual.
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Submit application to the Network Cross Functional Team
Part A application-New Employees
Part B application-Existing Employees
Part C application-Request to Exceed 40 hours
Part D application if removed and reapply
Applications must be renewed annually
Relative as Direct Support Employee Process
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Review of Service Comparison Chart
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Completed for Direct Service Employees Checklist is valid for the location of service
provision The Provider Agency will make and document at a
minimum a monthly site visit H/S checklist is maintained at the agency and
reviewed during QM onsite monitoring.
Health and Safety Checklist
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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School Policy Equipment and Supplies Location of Service Services in the Home of the Employee Out of State Provider Qualifications
Additional Guidance and Waiver Policy
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Services must be documented by all Medicaid providers and done so prior to service implementation
There should be follow-up documentation to reflect any service deviation.
All NC Innovations services require a daily or per service note or grid
Follow the procedures as noted in the Records Management and Documentation Manual 45-2 (Chapters 8 & 9).
Documentation
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Crisis Services Community Guide Individual/directed Goods and Services Natural Supports Education Specialized Consultative Services
Service notes:
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Community Networking Day Supports In-Home Intensive Supports In-Home Skill Building Residential Supports Personal Care Respite Supported Employment
Service Grids
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Completed quarterly
Should be documented within 7 working days of close of the quarterly progress period
Considered a ‘late entry” if not completed within required timeframe
Progress Summary
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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o Progress summary requirements:o Individual’s nameo Date of quarterly review and dates the review
coverso Progress towards goalso Recommendations for continuation, revision or
termination of goalo Signature of individual completing review
Progress Summary
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Required for the following services: Community Networking Supported Employment Residential Supports In-Home Skill building Personal Care Day Supports
Progress Summary
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Absences, Terminations, and Transfers
Terminations Transfer to and from CAP-I/DD Transfers to and from other PIHPs Transfers to and from Cardinal
Innovations
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Performance Indicators
Used to demonstrate that waiver assurances and sub-assurances
Reported to CMS PIHP will remediate
NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina
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Lessons Learned Do things that are familiar Use your managed care tools to
increase felicity and quality of care Look for opportunities to suggest to
DMA less rules through better system management
Stay focused the Vision of the waiver in every system you implement and decision you make