West Virginia Department of Health and Human Resources’

Bureau for Medical ServicesIntellectual/Developmental

Disabilities Waiver(IDDW)

Program Overview

Presented byTaniua Hardy, Program Manager

Pat Nisbet, Director, Home and Community-Based Programs

Agenda

▪ Introduction

▪Application Process

▪Program Eligibility/Re-eligibility

▪ Service Delivery Model (SDM)

▪Program Requirements

▪Available Services

▪Accessing Available Services

▪The Negotiation Process

▪Medicaid Fair Hearing

▪Questions

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Introduction

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Introduction

▪ The IDDW program is West Virginia Medicaid’s Home and Community-Based program for individuals with intellectual and/or developmental disabilities.

▪ The program is administered by the West Virginia Department of Health and Human Resources’ (DHHR) Bureau for Medical Services (BMS). The program reimburses for services to instruct, train, support, supervise and assist individuals with developmental disabilities in achieving the highest level of independence and self-sufficiency possible.

▪ The program provides services in natural family settings, licensed and unlicensed group homes of up to four people and communities where the member resides, works and shops.

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Application Process

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Application Process

▪ Applications can be obtained from the BMS website: http://www.dhhr.wv.gov/bms/Programs/WaiverPrograms/IDDW/Pages/How-to-Apply.aspx

▪ Completed applications can be submitted by:▪ Fax: 1.866.521.6882▪ Mail: KEPRO

1007 Bullitt StreetSuite 200Charleston, WV 25301

▪ Email: wviddwaiver@kepro.com▪ KEPRO is the Utilization Management (UM)

contractor for BMS for the day-to-day operations of the program.

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Program Eligibility/Re-eligibility

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Eligibility Criteria

▪To be medically eligible for the program, individuals must meet diagnostic and functionality criteria, and must demonstrate a need for active treatment.

▪Evaluations for eligibility must demonstrate that the individual has a need for intensive instruction, services, assistance and supervision in order to learn new skills, maintain current level of skills, and/or increase independence in Activities of Daily Living (ADLs).

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Diagnosis

▪ There must be a diagnosis of an intellectual disability or a related condition before the age of 22.

▪ Examples of related conditions include Cerebral Palsy, Spina Bifida, Autism or any condition other than mental illness found to be closely related to intellectual disability.

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Functionality

▪ Demonstration of substantial deficits is required in three of the six identified major life areas listed below:

1. Self-care

2. Cognitive and expressive language (communication)

3. Learning (functional academics)

4. Mobility

5. Self-direction

6. Capacity for independent living (home living, social skills, employment, health and safety, community and leisure activities)

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Active Treatment

▪ Active treatment includes aggressive, consistent implementation of a program of specialized and generic training, treatment, health services and related services.

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Eligibility Evaluation and Determination

▪ BMS contracts with a Medical Eligibility Contracted Agent (MECA) to determine program eligibility.

▪ Eligibility for initial applicants is based on MECA’s review of a psychological evaluation conducted by a member of the Independent Psychologist Network (IPN).

▪ Continuing eligibility for existing members is determined by MECA’s review of the Annual Functional Assessment conducted by KEPRO.

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Additional Eligibility Criteria

▪ Other eligibility criteria include:

▪ Meeting financial eligibility criteria,

▪ West Virginia residence, and

▪ Choosing Home- and Community-Based services over services in an institutional setting.

▪ Applicants must be at least three years old.

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Service Delivery Models

(SDM)

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Service Delivery Models

▪ Members can choose between two Service Delivery Models:

▪ Traditional Service Delivery Model

▪ Traditional with Personal Options Service Delivery Model

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Traditional Service Delivery Model

▪ All members of the Program will receive some form of Traditional Services.

▪ The provider agency is responsible for hiring, training and supervising staff.

▪ The agency is employer of record and determines staff schedule and hourly rate of pay.

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Traditional with Personal Options SDM

▪ Four services can be participant-directed via this option: ▪ Person-Centered Support▪ Respite, ▪ Transportation, and▪ Participant-Directed Goods and Services.

▪ The member, with the assistance of a chosen representative, is responsible for hiring, training, and supervising staff.

▪ The member is employer of record and determines staff schedule and hourly rate of pay.

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Traditional with Personal Options SDM (Cont.)

▪ If Traditional with Personal Options SDM is selected, the state-contracted fiscal/employer agent processes timesheets and is responsible for all other payroll functions.

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Program Requirements

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Annual Functional Assessments

▪ Each year, members are required to participate in an Annual Functional Assessment.

▪ The assessment may take about two hours and is conducted by a KEPRO Service Support Facilitator (SSF).

▪ During the assessment, members and his/her supports provide information about the assistance the member needs.

▪ Results of the assessment are used to determine continued eligibility and to determine the Annual Individualized Budget.▪ The Annual Individualized Budget is the dollar amount

that will be used to access services for the member’s coming service year.

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Individualized Program Plan

▪ The member is required to attend Interdisciplinary Team (IDT) meetings, where the Individualized Program Plan (IPP) is developed.

▪ The IDT convenes at least annually to identify service needs and how those needs will be addressed.

▪ The plan must be reviewed at least every six months, and can be reviewed more often as needs arise.

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Additional Responsibilities

▪ Members are also required to:

▪ Participate in a monthly home visit with the Service Coordinator.

▪ Maintain a safe work environment for staff.

▪ Implement portions of the IPP for which they have accepted responsibility.

▪ Participate in re-determination of financial eligibility as required.

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Available Services

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Professional Services

▪ The IDDW program offers the following professional-level services:

▪ Service Coordination (required)

▪ Behavior Support Professional (BSP)

▪ Registered Nurse (RN)

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Service Coordination

▪ Service Coordination (SC) services establish, along with the member, a life-long, person-centered, goal-oriented process for coordinating the supports (both natural and paid), range of services, instruction and assistance needed by persons with developmental disabilities.

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Behavior Support Professional

▪ BSP services are available to assist members with habilitation training and management of significant problem behaviors.

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Registered Nurse

▪ RN services are available to members who have significant medical needs.

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Extended Professional Services

▪ Dietary, occupational, physical and speech therapies are available to members who demonstrate assessed need for such intervention.

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Direct Support Services

▪ The program offers the following direct support services:

▪ Person-Centered Support (PCS)

▪ Respite

▪ Facility-Based Day Habilitation (FBDH)

▪ Pre-vocational

▪ Job Development

▪ Supported Employment (SE)

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Available Services Information

▪ Prior authorization is required for all services and is based on assessed needs.

▪ Services must be within the member’s IDDW budget and service limits.

▪ Initial requests that result in the budget being exceeded will not be authorized; if desired, the team can pursue the Exceptions Process (formerly known as the second level process).

For additional information on IDDW services, refer to the IDDW policy manual at:

http://www.dhhr.wv.gov/bms/hcbs/IDD/Documents/APP2.pdf

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Accessing Available Services

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IDT Meetings

▪ The IDT identifies the member’s assessed needs by reviewing and discussing evaluations conducted and recommendations made.

▪ Based on the assessed needs, the IDT determines the services and number of units of each service that will be requested.

▪ In addition to identified needs, the IDT must also consider service limits and the assigned budget when deciding which services to request.

▪ After the IDT agrees on the services and number of units of those services that the member needs, the Service Coordinator requests authorization from KEPRO.

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The Negotiation Process

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The Negotiation Process

▪ KEPRO will not authorize any requests that result in the annual individualized waiver budget being exceeded.

▪ If the cost of the services, agreed by the IDT, exceeds the budget, the team may choose to access the Exceptions Process (formerly know as the second level process).

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Exceptions Process

▪ The Exceptions Process request will be clinically researched by a panel of three people employed by BMS and its contractor (currently KEPRO).

▪ At least one person on the panel will have medical training.

▪ First, the panel will determine if any technical errors were made in the calculation of the budget range.

▪ Next, the panel will review the documentation submitted by the service coordinator on behalf of the member to determine if funds in excess of the budget are needed to purchase clinically appropriate services necessary to prevent risk of institutionalization.

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Exceptions Process (Cont.)

▪ The person seeking additional services through the Exceptions Process has the burden of showing that services in excess of the individualized budget are necessary to avoid a risk of institutionalization.

▪ A clear explanation must be made to the panel justifying why the additional services are needed.

▪ Any documents must be attached, enclosed and provided to the panel and the specific sections highlighted. Just referring to attached documents on the Exceptions Process form is NOT sufficient and will not be considered by the panel.

▪ Some documents must be attached to the request.

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Medicaid Fair Hearing

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Medicaid Fair Hearing

▪ Medicaid Fair Hearing is requested by submitting a Hearing Request form to the Board of Review at:

Board of Review

Building 6, Capitol Complex

Charleston, WV 25305▪ The Hearing Request form must be completed and

signed by the member or his/her legal representative, if applicable. ▪ The majority of invalid requests are signed by the

Service Coordinator.▪ Failure to submit a valid request may result in

timelines not being met.

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Requesting Medicaid Fair Hearing

▪ While in hearing status, the member can receive the prior level of services received the previous year, ifthe Board of Review receives the Hearing Request within 13 days of the date of the signature for the Notice of Decision.

▪ In order for the appeal to be heard, the request for hearing must be received by the Board of Review no later than 90 days of the date of the signature for the Notice of Denial.

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Requesting Medicaid Fair Hearing (Cont.)

▪ Members can request the hearing venue of their choice: in person with the hearing officer at the local DHHR; at BMS; via video-conference at the local DHHR; or via teleconference.

▪ On the hearing request form, the member/legal representative should indicate whether the member will be represented by an attorney. ▪ This will allow BMS to secure attorney representation.▪ An attorney can be retained after the Hearing Request

form has been submitted; the attorney must notify the Board of Review if this occurs.

▪ The hearing will be scheduled and a scheduling order will be forwarded to the member/legal representative and to BMS.

▪ When the member receives the scheduling order, he/she can contact KEPRO to request a pre-hearing conference.

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The Pre-hearing Conference

▪ The pre-hearing conference is an informal process which BMS and the member/legal representative have a last opportunity to negotiate.

▪ If there is attorney representation, both parties’ attorneys must be present if a pre-hearing conference is conducted.

▪ If BMS and the member/legal representative come to a negotiated agreement, KEPRO will contact the Board of Review to withdraw the hearing request.

▪ If BMS and the member/legal representative cannot come to an agreement, the hearing will take place as scheduled.

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The Hearing

▪ If no pre-hearing conference is scheduled or an agreement cannot be reached in the pre-hearing, the hearing will be held in the previously identified venue as scheduled.

▪ The hearing is more formal than a pre-hearing conference and is presided over by a Hearing Officer with the Board of Review.

▪ BMS (referred to during the hearing as “the Department”) will provide testimony first, then the member/legal representative (referred to during the hearing as “the Claimant”) will present their case.

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The Hearing (Cont.)

▪ Each party will have an opportunity to provide rebuttal testimony.

▪ There are two possible outcomes of the hearing:

▪ Reversed - a finding in the Claimant’s favor.

▪ Upheld - a finding in the Department’s favor.

▪ Both parties are notified via mail of the decision, which will be forwarded within 90 days of the hearing.

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After the Hearing

▪ If the member is not satisfied with the decision, he/she can request a review of the case by the Board of Review. If that review does not yield satisfactory results, a Circuit Court review may be requested.

▪ If the Department is upheld, and the member has received the number of units previously authorized, the authorized units will be prorated.

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WV Code 44A-1-15

▪ Eligibility of guardians or conservators employed pursuant to a DHHR waiver program.

▪ (a) A person employed pursuant to a written contract or other employment arrangement with a licensed provider of a behavioral health services for the purposes of providing services to a protected person may be appointed by a court as the guardian or conservator of the protected person if: ▪ (1) Payment for services provided under the contract or

employment agreement is made pursuant to a waiver program;▪ (2) The person is related to the protected person by blood,

marriage, or adoption; ▪ (3) The contract or arrangement is disclosed in writing to the court;

and▪ (4) The court finds that the appointment is in the best interests of the

protected person. ▪ (b) Without the prior approval of the court, a guardian or conservator may

not enter into a written contract or other employment arrangement with a licensed provider of behavioral health services in which the guardian or conservator will receive compensation pursuant to a waiver program.

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WV Code 4A-1-15 (Cont.)

▪ (c) For the purposes of this section:▪ (1) Behavioral health services mean services provided for the care and

treatment of persons with mental illness, intellectual disability, developmental disabilities or alcohol or drug abuse problems in a inpatient, residential or outpatient setting, including, but not limited to, habilitative or rehabilitative interventions or services and cooking, cleaning, laundry and personal hygiene services provided for such care; and

▪ (2) “Waiver program” means a West Virginia Department of Health and Human Resource administered waiver program, including, but not limited to, the “MR/DD” or “Intellectual and Developmental Disabilities” waiver program authorized by section 1915 (c) of the Social Security Act.

▪ (d) A person appointed to serve as a guardian or conservator prior to the effective date of this section, enacted during the 2011 Regular Session of the Legislature, who meets the requirements contained in Subsection (A), shall retain his or her authority, powers and duties in that capacity under the provisions of this section: provided, that the guardian or conservator informs the court, in writing, that he or she is employed pursuant to a written contract or other employment arrangement with a licensed provider or behavioral health services under the waiver program.

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Contact Information

Patricia Nisbet, DirectorHome- and Community-Based ServicesWest Virginia Department of Health and Human ResourcesBureau for Medical Services350 Capitol Street, Room 251Charleston, WV 25301Email: Patricia.S.Nisbet@wv.gov

Taniua Hardy, Program ManagerIntellectual/Developmental Disabilities WaiverWest Virginia Department of Health and Human ResourcesBureau for Medical Services350 Capitol Street, Room 251Charleston, WV 25301Email: Taniua.R.Hardy@wv.gov

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Questions

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