MCO/IME SUMMIT FOR HABILITATION · H2016 U9 provides for 17-24 hours of service, per day, and is the highest level of service oﬀered for Home-Based Habilitaon. The comprehensive

MCO/IME SUMMIT FOR HABILITATION DECEMBER6,2016

10:00AMTO3:30PM

FFA ENRICHMENT CENTER, DMACC 1055 SW PRAIRIE TRAIL PARKWAY

ANKENY

9:15–10:00 REGISTRATION10:00–10:15 WELCOMEANDINTRODUCTIONS10:15–12:00 REVIEWOFWORKFLOWANDTIERS12:00–1:00 LUNCHPROVIDED1:00–3:00 CONTINUEDCONVERSATIONREGARDINGTIERS

ANDUTILIZATIONREVIEW DISCUSSIONOFSCOPEOFWORKAND

DOCUMENTATION REQUIREMENTSFORHABILITATION

3:00–3:30 GENERALQUESTIONS

Habilitation Summit

PresentersGaylaHarken

LeAnnMoskowitzKarenWalters-

CrammondSaraHackbart

KimberlyLochner

Presented:December2016

Thismaterialisdesignedandintendedforgeneralinforma1onalpurposesonly.Theuserisresponsiblefordeterminingtheapplicabilityandlegalityofthisinforma1onandfordeterminingthemostrecentlaw,statuteorregula1on(s)thatmaybeapplicabletotheuser’spar1cularsitua1on.TheIowaAssocia1onofCommunityProvidersassumesnoresponsibilityfortheaccuracyorlegalityoftheinforma1oncontainedherein.

2

Objec1ves

Attheendofthistrainingpar1cipantswillunderstand:• ThepurposeandthegoalsoftheHCBSHabilita1onProgram• HowweworktogethertoprovidequalityHabilita1onservicesformembers—workflowforHabmembers

• Whatcriteriaareusedtodescribe/assignthevariousHabilita1on1ers

3

ProgramPurpose

ToprovidestateplanHomeandCommunityBasedServices(HCBS)toIowanswithfunc1onallimita1onstypicallyassociatedwithchronicmentalillness.

4

PersonCenteredPlanningisaMust

PersonCenteredPlanningisnowaFederalRequirementNeedsandservicesaredeterminedbythepersonandsupportedbytheIDT.TrainingiscomingFebruary21withDerrickDufresne

5

FocusonRECOVERY

SAMHSA,2012,establishedthedefini1onofrecoveryasaprocessofchangethroughwhichindividualsimprovetheirhealthandwellness,liveself-directedlives,andstrivetoreachtheirfullpoten1al.

6

FocusonRECOVERY

Hope,thebeliefthatthesechallengesandcondi1onscanbeovercome,isthefounda1onofrecovery.Aperson’srecoveryisbuiltonhisorherstrengths,talents,copingabili1es,resources,andinherentvalues.Itisholis1c,addressesthewholepersonandtheircommunity,andissupportedbypeers,friends,andfamilymembers.Samsha.gov2016

7

FocusonRECOVERY

ThebeliefinrecoveryforpersonswhohaveMentalIllnessiscentraltoprovidingHabilita1on.

8

Habilita1onServiceDescrip1ons

9

TheHabilita1onProcessIntegratedHealthHomes

• Establishestheinterdisciplinaryteamwiththemember• DevelopstheHCBSComprehensiveServicesPlan/Treatmentplanbasedonthemember’siden1fiedneedsandgapsincare

• Integratesserviceplan/treatmentplansamongmedicalandcommunitybasedprovidersandthemember

• Responsibleformonitoringoftreatmentplanimplementa1onandservices

• Responsibleforamendingtheservice/treatmentplanasiden1fiedbyachangeinthemembersneedsorcondi1on

10

RequiredAssessments

• Assessmentisrequiredini1allyatthe1meofapplica1on• Assessmentisrequiredannuallyatthe1meofeligibilityredetermina1on

• Assessmentisrequiredifthemember’scondi1onchangessignificantly

• Ages4to18-interRai–ChildandMentalHealth• Ages19andover-interRai–CommunityMentalHealth

11

Eligibility

12

HowDoYouEnrollinHab?

• MustbeeligibleforMedicaidthroughanexis1ngcoveragegroup

• Householdincomecannotexceed150%ofFederalPovertyLevel(FPL)

• Meetneeds-basedeligibilitycriteriaasdeterminedbyaNeeds-BasedEvalua1on–ComprehensiveFunc1onalAssessment

13

HowDoYouEnrollinHab?

• Meets1of2riskfactors:– Hasundergoneoriscurrentlyundergoingpsychiatrictreatmentmoreintensivethanoutpa1entcare,morethanonceinalife1me(e.g.,emergencyservices,alterna1vehomecare,par1alhospitaliza1onorinpa1enthospitaliza1on).

– Hasahistoryofpsychiatricillnessresul1nginatleastoneepisodeofcon1nuous,professionalsuppor1vecareotherthanhospitaliza1on.(e.g.,residen1alplacement)

14

HowDoYouEnrollinHab?• Meetsatleast2of5criteriashowinganeedforassistanceforatleasttwoyears:

– Isunemployed,oremployedinashelteredsehng,orhavemarkedlylimitedskillsandapoorworkhistory.

– Requiresfinancialassistanceforout-of-hospitalmaintenanceandmaybeunabletoprocurethisassistancewithouthelp.

– Showssevereinabilitytoestablishormaintainapersonalsocialsupportsystem.

– Requireshelpinbasiclivingskillssuchasself-care,moneymanagement,housekeeping,cooking,ormedica1onmanagement.

– Exhibitsinappropriatesocialbehaviorthatresultsindemandforinterven1on. 15

Workflow(Fee-for-service,Amerigroup,AmeriHealth,andUnitedHealthcare)

16

MatrixofHabProcessperFunder

hip://www.iowaproviders.org/assets/docs/habilita1on_matrix.doc

17

Home-basedHabilitaQonTierDescripQons

18

Home-basedHabilita1onIntensiveIIIH2016U9providesfor17-24hoursofservice,perday,andisthehighestlevelofserviceofferedforHome-BasedHabilitaQon.Thecomprehensiveperson-centeredplanisdevelopedwiththegoalofsymptomstabilizaQon.IntensiveIIIshouldbesupportedbythemember’spsychiatristorotherappropriateclinician.CollaboraQonshouldbeconsistentandongoingwithIHHstaff,habilitaQonsupervisor,in-homenurse,psychiatrist,andaddiQonalteammembers.Criteria:

– Membersdemonstra1ngimpairmentoffunc1oningasaresultofaseriousmentalillness(SMI);– Thememberhassignificantriskofharmtoselforothersordisturbancesofmood,thought,orbehaviorwhichrendershim/herincapableofappropriateself-careorself-regula1on17-24hoursaday;

– Lackofabilityorcapacitytopar1cipateinstructuredormeaningfulac1vityinthecommunityduetosignificantbehaviorsthatcouldcauseharmtoselforothers;

– Thislevelofcareincludessignificantinterven1onfromstafffor17-24hoursaday;– Membershowsinstabilityinhis/hermentalhealthneedingsignificantassistancewithmood,copingandothermentalhealthsystems. 19

Home-basedHabilita1onIntensiveIIH2016U8providesfor13-16.75hoursofservice,perday,tosupportthememberinordertogainproficiencyandtoincreaseindependence.Thecomprehensiveperson-centeredplanisdevelopedwiththegoalofstabilizingthemember’ssymptomstomaintainadailyrouQne.Criteria:

– Periodsfreefromsignificant,ongoingself-harmorharmtoothersthatputsselforothersatriskforinjury;

– Lackofabilityorcapacitytopar1cipateinstructuredandmeaningfulac1vityoutsidetheirresidence(e.g.goingtochurchwithastaffmemberoraiendingabookclubwithastaffmember);

– Memberneedssignificantsupporttocompletebasicskillssuchasfrequentinterven1onsorsupportintheirresidence,dayprogram,orworksehngfor13-16.75hoursperday;

– Memberneedssignificantinterven1onfromstafftoremainsafeinthecommunityandhomefor13-16.75hoursperday;

– Memberneedssignificantsupportfromstafftostabilizedailyrou1neandtomanagemood,copingorothermentalhealthsymptoms. 20

Home-basedHabilita1on

IntensiveIH2016U7providesfor9-12.75hoursofservice,perday,toassistthememberingreaterindependenceandcommunityintegraQonasreflectedbythecomprehensiveperson-centeredplan.ThemembershowsincreasedabilitytoparQcipateinthecommunitysuchasworking,volunteering,parQcipaQngindayhabilitaQon,orothermeaningfulacQviQes.Criteria:

– Periodsfreefromanysignificant,ongoingself-harmorharmtoothers;– Withoutsupportinthefollowingareas,thememberwouldbeatriskforhospitaliza1on,lossofindependentliving,incarcera1on,orincreasetoharmtoself:

• ProblemSolving;• Emo1onalmanagement;• Copingskills;• Relaxa1on/self-regula1on;• Crisisplanningandimplementa1on 21


MediumNeedH2016U6providesfor4.25-8.75hoursofserviceperday,everydaywiththegoalofincreasingparQcipaQoninthecommunityandregularlyparQcipaQnginmeaningfulacQviQes.Criteria:

– Thememberistransi1oningfromamoreintensivelevelofcareandcon1nuestoshowimprovementinsymptoms,ORthememberneedsmorestructureandsupportamerbeinginalowerlevelofcare;

– Thememberhasadailyminimalneedforsupportwithskillsinthefollowingareas:managingthelivingenvironment,performingac1vi1esofdailyliving(ADL’s),employingposi1vecommunityandsocialskills,andimplemen1ngascheduleordailyrou1ne.

22


RecoveryTransiQonalH2016U5providesfor2.25–4hoursofserviceperday,everyday,withtreatmentgoalsfocusedonmanagingADLs,interacQngwithinthecommunity,andpersonallydefinedgoals.Criteria:

– Greaterindependenceinnaviga1ngthecommunity;– Followsascheduleandisabletoleavethehomeforpurposefulac1vityORengagesinmeaningfulac1vi1esathomewithassistancefromstaffmembers.

23


HighRecoveryH2016U4providesfor.25-2hoursorserviceperday,everydayandisthelowestlevelofcareofferedunderHome-BasedHabilitaQon.MinimalintervenQonorstaffmembersupportisneeded.Thislevelofcarewouldbeconsideredastepaboveindependentliving.ThememberconQnuestoshowprogresstowardsgoalsofmanagingADLs,interacQngwithinthecommunity,andpersonallydefinedgoals.Theremustbeatleast15minutesofservicetobilloneunit.Criteria:

– Navigatesthecommunitywithliiletonoassistance;– Followsascheduleandisabletoleavehomeforpurposefulac1vi1esorengagesinmeaningfulac1vityathomeindependently.

24


Theamountof1mespentinHBHvariesfromdaytodayorweektoweek,wewouldexpecttoseetheaveragenumberofhoursofactualserviceprovidedinamonthtofallwithintherangeiden1fiedinthemember’s1er.

25

Addi1onalSupports

Thereisapoten1alforduplica1onofserviceandcoordina1onwithHabilita1onandsomeMedicaidservices.Canyouthinkofwheretheduplica1onmightbe?

26

Habilita1onwithIHH&CSS

27

Community Support Services (CSS) Integrated Health Home (IHH) + HabilitationMonitoring of mental health symptoms and functioning / reality orientation.

Serve as active team member, monitoring and intervening on progress of member treatment goals using holistic clinical expertise.

Supportive relationships Advocacy for participants, developing social support networks.

Communication with other providers. Serve as a communication hub, facilitating the timely sharing of information across providers 24 hours per day, 7 days per week. Care coordination (e.g. assessments, scheduling appointments, making referrals, collaboration with providers).

Assistance in attending appointments and obtaining medications.

Promoting self-direction and skill development in the area of independent administering of medication and medication adherence. Scheduling appointments. Assistance with medication and treatment management and adherence.

28

Community Support Services (CSS) Integrated Health Home (IHH) + Habilitation

Crisis intervention and development of a crisis plan.

Facilitate development of crisis plans, monitor for potential crisis escalation / need for intervention.

Development and coordination of natural mental health support systems.

Develop a person-centered care plan for each individual that coordinates and integrates all of his or her clinical and non-clinical health care-needs and services. Referral to community and social support services. Connection to peer advocacy groups, family support networks, wellness centers, NAMI and family psychoeducational programs.

Transportation Transportation is included with: •  Home-based habilitation •  Day habilitation •  Supported employment individual employment Non-emergency medical transportation (NEMT) can be used for: •  Transportation to and from other Medicaid services (non

HCBS habilitation services)

Habilita1onwithIHH&CSS,cont’d

Source: Community Mental Health Center Block Grant, 1915(i) State plan HCBS, IA-14-009 IA SPMI Health Home – Managed Care Implementation (Health Home State Plan Amendment)

Documentation Requirements

29

Habilita1onComprehensiveServicePlan

• FederallyrequiredforeachindividualreceivingStatePlanHCBSHabilita1onServices(1915(i))

• TheIHHmaycallthedocumenta“TreatmentPlan”or“CareCoordina1onPlan”,theCentersforMedicaidandMedicareServices(CMS)referstothedocumentasaComprehensiveServicePlan

30


• Mustiden1fytheservicesandsupportsthememberreceivesfromallfundingsourcesincludingMedicaid,Region,IVRS,Privateinsuranceetc.

• Mustbedevelopedthroughaperson-centeredplanningprocess

• IsestablishedwiththeIDTledbytheIntegratedHealthHomeCoordinatororCaseManager.

31


• Mustbeupdatedatleastannuallyandwhenachangeintheindividual’scircumstancesorneedschangesignificantly,andattherequestoftheindividual.

• Includespeoplechosenbytheindividual• Providesnecessaryinforma1onandsupporttotheindividualtoensurethattheindividualdirectstheprocesstothemaximumextentpossible

32

Habilita1onComprehensiveServicePlanandtheHCBSSehngRequirements

Servicesandthesehngsinwhichservicesaredeliveredmust:• EnsurethatpeoplereceivingservicesandsupportshavefullaccesstocommunitylivingtosameextentasindividualsnotreceivingMedicaidHCBSIndividualchoiceinlivingarrangements,serviceproviders,andlifechoices

• Ensurethatindividualrightsarenotrestricted.• Avoidregimenta1onindailyac1vi1es,schedules,andpersonalinterac1ons

33

ServicePlanDocumenta1on

• Reflectsindividual’sstrengthsandpreferences• Reflectsclinicalandsupportneeds• Includesobservableandmeasureablegoalsanddesiredoutcomes

• Iden1fyinterven1onsandsupportsneededtomeetthosegoalswithincrementalac1onsteps,asappropriate.

• Iden1fythestaffpeople,businesses,ororganiza1onsresponsibleforcarryingouttheinterven1onsorsupports.

34


Iden1fiesforamemberreceivingHomeBasedHabilita1on:a)  Themember’slivingenvironmentatthe1meofenrollment;b)  Thenumberofhoursperdayofon–sitestaffsupervisionneededbythe

member;andc)  Thenumberofothermemberswhowilllivewiththememberinthelivingunit.

35


Iden1fiesforamemberreceivingSupportedEmploymentservices

a)  Themember’splaceofemploymentatthe1meofenrollment;b)  Thenumberofhoursperdayofon–sitestaffsupervisionneededbythe

member;andc)  Thenumberofotherworkerswhoworkwiththememberandalsoreceive

publiclyfundedemploymentsupportsattheirplaceofemployment.d)  StatusofreferraltoIowaVoca1onalRehabilita1onServices

36


Iden1fiesforamemberreceivingPrevoca1onalservicesa)  Theloca1onwherePrevoca1onalservicesarebeingdeliveredatthe1meof

enrollment;b)  Thenumberofhoursperdayofon–sitestaffsupervisionneededbythe

member;c)  Theplanforwhenthememberwillpar1cipateinCareerExplora1onac1vi1es.d)  Thestatusofprovidingthememberwithinforma1onregardingSupported

Employmentandthebenefitsofwork,andreferraltosupportedemploymentservices

e)  StatusofreferraltoIowaVoca1onalRehabilita1onServices

37


Iden1fiesforamemberreceivingPrevoca1onalservicesa)  Theloca1onwherePrevoca1onalservicesarebeingdeliveredatthe1meof

enrollment;b)  Thenumberofhoursperdayofon–sitestaffsupervisionneededbythe

member;c)  Theplanforwhenthememberwillpar1cipateinCareerExplora1onac1vi1es.d)  Thestatusofprovidingthememberwithinforma1onregardingSupported

Employmentandthebenefitsofwork,andreferraltosupportedemploymentservices

e)  StatusofreferraltoIowaVoca1onalRehabilita1onServices

38


• Reflectsprovidersofservices/supports,includingunpaidsupportsprovidedvoluntarilyinlieuofwaiverorstateplanHCBSincluding:a)  Nameoftheproviderb)  Serviceauthorizedc)  Unitsofserviceauthorizedd)  Periodofserviceauthoriza1on

• Includesriskfactorsandmeasuresinplacetominimizerisk

39


• Includesindividualizedbackupplansandstrategieswhenneeded• Iden1fyanyhealthandsafetyissuesapplicabletotheindividualmemberbasedoninforma1ongatheredbeforetheteammee1ng,includingariskassessment.

• Iden1fyanemergencybackupsupportandcrisisresponsesystemtoaddressproblemsorissuesarisingwhensupportservicesareinterruptedordelayedorthemember’sneedschange.

• Providersofapplicableservicesshallprovideforemergencybackupstaff.

40


• Documentstheinformedconsentoftheindividualforanyrestric1onsonthemember’srights,includingmaintenanceofpersonalfundsandself–administra1onofmedica1ons,theneedfortherestric1on,andeitheraplantorestorethoserightsorwriiendocumenta1onthataplanisnotnecessaryorappropriate.

• Anyrightsrestric1onsmustbeimplementedinaccordancewith441IAC77.25(4).

41


• Includesindividualsimportantinsuppor1ngindividual• Includesthenamesoftheindividualsresponsibleformonitoringplan

• Iswriieninplainlanguageandunderstandabletotheindividual

• Documentswhoisresponsibleformonitoringtheplan

42


• Includesthesignaturesofallindividualsandprovidersresponsible

• Isdistributedtotheindividualandothersinvolvedinplan• Includespurchase/controlofself-directedservices• Excludesunnecessaryorinappropriateservicesandsupports

43

Services&Supports

Servicesdesignedtoassistinacquiring,retainingandimprovingtheself-help,socializa1onandadap1veskillsnecessarytoresidesuccessfullyinthecommunity.

• CaseManagement(membersthatalsoreceiveHCBSWaiverServices)

• Habilita1on– DayHabilita1on– Home-BasedHabilita1on– Prevoca1onalHabilita1on– SupportedEmploymentHabilita1on

44

Services&Supports

Home-BasedHabilita1on• Servicesprovidedintheperson’shomeandcommunity.• Assiststhemembertoresideinthemostintegratedsehngappropriatetothemember’sneeds.

• Provideforthedailylivingneedsofthemember• Typicalexampleswouldbeassistancewithmedica1onmanagement,budge1ng,groceryshopping,personalhygieneskills,etc.

45

HomeBasedHabilita1on

HomeBasedHabilita1onincludesthefollowingsupports:• Adap1veskilldevelopment• Assistancewithac1vi1esofdailyliving• Communityinclusion• Transporta1on(excepttoandfromadayprogram)• Adulteduca1onalsupports• Socialandleisureskilldevelopment• Personalcare• Protec1veoversightandsupervision

46


• Transporta1onisacceptableifitsupportstheacquisi1on,reten1on,orimprovementofanotherskill,suchasgroceryshopping,gehngmedicalcare,etc.

• Personalcareandprotec1veoversightandsupervisionmaybeacomponentofhome-basedhabilita1onservicesbutmaynotcomprisetheen1retyoftheservice.

• Home-basedhabilita1oncannotbeprovidedtomemberswhoresideinaresiden1alfacilityofmorethan16beds.

47


Home%Based%Habilitation%Tier%

Hours%of%supervision%and%support%needed%based%on%the%member’s%Comprehensive%Functional%

Assessment%

Procedure%code%

Modifier%

Intensive%III% 17@%24%hours%per%day% H2016% U9%Intensive%II% 13%to%16.75%hours%per%day% H2016% U8%Intensive%I% 9%to%12.75%hours%per%day% H2016% U7%

Medium%Need% 4.25%to%8.75%hours%per%day%as%needed% H2016% U6%Recovery%Transitional%

2.25%to%4%hours%per%day%as%needed% H2016% U5%

High%Recovery% .25%to%2%hours%per%day%as%needed% H2016% U4%

%

48

DayHabilita1on

• Providedinacommunitybaseddayprogramsehngoutsidethehome.• Assistancewithacquisi1on,reten1on,orimprovementinself-help,socializa1on,andadap1veskillstoaiainormaintainthemember’smaximumfunc1onallevel.• Focusesonareassuchassocialskills,communica1onskills,behaviormanagement,func1onalskilldevelopment,dailylivingac1vi1es,selfadvocacyskills,etc.

49

DayHabilita1on

• Dayhabilita1onservicesfocusonenablingthemembertoaiainormaintainhisorhermaximumpoten1alandshallbecoordinatedwithanyneededtherapiesintheindividual’sperson-centeredservicesandsupportsplan,suchasphysical,occupa1onal,orspeechtherapy.

• Personalcare/assistancemaybeacomponentpartofdayhabilita1onservicesasnecessarytomeettheneedsofamember,butmaynotcomprisetheen1retyoftheservice.

50

DayHabilita1on

• Memberswhoreceivedayhabilita1onservicesmayalsoreceiveeduca1onal,supportedemploymentandprevoca1onalservices.

• Amember’sperson-centeredservicesandsupportsplanmayincludetwoormoretypesofnon-residen1alhabilita1onservices.However,differenttypesofnon-residen1alhabilita1onservicesmaynotbebilledduringthesameperiodoftheday.

51

DayHabilita1on

• Dayhabilita1onmaybefurnishedinanyofavarietyofsehngsinthecommunityotherthanthemember’sprivateresidence.Dayhabilita1onservicesarenotlimitedtofixed-sitefacili1es

• Transporta1onbetweenthemember'splaceofresidenceandthedayhabilita1onsite,orothercommunitysehngs,inwhichtheserviceisdelivered,isprovidedasacomponentofdayhabilita1onservicesandthecostofthistransporta1onisincludedintheratepaidtoprovidersofdayhabilita1onservices.

52

DayHabilita1onHabilitation Habilitation Service Level of support and support needed based on the member’s

Comprehensive Functional Assessment and employment situation Procedure code

Day Habilitation Daily T2021

Day Habilitation 15 min T2020

A unit of day habilitation is 15 minutes (up to 16 units per day) or a full day (4.25 to 8 hours).

53

Prevoca1onalServices

• Providecareerexplora1on,learningandworkexperiences,includingvolunteeropportuni1es,wherethemembercandevelopnon-job-task-specificstrengthsandskillsthatleadtopaidemploymentinindividualcommunitysehngs.

• Areprovidedtopersonswhoareexpectedtobeabletojointhegeneralworkforcewiththeassistanceofsupportedemployment

54

Prevoca1onalServicesPrevoca1onalservicesareintendedtodevelopandteachgeneralemployabilityskillsrelevanttosuccessfulpar1cipa1oninindividualemployment.Theseskillsincludebutarenotlimitedto:

• theabilitytocommunicateeffec1velywithsupervisors,coworkersandcustomers,• anunderstandingofgenerallyacceptedcommunityworkplaceconductanddress;• theabilitytofollowdirec1ons;theabilitytoaiendtotasks,• workplaceproblem-solvingskillsandstrategies;• generalworkplacesafetyandmobilitytraining,• theabilitytonavigatelocaltransporta1onop1ons;• financialliteracyskills;• skillsrelatedtoobtainingemployment.

55

Prevoca1onalServices

• Prevoca1onalservicesincludecareerexplora1onac1vi1estofacilitatesuccessfultransi1ontoindividualemploymentinthecommunity.Par1cipa1oninprevoca1onalservicesisnotaprerequisiteforindividualorsmall-groupsupportedemploymentservices.

Careerexplora1on• Careerexplora1onac1vi1esaredesignedtodevelopanindividualcareerplanandfacilitatethemember’sexperien1allybasedinformedchoiceregardingthegoalofindividualemployment.

56

Prevoca1onalServicesTheexpectedoutcomeofprevoca1onalservicesisindividualemploymentinthegeneralworkforce,orself-employment,inasehngtypicallyfoundinthecommunity,wherethememberinteractswithindividualswithoutdisabili1es,otherthanthoseprovidingservicestothememberorotherindividualswithdisabili1es,tothesameextentthatindividualswithoutdisabili1esincomparableposi1onsinteractwithotherpersons;andforwhichthememberiscompensatedatorabovetheminimumwage,butnotlessthanthecustomarywageandlevelofbenefitspaidbytheemployerforthesameorsimilarworkperformedbyindividualswithoutdisabili1es. 57

SupportedEmploymentServices

Individualsupportedemploymentinvolvessupportsprovidedto,oronbehalfof,thememberthatenablethemembertoobtainandmaintainanindividualjobincompe11veemployment,customizedemploymentorself-employmentinanintegratedworksehnginthegeneralworkforce.Servicesareprovidedtomemberswhoneedsupportbecauseoftheirdisabili1es.

58


Long-termjobcoachingissupportprovidedto,oronbehalfof,thememberthatenablesthemembertomaintainanindividualjobincompe11veemployment,customizedemploymentorself-employmentinanintegratedworksehnginthegeneralworkforce.Long-termjobcoachingservicesareprovidedtooronbehalfofmemberswhoneedsupportbecauseoftheirdisabili1esandwhoareunlikelytomaintainandadvanceinindividualemploymentabsenttheprovisionofsupports. 59


Small-groupsupportedemploymentservicesaretrainingandsupportac1vi1esprovidedinregularbusinessorindustrysehngsforgroupsoftwotoeightworkerswithdisabili1es.Small-groupsupportedemploymentservicesmustbeprovidedinamannerthatpromotesintegra1onintotheworkplaceandinterac1onbetweenmembersandpeoplewithoutdisabili1es(e.g.,customers,coworkers,naturalsupports)inthoseworkplaces.

60


TheexpectedoutcomeofSupportedEmploymentservicesissustainedemployment,orself-employment,paidatorabovetheminimumwageorthecustomarywageandlevelofbenefitspaidbyanemployer,inanintegratedsehnginthegeneralworkforce,inajobthatmeetspersonalandcareergoals.Anexpectedoutcomeofsupportedself-employmentisthatthememberearnsincomethatisequaltoorexceedstheaverageincomeforthechosenbusinesswithinareasonableperiodof1me.

61

Prevoca1onalandSEServiceCodes

62

Addi1onalSupports

ThePersonCenteredPlanwillhelpguidethetypeandamountofsupportthatisappropriate.TherearetwoaiachmentssenttoyouthatalsocanhelpguidethedevelopmentoftheHabilita1onPlan

63

Ques1ons

64

NextIHHSummit

April20,2017

IowaStateCenter—SchemanBuilding

65

1

HABILITATIONPROCESSES*

EnrollmentinHabilitationTopic Fee-for-Service AmeriHealthCaritasIowa Amerigroup UnitedHealthcare

NotificationofInteresttoApplyforHabilitation

TheIHHlogsintotheIMEIndividualServicesInformationSystem(ISIS)toinitiateHabilitationservicesusingtheaddprogramtab.CompleteinstructionarelocatedintheHabilitationmanualat:http://dhs.iowa.gov/sites/default/files/Habilitation.pdf

TheIHHorCBCMentersanActivityintoJiva,requestinganinitialInterRAIforHabilitation.

TheIHHproviderorCBCMdeterminesifmemberhasaneedforandmeetsqualificationsforHabilitationservices.TheIHHproviderinitiatesHabilitationassessment.

TheIHHproviderorCBCMdeterminesifmemberhasaneedforandmeetsqualificationsforHabservices.TheIHHproviderinitiatesHabassessment.

InitialAssessment-completionoftheCoreStandardizedAssessment(InterRAI)

WhenHabilitationhasbeeninitiatedforaFFSmemberinISISandthememberisfinanciallyeligibleaworkflowiskickedofftotheIMECoreStandardizedAssessment(CSA)ContractortoscheduletheinterRAIassessmentinterview.TheCSAcontractorcontactsthememberorthemember’sguardianandtheIHHCareCoordinator(ifidentifiedinISIS)toscheduletheinterRAI.TheCSAcontractorprovidestheresultsoftheassessmenttotheIHHCCwithinfivebusinessdaysbypostingthereportintheIowaMedicaidPortalApplication(IMPA)system.ThemembermustbeenrolledwiththeIHHinIMPAandtheIHHmusthaveaccesstotheIMPAassessmentworkflow.IMPAinstructionsarelocatedonInformationalLetter.

AmeriHealthCaritasIowa(ACIA)sendstotheACIACoreStandardizedAssessment(CSA)contractoranoticetocompletetheInterRAI.TheCSAcontractorcontactstheIHH/CBCMtoassistinschedulingtheInterRAI.

TheIntegratedHealthHome(IHH)CareCoordinator(CC)(non-waiverHabilitation)orCommunityBasedCaseManager(CBCM)(waiverHabilitation)contactsthemembertoscheduleatimetocompletethecomprehensivestandardizedassessment(CSA).Fornon-waiverHabilitation,theCSAistheinterRAI.

CurrentlyUnitedHealthcare(UHC)isnotusingtheInterRAIassessmenttool.IHHProvidersareresponsibleforcompletingCSAassessmentsontheirownassessmenttoolandsubmittingtoUHCpriortoannualduedate.

2

Topic Fee-for-Service AmeriHealthCaritasIowa Amerigroup UnitedHealthcareSocialHistory TheIHHisresponsiblefor

documentingtheSocialHistoryoftheFFSmemberanduploadingthedocumenttoIMPA.

TheIHH/CBCMcompletesthesocialhistoryanduploadsittotheDocumentssectionofJiva.

TheIHHCCorCBCMsubmitstheinterRAIandsocialhistorytoAmerigroupviafaxwiththeMentalHealthOutpatientTreatmentForm-IAHealthLink(1-866-877-5229)orthroughtheproviderportal(www.availity.com).IHHindicatesonthefaxcoversheetorinthe“notessection”oftheportalthatitisaninitialrequest.

IHHcompletesthesocialhistory.Forinitialassessments,theIMPAcoversheetisincludedandsubmittedtoUnitedHealthcare.Forrenewals,includesummarysheetandsubmittoUnitedHealthcare.Submitformsperemail:[email protected].

EligibilityDetermination&CommunicationofDecision

AllinitialneedsbasedeligibilitydeterminationsaremadebytheIMEMedicalServicesUnitforallMedicaidmembers,regardlessifenrolledinmanagedcareorFee-For-Service(FFS).IHHCCreceivesamilestoneinISISnotifyingthemwhenadditionalinformationisrequiredandwhentheFFSmemberhasbeenapprovedordeniedforHabilitation.TheIHHisresponsibletoprovidetheNoticeofDecisiontothemember.

IMELevelofCarereviewerdetermineseligibilitybasedonInterRAIandSocialHistoryandsendsafiletoACIA.ACIAsendsasecureemailtotheIHH/CBCM,whothennotifiesthememberandproviders.

AGPforwardsthesocialhistoryandinterRAItoIMEforlevel-of-caredetermination.IMELevelofCarereviewerdetermineseligibilitybasedoninterRAIandsocialhistoryandnotifiesAGPbyStatefiletransfer.AGPcompletestherequestintheAGPsystemandfaxesthenotificationtotheIHH.TheIHHisresponsibletoprovidetheNoticeofDecisiontothememberandifneeded,IMEappealinformation.

IMELevelofCareMedicalReviewerdeterminesinitialassessments’determinationandissuesnoticeofdecision.UnitedHealthcarewillsendemailnotificationofdecisiontoIHH.Forrenewal/annualassessmentdeterminations,UnitedHealthcarewillsendanemailnotificationtotheIHHwithadecision.

3

AnnualRedetermination

30dayspriortotheannualredeterminationdatetheIHHreceivesamilestonenotifyingthemthattheannualredeterminationisdueandtheIHHCCrespondstotheassessmentmilestonekickingofftheworkflowtotheCSAcontractortocompletetheannualassessmentfollowingthesamestepsnotedabovefortheinitialauthorization.

ACIAsendstotheCSAcontractoronamonthlybasisallWaiverandHabilitationmemberswithrenewalassessmentduedates.CSAcontractorcompletestheInterRAI,whichisuploadedtoJiva.

Fourtosixweekspriortotheannualredeterminationdate,theIHHCCorCBCMcontactsthemembertoscheduleatimetocompletetheinterRAI.TheIHHCCorCBCMsubmitstheinterRAIandsocialhistorytoAmerigroupviafaxwiththeMentalHealthOutpatientTreatmentForm-IAHealthLink(1-866-877-5229)orthroughtheproviderportal(www.availity.com).IHHindicatesonthefaxcoversheetorinthe“notessection”oftheportalthatitisarenewalrequest.

IHHCareCoordinatorcompletestheassessmentandsubmitstoUnitedHealthcareperemailtouhc_iowa_integratedhealthhomes@uhc.comorFaxto877-960-5516.

4

Topic Fee-for-Service AmeriHealthCaritasIowa Amerigroup UnitedHealthcareContinuedEligibilityDetermination&CommunicationofDecision

AllannualredeterminationsofneedsbasedeligibilityaremadebytheIMEMedicalServicesUnitforFee-For-Service(FFS)members.IHHCCreceivesamilestoneinISISnotifyingthemwhenadditionalinformationisrequiredandwhentheFFSmemberhasbeenapprovedordeniedforHabilitation.TheIHHisresponsibletoprovidetheNoticeofDecisiontothemember.

ACIALevelofCareReviewerdeterminescontinuedeligibilitybasedonInterRAI.Ifapproved,theyemailtheIHH/CBCM.Ifdenied,theInterRAIisuploadedtoIMPAwithrequestforreviewbyIME.

AnAGPUtilizationReviewCareManagerdeterminescontinuedeligibilitybasedontheinterRAIandsocialhistory.Ifapproved,AGPcompletestherequestintheAGPsystemandfaxesthenotificationtotheIHH.Ifitappearsthememberdoesnotmeeteligibility,theinterRAIandsocialhistoryareforwardedtoIMEforfinallevelofcaredetermination.TheIHHisresponsibletoprovidetheNoticeofDecisiontothemember,andifneeded,IMEappealinformation.

UnitedHealthcarewillnotifytheIHHperemailoftheLevelofcaredecision.IfLevelofCareisdenied,theassessmentisuploadedtoIMPAforIMEreview.

TimeframesforReviewandDetermination

TheassessmentisuploadedtoIMPAwithin5businessdaysandtheIMEMedicalServicesunitmakesthedeterminationwithin7businessdaysofreceivingthemilestonetoreviewtheassessment.

Expectedtimeframeifalldocumentationiscompleteandreceivedis7daysforbothInitialandRenewaldeterminations.Ifthereareconcernsthatthedeterminationofamember’seligibilityisdelayed,IHHorCBCMshouldsendanemailwithmember’[email protected]

Expectedtimeframeifalldocumentationiscompleteandreceivedis7calendardaysforbothinitialandrenewaldeterminations.TheIHHorCBCMcancheckstatusoftherequestintheproviderportalunder“precertification”andthen“checkstatus”(www.availity.com).Toinquireaboutaneligibilityrequestthatwassubmitted8+daysprior,anemailwithmember’[email protected].

Expectedtimeframeifalldocumentationiscompleteandreceived-Initial:2-5dayssubmittedtoIME.Renewal:2-5daysreviewedanddeterminationdonebyUnitedHealthcare.Forconcernsorquestionsregardingamember’sdeterminationordelayofnotification,[email protected]

5

DisenrollmentfromHabilitation-memberinitiated

MembercommunicatestheirdesiretodisenrollfromHabilitationtotheIHHandtheIHHentersanenddateintotheHabilitationProgramRequestinISIS.CompleteinstructionsforclosingaHabilitationcasearelocatedintheHabilitationManualat:http://dhs.iowa.gov/sites/default/files/Habilitation.pdf

MembercommunicatestheirdesiretodisenrollfromHabilitationtotheIHHCCorCBCMandtheIHHCC/CBCMentersanoteinthemember’sOPEpisodeinJiva.IHHCCsubmitsaHealthHomeMCONotificationFormwithDisenrollmentorChangeinTier,asappropriate.ACIAnotifiesIMEofthemember’sdisenrollment(methodtobedetermined).

MembercommunicatesdesiretodisenrollfromHabilitationtotheIHHCCandCBCM.TheIHHCC/CBCMnotifiesAmerigroupofthechangefromICMtonon-ICMstatus.IHHCC’scanemailthisinformationtosara.hackbart@amerigroup.com.AGPnotifiesIMEofthemember’sdisenrollmentfromHabilitation.

MembercommunicatesdesiretodiscontinueHabservicesandinformstheIHH.TheIHHreflectstierchangeonthenextmonthlyclaim.

6

Topic Fee-for-Service AmeriHealthCaritasIowa Amerigroup UnitedHealthcareLossofMedicaidEligibility

IfamemberlosesMedicaideligibilitytemporarilyanditisreinstatedbacktothedateitisinitiallylost,Habilitationisreinstatedasfollows:• Iftheeligibilityhasbeenlostfor60daysorless,Habilitationeligibilityisreinstatedbacktothedateeligibilitywasinitiallylost.Habilitationproviders

maybillforservicesprovidedaftereligibilityisrestoredfordatesofservicewhenthememberiseligibleforbothMedicaidandHabilitation.• Iftheeligibilityhasbeenlostformorethan60days,and:

o themostrecentHabilitationassessmentwascompletedwithinthepastyear,HabilitationeligibilitywillbereinstatedbacktothedatethedecisiontoreinstateMedicaideligibilitywasmade.Forexample,amemberlosesMedicaideligibilityonJuly31andonOctober15itisdeterminedthatMedicaidwillbereinstatedbacktoAugust1.Themember’sHabilitationassessmentwascompletedonApril22.HabilitationeligibilitywillbereinstatedbacktoOctober15.

o themostrecentHabilitationassessmentwascompletedmorethanayearago,Habilitationeligibilityneedstoberedetermined.Forexample,amemberlosesMedicaideligibilityonJuly31andonOctober15itisdeterminedthatMedicaidwillbereinstatedbacktoAugust1.Themember’sHabilitationassessmentwascompletedonAugust8ofthepreviousyear.AnewassessmentandSocialHistorywillneedtobecompletedandsubmittedasifitisanewHabilitationapplication

7

ProcessforReinstatingHabilitationifMedicaidisLost60DaysorLess(PROCESSISDIFFERENTFROMWHATISIDENTIFIEDABOVEINTHE1STBULLET)

WhenMedicaideligibilityislost,ISISautomaticallyclosesthecase.IfMedicaideligibilityforthemonthisregainedwhenthepremiumispaidorthespenddownismet,thecasemustbereopenedinISISinorderforhabilitationservicestocontinue.Toreopenthecase:♦Gotothe“Add/CancelProgram”tabinISISandstartanewprogramrequestinthesamemanneraswhenopeninganewcase.♦Whenenteringthebeginningdateinthe“ProgramStartDate”field,makesurethedateisonedayafterthedatetheoriginalprogramrequestended.♦ISISthenmergesthenewprogramrequestwiththeonethatwaspreviouslyclosedandtheprogramwillcontinueuninterruptedInstructionsforreopeningaHabilitationcasearelocatedintheHabilitationManualat:https://dhs.iowa.gov/policy-manuals/medicaid-provider

Noactionrequired Noactionrequired Noactionrequired

8

Person-CenteredPlanningProcessTopic Fee-for-Service AmeriHealthCaritasIowa Amerigroup UnitedHealthcare

PersonCenteredServicePlanCoordination

TheIHHCareCoordinatordevelopstheinterdisciplinaryteam(IDT),schedulesandfacilitatesthepersoncenteredserviceplanmeetingonbehalfofthememberwiththememberandtheirIDT.

TheIHHCareCoordinatororCBCMschedulesandfacilitatesthepersoncenteredserviceplanmeetingonbehalfofthememberwiththememberandtheirinterdisciplinaryteam.(IDT)

TheIHHCCorCBCMschedulesandfacilitatesthepersoncenteredplan(PCP)servicemeetingonbehalfofthememberwiththememberandhis/herinterdisciplinaryteam(IDT).

UnitedHealthcarehasadesignatedPersonCenteredTreatmentPlan(PCTP)tool.ThetoolcanbedownloadedfromUHCCommunityplan.comunderProviderForms.

PersonCenteredServicePlanDevelopment

TheIHHCareCoordinatororCommunityBasedCaseManagerisresponsiblefordevelopingtheserviceplanbasedontheCSAandPCPplanningmeeting.

TheIHHCareCoordinatororCBCMisresponsiblefordevelopingtheserviceplanbasedontheCSAandPCPplanningmeeting.

TheIHHCCorCBCMisresponsiblefordevelopingtheserviceplanbasedontheinterRAIandPCPplanningmeeting.AGPdoesnothaveadesignatedtemplatefortheperson-centeredplan.

TheIHHCareCoordinatorwiththecollaborativeeffortoftheteamisresponsiblefordevelopingthePCTP.

PersonCenteredServicePlanDistribution

TheIHHCareCoordinatororCommunityBasedCaseManagerisresponsiblefordistributingtheplantothememberandproviders

TheIHHCareCoordinatororCBCMisresponsiblefordistributingtheplantothememberandproviders

TheIHHCCorCBCMisresponsiblefordistributingtheplantothememberandproviders.

TheIHHCareCoordinatorprovidesthememberandproviderswithacopyofthePCTP.

PersonCenteredServicePlanMonitoring

TheIHHCareCoordinatororCommunityBasedCaseManagerisresponsibleformakingmonthlycontacttomonitortheplanandquarterlyfacetofacemeetingwiththemember.

TheIHHCareCoordinatororCBCMisresponsibleformonitoringtheplanwithatleastmonthlycontactsandatleastquarterlyfacetofacemeetingswiththemember.

TheIHHCCorCBCMisresponsibleformonitoringtheplanwithatleastmonthlycontactand,atminimum,aquarterlyfacetofacemeetingwiththemember.

UnitedHealthcarerequiresmonthlymembercontactandatleastquarterlyfacetofacemembermeeting.DocumentationmustshowthatIHHismeetingthisrequirement.

PersonCenteredServicePlanReview

TheIHHCareCoordinatororCommunityBasedCaseManagerisresponsibleforongoingreviewandmonitoring.

TheIHHCareCoordinatororCBCMisresponsibleforreviewingprogressandtheneedforchangestotheplanaspartofthemonitoringprocess.

TheIHHCCorCBCMisresponsibleforongoingreviewandmonitoring.

TheIHHCareCoordinatorisresponsibleforsubmittingPCTPchangesperanaddendum.ThisaddendumwillneedtobesubmittedtoUnitedHealthcareperemailatuhc_iowa_integratedhealthhomes@uhc.comorFaxto877-960-5516.

9

Topic Fee-for-Service AmeriHealthCaritasIowa Amerigroup UnitedHealthcareDischargePlanning

Dischargeplanningoccursatthetimeofthepersoncenteredserviceplanmeetingandisdocumentedinthepersoncenteredserviceplan.Thedischargeplanshouldidentifywhatshouldoccurinordertoreducetheneedforservices.



TheIHHCareCoordinatorwiththeteamdevelopsthePCTPincludingdischargeplanning.

HabilitationProviderServicePlan

TheHabilitationserviceproviderisresponsibleforthedevelopmentofaservicespecificserviceplanwhichidentifiesthemember’sservicesgoalsandtheprovider’sobjectivestoassistthemembertomeettheirgoal

TheHabilitationserviceproviderisresponsibleforthedevelopmentofaservicespecificserviceplanwhichidentifiesthemember’sservicesgoalsandtheprovider’sobjectives/interventionstoassistthemembertomeettheirgoals.

TheHabilitationserviceproviderisresponsibleforthedevelopmentofaservicespecificserviceplanwhichidentifiesthemember’sservicesgoalsandtheprovider’sobjectivestoassistthemembertomeettheirgoals.

TheIHHisresponsibleforcoordinatingtheservicesofthememberincludingthedevelopmentofaproviderserviceplan.

10

HabilitationServiceAuthorizationsTopic Fee-for-Service AmeriHealthCaritasIowa Amerigroup UnitedHealthcare

ServiceAuthorizationProcess

TheIHHCareCoordinatororCommunityBasedCaseManagerisresponsibleforenteringtheservicespansintheprogramrequestinISIS.IMEMedicalServicesapprovestheserviceplan.OncetheserviceplanhasbeenapprovedtheIHHisresponsibleforsendingtheNODstotheHabilitationproviders.

TheIHHCareCoordinatororCBCMisresponsibleforenteringtheservicerequestsintoJiva.

TheIHHCCorCBCMisresponsibleforsubmittingaservicerequestwiththeperson-centeredplantoAmerigroupforreview.ThiscanbedoneviafaxwiththeMentalHealthOutpatientTreatmentForm-IAHealthlink(1-866-877-5229)orthroughtheproviderportal(www.availity.com).PriorauthorizationisrequiredforHabilitationservices.

UnitedHealthcaredoesnotrequirepriorauthorizationforHabservices.

ServiceReauthorization

TheIHHCareCoordinatororCommunityBasedCaseManagerisresponsibleforenteringtheservicespansintheprogramrequestinISIS.IMEMedicalServicesapprovestheserviceplan.OncetheserviceplanhasbeenapprovedtheIHHisresponsibleforsendingtheNODstotheHabilitationproviders

TheIHHCareCoordinatororCBCMisresponsibleforenteringtheservicerequestsintoJiva.

TheIHHCCorCBCMisresponsibleforsubmittingaservicerequestwiththeperson-centeredplantoAmerigroupforreview.ThiscanbedoneviafaxwiththeMentalHealthOutpatientTreatmentForm-IAHealthlink(1-866-877-5229)orthroughtheproviderportal(www.availity.com).

UnitedHealthcaredoesnotrequirepriorauthorizationforPrevocationalandSupportedEmploymentservices

ServiceChanges

IftheHabilitationserviceproviderormemberrequestschangestheycontacttheIHHCCorCBCMtorequestthechanges.TheIHHCareCoordinatororCommunityBasedCaseManagerisresponsibleforenteringtheservicespansintheprogramrequestinISIS.OncetheserviceplanhasbeenapprovedtheIHHisresponsibleforsendingtheNODstotheHabilitationproviders

IftheHabilitationserviceproviderormemberrequestschangestheycontacttheIHHCCorCBCMtorequestthechanges.

IftheHabilitationserviceproviderormemberrequestschangestheycontacttheIHHCCorCBCMtorequestthechanges.TheIHHCCorCBCMisresponsibleforsubmittingtherequestedchangesincludingtheamendedperson-centeredplan,viafaxwiththeMentalHealthOutpatientTreatmentForm-IAHealthlink(1-866-877-5229)orthroughtheproviderportal(www.availity.com).

IftheHabilitationserviceproviderormemberrequestschangestheycontacttheIHHCC.TheIHHCCisresponsibleforsubmitting,viafaxoremail,therequestedchangesincludingtheamendedperson-centeredplan.

11

Topic Fee-for-Service AmeriHealthCaritasIowa Amerigroup UnitedHealthcareUtilizationManagementProcess

TheIMEMedicalServicesUnitreviewsandapprovesthoseservicesthatrequirePriorAuthorization–PrevocationalandSupportedEmploymentservices

TheLTSSUMDepartmentreviewsandapprovesordeniestheservicerequests.UMstaffmaycontactIHH/CBCMstaffiftherearequestionsabouttheamount,duration,andscopeofservicesrequestedortoproposealternativesifdenialisanticipated.

TheBehavioralHealthUtilizationManagementDepartmentreviewsservicerequests.UMstaffmaycontacttheIHHCCorCBCMifadditionalinformationisneeded,forexample,scopeofservicesorfrequencyofmentalhealthsymptoms.

UnitedHealthcareAlertteamcompletesclaimreviewstoidentifytriggersregardingutilizationofservices.

CommunicationtoHabilitationProviders(additionalinformationpresentedinJune2016isavailableathttps://theiacp.memberclicks.net/assets/docs/accessing_mco_authorizations.pdf

TheIHHCCandCBCMisresponsibleforprovidingthecomprehensiveserviceplanandprovidinganoticeofdecisionfortheproviderforservicesauthorized.

TheIHHCCorCBCMisresponsibleforprovidingthecomprehensiveserviceplan.ProvidersaccesstheServicePlan,whichincludescurrentapprovedservices,throughtheProviderPortal.

TheIHHCCortheCBCMisresponsibleforprovidingthecomprehensiveserviceplantotheserviceprovider.Serviceprovidersmayaccesseligibilityandserviceauthorizationsthroughtheproviderportal/Patient360(www.availity.com).

UHCwillcommunicatetotheIHHapprovalsforlevelofcare(LOC)determinationviaemail.LOCguidelinesareavailableat:https://ubhweb.uhc.com/ubh/clinical_policy_standards/gls/state_specific/Integrated%20Health%20Home%20(IA%202-Final).pdf

ContactsforQuestionsaboutHabilitationServicesTopic Fee-for-Service AmeriHealthCaritasIowa Amerigroup UnitedHealthcare

QuestionsaboutHabilitationServicesinGeneral

IMEProviderServices1-800-338-7909

KarenWaltersCrammond515-330-3802kcrammond@amerihealthcaritasia.com

ProviderRelationsDepartment(seehandoutofmap)

IHHinquiriesgothroughUnitedHealthcareHHRNProgramManager.HabProvidergothroughtheIHH

QuestionsaboutSpecificMembers’Services

IMEMemberServices1-800-338-8366

WorkthroughtheMember’sIHHorCBCM

WorkthroughtheMember’sIHHorCBCMMemberServices:1-800-600-4441

Memberservices:800-464-9484

QuestionsaboutClaims

IMEProviderServices1-800-338-7909

Provider’sAccountExecutive ProviderRelationsDepartment(seehandoutofmap)

Providerservices:888-650-3462

12

*informationprovidedissubjecttochangeandiscontingentontheinterpretationofeachindividualhealthplan

Residential Setting Requirement for State Plan HCBS Habilitation services and HCBS Waiver services

All residential settings where Habilitation services are provided must document the

following in the member’s person-centered service or treatment plan: a. The setting is integrated in, and facilitates the individual’s full access to, the greater community,

including opportunities to seek employment and work in competitive integrated settings, engage in community life, control personal resources, and receive services in the community, like individuals without disabilities;

b. The setting is selected by the individual among all available alternatives and identified in the person-centered service plan;

c. An individual’s essential personal rights of privacy, dignity and respect, and freedom from coercion and restraint are protected;

d. Individual initiative, autonomy, and independence in making major life choices, including but not limited to, daily activities, physical environment, and with whom to interact are optimized and not regimented; and

e. Individual choice regarding services and supports, and who provides them, is facilitated.

Residential settings that are provider owned or provider controlled or operated including licensed Residential Care Facilities (RCF) for 16 or fewer persons must document the following in the member’s person-centered service or treatment plan:

a) The setting is integrated in, and facilitates the individual’s full access to, the greater community, including opportunities to seek employment and work in competitive integrated settings, engage in community life, control personal resources, and receive services in the community, like individuals without disabilities;

b) The setting is selected by the individual among all available alternatives and identified in the person-centered service plan;

c) An individual’s essential personal rights of privacy, dignity and respect, and freedom from coercion and restraint are protected;

d) Individual initiative, autonomy, and independence in making major life choices, including but not limited to, daily activities, physical environment, and with whom to interact are optimized and not regimented; and

e) Individual choice regarding services and supports, and who provides them, is facilitated. f) The setting is integrated in, and facilitates the individual’s full access to, the greater community,

including opportunities to seek employment and work in competitive integrated settings, engage in community life, control personal resources, and receive services in the community, like individuals without disabilities;

g) Any modifications of the conditions (for example to address the safety needs of an individual with dementia) must be supported by a specific assessed need and documented in the person-centered service plan.

h) The unit or room is a specific physical place that can be owned, rented, or occupied under a legally enforceable agreement by the individual receiving services, and the individual has, at a minimum, the same responsibilities and protections from eviction that the tenants have under the landlord/tenant laws of the State, county, city, or other designated entity.

i) Each individual has privacy in their sleeping or living unit j) Units have entrance doors lockable by the individual, with only appropriate staff having keys to

doors. k) Individuals sharing units have a choice of roommates in that setting. l) Individuals have the freedom to furnish and decorate their sleeping or living units within the lease

or other agreement. m) Individuals have the freedom and support to control their own schedules and activities, and have

access to food at any time. n) Individuals are able to have visitors of their choosing at any time. o) The setting is physically accessible to the individual.

Residential Setting Requirement for State Plan HCBS Habilitation services and HCBS Waiver services

StatePlanHCBSFederalRequirements

DHS,IME01.19.16 1915(i)Settings,PersonCenteredPlanningandServicePlans

StatePlanHCBSHabilitationComprehensiveServicePlan

Servicesmustbeincludedinacomprehensiveperson-centeredserviceplan.Thecomprehensiveperson-centeredserviceplanmustbedevelopedthroughaperson-centeredplanningprocessdrivenbythememberincollaborationwiththemember’sinterdisciplinaryteam,asestablishedwiththecasemanagerorIntegratedHealthHomeCoordinator.

Themember’scomprehensiveserviceplanmustbeupdatedatleastannuallyandwhenachangeintheindividual’scircumstancesorneedschangesignificantly,andattherequestoftheindividual.

Thecomprehensivepersoncenteredserviceplan:

• Includespeoplechosenbytheindividual

• Providesnecessaryinformationandsupporttotheindividualtoensurethattheindividualdirectstheprocesstothemaximumextentpossible

• Istimelyandoccursattimes/locationsofconveniencetotheindividual

• Reflectsculturalconsiderations/usesplainlanguage

• Includesstrategiesforsolvingdisagreement

• Offerschoicestotheindividualregardingservicesandsupportstheindividualreceivesandfromwhom

• Providesmethodtorequestupdates

• Conductedtoreflectwhatisimportanttotheindividualtoensuredeliveryofservicesinamannerreflectingpersonalpreferencesandensuringhealthandwelfare

• Identifiesthestrengths,preferences,needs(clinicalandsupport),anddesiredoutcomesoftheindividual

• Mayincludewhetherandwhatservicesareself-directed

• Includesindividuallyidentifiedgoalsandpreferencesrelatedtorelationships,communityparticipation,employment,incomeandsavings,healthcareandwellness,educationandothers

• Includesriskfactorsandplanstominimizethem

• Issignedbyallindividualsandprovidersresponsibleforitsimplementationandacopyoftheplanmustbeprovidedtotheindividualandhis/herrepresentative



StatePlanHCBSHabilitationWrittenComprehensiveServicePlanDocumentation

� Reflectsindividual’sstrengthsandpreferences

� Reflectsclinicalandsupportneeds

� Includesobservableandmeasureablegoalsanddesiredoutcomes

a) Identifyinterventionsandsupportsneededtomeetthosegoalswithincrementalactionsteps,asappropriate.

b) Identifythestaffpeople,businesses,ororganizationsresponsibleforcarryingouttheinterventionsorsupports.

� Identifiesforamemberreceivinghome–basedhabilitation:

a) Themember’slivingenvironmentatthetimeofenrollment;

b) Thenumberofhoursperdayofon–sitestaffsupervisionneededbythe

member;and

c) Thenumberofothermemberswhowilllivewiththememberinthelivingunit.

� Reflectsprovidersofservices/supports,includingunpaidsupportsprovidedvoluntarilyinlieuofwaiverorstateplanHCBSincluding:

a) Nameoftheprovider

b) Serviceauthorized

c) Unitsofserviceauthorized

� Includesriskfactorsandmeasuresinplacetominimizerisk

� Includesindividualizedbackupplansandstrategieswhenneeded

a) Identifyanyhealthandsafetyissuesapplicabletotheindividualmemberbasedoninformationgatheredbeforetheteammeeting,includingariskassessment.

b) Identifyanemergencybackupsupportandcrisisresponsesystemtoaddressproblemsorissuesarisingwhensupportservicesareinterruptedordelayedorthemember’sneedschange.

c) Providersofapplicableservicesshallprovideforemergencybackupstaff.



� Includesindividualsimportantinsupportingindividual

� Includesthenamesoftheindividualsresponsibleformonitoringplan

� Iswritteninplainlanguageandunderstandabletotheindividual

� Documentswhoisresponsibleformonitoringtheplan

� Documentstheinformedconsentoftheindividualforanyrestrictionsonthemember’srights,includingmaintenanceofpersonalfundsandself–administrationofmedications,theneedfortherestriction,andeitheraplantorestorethoserightsorwrittendocumentationthataplanisnotnecessaryorappropriate.

Anyrightsrestrictionsmustbeimplementedinaccordancewith441IAC77.25(4).

� Includesthesignaturesofallindividualsandprovidersresponsible

� Isdistributedtotheindividualandothersinvolvedinplan

� Includespurchase/controlofself-directedservices

� Excludesunnecessaryorinappropriateservicesandsupports