1

The Children’s Waiver

Program

An Overview

November 2015

Welcome and Introductions

Audrey Craft, Specialist, Federal Compliance

Section, MDHHS

Joan Deschamps, Children’s Waivers

Specialist, Retired, MDHHS

Kelli Dodson, Children’s Waivers Analyst,

MDHHS

2

3

What Will We Cover Today?

Legal authority

Funding

Eligibility

Prescreens

Application

process

Plan development

Decision guides

Services

Provider qualifications

PDN

Budgets

Administrative hearings

Choice Voucher

Quality assurance

4

Other Topics of Interest?

What would you like to know about

the CWP?

5

Legal Authority

Authorized under Section 1915(c) of

the Social Security Act

Allows states to waive parental

assets and income and make a child

eligible for Medicaid as a “family of

one”

Provides additional services specific

to, and limited to, the waiver

population

6

State Funding

An appropriation controlled by the

Michigan Legislature

Matched with federal funds

Limited to the number of children it

can support on the CWP

7

CWP Eligibility Requirements

Up to age 18

Meets financial eligibility for Medicaid as a “family of one”

Resides w/parent(s)or guardian (relative)

Receives at least one waiver service per month

At risk of out of home placement

Has a Developmental Disability as defined in the mental health code AND meets criteria for an ICF/IID

8

Intermediate Care Facility for the (ICF/IID )

An individual must have the need for an active treatment program of specialized and generic training, treatment, health and related services directed toward the acquisition of behaviors necessary to function with as much self-determination and independence as possible.

9

When Considering a CWP

Pre-Screen

Is the child currently Medicaid eligible? If so, CMH is

responsible to provide medically necessary supports and

services.

Is the child developmentally disabled?

Does the child meet criteria for ICF/IID, including needing

“active treatment”?

What service needs have been identified?

Can services be provided through CMHSP and other

resources, including a commercial insurance benefit?

Assessing Eligibility for the

CWP

Per contract with MDCH, all CMHSPs are expected

to have a process in place to assess eligibility for the

CWP.

If a family requests a prescreen for the CWP and the

CMHSP determines the child is not eligible, the

CMHSP must provide the family with a Medicaid Fair

Hearing adequate notice denying the CWP.

If the CMHSP determines the child is eligible, then a

prescreen must be submitted via the Waiver Support

Application (WSA).

10

11

Factor 10: Home Care Supports

Factor 9: Health & Safety; Medical/Behavioral

Challenges

Factor 8: Risk of Out-of-Home Placement

Factor 6: Family Stress and/or Physical Health

Problems

Factor 5: Other Children with Special Needs in the

Home

Factor 4: Child in Nursing Home

Factor 3: Child in ICF/IID (formerly ICF/MR)

Factor 1: Child in Foster Care

Prescreen Factors

12

CWP Pre-screen Updates

Annual update is required

An update within the past six months is

necessary for an invitation to apply

If a child no longer qualifies for the CWP, or if the family no longer wants waiver services, the child’s name will be removed from the Priority Weighing List

13

When Waiver Slots Become Available

DCH issues an “invitation to apply”

via the WSA

The case is moved to the Case Worker’s work

queue and the WSA generates an email to all CMH

staff with prescreen, case worker and supervisor

security roles

The assigned case manager contacts the child’s

parent(s) to confirm:

Child’s service needs

Current residence

Medicaid status

Family still wants waiver services

14

Initial Application Process - CMHSP

Within 30 days the invitation to apply was issued

Complete Waiver Certification form, enter specified data

elements into the WSA and mail the signed form to MDCH

(please note date mailed in “comments” field on WSA

Certification tab)

Complete the Demographic tab in the WSA

Complete a DHS-49 form, enter specified data elements into the

WSA and retain the DHS-49 in the case file (do not mail to

DCH)

Documentation of a current annual physical for the child can

be used in lieu of a DHS 49 form (note “source” in comments

field on WSA DHS49 tab)

Supervisor approves and submits initial application to DCH via

the WSA

Initial Application Documents For

Children The CMHSP Believes Are

Eligible For PDN

PDN eligibility worksheet

Health care plan

Copy of physician’s order for PDN

Two weeks of the most recent

nursing notes (if child has been

receiving hourly nursing)

IPOS

15

16

Approval Process

Clinical Review Team

(CRT) reviews waiver

application for clinical

eligibility

CRT “approves” case

on the WSA, completes

DHS-49-A tab & sends

signed Initial Cert to

CMH

Effective date is 1st of

month for which child

was invited to apply

WSA generates email

to CMH

CWP sends approval

memo to Medicaid

liaison with local

MDHHS

Medicaid liaison sends

approval packet to

family

Medicaid liaison sends

Policy Memo to local

MDHHS office

Medicaid Application

The family should

wait until they

receive the approval

packet to apply for

Medicaid.

The family should

follow the

instructions in the

approval packet

exactly.

17

18

After Approval of Initial

Application The CMHSP: Completes relevant assessments and a Category of

Care narrative

Develops the child’s Individual Plan Of Service (IPOS)

Establishes a budget based on the IPOS and enters the budget detail into the WSA

Trains CLS and respite staff in the IPOS and assures staff meet all other training/provider requirements before providing services

Follows-up with the family regarding the Medicaid application and Medicaid eligibility

WSA Budget Detail Budget detail entered into the WSA

includes:

All services identified in IPOS

Procedure code for each service

Amount of service (# of units) to be

provided & frequency (month or year)

CMHSP’s charge for each service

The WSA calculates the estimated cost to

Medicaid at the lesser of charge or fee-screen

Budget detail is by fiscal year (not IPOS

year) and is not “sent” to DCH

19

20

After DCH approves the initial application and the case status is “open”, the CMHSP should follow-up with the family regarding application for Medicaid and Medicaid eligibility

Did they make the application after receiving the

approval packet from DCH

Did they request retroactive eligibility

Did they have any problem with the application

Did the letter from DHS say anything other than

“Medicaid” (e.g., MIChild, Transitional Medicaid)

Is the Medicaid “start date” later than the CWP

Enrollment start date

Final Application Process

21

As soon as the CMHSP confirms Medicaid is active,

the CMHSP should

Enter the MAID# on the Enrollment tab in the

WSA

Review detail for the Initial Budget on the Budget

tab in the WSA

“Approve and submit” the case to MDCH

CWP must “review & approve” the MAID# and Initial

Budget before CWP eligibility is uploaded to

CHAMPS

CWP claims cannot be paid until both the MA and CWP

Benefit Plans are on CHAMPS

Final Application Process - Continued

22

Annual Renewal - CMHSP Annual Recertification form must be completed

within 365 days of the Initial Waiver Certification (or the most recent Annual Recertification)

Parent must sign section three (choice

assurance) of the Waiver Certification form

Medical Examination Form (DHS-49) must be completed within 365 days of the previous physical exam date

WSA Certification and DHS-49 tabs must be modified to update the specified fields

Neither form is sent to DCH; both forms are maintained in the local case file

DCH does not sign section four of the annual

recertification form

Annual Renewal - PDN

When the annual recertification is due for

children who qualify for PDN, the CMHSP

must submit

PDN eligibility worksheet

Two weeks of the most recent nursing

notes

Health care plan

Copy of physician’s order for PDN

Current IPOS

23

24

What is a

Decision Guide ?

It is a tool to:

Assist the child’s team in determining the

amount of publicly supported CLS or PDN

hourly care.

Ensure consistency across the state of

Michigan

Review the care needs of the child and the

resources available to the family

Documentation of training must be

maintained in case managers personnel file

25

DOCUMENTED CATEGORY OF NEED FOR HOURLY

CARE AUTHORIZATION*

ADDITIONAL FAMILY

RESOURCES

CATEGORY

IV

CATEGORY

III

CATEGORY

II

CATEGORY

I

Section I – Number of

Caregivers

1. Two or more

caregivers live in

home; both work F/T

2. Two adult

caregivers; one

works F/T

3. Two adult

caregivers; neither is

employed

4. One adult caregiver

lives in home and

works F/T

5. One adult caregiver;

does not work F/T

4-8

2-8

2-4

4-8

2-6

6-10

2-8

2-6

4-10

2-8

8-12

4-10

4-8

8-12

8-10

12-16

10-16

8-12

12-16

10-14

26

DOCUMENTED CATEGORY OF NEED FOR HOURLY

CARE AUTHORIZATION*

ADDITIONAL FAMILY

RESOURCES

CATEGORY

IV

CATEGORY

III

CATEGORY

II

CATEGORY

I

Section II – Health Status

of Caregivers

1. Significant health

issues

2. Some health issues

6-8

4-6

6-10

4-8

10-14

8-12

12-16

10-12

Section III – Additional

dependent children

1. Applicant has one or

more sibs, age five

or older

2. Applicant has one or

more sibs under

age five.

2-4

4-6

2-6

4-8

4-8

6-8

8-12

8-12

27

DOCUMENTED CATEGORY OF NEED FOR HOURLY

CARE AUTHORIZATION*

ADDITIONAL FAMILY

RESOURCES

CATEGORY

IV

CATEGORY

III

CATEGORY

II

CATEGORY

I

Section IV – Additional

Children with Special Needs

1. Applicant has one or

more siblings with

nursing needs

2. Applicant has one or

more siblings with

non-nursing special

needs

4-8

2-4

6-8

2-6

4-8

N/A

8-12

N/A

Section V – Night

Interventions

1. Requires 2 or fewer

interventions at night

or total time less

than one hour

2. Requires 3 or more

interventions

requiring one hour or

more to complete

2-4

4-8

2-6

6-8

4-8

6-10

8-12

8-12

Section VI – School

Child attends school an

average of 25 hours per

week

6 max

6 max

8 max

12 max

28

Categories of Care Demonstrates mild level behaviors that may interfere with the

daily routine of the family.

Demonstrates a daily pattern of medium level behaviors including self-injurious, physically aggressive or assaultive behaviors that have not resulted in hospitalization or emergency room treatment for injuries in the past year, or has engaged in occasional, significant property destruction that is not life-threatening.

Demonstrates a daily pattern of moderate self-injurious, physically aggressive or assaultive behavior when medical intervention, or hospital emergency room treatment has been required for treatment of injuries in the past year without resulting hospitalization, or if the child has engaged in frequent, significant property destruction that is not life-threatening.

Demonstrates a pattern of severe self-injurious, physically aggressive or assaultive behavior, or life threatening property destruction that has occurred one or more times in the past year. Documented evidence of additional behavioral problems on a frequent basis each day supports a need for one-to-one intensive behavioral treatment.

29

COC Documented Narrative

Assessment of Need

Type of behaviors

Frequency, intensity and duration of behaviors

How recently behaviors occurred

Effects of behavior on family & property

Additional Resources

# of caregivers

Health of Caregivers

Dependent Children

Children w/special needs

Night Interventions

School Schedule

30

Services Available to Children

on the CWP

All mental health services included in

the CWP Services database when:

Used to address an assessed need

Identified in the IPOS

Services include:

“State plan” mental health services, and

“Waiver” services

31

Waiver Services

Community Living Supports (CLS)

Enhanced Transportation

Respite Services

Home Care Training, Family

Specialty Services

Home Care Training, Non-Family

Specialized Medical Equipment & Supplies

Environmental Accessibility Adaptations

Fiscal Intermediary

32

Medicaid State Plan Services

Private Duty Nursing

Occupational Therapy

Physical Therapy

Speech Therapy

Targeted Case Management

Durable Medical Equipment

Professional

Evaluations &

Testing

Health Assessments

Medication Review

etc.

33

Community Living Supports H2015 - Community Living Supports; per 15

minutes

Must be trained in:

IPOS

Recipient Rights

Basic First Aid, CPR

Emergency Procedures

Can be provided in the child’s home or in the

community

Cannot be provided in the CLS provider’s

home

34

Enhanced Transportation

Enhanced Transportation

S0215 - Non-Emergency Transportation; mileage (per mile)

CLS costs include transportation

Transportation may be billed when

provided by staff other than CLS

Limited to resident’s county or

surrounding county

Is identified in the IPOS

35

Respite Care

T1005 - Respite Care, per 15 minutes

Can be provided in: child’s home,

licensed foster home, licensed respite

care facility, licensed camp

Respite limits: 1152 hours (4608 units)

per fiscal year beginning Oct. 1, 2012

Amount authorized and used can vary

by month to meet child’s & family’s

needs, as identified in the IPOS

36

Family Training S5111 - Home Care

Training, Family; per session

Provided by MSW, LLP or QMRP

Includes: Instruction about

treatment regimens & use of equipment specified in the IPOS

A counseling service to families

37

Specialty Services

G0176 for:

Music Therapy

Recreation Therapy

Art Therapy

97124 for:

Massage Therapy

Limit of 4 sessions

per month per type

of specialty service

38

Non-Family Training

S5116 - Home Care Training, Non-Family;

per session

Provided to CLS and respite staff by an

MSW, LLP or other clinician (OT, PT, SLP or

nurse) who is a QIDP

The provider is selected on the basis of

his/her competency in the aspect of the

service plan on which they are conducting the

training

Reminder: Multiple Units of

Family & Non-Family Training

Beginning January 2013, CMS set “MEU”

parameters for many codes

The “medically expected unit” for family &

non-family training is maximum “1” per date-

of-service (DOS)

This means multiple units of these services

cannot be paid for the same DOS

Note implications for scheduling these services

39

40

Specialized Medical

Equipment & Supplies

Must be:

Medically necessary and beyond what is ordinarily found in the home or expected to be provided by parents

Specified in the IPOS

Includes devices, controls and appliances not covered under Medicaid State Plan

41

Environmental Accessibility

Adaptations S5165 - Home

Modifications must be:

Prior authorized by MDCH

Specified in the IPOS

Necessary to ensure the health, welfare and safety of the child

Fiscal Management Services

(FI)

The fiscal intermediary must meet

requirements as identified in the

“MDCH/CMHSP Managed Mental Health

Supports and Services Contract – Attachment

P.4.7.1 Medicaid Managed Specialty

Supports and Services Concurrent 1915(b)(c)

Waiver Program FY 15”

Monthly all-inclusive code – T2025

42

Prior Authorization

Yours (locally authorized)

Adaptive toys: T1999

ADL aids: S5199

Allergy control supplies: T2028

Ours (CRT authorized)

Enhanced hours (CLS & PDN)

Environmental safety & control devices: T2029

Repair or non-routine service for DME: K0739

Vehicle modifications: T2039

Environmental accessibility adaptations: S5165

Durable medical equipment, misc.: E1399

• Therapeutic items; assistive technology; other DME for sensory, communication, mobility needs; generators; window air conditioners

43

44

Administrative Hearing

A notice of action:

Must be sent whenever a Medicaid

covered service is denied, suspended,

reduced or terminated – for any reason

(including when child ages-out of CWP)

Provides consumer with the opportunity to

request an Administrative Hearing, held by

an Administrative Law Judge (ALJ)

All terminations must be done on the WSA

(Note: this includes those aging-out of CWP)

45

The Choice Voucher System

Must be made available for children enrolled

in CWP

Provides parents of minor children a method

to control and direct how their child’s IPOS is

implemented and who are the providers

Participation by families is voluntary

46

How the System Works Family & CMHSP,

using the PCP process, develop child’s IPOS identifying needed services and supports

A CWP budget is developed based on the IPOS

Parent implements arrangements through the Choice Voucher System

A Choice Voucher

Agreement between

the CMHSP and

Parent is signed

The funds in the

CWP budget are

lodged with a fiscal

intermediary

47

Quality Assurance &

Improvement

CMS requires changes to quality assurance

and improvement strategies:

Bi-annual site-reviews (QMP & CWP); we

must review more records; CWP site review

protocol & Department-level processes

revised to align with “CWP Performance

Measures”; plans of correction still required;

we must report “remediation” of problems to

the consumer-level

48

For Additional

Information

Medicaid Provider Manual-Mental

Health/Substance Abuse Chapter/Children’s

Waiver Program Section 14

Audrey Craft

517.241.5757 – crafta@michigan.gov

Kelli Dodson

517.335.6078 - dodsonk@michigan.gov

Children’s Waiver Program (CWP) User Training

Manual

WSA Splash Page - (Under Training Menu)