Audio (MP3) Listen in New Window Presentation (PDF) Open in new window Background - Rate Reform Effort Began in 2013 - Initial Work Group Charge - Develop Daily Rate for Residential Services - Address the Ratios for Day Services - Work Group Included: - Steve Cook - Jim Van Dyke - Pat Cockrum - Jon Burlison - Misty Woltman - Jane Wear - Steve Sacksteder - Tracy Mitchell - INARF Staff Purpose/Goals - Current System: - Administratively Cumbersome - Focused on Inputs - Daily Rate Approach Intended to: - Shifts Focus to Outcomes, Quality & Satisfaction - Reduce Administrative Complexity - Streamline Billing and Documentation - More Attention to Consumer Experience - Increase in Natural Supports Rate Development - Available to individuals who are - Assessed as an Algo 3, 4, or 5 and - Live with housemates and sharing staff - Live outside the family home - Rates Established, as follows: Grid Hours Based on Algo and Living Situation X Current Hourly Rate Residential Habilitation Daily Rate - RH Daily Rate "Grid" Service Description Nat'l Code Mod 1 Mod 2 Mod 3 Mod 4 Rate Unit Size ALGO Level People in Setting INsite Sub_Code RHS Daily Level 1 T2016 U7 U5 UN UA $155.29 1 Day 3 2 RD32 RHS Daily Level 2 T2016 U7 U5 UN UB $219.00 1 Day 4 2 RD42 RHS Daily Level 3 T2016 U7 U5 UN UC $238.92 1 Day 5 2 RD52 RHS Daily Level 4 T2016 U7 U5 UP UA $155.29 1 Day 3 3 RD33 RHS Daily Level 5 T2016 U7 U5 UP UB $201.09 1 Day 4 3 RD43 RHS Daily Level 6 T2016 U7 U5 UP UC $219.01 1 Day 5 3 RD53 RHS Daily Level 7 T2016 U7 U5 UQ UA $145.34 1 Day 3 4 RD34 RHS Daily Level 8 T2016 U7 U5 UQ UB $187.15 1 Day 4 4 RD44 RHS Daily Level 9 T2016 U7 U5 UQ UC $199.10 1 Day 5 4 RD54 Move to Implementation - Assembled Implementation Work Group - Familiar with Day to Day Realities - Understand BMR, BRQ, and related processes - Work Group Includes: - Margie Cantey - Amy Flint - Chrissie Biek - Cheryl Schade - Danielle Blake - Peter Zubler - Holly Piggot - Jacque Pulling - Pat Cockrum - Steve Sacksteder - Jon Burlison - INARF Staff Reimbursable Activities - Assistance with acquiring, enhancing, and building natural supports - Working with participant to meet ISP goals - Training participant to enhance home-making skills, meal preparation, household chores, money management, shopping, communication skills, and positive behavior - Provision of transportation to fully participate in social and recreational activities - Provision of transportation to community employment and/or volunteer activities - Coordination and facilitation of medical and wellness services to meet the healthcare and wellness needs - Individual must be present and receive RHS Daily services for at least a portion of any day the provider bills - Electronic Monitoring Limitations - RHS Daily Provider may not provide more than 10 hours/mo of CHIO to individual - Exception process for instances where CHIO is the primary component of an individual’s day due to medical or behavioral reasons - Upon conversion, RHS Daily provider CHIO will be capped at 10 hours. - Remaining balance under the DAYS Reserve if any will remain on plan with Provider TBD. - IST determines how to proceed – i.e. exception, select new provider, reconfigure services - BMR will not be considered or granted for loss of housemate(s). - IF 2 person setting, individual remaining transitions to RHS20 Default. If needed, team can seek BMR - If +2 person setting, individuals remaining adjust to Daily Rate Grid based on new living situation. - Provider and Case Manager will have duty to timely report housemate changes - If additional support needed, team should first consider BRQ, then consider transition to RHS20 and seek BMR. - BMRs will only be considered for extraordinary Health and Safety or Behavioral Issues. - Use the newly published BMR policy and procedure - When approved, individual will transition to RHS20 with BMR for duration of the temporary, extraordinary support. - Providers will not be reimbursed separately for Electronic Monitoring. If used as part of RHS Daily, must adhere to EM Service Definition - Provides flexibility and options in considering how to use resources associated with the Daily Rate to support the individual’s identified goals and desired outcomes - Providers may not bill for RHS Daily reimbursement for - When staff/paid caregiver is asleep - When participant is admitted to hospital - Can be billed on the day of a hospital admission and day of discharge, if services provided on these days. - Activities Not Allowed - Services to individuals in Structured Family Caregiving - Services that are available under Medicaid State Plan Board Identified Issues - Individuals with authorized services above the daily rate grid for their Algo level and setting size - Individuals with special rulings or identified with extraordinary support needs will not be converted. - Request to advise providers of who is in or out of daily rate, prior to implementation. - Addressing individuals who shift resources from Other Allocation to DAYS Reserve - Work Group completed significant analysis of individuals who budgeted over the DAYS Reserve - After analysis, only about 700 individuals appear to actually utilize above the DAYS Reserve - Notification to be sent to Case Manager and DAYS Provider(s) - IST determines how to proceed - reconfigure services to fit within DAYS reserve - request exception due to qualifying event Other Considerations - Sites with Daily and Non-Daily Individuals - Mix of Rates, but all DD-Model Waivers - Mix of DD-Model and Aging-Model Waivers - RHS Daily Rate and PA Services - Transportation and RHS Daily - Wellness and RHS Daily - Finalizing Documentation Standards - Still Waiting for CMS Approval - Target Implementation Date 07/01/15 What To Do Now? - Review current supports for those you serve - With the greater flexibility offered by the daily rate, are there opportunities to consider options / approaches that increase flexibility within the setting, promote greater independence, and facilitate natural supports? - Is the individual receiving more than 10 hours of CHIO from the residential provider? - If so, how / why is the service being used? - What is the expected outcome for the service? - What alternative service options / approaches could be used to achieve this outcome? - Have they been tried? If so, what was the result? - Is an exception needed? If so, what documentation is needed? - Is the individual shifting resources from OTHER to DAYS Reserve? - If so, how / why is the service being used? - What is the expected outcome for the service? - What alternative service options / approaches could be used to achieve this outcome? - Have they been tried? If so, what was the result? - Is an exception needed? If so, what documentation is needed? - Other Considerations - Ensure living situations are accurate in Advocare - Consider impact on DAYS Providers - Case Management Perspective Final Thoughts - Not just a change in billing practice or a means to reduce administrative complexity – though it does accomplish both. - Not intended to maintain services where they are today – though can if consistent with the individual’s needs. - Opportunity for teams to work collaboratively to - use good person centered planning practices - identify appropriate expectations to ensure health and safety and - support the individual in building a valued life. - Proof of the change is not in counting inputs, but rather the outcome of the effort –the individual is healthy, safe, and living a life consistent with their values and expectations.