balancing incentive program – no wrong door january 27, 2014 1 balancing incentive program and...

Balancing Incentive Program – No Wrong DoorJanuary 27, 2014 1

Balancing Incentive Program

and LTSS ScreenJoyce Pohlman

Grants Coordinator

Community Access and Grants

DADS


Balancing Incentive

The Affordable Care Act created the Balancing Incentive Program (BIP), which helps states provide quality care in the most appropriate, least restrictive setting.


Balancing Incentive

Increases the Federal Matching Assistance Percentage (FMAP) to States that make structural reforms to increase nursing home diversions and access to non-institutional LTSS.

Enhanced matching payments are tied to the percentage of a State’s LTSS spending, with lower FMAP increases going to States that need to make fewer reforms.


BIP Mandated Requirements

Requires structural reforms to increase access to Medicaid community based long-term services and supports (LTSS).

Create a “no wrong door” to provide a single point of information and allow individuals to provide demographic information once.

Core standardized assessment instruments: ensure all assessment instruments cover mandated “domains”

Ensure “conflict-free” case management in all programs

All objectives must be met by September 30, 2015


LTSS Screen

A short, easy to complete process that directs individuals to long term services and supports (LTSS) for which they may be eligible.


LTSS Screen

BIP Requirements

Part of No Wrong Door Required by BIP - Level 1 Screen

Efficient, standardized approach to needs assessment

Refers people who are potentially eligible for Medicaid LTSS


LTSS Screen

No Wrong Door

A common screen used in all major entry points to the LTSS system

Individuals have a uniform experience

Directs individuals to participating LTSS Doors


LTSS Screen

Simple, concise, easy to complete

Individuals tell their story only once

Most will be completed via web or phone, but may be done in person

LTSS Screen


Participating LTSS Doors

Aging and Disability Resources Centers (ADRC)

Area Agencies on Aging (AAA)

Local Authorities (LA)

DADS Regional Office (RO)

DADS Access and Intake Interest List (A&I IL)

Medicaid Managed Care Organization (MCO)

HHSC STAR+ Program Support Unit (PSU)

Local Mental Health Authorities (LMHA)

Outreach, Screening, Assessment, and Referral Centers (OSAR)


LTSS Screen

Advantages to Individuals

Receive assistance from programs for which they may be eligible

Find the right help more easily

Tell their story only once


LTSS Screen

Advantages to intake workers

Less time gathering demographic information

More time providing personal assistance

System automatically produces referrals

Individual contact history is maintained


LTSS Screen

Advantages to organizations (Doors)

Provides enrollment and referral information for the individual

Reduces need for in-depth understanding of other programs

Consistent evaluation of individual’s LTSS needs


LTSS Screen

Process for Developing Screen:

Surveyed LTSS Doors Reviewed current intake forms Reviewed other states’ screens Developed and evaluated draft screens Met with representatives for each LTSS

Door


LTSS Screen

Screen Questions - Demographic

Name Address where services will be delivered Date of birth Gender Race/ethnicity Social Security Number Caregiver information Military service Insurance information


LTSS Screen

Screen Questions

Determination of LTSS need Need for benefits counseling Caregiver need Nursing facility risk Referral to programs with Interest

Lists Behavioral health Alcohol and drug abuse


LTSS Screen

Tell us about the individual’s needs

a) Has an intellectual disability (IQ is less than 70).

b) Has an autism spectrum disorder.

c) Has dementia (not able to think clearly), Alzheimer's disease, a brain injury, or other cognitive impairment.

d) Needs help with daily living needs such as bathing, dressing, eating, shopping, laundry, or making meals.

e) Cares for someone with one or more of the conditions listed above (a. to d.) and doesn't get paid to give care.

f) Gets care from someone who: (1) helps with daily living needs such as bathing, dressing, eating, shopping, laundry, and making meals, and (2) doesn't get paid to give care.

g) Has or had a mental health diagnosis.

h) Lives alone or doesn't have anyone to call for help in case of emergency.

i) Has a physical disability (for example, can't walk, can't see, or can't hear) and needs help paying for items or services needed for medical reasons.

j) Has or had a diagnosis of alcoholism or drug abuse.


LTSS Screen

Do you have any questions about Medicare or private long-term care insurance?

Yes No No answer Have you dropped many activities and interests lately?

Yes No No answer Do you feel full of energy?

Yes No No answer

How many times in the past 12 months have you had 3 or more drinks of alcohol

in a single sitting? □ 0 □ 1 □ 2 □ 3 □ 4 □ 5 or more

If you can't get care at home, how likely are you to move into a nursing home? Very likely Likely Somewhat likely Not likely A nursing home is not an option that is being considered No answer


LTSS Screen

Does Homer think it is wonderful to be alive now?

Yes No No answer

During the past 30 days, has Homer taken any of the following? (check all that apply) □ Medicines for pain or problems like back pain, muscle pain, headaches, arthritis, or fibromyalgia. Don't count: (1) vitamins, (2) herbs, (3) natural remedies, or (4) over-the-counter medicines such as aspirin, ibuprofen, TYLENOL, Advil, or Aleve.

□ Medicine for diabetes.

□ Medicine to help with sleep. Don't count: (1) vitamins, (2) herbs, (3) natural remedies, or (4) over-the-counter medicines such as melatonin, Benadryl, TYLENOL PM, or Advil PM.

□ Medicine for anxiety, nerves, or emotional upset. Don't count (1) vitamins, (2) herbs, (3) natural remedies, or (4) over-the-counter medicines.

□ Medicine for heart disease or high blood pressure.

□ Alcohol - beer, wine, wine cooler, or hard liquor.


LTSS Screen Do you feel that your life is empty?

Yes No No answer

Programs you think might help.

Learn more about these programs at www.dads.state.tx.us. Most of these programs have an interest list. Check all that apply. If you're not sure about a program, check it anyway:Helps older adults and people age 21 and older with disabilities get support services in a home setting. (STAR+PLUS Waiver)

Helps people living in certain Texas areas get support services. See the list of areas. (Program for All-inclusive Care for the Elderly - PACE)

Helps people with developmental disabilities get support services. (Community Living Assistance and Support Services Waiver - CLASS)

Helps get support services for people who: (1) are deaf and blind, and (2) have another disability that keeps them from living on their own. (Deaf Blind with Multiple Disabilities Waiver - DBMD)

Helps get support services to families who are the main caregivers for children and young adults who need help with their medical care. Helps the child or young adult with: (1) moving from a nursing facility to a home setting or (2) staying in a home setting. (Medically Dependent Children Program - MDCP)


LTSS Screen

You told us that you take care of someone. Could you use help? Help can include: (1) getting a short break - respite services, (2) helping you learn more about giving care, or (3) telling you about other support services.

Yes No No answer

The person you care for has: Dementia (can't think clearly), Alzheimer’s disease, brain injury, or other cognitive

impairment. Another disability.

Tell us more about the person you care for: Their age Their relationship to you Do they live with you?

Yes No No answer


Using the

LTSS ScreenDarshana Gore

Business Analyst

DADS IT Project Management Office


Step One:Access the Screen

By phone



By phone

In person



Internet

By phone

In person

By Internet


Step Two:Data Collection

Internet

By phone

In person

By Internet

DataCollection


Step Three: Generate Referrals

System Generates Referrals

DataCollection


LTSS Screen


ReferralManagement

AAAADRCA&I IL

LALMHA/OSAR

MCOPSURO

Data Collection


Data Collection

Collected by Intake Demographic data Screen responses

Pulled from existing systems (automatically) Managed care enrollment Enrollment DADS LTSS programs and Interest List Medicaid eligibility



Individual consent Allows release of information to other Doors Can limit information shared Identifies organizations that can receive

information


Referrals

What is on the referral? Date and time of Screen Access mode (web/phone/in-person) Who conducted the Screen Demographic data Current enrollment data Screen responses List of referrals generated and organization contact

information Comments


Referrals

Referral to the Medicaid Managed Care Organization

(MCO)


Referrals to MCO

ScenarioThe individual is receiving Medicaid andCurrently enrolled with MCO and Needs assistance


Referrals

Referral to the

Program Support Unit

(PSU)


Referrals to PSU

Scenario 1Individual is receiving MedicaidNOT enrolled with Medicaid Managed

Care Organization• Potential MCO enrollment


Referrals to PSU

Scenario 2Individual is NOT receiving MedicaidIs at risk of moving to a nursing

facility

Scenario 3Individual is NOT receiving MedicaidExpresses interest in STAR+ Waiver

services


Referrals to MCO or PSU


ReferralManagement

MCO/PSU

Data Collection


Referrals

Referral to the Regional Office (RO)


Referrals to RO

Scenario 1Individual is a Texas resident and needs

help with at least one of the following:• Activities of Daily Living (ADL)• Instrumental Activities of Daily Living

(IADL)• Cognitive Impairment• Emergency Response Services• Has physical disability and needs

assistance purchasing medically necessary items or services


Referrals to RO


ReferralManagement

RO

Data Collection


Referrals

Referral to the

Area Agency on Aging

(AAA)


Referrals to AAA

Scenario 1Any Individual who has questions about

Medicare or Long-term Care Insurance

Scenario 2Individual or caregiver age 60 and over,

needing help or information


Referrals to AAA

Scenario 3Caregiver caring for an individual (care

recipient) with Alzheimer’s Disease OR related disorders OR neurological/brain dysfunction

Scenario 4Caregiver over age 54, who is a relative

other than parent or spouse, living with and caring for an individual (care recipient) under age 19 or disabled


Referral to AAA


ReferralManagement

AAA

Data Collection


Referrals

Referral to the Local Authority (LA)


Referrals to LA

Scenario 1Individual is receiving MedicaidCurrently enrolled with Medicaid Managed

Care Organization andEnrolled in one of the following:

• Home and Community-Based Services• Texas Home Living• Intermediate Care Facilities for Individuals with IDD


Referrals to LA

Scenario 2Individual has Autism Spectrum Disorder

Scenario 3Individual has an Intellectual Disability


Referrals to LA


ReferralManagement

LA

Data Collection


Referrals

Referral to the Access and Intake Interest List (A&I IL)


Referrals to A&I IL

Scenario 1An Individual is interested in learning more

about one of the following:• Community Living Assistance and Support

Services• Deaf-Blind with Multiple Disabilities• Medically Dependent Children Program


Referral to A&I IL


ReferralManagement

A&I IL

Data Collection


Referrals

Referral to the Aging and Disability Resource Center

(ADRC)


Referrals to ADRC

Scenario 1After a screening, an Individual does not

have a referral to any of the other Doors

Scenario 2Individual is a veteran

Scenario 3Individual at risk of placement to a nursing

facility


Referrals to ADRC

Scenario 4Individual needs caregiver support, but

does not qualify for AAA services

Scenario 5ADRC can be manually added to the list of

referrals


Referral to ADRC


ReferralManagement

ADRC

Data Collection


Referrals to LMHA and OSAR

Referral to the LMHA and OSARExperts from these areas defined Referral

CriteriaBehavioral health questionsAlcohol and drug abuse


Referral Management

Receiving a referral

Acknowledge

Process

Forward, as necessary


Questions?

balancing incentive program – no wrong door january 27, 2014 1 balancing incentive program and...

Documents