managed care organization panel discussion on community living and community living supports (cls)...
TRANSCRIPT
Managed care organization panel discussion on community living and Community Living Supports (CLS) services
October 29-30, 2014
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Tennessee Managed Care
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Overview of CHOICES
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Guiding principles for CHOICES
• Focus on the whole person – coordination across medical, behavioral, and long-term services and support (LTSS) continuum• Promote independence, choice, dignity and quality of life• Reduce fragmentation – offer a seamless approach to needs,
including a one-stop shop for LTSS information and assistance
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CHOICES benefits
• Improves (and simplifies) access to the LTSS system• Increases options (choices) for members• Offers efficient utilization of limited resources• Improves quality of care
Provides the right care in the right place at the right time.
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CHOICES member groups
• Group 1 – Members who are receiving Medicaid-reimbursed LTSS in a nursing facility who meet nursing facility level of care (LOC).
• Group 2 – Members who are receiving Medicaid-reimbursed home- and community-based services (HCBS) as an alternative to nursing facility care who meet nursing facility LOC.
• Group 3 – Members in the community who are receiving Medicaid-reimbursed HCBS to prevent or delay the need for nursing facility care who meet at-risk LOC (effective July 1, 2012).
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CHOICES member eligibility
In order to be enrolled in CHOICES, a member must:• Qualify for Medicaid• Require nursing facility LOC or be at risk for nursing facility
care• Need LTSS• Actually be receiving LTSS*
* Satisfaction of the eligibility criteria for CHOICES is not sufficient for enrollment.
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CHOICES Community Living Support (CLS) benefits
Benefits include: • Hands-on assistance with activities of daily living,
including but not limited to toileting, transfers and mobility, bathing, dressing, transportation, skilled care services, etc.
• Personal emergency response system• Pest control• Minor home modifications
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Care coordination role
• Functions as the primary case manager for each CHOICES member• Conducts a comprehensive assessment addressing medical,
behavioral, environmental and psychosocial needs of each CHOICES member• Develops a plan of care inclusive of all member needs• Coordinates service delivery to ensure safety, including
linkage to community resources• Educates the member/member representative on CHOICES
benefits and other community resources
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New residential options for CHOICES membersCommunity Living Supports (CLS) andCommunity Living Supports - Family Model (CLS-FM)
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New residential supports
CLS supports:
• Community-based residential alternative
• Up to four elderly or disabled Individuals (CHOICES members
only)
• Up to three elderly or disabled individuals in a Division of
Intellectual Disabilities Services (DIDDS) blended home
• Independence and integration in the community
• Includes hands-on assistance, supervision, transportation and
other supports as needed
• Member is responsible for room and board
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CLS
CLS1 • $1,100/monthly; T2032 UD, U1; or • $36.16/day; T2033 UD, U1. • This is available for members who: • Are primarily independent or have other paid or unpaid
supports that can assist in meeting their needs• Require limited intermittent care ‒ less than 21 hours per
week• Do not require overnight assistance (staff is on call 24/7)
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CLS
CLS2 $100/day; T2033 UD, U3. This is for members who: • Can be left alone for several hours at a time• Require minimal to moderate support on an ongoing basis• Do not require overnight assistance (staff is on call 24/7)
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CLSCLS3
• $139/day; T2033 UD, U4.
• This is available for members who: • Have a higher acuity of needs
• Require moderate to maximum assistance
• Require overnight assistance or supervision for safety
• Have significant physical disabilities requiring:• Frequent intermittent hands-on assistance with activities of daily
living (ADL)• Assistance with complex health conditions and compromised
health status• Medication assistance and daily nurse oversight • Monitoring and/or skilled nursing services
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CLS - Family Model (CLS-FM)
CLS-FM is a Community-based residential alternative with the following features: • Up to three elderly or disabled individuals live in a home with a
trained family who provides care and support (this is an unrelated family)
• Supports independence and integration in the community• Includes hands-on assistance, supervision, transportation and other
supports as needed• Member is responsible for room and board
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CLS - FM
CLS – FM1 • $38/day; T2016 UD, U1. • This is for members who: • Are primarily independent• Require limited intermittent care• Do not require overnight assistance (family caretaker is on
call 24/7)
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CLS-FM
CLS – FM2 • $70/day; T2016 UD, U2. • This is available for members who: • Can be left alone for several hours at a time• Require minimal to moderate support on an ongoing basis• Do not require overnight assistance or supervision, but
family caretaker on call 24/7
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CLS-FM
CLS-FM3 • $115/day; T2016 UD, U3. • This is available for members who: • Have higher acuity of needs• Require moderate to maximum assistance• Require supports and/or supervision 24 hours per day• Have significant physical disabilities requiring frequent
intermittent hands-on assistance with:• ADLs• Complex health conditions and compromised health status
requiring medication assistance• Daily nurse oversight and monitoring • Skilled nursing services
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CLS LOC
• LOC is determined by a comprehensive individualized assessment conducted by the MCO CHOICES care coordinator.
• CHOICES group level does not equal a CLS level.
• Takes into account the individual needs of a member, which will be included in the member’s Plan of Care.
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Discussion topics
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Billing for CLS services
• CLS will not be billed through the electronic verification system.• Agencies must submit electronic claims on the UB-04 form
using a clearinghouse.• Managed Care Organizations (MCOs) will have a provider
representative assigned to your company to help with this process and answer questions.• Billing frequency would depend on the service in place and
the structure of the service.
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Program requirements for CLS services
• MCOs are working to develop requirements that will align with the provider’s current processes.
• Will address key documentation and quality standards.
• Will be developed collaboratively among the MCOs to ensure consistency and ease for the providers.
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Does the Personal Support Services Agency license cover CLS services?
No. You will need to be licensed as a:• Mental Retardation Semi-Independent Living Services
licensed provider by DIDDS for:• CLS1 • CLS2 • CLS-FM1 • CLS-FM2
• Mental retardation supported living and/or residential habilitation facility provider by DIDDS for:• CLS3• CLS-FM3
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What type of quality assurance will be in place?
• Critical incident reporting
• Monthly contacts with care coordinators by phone or face to face
• Provider advocate annual HCBS audits
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Who develops the plan of care?
• In CHOICES, the plan of care (POC) is a very similar document to the individual support plan (ISP), including:• Relevant information regarding the members’ services• Natural supports• Back-up plans• Disaster planning• A summary of the individual’s physical, social and emotional
needs • Any self-directed care the member qualifies for
• Each MCO has a different format but all POCs contain the same information.• The CHOICES care coordinator is responsible for developing
the POC.25
How will medications be administered?
• CHOICES members will be allowed to use self-direction for medication administration if determined appropriate.
• A verbal order will be obtained from the member’s PCP and included on the POC allowing a paid worker to assist in this health care task.• This is limited to the administration of oral, topical and
inhaled medications.
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Will the person’s MCO for medical services be the only choice he or she has for the
CLS service?
• Each MCO has the right to administer a single case agreement with individual providers.
• We strongly encourage participation with all MCOs to ensure continuity of care.
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Have MCOs started contracting with DIDDS providers? What is the
process?• Yes, we all have.• The process is similar for each MCO. • When a member is identified to move into a CLS
housing, a single case agreement will be completed.• We will be moving to global contracts some time in
2015.
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Who to contact at each MCO?
• Each MCO has a different point of contact. We encourage you to reach out to your provider representative if you already have one.
• We also encourage you to meet with representatives that are present from each MCO here today to exchange information on how to reach out to them.
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Time frame from identification of a member until move-in day?
• This can range from seven to 45 days.
• Each case is different and specific to the member.
• Specific items that may impact this time frame are: • A member’s physical status and need for additional care to
resolve acute conditions• Need for a home modification• Need for member & care coordinator to obtain needed
household items for community living30
Amerigroup contacts• West Tennessee Grand Region:
Debra Phillips, RNLTSS Manger I/Transitions-MFPEmail: [email protected]: 615-948-1389 Office phone: 615-316-2400, ext. 22481
• Middle Tennessee Grand Region:Anita McClard, RNLTSS Manager I/Transitions-MFPEmail: [email protected]: 615-670-0313Office phone: 615-316-2400, ext. 22516
• East Tennessee Grand Region:Sharon SpontakLTSS Manager I/ Transitions-MFPEmail: [email protected]
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UnitedHealthcare contacts• West Tennessee Grand Region:
Lynn SandersMember AdvocateEmail: [email protected] phone: 901-377-9197
• Middle Tennessee Grand Region:Beth ZanoliniMember AdvocateEmail: [email protected] phone: 615-438-7148
• East Tennessee Grand Region:Traci McKenzieMember AdvocateEmail: [email protected] phone: 423-334-1016 32
UnitedHealthcare Provider contact for contracting:• Deborah Stewart
Director, Provider AdvocateEmail: [email protected]: 615-589-3389
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BlueCare CLS Level of Care Determination
BlueCare CHOICES Care Coordinators (CCs) complete needs assessments for members prepared to transition to community living
Assessments are documented and submitted to TennCare Medical Director for approval
Once approval for level of care received, MCO Single Points of Contacts initiate provider collaboration to provide required member services and housing
BlueCare CLS Claims Submission and Billing
BlueCare CHOICES Point of Contacts will conduct a site visit with Provider and provide program billing training
Use of the CMS-1450 (UB-04) Electronic Funds/Electronic Payments HCPCS, rates and frequency driven by approved
services
BlueCare Contacts
Mary GauseManager, Statewide CHOICES Clinical SupportEmail: [email protected]: 615-565-1905(member care coordination)
Phyllis WhiteManager, Statewide Provider RelationsEmail: [email protected] Phone: 615-386-8591(credentialing and contracting)
Questions?
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