Maryland Developmental Disabilities Administration Resource Coordination Provider Recruitment

Transcription

Maryland Developmental
Disabilities Administration
Resource Coordination
Provider Recruitment
December 18, 2013
2
Agenda
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2)
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4)
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6)
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14)
Introduction/Overview
DDA Service Delivery System
Resource Coordination Services, Activities, and Data
Provider Client Information System (PCIS2)
Units
Billing & Payments
Working Capital
Rates
HIPAA
Medicaid Fraud
Application Submission
Business Plan
Timelines
Questions
3
Introduction/Overview

The Developmental Disabilities Administration (DDA) provides a
coordinated service delivery system so that people with
developmental/intellectual disabilities receive appropriate services
oriented toward the goal of integration into the community.

Services are provided through a combination of State Residential
Centers (SRCs), Forensic Residential Facilities (FRC), and a wide
array of community-based services delivered primarily through a
network of non-profit providers licensed by the DDA.

Resource Coordination (RC) is primarily a Medicaid rate-based
service under Medicaid Targeted Case Management (TCM) in
Maryland’s state plan. The same scope of services and rate
structure is used for non-Medicaid eligible.
4

The DDA partners with people with developmental/intellectual
disabilities to provide leadership and resources to live fulfilling lives.

People with developmental/intellectual disabilities have the right to
direct their lives and services.

The DDA’s community-based service delivery systems includes
various home and community-based services and supports provided
through either a Medicaid State Plan or Waiver program or via DDA
State funded services.
5

The DDA has organized its Service Delivery System into regions.

Resource coordination providers need to provide services on a
regional basis
Region
Counties
Western
Allegany, Carroll, Frederick, Garrett, Washington
Central
Anne Arundel, Baltimore City, Baltimore, Harford,
Howard
Southern
Calvert, Charles, Montgomery, Price George’s, St.
Mary’s
Eastern
Caroline, Cecil, Dorchester, Kent, Queen Anne’s,
Somerset, Talbot, Wicomico, Worcester
6
People DDA Supports


The DDA supports both children and adults with various ages,
needs, and environments across the State.
Some people have complex needs including:

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medically complex conditions;
emotional and/or behavioral challenges and needs;
court involvement; and
transition from foster care and various institutions (e.g., out of State
placements, State Residential Centers, State Psychiatric Hospitals,
Nursing Facilities, etc.).
7
People DDA Supports
Some people have involvement with multiple State service delivery
systems, including:

Maryland State Department of Education
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
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Division of Rehabilitative Services
Special Education
Department of Human Resources (DHR) foster care,
Department of Juvenile Services (DJS) juvenile services,
Mental Hygiene Administration (MHA) behavioral health services,
Medicaid’s skilled care, and
Other Medicaid Waiver programs such as the Autism, Model, and
Living at Home Waiver programs.
8
Resource Coordination Services

Resource coordination (RC), also known as Targeted Case
Management (TCM) by Medicaid, plays a vital role in the delivery of
services to people with developmental disabilities.

Resource coordination covers a wide range of assessment,
planning and coordination, referral, and monitoring activities to
assist a person to obtain and retain services needed, including
comprehensive assistance in gaining access to needed supports
and services regardless of how the services are financed.

Resource coordination is critical for connecting people with
developmental disabilities and their families to services and
supports within various other systems or community resources
including medical services, educational services, housing
assistance, food stamps, public transportation, social activities, etc.
9

The DDA provides resource coordination services to:





People applying for funding
Comprehensive Assessment;
People eligible for services on the DDA Waiting List in the crisis
resolution, crisis prevention, and current request priority categories as
defined COMAR 10.22.12.07
Waiting List Coordination;
People currently receiving on-going community services regardless of
program (i.e. Waiver or State Funded)
Community Coordination; and
People eligible for services transitioning into the community from an
institution
Transition Coordination.
Resource coordinators assist people and families by applying,
planning, coordinating, assessing and monitoring needs, services,
and compliance with program rules and regulations and may be
contacted to assist the DDA during emergencies outside of normal
business hours.
10


The DDA funds three types of ongoing RC services to eligible
people, including Waiting List Coordination Services, Community
Coordination Services, and Transition Coordination Services. Each
of these services includes three RC activities:

Development and periodic revision of the Individual Plan
(Reference: COMAR 10.09.48.06B);

Referral and related activities (Reference: COMAR 10.09.48.06C); and

Monitoring and follow-up (Reference: COMAR 10.09.48.06D).
Resource coordinators’ primary work should focus on

Assuring that DDA-funded and other services are meeting the person’s
needs, support outcomes, and goals, and are being delivered as
specified in the individual plan; and

Ensuring the person’s safety.
11
Comprehensive Assessment



Face-to-face assessment of the person’s needs and supports to
determine eligibility as noted in COMAR 10.09.48 and 10.22.12.
Assistance with information gathering such as obtaining
professional evaluations and assessments necessary to document
and recommend eligibility and priority for services.
Provide Referral and Related services including:


Sharing information about relevant resources and making referrals, and
Providing assistance with applications to generic community, local, state
and federal programs for medical, social, educational and other
necessary services.
12
Individual Plan

Development of a “person centered” service plan referred to as the
Individual Plan (IP);

Facilitating and coordinating interim meetings based on the
individual’s “person centered planning methodology” preference
(i.e. Essential Lifestyles Plan, MAPS, Paths, etc.);

Entering critical information from an individual’s IP into the DDA’s IT
system;

Update and revise the IP as circumstances change; and

Facilitating and coordinating the annual IP update to be conducted
within 365 days of the previous plan.
13
Referral and Related

Share information about relevant resources and make referrals

Assist with applications to generic community, local, state and
federal programs for medical, social, educational and other
necessary services.

Complete National Core Indicators Pre-Survey
14
Monitoring and Follow-Up

Assessment of:



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
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
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Services being rendered as specified in the Individual Plan;
Current circumstances;
Progress toward goals and intended outcomes;
Referral status;
Needs and supports to maintain eligibility for Medicaid, waivers, DDA
services, and any other relevant benefits or services;
Identification of new medical, health services, or other needs;
Recommendation of priority category change (as applicable);
Request for DDA service change;
Identification of new support or resource options;
Review and revisions to emergency plan;
Monitoring of changes and actions items as a result of incidents; and
Application or reapplication for necessary programs or services to
prevent or remedy a gap ineligibility.
15
DDA Waiting List Coordination Monitoring Frequency
Based on DDA Waiting List priority category

Crisis Resolution–minimum monthly face-to-face contacts for first
90 days and then face-to-face quarterly meetings until priority
category changes, unless otherwise authorized by DDA, or
services offered;

Crisis Prevention–minimum quarterly face-to-face contacts until
priority category changes, unless otherwise authorized by DDA, or
services offered;

Current Request–minimum annual face-to-face contact until priority
category changes, unless otherwise authorized by DDA, or
services offered.
16
DDA Community Coordination Monitoring Frequency
On a minimum quarterly basis:

Face to face with the participant

In different services delivery settings (employment site, residential
program, etc.)

At least one time in each service delivery setting
17
DDA IT System – PCIS2


The DDA’s Provider Client Information System (PCIS) is required
for documentation of resource coordination services, activities, and
billing.
PCIS Modules
1. Individual Plan
2. Resource Coordination Notes

Development of Plan

Referral and Related

Monitoring and Follow-Up
3. Incidents


Auto generation of invoice based on certified notes
All new providers must have resource coordinators directly input
data into PCIS2.
18
Resource Coordination Population
Estimated RC Counts By Region
Region
Western
Central
Southern
Eastern
Total
Current
3,249
10,061
3,554
2,297
19,161
Currently Assigned Statewide Population
Category
Current Percentage
Community Coordination
13,368
69.77%
Transition Coordination
24
0.13%
Crisis Resolution
66
0.34%
Crisis Prevention
1,038
5.42%
Current Request
4,665
24.35%
Total
19,161
100.00%
Available
3
112
3,709
32
3,856
Total
Percentage
3,252
14.13%
10,173
44.20%
7,263
31.55%
2,329
10.12%
23,017
100.00%
New Individuals Entering Service (FY2009 - FY2013 Average)
Category
Current Percentage
Crisis Resolution
61
5.26%
Crisis Prevention
191
16.48%
Current Request
907
78.26%
Total
1,159
100.00%
19
Western Availability
Category
Crisis Resolution
Crisis Prevention
Current Request
Total
Choice
Available
91
2
0
0
0
0
7
0
32
1
130
3
New
Central Availability
Category
Crisis Resolution
Crisis Prevention
Current Request
Total
Choice
Available
281
78
1
0
1
0
22
6
98
27
403
111
New
0
0
9
27
128
164
0
0
27
84
401
512
Total
93
0
9
34
161
297
Total
359
1
28
112
526
1,026
20
Southern Availability
Category
Crisis Resolution
Crisis Prevention
Current Request
Total
Choice
99
8
35
142
Available
2,588
5
13
201
903
3,710
New
-
Eastern Availability
Category
Crisis Resolution
Crisis Prevention
Current Request
Total
Choice
64
5
22
91
Available
22
2
8
32
New
-
19
60
286
365
6
19
92
117
Total
2,687
5
32
269
1,224
4,217
Total
86
6
26
122
240
21
Unit Allocation


The DDA will allocate billing units annually per person based on the
person’s eligibility for services.
As outlined in regulations, billing units have been specified for each
type of RC service to guide resource coordinators in the efficient
use of units and constrain the costs to the system.
Units Allocated by RC Service Type (per individual)
RC Service Type
Annual Units
Annual
Hours
Expected
Hours
212
53
39.75
208
52
39
Waiting List – Crisis Resolution
168
42
42
Waiting List – Crisis Prevention
112
28
28
Waiting List – Current Request
60
15
15
22
Unit Allocation

Service requirements are outlined in COMAR 10.09.48.06

The regulations regarding service provision are not related to the
payment unit limits outlined in COMAR 10.09.48.08: Payment
Procedures.

Unit limits are associated with payment; therefore, they do not
restrict service delivery to people if excessive units are used by
resource coordination providers.

If all available units are used for an individual, a provider may
request the approval of additional units in order to resolve an
emergency or complete the required RC activities for the remainder
of the fiscal year.
23
Unit Allocation
Requests for additional units are reviewed to meet at least one of the
following criteria:
 A crisis or emergency situation that meets the defined criteria for
the crisis resolution priority (even if the individual is not currently in
that category), including requests for individuals whose crisis
occurred earlier in the fiscal year;
 Transitioning Youth (TY) who are new to the DDA and have been
found eligible for TY funding in the current fiscal year; or
 Complex transfers between providers.
Requests that do not meet those criteria will be reviewed on a caseby-case basis.
24
Billing Increments
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Units
1
2
3
4
5
6
7
8
A unit of service is paid if at least 8 minutes of service is provided.
Data indicates that the paid time gained through the round up
covers time lost by activities with a duration of less than 8 minutes.
Despite this rounding, all activities should be entered in PCIS2.
Minutes of Service
Greater than or equal to 8 minutes, but less than 23 minutes (8-22 minutes)
Note: Units are cumulative minutes for all activities per day per person.
25
Billable Activities
Billable activities involve:

Face to face activities with the person eligible for services (direct contact);

Telephone contacts with the person served and their supports (indirect);

Collateral contacts such as face to face meetings, telephone, or email with
family members, providers, etc.;
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Team meetings;

Assessment, service planning, and reviews; and

Critical or reportable incidents.
26
Billable Activities Examples
Examples Include:

Application and reapplication assistance

Assisting the person in obtaining required supporting documentation

Assistance completing the waiver application

Developing and submitting the Medicaid waiver packet

Information and referrals to various community resources to support goals
and protect health and safety

Eligibility confirmation and maintaining benefits

Coordinating transitions from service providers or institutional settings

Individual Plan -pre-planning, meeting coordination, development of IP,
writing, etc.

Telephone calls, emails, and site visits with person or team to monitor the IP

Assessment of progress on goals and services as written in plan

Assisting the person in identifying and overcoming barriers
27
Non-billable Time
Examples include:

Traveling time to and from site visits and meetings;

Staff training;

Supervisor management, oversight, supervision, evaluation, etc. of resource
coordinator;

Agency accounting processes and audits;
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Licensing processes, reviews, plan of corrections, etc.

Community outreach; networking with providers

Technical problems; correcting upload errors

Caseload review

Assisting colleagues; two coordinators serving the same individual in one day;
supervision

Transfers (only one agency can bill)

Administrative activities (time sheets, general voicemails, etc.)

Time spent after a death
28
Payment Rates
Fiscal Year
RC Rate
$59.95
FY2016
$61.42
$472.41 FY2015 Rate Shown w/ Potential COLA
FY2017
$62.94
$484.03 FY2016 Rate Shown w/ Potential COLA
$70.16
FY2015





Notes
The Rate of $70.16 only applies to FY2014 as
$450.00 the Transition Year
$58.51 Rate Shown w/ Potential COLA - Rate is
$461.07 being reviewed.
FY2014

CA Rate
Comprehensive assessment shall be reimbursed per assessment.
All other activities (i.e. referral and related, individual plan, and monitoring
and follow up), providers shall be reimbursed at a per unit of service
(billable activity).
The FY 2014 is a transition rate to allow for ramp-up.
FY 2015 – FY 2017 rates are shown with a potential COLA.
The FY 2015 rate is currently being reviewed.
All rate changes must be approved by the state budget office and CMS.
29
Payment
 Payment shall be made only to one approved provider for covered
services rendered to a participant on a particular date of service.
 Invoices should be submitted by the 15th of the month following
service and will be paid within 45 days following the review of the
invoice.
 Payment for the services:

Shall be considered as payment in full; and

May not supplement or be supplemented by payment from other
sources, such as the participant, family, a public program, or private
agency.
30
Working Capital

DDA will provide a Working Capital (WC) advance every year.

Advance will be based on 33% of expected annual projected claims
per census count (i.e. # of people receiving Waiting List,
Community, and Transition Coordination resource coordination
services).

WC will be forwarded annually to providers on or about July 1 or at
the start of service initiation. The payment of working capital for
current providers will be dependent on the certification of the last
invoice of the previous fiscal year.

WC will be repaid via income earned in March, April, May, and June
or during the last quarter of a partial year of service.

Any remaining balance will be paid from the subsequent WC
31
Working Capital
Working Capital: $100,000
Month of Service
Month of Payment
Amount Due as
Payment for Service
Amount Paid
Working Capital
Balance Owed
July
August
$25,000
$25,000
$100,000
August
September
$25,000
$25,000
$100,000
September
October
$25,000
$25,000
$100,000
October
November
$25,000
$25,000
$100,000
November
December
$25,000
$25,000
$100,000
December
January
$25,000
$25,000
$100,000
January
February
$25,000
$25,000
$100,000
February
March
$25,000
$25,000
$100,000
March
April
$25,000
$0
$75,000
April
May
$25,000
$0
$50,000
May
June
$25,000
$0
$25,000
June
July
$25,000
$0
$0
32
Working Capital

DDA may revoke the working capital advance based on:
 Quality of care deficiencies;
 Changes in business practice that are detrimental to service recipients;
 Impending bankruptcy; or
 Other good cause

If the DDA revokes the working capital advance, the provider shall
immediately repay the total amount of the advance to the DDA.
33
HIPAA
Resource Coordination Agencies providing targeted case
management services are considered Covered Entities under the
Health Insurance Portability and Accountability Act (45 CFR parts160,
162 and 164). As healthcare providers to individuals, Agencies are
responsible to safeguard Protected Health Information (PHI) through
privacy and security policies and practices in accordance with all
applicable regulations.
34
Medicaid Fraud
MFU’s Jurisdiction

Investigate and prosecute healthcare provider fraud in the Medicaid
program

Prosecute resident abuse and neglect in healthcare facilities
receiving Medicaid funding or other long-term care facilities such as
Assisted Living

May review and prosecute complaints of the misappropriation of
resident’s private funds in facilities receiving Medicaid funding
35
Medicaid Fraud
There are criminal and civil penalties associated with Medicaid Fraud
and there is a National Practitioner Data Bank (NPDB) - National
Health Care Fraud database for the reporting of specific final adverse
actions against health care practitioners, providers and suppliers.
Criminal Prosecution
Civil Prosecution
General Maryland criminal
statutes:
Theft § 7-101 et. seq.
Identity Fraud § 8-301
Assault § 3-202, 203
Specific Maryland criminal
statutes:
Medicaid Fraud § 8-508
Abuse or Neglect of a Vulnerable
Adult § 3-604,605
Exploitation of Vulnerable Adults
Prohibited § 8-801
Federal False Claims Act
31 U.S.C. § 3729-3733
Those who knowingly submit, or cause another
person or entity to submit, false claims for
payment of government funds are liable for three
times the government’s damages plus civil
penalties of $5,500 to $11,000 per false claim.
Maryland False Claims Act (New)
Health General § 2-601 et. seq.
To recover damages and penalties from
individuals who defraud the state by filing false
claims against state health plans and programs,
including Medicaid.
36
Application and Proposal

The standardized application and business plan template must be
used for submission

Professional references are to submit the provided reference form
directly to the DDA
37
Timelines

Business Plan Webinar January 7, 2014 at 12 PM (Details will be
forthcoming)

Application Questions due by January 10, 2014

Applications are due January 21, 2014 by 12 PM

Evaluation Decisions by February 3, 2014

New Provider Orientation for Management – February 10 & 11

Resource Coordinators Training (Mandatory) – February 18 & 19

PCIS2 Access and Module Training – February 20 – March 3, 2014

Service Referrals begin March 3, 2014
Questions
38

Maryland Developmental Disabilities Administration Resource Coordination Provider Recruitment

Transcription

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