Slide 1 - Smoky Mountain Center by wulinqing


									    Talking Points For the
Proposed Changes to CAP-I/DD
  The NC Division of MH/DD/SAS, in partnership with the Division of
     Medical Assistance and with the support of the Developmental
       Disabilities Training Institute, will be hosting five CAP-I/DD
Informational Sessions for the purpose of communicating the changes
  in the CAP-I/DD Comprehensive and Supports Waivers that will be
                            effective 11/1/2011.

 The sites for the sessions were selected to accommodate as many
  interested individuals a s possible in each region. There will be no
charge for these events, and registration is now open. The events are
                         scheduled as follows:
                                        Tuesday, Sept. 20, Greenville
                                       Wednesday, Sept. 21, Wilmington
                                         Monday, Sept. 26, Asheville
                                         Tuesday, Sept. 27, Newton
                                        Wednesday, Sept. 28, Sanford

To register for a session, please visit

We encourage all who are interested in attending to register as soon as possible so we can monitor the attendance
        numbers. We also encourage attendees to arrive early to sign in, as we expect large numbers.
Why is CAP-I/DD Changing?
• 1915(c) HCBS waivers must be renewed
  every 3 to 5 years
• Existing CAP-I/DD waivers expire on
North Carolina serves eligible CAP-I/DD
recipients in two 1915( c) waivers:

The Supports Waiver (Indicator C2) provides
serves with a yearly maximum of $17,500.

The Comprehensive Waiver ( Indicator CM)
provides services with a yearly maximum of
• Both Waivers shall offer a Self-Direction

Self Direction Link:
      Home and Residential
• Home
  – Own home
  – With biological, adoptive, step family members
    and/or legal guardians of the person who are family

• Residential
  – Alternative Family Living
  – Provider managed residences
       Natural Home Setting
• Is the adult participant‟s own personal
  home or a home he/she shares with
  parents or other family members
• Both children and adult participants who
  reside in their natural homes may receive
  Personal Care Services and Home and
  Community Supports provided by staff
  who do not live in the participant‟s home
• Adult participants residing with their
  parents may receive Home and
  Community Supports and Personal Care
  Services provided by people residing with
  them as indicated in Section H and I. or
  Personal Care Services and Home and
  community Supports provided by staff that
  do not live in the participant‟s home
       Alternative Family Living
For the purposes of the CAP-I/DD waiver, an Alternative
Family Living (AFL) home or adult foster home is
considered an out-of-home setting for a person who
chooses this setting.

The participant receives 24-hour care and lives in a private
 home environment with a family who are paid to provide
services to address the care and habilitation needs of the
Person-Centered Planning
– Process to determine real-life outcomes and strategies to
  achieve those outcomes
– Should include people that are important in the
  participant‟s life
– Should identify both paid and unpaid supports tailored to
  meet the needs of the participant
– Provider agencies of targeted case management shall
  establish or adopt policies to ensure that all good-faith
  efforts are made to inform participants, guardians, and
  legally responsible persons of the full array of provider
  choices, including other agencies providing targeted case
– Must be signed by participant and/or representative and
  QP to be considered complete
• Natural supports are places, things, and people who are a part
  of a participant‟s interdependent life and whose relationships are
  reciprocal in nature and often vital to a participant‟s welfare.

• Person-centered planning promotes the concept that purchased
  or funded supports are intended to supplement and not replace
  natural supports available to the participant when they are
  appropriate to the participant‟s needs.

• For guidelines regarding the provision of waiver services
  furnished to adult participants by family members, guardians,
  and legally responsible persons, please refer to Sections H, I
  and J for additional information.

• Waiver services cannot be provided to minor children (18 years
  or younger) by family members, guardians, or legally
  responsible persons regardless of whether the minor child
  resides in the natural home with the family members, guardians,
  or legally responsible persons or resides outside the home.
  Waiver services may not be provided by a spouse of the
  participant (a spouse is considered a legally responsible

• The NC Support Needs Assessment
  Profile (NC-SNAP)
  – Scores indicative of levels of service
  – 5 levels indicated in section 1.1.2
  – Should be a positive correlation between the
    SNAP score and requested/authorized
• EPSDT – Early Periodic Screening, Diagnosis, and
     Allows a participant less than 21 years of age to
     receive services in excess of the limitations or
     restrictions when services are medically necessary
     health care services to correct or ameliorate a defect,
     physical or mental illness, or condition [health
     problem]; that is, documentation shows how the
     service, product, or procedure will correct or improve or
     maintain the participant‟s health in the best condition
     possible, compensate for a health problem, prevent it
     from worsening, or prevent the development of
     additional health problems.

– Does not apply to 1915(c) waiver services
– Applies to all other Medicaid services that may be
  indicated in the Person Centered Plan
  Basic Medicaid Billing Guide

EPSDT provider Page
    Habilitation Services

– Assist in acquiring, retaining, and
   • Self-help
   • Socialization
   • Adaptive skills
   Necessary to reside successfully in
     home and community –based settings
   Individual Services

– All services are individual services unless a
  group service is identified and a group billing
  rate has been established
– Require one-to-one direct staff contact with
  the participant
   Limitations of Coverage

• Utilization Guidelines become
  Utilization Criteria
• 129 hours/month for any combination of
  habilitation services
    • Edit will be implemented through HP
    • Habilitation hours may be exchanged for
      Personal Care hours
    • Children limited to 20 hours per week when
      school is in session
 Direct Contact Hours

• One-to-one “active” service
• Individualized supports designed to meet
  needs of the participant
• Do NOT involve passive general supervision
  and monitoring
• Will be enforced at prior approval
      Limitations of Coverage
• Direct Contact Hours are figured into the
  overall habilitation hours
• Habilitation limited to 12 hours per day
• Individuals in residential placements are
  eligible to receive only the Individualized
  Day Program (community component) of
  Home and Community Supports
   Limitations of Coverage

• Private Duty Nursing is only available for
  short-term acute care
• If need is in excess of 30 days, re-
  evaluation for CAP-I/DD LOC is required
      Limitations of Coverage
• Cost limits raised for the following services
  to account for 5 year waiver
  – Home Modifications
  – Individual Goods and Services
  – Vehicle Adaptations
        Eliminated Services

•   Nursing Levels of Respite Care
•   Enhanced Personal Care
•   Enhanced Respite Care
•   Home Supports
Nursing Levels of Respite Care

• Levels eliminated because of
  availability of private duty nursing
  through regular Medicaid
• Service was being intermingled with
  private duty nursing
         Enhanced Services

• Eliminating Enhanced Personal Care and
  Enhanced Respite Care
• Reviews and audits indicate that there is
  very little difference from standard level of
            Home Supports
• Will be replaced by Home and Community
  Supports and/or Personal Care
• Individuals living in the natural home with the
  participant limited to total of 40 hours per
• If more than one adult child is receiving
  services in the home, limit is a total of 40
  hours per week by individuals living in the
• 129 hour habilitation service limit applies
• Effective November 1, 2011, No More Than 129 hours
  of Habilitation per Month

• Effective November 1, 2011, the total habilitation hours
  received by a participant must not exceed 129 hours of
• habilitation per month.

•    Please review the CAP MR/DD services that are
    available. The 129 hours per month limit is inclusive of
    the habilitation the participant may receive through
    engagement in Day Supports, Supported Employment,
    Long Term Vocational Supports and Home and
    Community Supports. NOTE: The combination
    or distinct utilization of these services is not to exceed
    129 hours a month.
Services Provided by Family Members

• Language changed to account for
  elimination of Home Supports and hourly
• Review by LME not required
Services Provided by Legal Guardians

 • Of the person only
 • Must be reviewed by LME
 • Added language to clarify that decision
   from LME must be included in submission
   to UR vendor
CAP-I/DD Participants Residing at Home
                 Level 1        Level 2         Level 3           Level 4
                 Index 24-44    Index 45-79     Index 80-94       Index 95-230
 Respite                                576 hours/year
 Personal        40             80/             120               180
 Care            hours/month    hours/month     hours/month       hours/month
 Residential                                  N/A
 Home and        129 hours/month for any combination of these services
 Supports,       For Adults and Children who are NOT in school.
 Long-Term       For children in school, 20 hours per week is the maximum for
 Vocational      habilitation.
 Supports, and
   CAP-IDD Participants Receiving
       Residential Supports
• Residential Supports is a habilitation
  service with built-in Personal Care at a
  daily rate to meet the flexibility daily needs
  of the individual.
• Its range of hours for each NC-SNAP level
  of service (level 1-level 4) includes both
  components –personal care and
• This hour range indicates the hours of
  direct contact services and support
  expected for each level of the service
       Residential Supports
• Limited to those in the Comprehensive
  Waiver but not the Supports Waiver
• No new admissions to 16+ bed in specialty
      Residential Supports

• Range of Direct Contact Hours required
  for daily rates
• Direct Contact Hours are figured into
  the overall habilitation hours
• Habilitation limited to 12 hours per day
• Respite Care may not be billed on
  same day
                                 Residential Supports

Service                   NC SNAP      NC SNAP           NC SNAP          NC SNAP
                          Level 1      Level 2           Level 3          Level 4
                          Index 24-    Index 45-79       Level 3          Index 95-
                          44                             Index 80-        230
Respite                                                 N/A
Personal Care                                           N/A
Residential Supports†     2 ½ to 5     4 ½ to 6 ½        6 ½ to 9         8 ½ to 12
Daily rate for hours of
                          hours per    hours per         ½ hours          ½ hours
Direct contact in the
following ranges          day          day               per day          per day

Home and Community                    129 hours/month for any combination of these
Supports,§ Day                                            services
Supports, Long-
                                     for adults and children who are not in school. or
Term Vocational
                                  children in school, 20 hours per week is the maximum
 Supports, and
Supported Employment                                   for habilitation
             Residential Supports
• Can be provided in 3 beds or less including an Alternative Family
  Living or Foster Homes and unlicensed alternative family living
  homes serving one adult
• Residential Supports may also be provided in licensed residential
  setting of 4 to 6 beds which were licensed prior to the
  implementation of the 11/1/08 waiver and demonstrate a home and
  community charter
• Participants currently living in a licensed group home or adult care
  home with 7-15 beds, participating in the CAP-IDD Waiver at the
  time of the implementation of the 11/1/08 waiver may continue
  receiving Residential Supports in their current living arrangement, if
  it is justified in the PCP as to the appropriateness of this placement
    Individualized Day Program

• Community Component of Home & Community

• Structured day program based upon the participants

• 4 hour daily limit has been removed
• Examples
   – Attending community college
   – Volunteer work
   – Senior Center
         Respite Care
• May not be used for participants who are
  living alone or with a roommate
• May not be provided on the same day that
  a participant receives Residential Supports
• May not be provided by anyone living with
  the participant
                    Pathways UR

                     Pathways expects approximately 350 revisions in
   addition to their normal Continued Need Review‟s for November

• Beginning January 20, 2011, Pathways LME began conducting
  reviews for designated services related to CAP I/DD services for all
  Medicaid Waiver Recipients whose Medicaid originated from
  counties in Smoky Mountain LME,

• How to Reach Pathways:
  Phone: 1-855-PATH-CAP(1-855-728-4227)Fax: 1-855-PATH-
Required Documents for CAP Authorization

 All Submissions must include:
• CTCM form (word or excel)
• Recipient‟s Name
• Date of Birth
• Medicaid ID number
• Provider‟s Medicaid Provider number
• Provider‟s NPI number
• Provider‟s contact information
• Description of requested service
• Start date
• Required signatures
• Supporting documentation
• Clinical information to determine Medical
    Initial and Concurrent Requests
               must include:
•   I/DD TCM contact information
•   Complete PCP with Crisis Plan
•   Current MR2
•   Current Psychological
•   Supporting assessments
•   Cost Summary
•   CTCM
Revisions (adding, discontinuing or
changing a service) must include :

•   PCP Update/Revision
•   Cost Summary
•   CTCM
•   Supporting assessments
•   Please do not wait until the last minute to
    submit revisions or CNR‟s

•   Once submitted, continue through the
    process. Some providers don‟t have access
    to the portal access. You can call Pathways
    to access this information over the phone
    (five at one time)

•   Check and re-check the portal access to
    monitor the progression of the review

•   Be mindful of Pathways „Turn Around Time‟
    and plan accordingly

•   You can submit your revisions early

•   Although some plans may be retro-actively
    approved in some situations….don‟t count
    on this!
Q: Do I have to wait until the Clinical Coverage Policy No.: 8M is approved before I do a
   plan revision or Continued Need Review?
A: No-however know that the current policy is effective until 10/31/11. Changes with the
   new proposed services should not be requested prior to the 11/1/11 date. It is
   recommend that you plan ahead with families and guardians to make them aware of
   the proposed changes effective 11/1/11 and plan accordingly.

Q: What should TCM‟s be doing about appeal rights?
A: TCM‟s should inform families and legal guardians about the proposed changes and
   make them aware that appeal rights are not available for any service that will be not a
   part of the approved clinical policy.

Q: Do I have to submit a revision or will there be a crosswalk?
A: There will not be a crosswalk with the proposed changes.

Q: Can you clarify the habilitation hours for children who are in school?
A: The maximum amount of habilitation services for children in school is 20 hours per
   week AND the maximum amount per day is 3 hours. Waiver services are not allowed
   to be provided in the school setting while a child is in school.
Q: Can Respite and Residential Supports be provided on the same day?
A: No

Q: Can an Adult recipient receive more than 12 hours of habilitation services if justified?
A: No

Q: If both the parents of the adult child are providing services to the adult waiver recipient, can
       they continue to do so under the new proposed clinical policies?
A.     Yes. If they are the natural parents, step-parents, or adoptive parents of the participant,
they can only provide Home and Community Support and Personal Care to the adult child who
resides with them as long as the services are clinically justified. Both parents are able to
provide up to the 40 hours per week limitation of paid services. For example, if the adult
recipient receives 60 hours per week of habilitation services and chooses parents as paid
workers-one parent can provide up to 40 hours per week and the remaining parent can provide
 the remainder of authorized services. (Staff qualifications apply –refer to section H Waiver
Services Provided by Family Members for further guidelines).

Q: What if I have more than one adult child receiving paid services by the live in family
A. In situations where there is more than one adult child receiving services, parents or other
       family members residing in the household may provide only 40 hours per week of
       service in total.
                What you can do now….

Plan ahead of time

Talk with families and guardians about the
proposed changes

Don‟t wait until the last minute
Current DMA Clinical Policy #8M CAP-MR/DD

Proposed DMA Clinical Policy #8M CAP-I/DD

Pathways LME-CAP MR/DD Utilization Review

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