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Managing a Non-Traditional Workforce: Appendix E: Participant Direction of Services Scott Pelham, CES NASDDDS Mid-Year Rapid City, South Dakota May 11, 2007 Topics within Appendix E: • What types of Financial Management Services are available today • Budget and employer authority for Consumers Factors that limit the choices States make on Appendix E: Participant Direction of Services: - Concerns that participants cannot be supported to exercise adequate decision-making authority to be able to hire/manage their own workers - Concerns that the State cannot provide the support and protection needed for participants to have more decision-making authority over their budgets - Concerns that available Financial Management Services are insufficient to ensure legal compliance and fund accountability - Concerns that overall information management and reporting will be unmanageable in a multiple FMS environment Services offered by CES that address these concerns for South Dakota: - Online and manual time card and invoice controls with participant approval and Personal Agent/Support Coordinator or FMS closing features - Automated Plan of Care management from authorization/amendments to payment for services (code, rate, time and cost controls; pre- and post-authorization) - Real-time Service Code level budget utilization reporting (up to the last transaction) - Controls minimize error and fraud and increase auditability - Single statewide database and reporting system; allows States to offer both Fiscal/Employer Agent and Agency with Choice models to meet participant’s needs Managing a Non-Traditional Workforce: Using Organized Health Care Delivery Systems Jean E. Tuller NASDDDS Mid-Year Rapid City, South Dakota May 11, 2007 Origins of the OHCDS Approach State Medicaid Director Letter: December 20, 1993 “ Many states established systems under which single providers subcontracted with providers of other waiver services and were paid by the state for furnishing the entire “package” of care to an individual. However, this rendered the waivers vulnerable to problems with the statutory requirement of free choice of provider, direct payment and provider agreement.” Provider Payment Methods • Traditional Method: Each provider furnishes service directly and each provider has a Medicaid provider agreement. Medicaid pays the provider directly or uses a fiscal agent • Voluntary Reassignment to a Governmental Agency: Providers reassign their rights to direct Medicaid payment to a governmental agency; e.g., a county, a state DD agency. The provider and Medicaid sign an agreement and the governmental agency may be a co-signatory to that agreement. 42 CFR 447.10(e) • Limited Fiscal Agency: A payment and tracking system separate from that used for State Plan services. This is a subsystem of the state’s MMIS and thus 75% may be available. • OHCDS: “…a public or private organization for delivering health services. It includes, but is not limited to, a clinic, a group practice prepaid capitation plan, and a health maintenance organization.” 42 CFR 447.10(b) OHCDS Defined Instructions: Version 3.4 HCBS Waiver Application • An organization that provides at least one Medicaid service directly (utilizing its own employees) and contracts with other qualified providers to furnish other services • Medicaid agreement executed between state and the OHCDS • The OHCDS acts as the Medicaid provider • The OHCDS subcontracts with other providers OHCDS Defined Instructions: Version 3.4 HCBS Waiver Application • Subcontractors must meet the standards under the waiver to provide waiver services under the OHCDS • When OHCDS provides waiver services, payment is made directly to the OHCDS • The OHCDS reimburses the subcontractor • The contractual arrangement must be voluntary • Participants may not be required to secure services exclusively through the OHCDS Waiver Application I-3-g-ii CMS Review Criteria The state: 1. Describes the types of entities that are designated as an OHCDS 2. Has a methodology to designate entities as OHCDS and these entities meet the regulatory definition of an OHCDS 3. Ensures that there are adequate safeguards to ensure that OHCDS subcontractors possess required qualifications 4. Ensures that the OHCDS arrangement provides for appropriate financial accountability safeguards Waiver Options • 1915(c): 1. Non-capitated arrangements 2. No prepaid enrollment 3. Individuals may not be restricted to providers within the OHCDS • 1915(b)/1115: 1. Pre-paid capitation 2. Individuals are enrolled within the system and receive services from the system, its employees and contractors State Examples • NY: OMRDD functions as an OHCDS • MA: DMR functions as an OHCDS • MD: Community Pathways waiver for people with DD • NC: Community Alternatives waiver program for aged/disabled administered by DMA • VT: DD’s “Designated Agencies” Excellent contract example available that specifies responsibilities DDD Standards for the Fiscal Employer Agent • HIPAA compliant information security with SSL 128-bit encryption; • Systems that are mirrored, redundant, housed in Class 5 facilities and supported with daily tape back-ups; • Web interfaced log-in portal for all authorized system users with individualized permissions/functions access; • All required forms and reports needed to facilitate self-directed services; • Initial and ongoing training to system users; • Ongoing customer service and support; • Plan of care based software that serves as a check and balance system for authorized services; • Real-time spending and forecasting reports at the individual, service coordinator, program and state level; • Checks and balances for time card submission and approval; • Options for payroll checks to include direct deposit, paper checks or pay cards. Managing a Non-Traditional Workforce: Web Based Approach for Financial Management Services Dan Tanguay, CES NASDDDS Mid-Year Rapid City, South Dakota May 11, 2007 What Challenges Do States Face Today? • Distance between employers and the FEA • I-9 Verification • Time Card Processing and Verification • Communication Around Employee Performance issues • Documentation Requirements • Ease of Administration What Are The Benefits of Using an On-Line Web Based System? • Access to information and the ability to take action from any computer with an internet connection • One Single Database of information that can only be updated by individuals with the appropriate security level • Elimination of “Waiting Time” between Actions or Processes • Ability to Audit Information “On Demand” from anywhere • Accountability Controls are built into the service to eliminate the majority of errors associated with 1500 claim form submission. What Are Your Pain Points? • Questions and Comments from Attendees • Live demonstration of CES services after conference closing remarks • Thank You!
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