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									THE CHILDREN’S WAIVER
      PROGRAM

    AN OVERVIEW
      September 2009




                        1
What will we cover today?
– Legal authority     – Plan development
– Funding             – Decision guides
– The CWP Manual      – Services
  as a resource and   – Provider
  information guide     qualifications
– Eligibility         – PDN
– Demographics        – Budgets
– Prescreens          – Administrative
– Application           hearings
  process             – Choice Voucher
                      – Quality assurance
                                            2
        Legal Authority
 Authorized under Section 1915 of
  the Social Security Act
 Allows states to waive parental
  income and make a child, living at
  home and at risk of placement into
  an institution, eligible for Medicaid
 Provides additional services specific
  to, and limited to, the waiver
  population
                                          3
State Funding

   An appropriation controlled by the
    Michigan Legislature

   Matched with federal funds

    Limited to the number of children it
    can support on the CWP
                                            4
Children’s Waiver Program



2004 Technical Assistance
    Manual Training

                            5
Accessing the
Children’s Waiver Manual




                           6
http://www.michigan.gov/mdch/0,1607,7-132-
2941_4868_7145-14669--,00.html




                                             7
    TABLE OF CONTENTS

    SECTION 1:    INTRODUCTION
    SECTION 2:    PARENT-TO-PARENT
   SECTION 3:    ELIGIBILITY
    SECTION 4:    SERVICE DESCRIPTIONS
   SECTION 5:    CHOICE VOUCHER
   SECTION 6:    PRE-SCREEN PROCESS
   SECTION 7:    APPLICATION AND RENEWAL PROCESS
   SECTION 8:    TARGETED CASE MANAGEMENT
   SECTION 9:    TRAINING, MONITORING AND SUPERVISION

    SECTION 10:   DECISION GUIDE FOR CLS HOURLY CARE
   SECTION 11:   EXCEPTION PROCESS FOR COMMUNITY LIVING
                 SUPPORTS AND PRIVATE DUTY NURSING HOURS
    SECTION 12:   DEVELOPMENT OF AN INDIVIDUAL PLAN OF
                  SERVICES

    SECTION 13:   APPEALS

    SECTION 14:   TRANSFERS/TERMINATIONS

    SECTION 15:   QUALITY ASSURANCE AND IMPROVEMENT

   SECTION 16:   AUTHORIZATION OF SPECIALIZED EQUIPMENT AND
                  ENVIRONMENTAL ACCESSIBILITY ADAPTATIONS

   SECTION 17:   PRIOR AUTHORIZATION OF PRIVATE DUTY
                 NURSING
   SECTION 18:   SERVICES COST SUMMARY
    SECTION 19:   SERVICES AND SUPPORTS BILLINGS
                                                               8
    SECTION 20:   GLOSSARY OF TERMS
    SECTION 21:   APPENDIX
        CWP ELIGIBILITY
        REQUIREMENTS
 Up to age 8            At risk of out of
 Meets financial         home placement
  eligibility for        Has a
  Medicaid as a           Developmental
  “family of one”
                          Disability AND
 Resides
                          meets criteria for
  w/parent(s)or
                          an ICF/MR
  guardian (relative)
                         At risk for health
 Receiving at least
  one waiver              and safety
  service per month                            9
Intermediate Care Facility for
    the Mentally Retarded
          (ICF/MR )
 An individual must have the need for an
active treatment program of specialized and
generic training, treatment, health and
related services directed toward the
acquisition of behaviors necessary to
function with as much self-determination and
independence as possible.
                                         10
CHILDREN BY COUNTY                                        as of 8-09

   Allegan            2        Manistee             1
   Ausable Valley     0        Monroe               5
   Barry              1        Montcalm             0
   Bay-Arenac         1        Newaygo              4
   CEI Counties       36       North Country        0
   Muskegon           8        Northeast Michigan   1
   Central Michigan   11       Northern Lakes       5
    Kent County       28       North Pointe         0
   Copper County      0        Oakland County       57
   Detroit/Wayne      23       Ottawa               24
   Genesee            6        Pathways             9
   Gratiot            2        Pines                2
   Gogebic            1        Saginaw              7
   Hiawatha           10       Shiawassee           8
   Huron              0        St. Clair            8
   Ionia              6        Summit Pointe        1
   Kalamazoo          9        Tuscola              0
   Kent               25       Van Buren            2
   Lenawee            1        Washtenaw            23
   LifeWays           3        West Michigan        1
   Livingston         10       Woodlands            4                11
   Macomb             110
      When considering a CWP
            Pre-Screen
Is   the child:
       developmentally disabled and meets criteria for
      ICF/MR?
         a current Medicaid beneficiary?
           If   Not:
                 at risk for health and/or safety or out of
                 home placement?
                    What service needs have been identified?
                  Can services be provided through
                 PIHP/CMHSP and other community sources?
                                                               12
    Priority Weighing Criteria
   Factor 10: Home Care Supports Other Than the CWP
   Factor 9: Health and Safety
   Factor 8: At Risk of Out-of-Home Placement
   Factor 7: Other Minor Children Residing in the Home
   Factor 6: Family Stress and/or Physical Health Problems
   Factor 5: Other Children with Special Needs
   Factor 4: Child Presently in a Nursing Home
   Factor 3: Child Presently Resides in a ICF/MR Facility
   Factor 2: For Future Use
   Factor 1: The Child is Presently in Foster Care and Needs
                   Support                                      13
Children’s Waiver Program                                                      ____ Update

               CHILDREN’S WAIVER PROGRAM PRIORITY WEIGHING SCORE

Name: _______________________________________________________ CMHSP:
__________________________
Case Manager: ________________________________________________
Date Preliminary Pre-screen Received: ________________ Date of Most Recent Pre-screen
Update: ______________
        FACTOR              SCORE     TOTAL               REASON FOR SCORE

10 Home Care Support        x _____   = _____



9 Health & Safety
                            x _____   = _____
  Medical/Behavioral



8 Risk of Out-of-Home       x _____   = _____


7 # of Minor Children       x _____   = _____



6 Family Stress, Therapy,
  Disability, Physical      x _____   = _____
  Health



5 Other Special Needs
                            x _____   = _____
  Children


4 Child in Nursing Home     x _____   = _____


3 Child in ICF/MR           x _____   = _____


2 Future Use                x _____   = _____


1 Child in Foster Care      x _____   = _____

                                                                                             14
      TOTAL NUMERIC SCORE = ________
DATE:

CASE MANAGER:

CMHSP:

NAME OF CHILD:                                          (cc:       )

PRE-SCREEN SCORE:

Attached is a copy of the pre-screen results identified above.
Based on a review of the information you submitted, the
following resources may also be available to serve the family.
Please follow up with the family in accessing the additional
resources checked below:

_____ The child is Medicaid eligible in his/her own right in the
   proposed setting and may meet eligibility requirements for
   personal care or home health services. The family may
   wish to apply for these services through their county FIA.

_____ The child may meet eligibility requirements for CSHCS
   Hourly Nursing Benefit. Please contact Matt Richardson’s
   secretary at (517) 335-8535 for application information.

May 2004                  Appendix 6-b             Pre-screen Cover Memo

                                                                           15
    CWP Pre-screen Updates

 Annual update is required
 An update within the past six months is
  necessary for an invitation to apply
 If a child no longer needs or qualifies for
  CWP services the child’s name should
  be removed from the Weighing List


                                          16
When Waiver Slots
Become Available
    Case manager contacts the
     child’s parent(s) to confirm
     the child’s:
       Service needs


       Current residence

       Medicaid

                                    17
             CWP Application

                     Initial Application
                            Period
                       Within 30 days


Children's Waiver    DHS 49 MED EX         Demographic Form
Certification Form




                                                        18
          Application Period
   Application period (for those invited to
    apply) is 30 days




                                               19
         Approval Process
   MDCH Clinical             Approval
    Review Team                notification is sent
    reviews waiver             to:
    application for            – case manager
    clinical eligibility       – DHS
                               – Family




                                                  20
    After Initial Approval

 The Child’s Individual Plan Of Service
  (IPOS) must be completed within 7
  days of commencement of services
 CLS and Respite staff must be trained
  in the IPOS and meet all other
  training/provider requirements before
  providing services



                                           21
       After Initial Approval

   Waiver Budget must reflect
    – Only services identified in IPOS
    – Amount of service to be provided
   Refer to Section 18 of the CWP
    manual for instructions



                                         22
    Final Application Procedures
   The CMHSP may begin to provide
    services once there is :
    – Clinical approval
    – Completed IPOS
    – Active Medicaid
    – Trained and/or qualified Staff




                                       23
    Final Application Procedures


 CWP budget
 Revised Waiver Certification form (if
 necessary)




                                          24
          Completion of the
         Application Process
    Children who meet criteria for COC I
    or Intensity of Care-High:

   Waiver Certification (revised, if necessary)
   DHS-49-Medical Examination form
   Copy of mihealth card (Medicaid)
   All pertinent assessments and medical records
   IPOS
   Budget

                                                25
    Final Application Process
Children who meet criteria for COC
2, 3 and 4 or Intensity of Care-
Medium or Low require:
   Waiver Certification (revised, if necessary)
   DHS-49-Medical Examination form CSHCS
    documentation
   SSI documentation
   Copy of mihealth card (Medicaid)
   Budget
                                                   26
          Annual Renewal
October 1st of each year, the case
 manager must submit to MDCH the
 following:
  Budget
 Update Demographic Intake Form (if there
   are changes)
If due:
 Waiver Certification Form (if due)
 Copy of the Medical Examination Form
   (DHS-49) (if due)

                                             27
       What is a
    Decision Guide ?
It is a tool to:

 Assist the child’s team in determining
  the amount of publicly supported CLS
  hourly care
 Ensure consistency across the state of
  Michigan
 Review the care needs of the child and
  the resources available to the family
                                       28
                               DOCUMENTED CATEGORY OF NEED FOR HOURLY
                                        CARE AUTHORIZATION*


ADDITIONAL FAMILY              CATEGORY CATEGORY CATEGORY CATEGORY
   RESOURCES                      IV       III       II       I

Section I – Number of
Caregivers

   1. Two or more                4-8       6-10      8-12      12-16
      caregivers live in
      home; both work F/T
   2. Two adult
                                 2-8       2-8       4-10      10-16
      caregivers; one
      works F/T
   3. Two adult                  2-4       2-6        4-8      8-12
      caregivers; neither is
      employed
   4. One adult caregiver
      lives in home and          4-8       4-10      8-12      12-16
      works F/T
   5. One adult caregiver;       2-6       2-8       8-10      10-14
      does not work F/T                                               29
                             DOCUMENTED CATEGORY OF NEED FOR HOURLY
                                      CARE AUTHORIZATION*


ADDITIONAL FAMILY            CATEGORY CATEGORY CATEGORY CATEGORY
   RESOURCES                    IV       III       II       I


Section II – Health Status
of Caregivers
                               6-8       6-10      10-14     12-16
   1. Significant health
      issues                   4-6       4-8       8-12      10-12
   2. Some health issues


Section III – Additional
dependent children
                               2-4       2-6        4-8      8-12
   1. Applicant has one or
      more sibs, age five
      or older                 4-6       4-8        6-8      8-12
   2. Applicant has one or
      more sibs under
      age five.

                                                                 30
                                DOCUMENTED CATEGORY OF NEED FOR HOURLY
                                         CARE AUTHORIZATION*


ADDITIONAL FAMILY               CATEGORY   CATEGORY   CATEGORY   CATEGORY
   RESOURCES                       IV         III         II         I


Section IV – Additional
Children with Special Needs
   1. Applicant has one or         4-8        6-8        4-8       8-12
       more siblings with
       nursing needs
   2. Applicant has one or         2-4        2-6       N/A        N/A
       more siblings with
       non-nursing special
       needs

Section V – Night
Interventions
    1. Requires 2 or fewer         2-4        2-6        4-8       8-12
       interventions at night
       or total time less
       than one hour
    2. Requires 3 or more          4-8        6-8       6-10       8-12
       interventions
       requiring one hour or
       more to complete

Section VI – School
Child attends school an           6 max      6 max      8 max     12 max
average of 25 hours per
week                                                                        31
         Assessment of Need

   Type of behaviors identified
 Frequency, intensity and duration of the
identified behaviors
   How recently serious behaviors occurred
 Specific effects of the behavior on
persons in the family and property


                                             32
            Categories of Care
   Demonstrates mild level behaviors that may interfere with the
    daily routine of the family.
   Demonstrates a daily pattern of medium level behaviors
    including self-injurious, physically aggressive or assaultive
    behaviors that have not resulted in hospitalization or emergency
    room treatment for injuries in the past year, or has engaged in
    occasional, significant property destruction that is not life-
    threatening.
   Demonstrates a daily pattern of moderate self-injurious,
    physically aggressive or assaultive behavior when medical
    intervention, or hospital emergency room treatment has been
    required for treatment of injuries in the past year without
    resulting hospitalization, or if the child has engaged in
    frequent,significant property destruction that is not life-
    threatening.
   Demonstrates a pattern of severe self-injurious, physically
    aggressive or assaultive behavior, or life threatening property
    destruction that has occurred one or more times in the past
    year. Documented evidence of additional behavioral problems
    on a frequent basis each day supports a need for one-to-one 33
    intensive behavioral treatment.
COC Documented Narrative
   Assessment of          Additional
    Need                  Resources
    – Type of behaviors       –# of caregivers
    – Frequency,              –Health of Caregivers
     intensity and
     duration of              –Dependent Children
     behaviors                –Children w/special
    – How recently            needs
      behaviors           Night
      occurred            Interventions
    – Effects of
     behavior on          School    schedule34
     family & property
Services Available to Children
         on the CWP
    All mental health services included in
     the CWP Services database when:
     – Used to address a need
     – Identified in the IPOS
    Service include:
     – “state plan” mental health services, and
     – “waiver” services

                                                  35
    Waiver Services Include:
 Community Living    Specialty Services
  Supports (CLS)      Home Care
 Enhanced             Training, Non-
  Transportation       Family
 Respite Services    Specialized Medical

 Home Care
                       Equipment &
  Training, Family     Supplies
                      Environmental
                       Accessibility
                       Adaptations
                                         36
Medicaid State Plan Services
Include, But Are Not Limited
To:
    Private Duty Nursing      Professional
    Occupational               Evaluations &
     Therapy                    Testing
    Physical Therapy          Treatment Planning
    Speech Therapy            Health Assessments
    Targeted Case             Medication Review
     Management
                               etc.
    Durable Medical
     Equipment
                                                37
     Prior Authorization For
    Waiver Services & Private
          Duty Nursing
   DCH prior authorizes all Waiver
    services for children who qualify for:
    – Category I of the Children’s Waiver Hourly
    Care Decision Guide;
    – Intensity of Care-High of the Private Duty
    Nursing Decision Guide; or
    –Exception hours


                                               38
Community Living Supports

   H2015 - Community Living Supports;
    per 15 minutes
 Must be trained in:
    – PCP & IPOS
    – Recipient Rights
    – Basic First Aid, CPR
    – Emergency Procedures

                                         39
     Enhanced Transportation
Enhanced Transportation
   S0215 - Non-Emergency
    Transportation; mileage (per
    mile)
    – CLS costs include transportation
    – Transportation may be billed when
      provided by staff other than CLS
    – limited to resident’s county or
      surrounding county
    – Is identified in the IPOS
                                          40
              Respite Care
   T1005 - Respite Care, per 15 minutes
    – Up to 96 hours per month, based on the
      IPOS
    – Can be provided in:
       • Child’s home
       • Foster home
       • Licensed respite care facility
       • Licensed camp


                                               41
        Vacation Respite
 S5151 - CLS (aide level), per diem
   – TT = multiple patients
 H0045 - Nursing Respite, not in the
  home, per diem
   – TD = RN and TE = LPN
 S9125 - Nursing Respite, in the home,
  per diem
   – TD = RN and TE = LPN


                                          42
          Vacation Respite
   Vacation Respite…
   Is used when parent(s) are ‘gone’ for 24
    hours or more
   Can be used when the child is in school
    and the parents are away
   Cannot be used for a couple of hours a
    day
   Cannot be used in addition to ‘regular’
    daily care on the same date of service
   Does not ‘reduce’ the monthly allocation
    for respite
   Does ‘reduce’ the monthly allocation for
                                               43
    CLS or PDN
           Family Training
 S5111 - Home Care
  Training, Family; per
  session
 Provided by MSW,
  LLP or QMRP
 Includes:
   – Instruction about
     treatment
     regimens & use of
     equipment
     specified in the
     IPOS
   – A counseling            44

     service to families
          Specialty Services
 G0176 for:
   – Music Therapies
   – Recreation
     Therapies
   – Art Therapies
 97124 for:
   – Massage
     Therapies
   Limit of 4 sessions
    per month per type
                               45
    of specialty service
      Non-Family Training

 S5116 - Home Care Training, Non-Family;
  per session
 Provided by an MSW, LLP or QMRP to CLS
  and/or respite staff




                                            46
     Specialized Medical
    Equipment & Supplies




   Must be:
    – medically necessary, and beyond what is
      ordinarily found in the home.
    – specified in the IPOS
   Includes devices, controls and
    appliances not covered under Medicaid
                                        47
    State Plan
Environmental Accessibility
       Adaptations
   S5165 - Home
    Modifications
    Must be:
       • prior
         authorized by
         MDCH
       • specified in the
         IPOS
       • necessary to
         ensure the
         health, welfare
         and safety of      48

         the child
      Administrative Hearing

   A notice of action:
    – Must be sent whenever a Medicaid
      covered service is denied, suspended,
      reduced or terminated
    – Provides consumer with the opportunity to
      request an Administrative Hearing, held by
      an Administrative Law Judge (ALJ)


                                               49
The Choice Voucher System

 Available for children served by the
  CWP
 Provides parents of minor children a
  method to control and direct how their
  child’s IPOS is implemented and who
  are the providers
 Is voluntary


                                           50
             Advantages

 Control over resources allocated to the
  child’s IPOS
 Greater flexibility in tailoring supports to
  meet individual needs
 Ability to choose and manage providers




                                             51
     How the System Works
   Family & CMHSP,       A Choice Voucher
    using the PCP          Agreement between
    process, develop       the CMHSP and
    child’s IPOS           Parent is signed
    identifying needed
    services and          The funds in the
    supports               CWP budget are
   A CWP budget is        lodged with a fiscal
    developed based        intermediary
    on the IPOS
   Parent implements
    arrangements
    through the Choice
    Voucher System                            52
         Quality Assurance &
            Improvement
   DCH - SEDW staff conduct:
    – State level reviews of all applications and re-
      certifications, and
    – On-site reviews:
       • Use a SEDW quality management protocol to
         ensure that federal requirements and assurances
         of quality are met.
       • Are conducted bi-annually.
          – Report of the findings
          – Plans of correction

                                                           53
        For Additional
        information
The CWP Technical Assistance Manual
at:
http://www.michigan.gov/mdch/0,1607,7-
132-2941_4868_7145-14669--,00.html
Call Debbie Milhouse, MDCH
517.241.5757, Milhouse@michigan.gov


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