ODP Announcement. Guidance: Fiscal Year (FY) ISP Renewal Period. ODP Communication Number

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1 ODP Announcement Guidance: Fiscal Year (FY) ISP Renewal Period ODP Communication Number The mission of the Office of Developmental Programs is to support Pennsylvanians with developmental disabilities to achieve greater independence, choice and opportunity in their lives. AUDIENCE: PURPOSE: Administrative Entities (AEs), Supports Coordination Organizations (SCOs), All Direct Service Providers (Waiver and Base Providers), and Other Interested Parties This Office of Developmental Program (ODP) communication is intended to provide guidance to AEs, SCOs, SCs and direct service providers for creating fiscal year (FY) Individual Support Plans (ISPs). The following topical areas are included in this communication: Changes for FY P/FDS Individual Cap Exceptions FY 2017/2018 plans with 6 months or less service/date segments Variance Approvals for FY including those for enhanced services Residential Habilitation With and Without Day Consolidated Waiver Licensed Residential Rate Exceptions Auto Approval Rules and Manual Approval Override Checkbox FY Waiver Rate Load Community Participation Supports Update Units on FY 2018/2019 Renewals for Residential Habilitation Services Changes to an Individual s Needs Level/Needs Group Reserve to Encumbrance (R2E) Appendix A: Auto Approval Rules ODP Communication Number

2 CHANGES FOR FISCAL YEAR The following is a list of changes that are anticipated to be made to existing services for FY Renamed HCSIS Service Names: The Life Sharing HCSIS service names will be renamed slightly during the week of April 23, 2018 to assist users with clearly identifying which service best meets the anticipated needs of the individual. When the HCSIS service names are renamed, all instances of current and historical HCSIS service names will be updated to reflect the new name. Specifically, a 30 hour designation will be added to all Life Sharing HCSIS service names so users are better able to distinguish which life sharing procedure codes are associated with greater than 30 hours and which are associated with less than 30 hours of service per week. The 55 Pa. Code (f)(5) licensing regulations exclude life sharing homes that serve 2 or fewer individuals with an intellectual disability or autism 18 years of age or older who need a yearly average of 30 hours or less of direct staff contact per week per home. Per the version of the ISP Manual, associated with Bulletin , All relatives may provide Life Sharing services. In accordance with 55 Pa. Code , a host home that is owned, rented, or leased by a parent, child, stepparent, stepchild, grandparent, grandchild, brother, sister, half-brother, half-sister, aunt, uncle, niece or nephew does not need to be licensed. Therefore, regardless of the number of hours of service provided per week, when Life Sharing is provided by a relative, the home does not require licensing. A Life Sharing provider who will be rendering Life Sharing services by a relative would enroll as specialty 524, which represents unlicensed. Needs Level/Needs Group (NL/NG) and Effective Begin Date will be added to two reports: With the June 16, 2018 HCSIS release, the NL/NG of each individual will be added to the Service Authorization Notice. Authorized providers will have access to this information. In addition, the Effective Begin Date associated with the NL/NG will be added to the Print Plan and Service Authorization Notice. SCs, SCOs and AEs should ensure they monitor any changes made to the NL/NG and adjust plans accordingly and in a timely manner. Update to Plan > Serv & Supp > SSD > Search screen: Also with the June 16, 2018 HCSIS release, procedure code, modifier(s), provider type and specialty code will be added to the Service Name dropdown. The service names in the dropdown will be displayed in alphabetical order by service name. Future Anticipated Updates: In the HCSIS September 29, 2018 release, ODP is planning to create the following: o New functionality where SCs and AEs will be alerted when there is a change to an individual s NL/NG. This new functionality should assist users with more readily identifying when a change in the NL/NG has occurred so plans can be adjusted accordingly and timely, when applicable. ODP encourages stakeholders to be mindful of NL/NG changes and updating plans timely when applicable. ODP Communication Number

3 o Adding a new field to the Service Details, Split Service and Mass Rate Change screens to display the calculated total amount remaining for Employment services that can be authorized against the P/FDS Funding Stream. P/FDS INDIVIDUAL CAP EXCEPTIONS Approved Individual Cap Exceptions Will Continue: Individuals who are currently approved for a P/FDS cap exception will continue to be exempt from the P/FDS cap for FY ODP will be performing reconciliation reviews during FY for each individual currently approved for a P/FDS cap exception. After the reconciliation reviews have been completed, ODP will be communicating determinations made for each individual currently exempt from the P/FDS cap. Annualized Amounts: The approved individual cap exception annualized amount should not be exceeded for FY 2018/2019. Reserve to Encumbrance (R2E) and the Mass Rate Change: Effective March 10, 2018, modifications were implemented in HCSIS that prevents Master Client Index identifiers (MCIs) approved for a P/FDS cap exception to be excluded from the exception reports for MRC or R2E. FY 2017/2018 PLANS WITH 6 MONTH OR LESS SERVICE/DATE SEGMENTS Many services in FY 2017/2018 had a start date of January 1, 2018, including all services associated with the Community Living Waiver. When doing FY 2018/2019 renewals, units and dollars on plans will need to be adjusted to reflect the individual s assessed need for the entire 2018/2019 fiscal year. VARIANCE PROCESS FOR ESTABLISHED SERVICE REQUIREMENTS ODP Announcement , titled Consolidated and P/FDS Consolidated Request for Variance to Established Service Requirements Effective July 1, 2017, described the following: The process to request a variance to the established service requirements, The circumstances in which a service variance request is required, The timeline for the implementation of the requirement, The date by which a variance will be needed and; The entity which will provide a determination on the variance. Intensive Staff Support: Enhanced Service Levels The need for the following enhanced levels of service must be reviewed every 6 months and the variance form must be completed based upon that review: 1:1 enhanced staffing, 2:1 staffing and/or 2:1 enhanced staffing for Community Participation Support. 2:1 staffing and/or 2:1 enhanced staffing for In-Home and Community Support. ODP Communication Number

4 How will approvals for a 14-Hour Rule variance in FY be handled in FY 2018/2019? Current 14-hour rule variance approvals for FY 2017/2018 will continue to be approved until the annual review update date in FY 2018/2019. If after review and discussion by the ISP Team a determination has been made that more than 14 hours per day of Community Participation Supports, In-Home and Community Support and Companion services will continue to be needed beyond the Annual Review Update date and the established waiver requirements for FY 2018/2019, the variance process will need to be followed. New requests should be submitted, per the established process, when there is a need for the supports identified as they could indicate the need for a critical revision. Please ensure new requests are submitted prior to the Annual Review Update Date to ensure ODP determinations are made before the Annual Review Update Date arrives. CONSOLIDATED WAIVER RESIDENTIAL HABILITATION WITH DAY AND WITHOUT DAY Without Day : Licensed Residential Habilitation Without Day (Modifier HI ) is any day in which one of the following occurs: A participant solely receives services that are part of the Residential Habilitation service; or A participant receives fewer than five (5) hours of services and/or unpaid supports that are not included in the Residential Habilitation service. With Day : Licensed Residential Habilitation With Day is any day in which a participant receives five (5) or more hours of services and/or unpaid supports that are not included in the Residential Habilitation service. Residential Habilitation is authorized as day units either With Day or Without Day as described above. To minimize critical revisions related to calculations of With Day and Without Day, SCs may include total combined units in the With and Without day service segments on the ISP beyond 365 day units annually up to a maximum of 400 units total. In situations where it is unclear how many days the individual will use With Day or Without Day, the default allocation of day units should be the following: 4 DAYS/WEEK WITH DAY 3 DAYS/WEEK WITHOUT DAY CONSOLIDATED WAIVER RESIDENTIAL RATE EXCEPTIONS ODP Communication number , titled Consolidated Waiver Fee Schedule Residential Rate Exception Process, described the Residential Rate Exception Process for individuals in Needs Group 4 that, due to extraordinary behavioral or medical needs, require a staffing pattern and/or staff expertise that exceeds the assumptions that are the basis for the rate for individuals in Needs Group 4. According ODP Communication Number

5 to this communication, ODP indicated that exceptions will need to be approved/re-approved on an annual basis. Every currently approved rate exception will have at least a preliminary review by ODP by June 30, After the preliminary review has been completed, all currently approved rate exceptions will be prioritized for more in depth programmatic review throughout the year. Unless the approval was needed due to an acute/time limited situation, the FY 2018/2019 Renewal should reflect the granted rate exception until otherwise communicated by ODP. AUTO APPROVAL RULES AND MANUAL APPROVAL OVERRIDE CHECK BOX Effective March 10, 2018, the Community Living waiver became subject to the auto approval rules. See Appendix A for a list of the auto approval rules and plan categories subject to the rules. As a reminder, auto approval rules do not apply to the following plan types: Plan Creation, Biannual Review, Quarterly Reviews or General Updates. For these plan types, changes will always be subject to manual review by the AE. For FY Renewals and individuals not approved for a P/FDS individual cap exception, unit increases/decreases will always auto approve for P/FDS and Community Living waiver as long as the total amount is within cap limitations associated with both waivers. To prevent auto approval, the SC should ensure they check the manual review checkbox to override auto approval. Can a user identify MCIs/plans approved for a cap exception on the Auto Approval report? The Plan Approved by (Column L) will show ODP, APPROVED for plans that were auto approved; however, there is no indicator as to whether or not the plan is associated with an individual who has been approved for a cap exception. To ensure all P/FDS cap exception plan changes are seen and/or reviewed by the AE, the SC must check the manual review checkbox prior to plan submission so the plan is sent to the AE Dashboard for manual review by the AE. REMINDER: The ISP Approved Report is available to view all plans which have been approved, either manually, or automatically, for the timeframe specified by the user. This report displays ISPs that went through and passed the auto approval process and were not sent to the AE dashboard for manual approval. LMS contains a resource that explains this report and the auto approval functionality. This report is titled, Auto Approval Rules, Auto Authorization Rules, AE DashBoard and ISP Approved Report. Please note the following about the report: The report does not highlight plans where an individual is exempt from the P/FDS cap. To monitor plan changes for these individuals, the SC should check the manual review checkbox so the plan bypasses auto approval and is sent to the AE Dashboard for manual review. Plans with a "Plan Approved By" label of "ODP Approved" indicate that a plan was automatically approved by the system. Plan history and this report will show ODP Approved for all rules other than a critical revision with no service change. For a critical revision with no service change, the plan ODP Communication Number

6 will auto approve and the person who submitted the plan will be displayed in the Plan Approved by column. See Appendix A for more information regarding the rules that were created that will force plans to be sent to the AE Dashboard for manual review by the AE. FY WAIVER RATE LOAD It is anticipated that the waiver rate load for FY will take place on April 27, The FY 2017/2018 cost based rates for Transportation Trip will continue to be used for FY 2018/2019 until the Consolidated, P/FDS and Community Living waiver amendments are approved by CMS. The procedure codes associated with Transportation Trip are: W7274, W7275 and W7276 Note: Attention should be taken to ensure the P/FDS and Community Living waiver caps are not exceeded if applicable FY 2018/2019 plans are completed before the rate load. SCs/SCOs/AEs should plan accordingly. The estimated waiver rates are subject to the final amounts appropriated by the General Assembly. COMMUNITY PARTICIPATION SUPPORTS (CPS) For guidance regarding CPS services, please see: ODP Communication , titled REISSUE Community Participation Support ISP FY 2018/2019 Renewal Template. UPDATE UNITS ON FY 2018/2019 RENEWALS FOR LIC. RESIDENTIAL HABILITATION SERVICES All FY 2018/2019 Renewals that contain licensed Residential Habilitation services will need units adjusted. Adjustments are needed because the Residential Habilitation rate methodology changed halfway through FY 2017/2018 so units carried over to the FY renewal will not reflect the entire fiscal year and will need to be adjusted. At the same time, it is strongly recommended that the Needs Level/Needs Group screen is reviewed for any updates that may have been made prior to FY 2018/2019 Renewal Draft Plan submission and before the plan is approved to ensure services associated with the Needs Level/Needs Group are accurate on the FY 2018/2019 Renewal. CHANGES TO NEEDS LEVEL/NEEDS GROUP The Needs Level/Needs Group Effective Begin Date found on the Needs Level/Needs Group screen in HCSIS reflects the SIS Interview Date found in SISOnline. When ODP performs the physical update to the Needs Level/Needs Group screen in HCSIS, it is entered after the new Needs Level/Needs Group s Effective Begin Date and becomes effective retroactively. As a result, when a Needs Level/Needs Group changes, a critical revision may be needed if the Needs Group changed and the individual has authorized services on their ISP that are associated with a Needs Group. Before doing critical revisions for a change to NL/NG, it is important that any claims billed against the incorrect previous NL/NG are either adjusted or voided so units are restored to the ISP prior to ODP Communication Number

7 performing the critical revision. SCOs and AEs are encouraged to coordinate with the impacted provider when there has been a change to the NL/NG. NOTE: A Needs Group may change and require a critical revision to the FY 2017/2018 ISP after the FY Renewal has already been submitted and approved. As a result, it is important that the Needs Level/Needs Group screen is reviewed regularly for any updates. RESERVE 2 ENCUMBRANCE (R2E) AE/COUNTY ACTION: Please note that the following actions are contingent upon ODP s entry of the projected county allocations, which is anticipated to occur no later than May 30, ODP will communicate the R2E schedule and date County allocations will be entered into HCSIS via the AE Listserv. ODP regional staff will also notify applicable stakeholders using the same communication method employed during previous fiscal years. A. Preparation tasks before running the year end R2E process 1 1. Run the Provider Service Status Report (contract types) for FY and Provisional On- Hold Contracts: Tools --> Reports --> Reports Request 2. Run the Provider Service Status Report for FY , Real Contracts: Tools --> Reports --> Reports Request. 3. Review the base allocation amount by accessing the Funding Level screen. To make changes, navigate to the Non-Service Encumbrance, Overbooking and Revenue Adjustment screens. 4. Run the County Funding Level Report for the upcoming FY and all Funding Streams: Tools --> Reports --> Reports Request 5. Run R2E after: ODP communicates the R2E batch has been released There are no incorrect rates for real contracts in the upcoming FY Providers have service authorizations and can begin providing services B. Enter the Projected Plan Budget (PPB) for Base ISPs 1. Use last fiscal year s (FY ) PPB amounts to populate the PPB amounts for FY This task can be accomplished by doing one of the following: a. The county user can use the View / Update Budget Amount By Individual option from the Budget Management Menu screen to enter the PPB amount for one individual at a time - or - b. The county user can use the Populate Future Fiscal Year Projected Plan Budget Amounts option to auto-populate future fiscal year (target fiscal year) PPB amounts for all the individuals within their scope using existing data from the previous fiscal year (source fiscal year). 2. If the user entered the PPB amounts by copying over the prior year s funding before ODP entered the FY funding streams, the FY funding stream(s) would have been selected. Once the AE runs the Reserves to Encumbrance (R2E), the funding stream(s) 1 Resource located in HCSIS > LMS > FM Guidebook and Supporting Materials > Year End R2E Process Checklist v2.0 06/17/10 ODP Communication Number

8 will automatically be replaced by the corresponding funding stream applicable for FY The request to copy over the PPB amounts is processed overnight. The next day, the Populate Future Fiscal Year Projected Plan Budget Amounts Report is made available on the Reports Inbox screen. 3. If manually entering the PPB amounts after ODP entered the FY funding streams, select the HUMAN SERVICE DEVELOPMENT FUND - Waiver Ineligible funding stream. 4. Run the Projected Plan Budget Amount Exceeded Report for FY : Tools --> Reports --> Reports Request NOTE: The R2E process may be run many times, however it must be run at least once AFTER 6/30 and BEFORE providers submit claims. For inquiries regarding this communication, contact the appropriate person at your ODP Regional Office. ODP Communication Number

9 APPENDIX A: AUTO APPROVAL RULES Rules/Rule Descriptions that Prevent Auto Approval and Requires AE Manual Review The following table identifies the Plan Category and waiver(s) subject to the Rules listed under the Rule Name column. When a Yes is displayed below and rule conditions are met, the plan will go to the AE Dashboard and the AE will be required to manual review and approve it. Blank spaces below mean the plan will auto approve when the rule is met. For FY Renewals, any unit increases or decreases for P/FDS and CLW individuals will auto approve as long as the total dollars associated with the increase/decrease is within the cap. For P/FDS individuals with an approved cap exception, all unit increases/decreases will be auto approved for FY Renewals. Any plan category/waiver combination not listed below (Plan Creation, Bi-annual Review, Quarterly Reviews or General Updates) will not be subject to the rules in the Rule Name column. Rules for the P/FDS and Consolidated waivers became effective July 1 st Rules for the Community Living Waiver (CLW) became effective March 10, Plan Categories That Require AE Manual Review FY Renewal Annual Review Update Critical Revision Rule Name Rule Description Consld. CLW P/FDS Consld. CLW P/FDS CLW P/FDS Service Addition Rule A service is added to the current plan that was not on the previous plan and it does not satisfy an Old to New Service Definition Mapping. Yes Yes Yes Yes Yes Yes Yes Yes Service Removal Rule A service is removed from the current plan that was on the previous plan. Yes Yes Yes Yes Yes Yes Unit Increase Rule The service units have increased by more than 0% as compared to the previous plan. Yes Yes Unit Decrease Rule The service units have decreased by more than 0% as compared to the previous plan. Yes Yes Base Services Rule Services mapped to only Base Yes Yes Yes Yes Yes Yes Yes Yes funding streams exist on the current plan and service information has changed. ODP Communication Number

10 APPENDIX A: AUTO APPROVAL RULES Plan Categories That Require AE Manual Review FY Renewal Annual Review Update Critical Revision Rule Name Rule Description Consld. CLW P/FDS Consld. CLW P/FDS CLW P/FDS Prior Plan Pending Rule Future FY plan being submitted when there is a non-approved Critical Revision of the current FY plan. Yes Yes Yes Missing Annual Review Rule The Annual Review Update date has passed and no Annual Review Update was performed in the current FY. Yes Yes Yes Yes Yes Waiver/Program Transfer Rule The Waiver/Program of the Yes Yes Yes Yes Yes Yes Yes Yes individual has changed since the last approved plan. Service Combination Rule Certain combination(s) of services exist concurrently on the plan and service information has changed. Multiple Funding Stream Rule Requested for Manual Approval Rule System Exception Rule* Services are mapped to more than one funding stream and an authorization decision has not yet been made. SC selected Request for Manual Approval checkbox on Draft Plan screen. Plan meets the error condition(s) of an existing Plan Approval or Service Authorization screen validation. Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes ODP Communication Number