WYANDOTTE COUNTY DEVELOPMENTAL DISABILITY ORGANIZATION. FUNDING SERVICES Definitions and General Policies and Procedures for All Funding Sources

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1 WYANDOTTE COUNTY DEVELOPMENTAL DISABILITY ORGANIZATION POLICY NUMBER: CDDO 42-1 IMPLEMENTATION DATE: 04/15/99 REVISION DATE: 12/18/2008 REVIEW DATE: 7/31/08 FUNDING SERVICES Definitions and General Policies and Procedures for All Funding Sources PURPOSE: The objective of this policy is to establish definitions and general policies and procedures that will affect all funding sources available. POLICY: The CDDO will be using the definitions and procedures listed in this area to clarify how an Affiliated Community Service Provider can access funds to serve persons. This should also clarify the conditions under which a person's services will or will not be paid. PROCEDURES: 1. Definitions that will be used throughout Policy Section # 42 - Funding. a. Case manager the individual chosen to assist the person receiving services and their support network to identify, select, obtain and coordinate the persons services and supports. b. Case management supervisor staff person responsible to supervise the case management department. c. HCBS/MR Waiver Funding - Home and Community Based Services for the Mentally Retarded. Medicaid funding that has requirements and limitation outlined in the Handbook of Services for Persons with Mental Retardation or Otherwise Developmentally Disabled published April d. State General Funds (SGF) Funds allocated in the CDDO contract. This funding is 100% state dollars.

2 e. State Aid funds distributed pursuant to K.S.A et.seq. and K.A.R et.seq. and the uses of these funds are governed only by those citations. f. County Mill Levy Funds funding allocated by the Unified Government to fund the CDDO, fund consumer needs, and provide supports to agencies that provide MR/DD services. 2. Requirements for requesting funding for referred individuals: a. The agency billing the CDDO must be an Affiliated Community Service Provider or be a provider approved by the CDDO for special projects. b. The individual must be eligible for MR/DD services as outlined by SRS/DBHS policy 92-1 criteria. Eligibility determination must be done by the CDDO. c. The case manager will request any new funding, crisis funding, emergency respite hours, and special project funding in writing to the CDDO Quality Assurance Coordinator in charge of that individual s case. d. The CDDO will verify funding eligibility and current tier levels in the BASIS system. If the person has not been entered into BASIS, the CDDO will return the Request for Funding to the case management supervisor. e. Funding requests will be reviewed by the Quality Assurance Coordinator, the Quality Assurance Administrator and the Management Team. f. If the individual is approved for funding, the case manager will be notified. If the person is approved for funding and there is no more funding available, the person will be placed on the Statewide waiting list or the CDDO's Services Needed List. The case manager will be informed that the person can enter services as soon as there is funding available. If this is an emergency, CDDO staff will meet with the case manager to see if the individual meets the definition for crisis funding as outlined in the SRS/DBHS contract. 3. Requirements for requesting additional funding and/or services for persons already being served: a. If the individual's tier changes and no additional services are being requested, the case manager need only send in the updated plan of care for entry.

3 b. If the BASIS assessment causes a change in the funding source for which the individual is eligible from the HCBS MR/DD Waiver to the Community Supports and Services Grant, submit a plan of care noting tier zero, change the BASIS services page to reflect the funding change and notify the CDDO Financial Administrator of the change in writing. c. If the request is for additional services and/or supports follow step 2, sections a through f. In addition, a copy of the current plan of care and the plan of care outlining the changes in funding must accompany the funding request. If the request is for additional In-Home Family Supports, a needs assessment and crisis information must also be sent in. 4. Requirements for requesting a decrease in funding or a change in services: a. If the individual wants to terminate a service, no longer is eligible for their current funding source, is eligible for a new funding source, plans to move to a different state, is entering an ICF/MR or passes away the following is the procedure to be followed for all funding sources: (1) The case manager will notify the CDDO Quality Assurance Coordinator for that individual in writing. A Death Report will be filed with the CDDO Quality Assurance Administrator if the individual has passed away. (2) The case manager will fill out the services page closing any services the person has requested terminated. This section will be filled out completely, including the number for the reason terminated. If the person has changed funding sources or service providers, do not change the date the person entered that service, just the funding source. 5. CDDO s course of action when a person is not longer determined eligible for the waiver. a. If an individual in day and/or residential is determined no longer eligible for the waiver, every attempt will be made to keep the person in services. The financial administrator will check the persons currently receiving CSS Grant Services for someone who is a tier 5 receiving the same service(s). Once a list of persons waiver eligible has been compiled, the financial administer will check their converted scores. The person with the highest converted score will then be transferred to the waiver. If there is no one to switch the person with, spending on the grant will be reconciled and if funds are available, the person will be placed on the CSS Grant. If no funds are available, the financial administrator will determine if funds are available from either state aid or mill levy. Depending on the availability

4 of funds, the person may see a reduction in services. Only if there are no available funds, will the person be dropped from services. b. If an individual in supportive home care, personal assistant or supported employment services is determined no longer eligible for the waiver, every attempt will be made to keep the person in services. Spending on the grant will be reconciled and if funds are available, the person will be placed on the CSS Grant. If no funds are available, the financial administrator will determine if funds are available from either state aid or mill levy. Depending on the availability of funds, the person may see a reduction in services. Only if there are no available funds, will the person be dropped from services. 6. CDDO s course of action when person is no longer attending services. If a person does not utilize their services for a three month period, the CDDO s financial administer will contact the case manager to determine the reason. a. If the person is ill or in the hospital, nothing will happen. b. If the person is in supportive home care and cannot find a provider, nothing will happen. c. If the person is in day or residential services and wants a new provider, the person will be notified by certified mail that a decision must be made in 30 days and attendance started within 45 days. d. If the person is not attending because they just don t feel like it, a certified letter will be sent to the person allowing them three weeks to begin attending. If they do not begin attending and continue attending at least one day per month, their funding will be withdrawn for that service. They will then be given 10 days to have a reconsideration done by the CDDO. 7. All forms will need to be completed in their entirety or they will be returned to the case manager.

5 WYANDOTTE COUNTY DEVELOPMENTAL DISABILITY ORGANIZATION POLICY NUMBER: CDDO 42-2 IMPLEMENTATION DATE: 04/15/99 REVISION DATE: 12/18/08 REVIEW DATE: 7/31/08 UTILIZATION AND MANAGEMENT OF STATE AID PURPOSE: The objective of this policy is to establish the method by which the CDDO will utilize and manage the State Aid funds. POLICY: State Aid funds will be utilized to fund services for persons who are already in services on the waiver, but have been determined no longer eligible for the waiver. Any funds not distributed for services will be allocated to licensed service providers using the same formula that is used to distribute the Mill Levy. These funds can be used to offset the costs of services that are not paid for by state and federal funds. PROCEDURES: 1. When a person is determined no longer eligible for the waiver and there are no available funds in the CSS Grant, that person may be funded with State Aid. Follow the instructions for billing for services in Policy Number The total WCDDO allocation for State Aid will be distributed to licensed affiliates after needed supports are provided to the persons listed in 1. using the following formula a. Residential Services Unit: Per person in Residential Services Rate: 40% of available CML Limitations: Individuals listed in the BASIS database maintained by the CDDO. b. Day Services Unit: Rate: Limitations: CDDO. Per person in Day Services 25% of available CML individuals listed in the BASIS database maintained by the

6 c. Transportation Unit: Per person receiving Residential and/or Day Services Rate: 15% of available CML Limitations: Individuals listed in the BASIS database maintained by the CDDO. d. Case Management Unit: Per person receiving Case Management Services Rate: 20% of available CML Limitations: Individuals listed in the BASIS database maintained by the CDDO. 3. The CDDO shall withhold payment of State Aid if funds are not appropriated in the CDDO State contract. The CDDO will resume payment and back payments if funds are appropriated or again made available. 4. The CDDO shall withhold payment of State Aid Funds should the CDDO-CSP affiliation agreement be terminated.

7 WYANDOTTE COUNTY DEVELOPMENTAL DISABILITY ORGANIZATION POLICY NUMBER: CDDO 42-3 IMPLEMENTATION DATE: 04/15/99 REVISION DATE: 12/18/08 REVIEW DATE: 7/31/08 UTILIZATION AND MANAGEMENT OF WYANDOTTE COUNTY MILL LEVY FUNDS PURPOSE: The objective of this policy is to establish the method by which the CDDO will identify how MR/DD County Mill Levy funds are utilized and managed within Wyandotte County POLICY: The County Mill Levy funds will be used to fund services and supports as outlined in the approved allocation methodology. Only Community Service Providers who have entered into an Affiliate Agreement with the CDDO ( Affiliated Service Providers ) will be eligible for these funds. The CDDO will determine the total amount of Mill Levy Funds to be allocated. All allocations will be subject to the availability of funds. ALLOCATION: The County Mill Levy Funds may be used for any expenditure that the CDDO determines to be necessary. If funds remain after such expenditures, the CDDO will distribute those funds among Affiliated Services providers based on the following services and limitations. 1. CDDO Crisis Case Management Unit: Per 15 minutes of service Rate: Same rate as paid by Medicaid Limitations: Persons not eligible for Medicaid who NEED case management. The need for the service must be identified by WCDDO. The same limitations and regulations will apply as stated in the Medicaid handbook. 2. BASIS assessments for non-medicaid individuals Unit: Per one assessment annually Rate: The same rate paid by Medicaid Limitations: Persons who do not have Medicaid and are eligible for MR/DD services. Maximum of one assessment per year.

8 3. Unfunded Individuals Currently Receiving Services. Unit: Per day of Residential and Day Service Rate: Amount allocated for State Grant Funds as outlined in CDDO contract Limitation: Funds are limited to individuals funded with County Mill Levy Funds as of July 1, If at any time any of the individuals currently funded with CML funds cease to receive services they will no longer be eligible for MR/ DD funds of any kind. 4. Eligibility Determination Unit: Evaluations as needed to determine a person s eligibility Rate: As determined by evaluator Limitation: If the person has insurance that must be billed first. Mill Levy will be the payer of last resort. WCDDO will only pay for the evaluations needed to determine eligibility. Any other evaluations or treatments requested by the client or the client s guardian are the client s or the guardian s responsibility. 5. Residential Services Unit: Per person in Residential Services Rate: 40% of available CML Limitations: Individuals listed in the BASIS database maintained by the CDDO. 6. Day Services Unit: Rate: Limitations: Per person in Day Services 25% of available CML individuals listed in the BASIS database maintained by the CDDO. 7. Transportation Unit: Per person receiving Residential and/or Day Services Rate: 15% of available CML Limitations: Individuals listed in the BASIS database maintained by the CDDO. 8. Case Management Unit: Per person receiving Case Management Services Rate: 20% of available CML Limitations: Individuals listed in the BASIS database maintained by the CDDO. PROCEDURES: 1. Affiliated Service Providers will be notified of the amount of CML funds allocated for MR/DD services and the anticipated disbursement of that funding.

9 2. A BASIS report will be pulled for the third week of each month. Only individuals listed in the BASIS system at that time and the Affiliated Service Provider(s) listed will be used to distribute the CML for that month. 3. The above allocation methodology will be used to determine a per person rate for each service category.

10 WYANDOTTE COUNTY DEVELOPMENTAL DISABILITY ORGANIZATION POLICY NUMBER: CDDO 42-4 IMPLEMENTATION DATE: 04/15/99 REVISION DATE: 12/18/08 REVIEW DATE: 7/31/08 BILLING FOR SERVICES Payment of State Grant Funds, State Aid, and County Mill Levy PURPOSE: To define a method in which the Affiliated Community Service Provider may request payment for individuals served and funded by State General Grant Funds, State Aid, or County Mill Levy. It outlines how and when CDDO may withhold payment or recoup payment from an Affiliated Community Service Provider. POLICY: The CDDO shall pay an Affiliated Community Service Provider for services. The services paid for will be for individuals who have been determined eligible by the CDDO and have an approved Plan of Care (CDDO FUNDING FOR NON HCBS SERVICES). The CDDO Management Team must authorize any new funds and the service provider must have an affiliate agreement with the CDDO. PROCEDURES: 1. For services for persons funded under any of the above funding streams, payments will be made monthly on a fee for services basis. 2. The service provider will send an invoice to the CDDO stating at a minimum the number of persons served, the number of days served, the rate being billed and the total amount being charged to the CDDO. 3. Before payment, the CDDO will verify that the individual has been entered into the BASIS System and verify State or County Funds have been allocated to the individual. The amount paid will not exceed the amount of services listed on the CDDO Plan of Care. 4. The CDDO will pay the approved invoice within 15 business days of receipt unless a discrepancy has been noted.

11 5. The CDDO may withhold payment or recoup funds from the Affiliated Community Service Provider for any period that the CDDO can demonstrate that the services were not provided by the Affiliated Community Service Provider. 6. The CDDO shall withhold payment when, as stipulated in the CDDO-CSP affiliation agreement, funds are not appropriated by SRS/DBHS or the Unified Government of Wyandotte County. In these cases, the CDDO shall resume payment and back payments if funds are appropriated or again made available. 7. The CDDO shall withhold payment when, as stipulated by the CDDO-CSP affiliation agreement, the agreement has been terminated.

12 WYANDOTTE COUNTY DEVELOPMENTAL DISABILITY ORGANIZATION POLICY NUMBER: CDDO 42-5 IMPLEMENTATION DATE: 04/15/99 REVISION DATE: 12/18/08 REVIEW DATE: 7/31/08 HCBS/MR WAIVER FUNDING Special Procedures for Billing and Receiving Funds PURPOSE: The purpose of this policy is to clarify the differences in accessing HCBS/MR Waiver funding, the changing of tier rates, changing services and terminating services. This policy is also designed to describe what information is required by the CDDO regarding HCBS billing and HCBS cash receipts. POLICY: The CDDO will require that the Affiliated Case Management Agency will send all plans of care to the Quality Assurance Coordinator for that individual. The Quality Assurance Coordinator will then check the plan of care for accuracy. If the plan of care is inaccurate, it will be sent back to the case manager for revision. If the POC is accurate, it will be entered into the POC system and referred them to SRS/DBHS for final approval. The CDDO will be reviewing BASIS to make sure all the information is correct. Any Affiliated Community Service Provider that bills the Medicaid Fiscal Agent will be expected to file reports as requested. These reports will cover but not be limited to both the billings and the cash receipts for the persons being served on the MR/DD Waiver. Any Affiliated CSP may also be audited by the CDDO to make certain that the services billed for have been provided. PROCEDURES: 1. The case manager will complete the funding request forms. This individual will be responsible for submitting additional information to the CDDO funding committee. 2. The CDDO will track the date a funding request is received, check BASIS reports to establish the individual has been entered into the BASIS system and the individuals score and tier rate. If the individual has not been entered into the system, the CDDO will return the Request for Funding to the submitting case management supervisor. 3. Initial Requests for HCBS/MR Waiver funds: Page 1 of 1

13 a. Please refer to Policy Number CDDO 42-1 for the procedures for requesting new funding for an individual. If the individual is approved for funding per Policy Number CDDO 42-1, the CDDO will sign the funding request form and return all to the case manager. b. If the funding has been approved and funding is not available, the individual will be placed on the Statewide Waiting List. If an individual is in crisis or is in imminent risk of crisis, the case manager will need to submit a crisis request form to the person s Quality Assurance Coordinator. The crisis request form will be reviewed by the Management Team to determine if the crisis definition, as listed in the SRS/CDDO contract, has been met. c. Once the plan of care has been approved by DBHS/CSS, the individual can begin services. 4. Requesting Additional or Decreasing HCBS/MR Waiver Funding: a. Please refer to Policy Number CDDO 42-1 for the procedures for requesting new funding for an individual. If the individual is approved for funding per Policy Number CDDO 42-1, the CDDO will notify the case manager in writing. If the individual's increase is due to a tier change and the person was not a tier 0 nor has become a tier 0, the case manager need only send in the new plan of care showing the new tier rate. b. The case manager is responsible for making revisions, approved by the CDDO, to the plan of care. The revised POC must be referred to the CDDO. The CDDO will review the revised POC to assure funds have been approved and refer the POC to SRS/DBHS for final approval. 5. Requesting Termination of HCBS/MR Waiver Funds: a. Please refer to Policy Number CDDO 42-1 for procedures for requesting termination of HCBS/MR Waiver funds. b. The case manager is responsible for notifying the CDDO and all services providers listed on the Prior Authorization that the services have been terminated and the date of termination. The revised Prior Authorization Plan must be referred to the CDDO. The CDDO will review the revised POC and refer the POC to SRS/DBHS for final approval.

14 WYANDOTTE COUNTY DEVELOPMENTAL DISABILITY ORGANIZATION POLICY NUMBER: CDDO 42-6 IMPLEMENTATION DATE: 03/01/2005 REVISION DATE: 12/18/08 REVIEW DATE: 7/31/08 Case Management PURPOSE: The objective of this policy is to outline the process by which an affiliated can bill and get paid for Case Management Services. POLICY: In order for the CDDO to meet its fiscal responsibility to make certain all Affiliated Case Management Agencies are following CMS Guidelines. PROCEDURES: 1. An affiliated case management provider will bill for and directly receive their payments from the Medicaid fiscal agent. 2. The case management provider is responsible for maintaining the documentation necessary to demonstrate that the services that were paid for were provided. 3. If the case management agency is denied by the Medicaid fiscal agent for a provided service, the agency needs to contact the fiscal agent to determine the reason for the denial. 4. The CDDO may review the documentation of a case management agency to verify that the services being paid for have been provided and that the documentation properly supports the billing.