Innovations Waiver Update. Presentation Members and Other Stakeholders

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Andrea Randall
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1 Innovations Waiver Update Presentation Members and Other Stakeholders

2 Training Overview Disclaimer How we arrived here Individual Budgeting Individual Budget Tool Letters Other Changes in the Waiver Amendment

3 Stakeholder Engagement Consumer, advocate and provider input through listening sessions which were held across the state from 9/3/14 through 10/27/14 individuals with I/DD and their families, providers, MCO staff and advocacy groups. IDD State Stakeholder Group met on a regular basis from August 2014 through October Included Service recipients, family members, State and local CFACs, providers, provider associations and advocacy organizations.

4 Stakeholder Engagement Individual Budgeting is a new way to look at service planning Budgets are determined based on a person s assessed level of need, so that each person receives what they need no more and no less. The resulting model is a best fit solution so care must also be taken to accommodate individuals with extraordinary needs.

5 Implementation The Centers for Medicare and Medicaid Services (CMS) have approved the Technical Amendment of the NC Innovations Waiver (0423). The technical amendment is not a new waiver, it revises the existing Innovations waiver The effective date of the waiver is November 1, Changes will include new and revised services and individualized budgeting

6 Individual Budgeting

7 Individual Budgeting Terminology: SIS Individual Budget Tool Base Budget Services Non-base Budget Services

8 Individual Budgeting SIS Age Base Budget Living Arrangement

Individual Budgeting The Supports Intensity Scale (SIS) is an assessment tool to measure the supports an individual needs to live a meaningful life in the community.

9 Individual Budgeting The Supports Intensity Scale (SIS) is an assessment tool to measure the supports an individual needs to live a meaningful life in the community. It is used to inform supports planning and also budgeting. People are asked questions about their specific level of need for support in several areas. The SIS also provides an opportunity to account for extraordinary medical or behavioral needs. *For information on SIS reliability, validity & use by states go to:

Individual budgeting Age*: (1) Individuals under age 22 (2) Individuals 22 and over *will be determined by high school graduation status as it pertains to services potentially available

10 Individual budgeting Age*: (1) Individuals under age 22 (2) Individuals 22 and over *will be determined by high school graduation status as it pertains to services potentially available through funding allocated from the Individuals with Disabilities Education Improvement Act (IDEA). _improvement_act_of_2004

11 Individual budgeting Living Arrangement (by service received): (1) Receiving Residential Supports or Supported Living (2) Not Receiving Residential Supports or Supported Living

12 Individual budgeting Important: The Individual Budget Tool is a guideline. People may request services they feel are necessary

13 Living situation and Age/School status Categories Child Non- Residential Child Residential Adult Non- Residential Adult Residential Levels A B C D E F G A B C D E F G A B C D E F G A B C D E F G SIS

14 Individual budgeting There are 7 Levels of Support, A through G: Levels A E: provide budgets to address progressively increasing levels of support Levels F and G: provide budgets to address exceptional medical and/or behavioral supports

15 How will I be notified about my budget? 1. You will receive a Frequently Asked Questions (FAQ) documents that will provide more information about the reasons for the letter and the budget 2. You will also receive a budget letter providing the budget recommendation and the effective date of this recommendation. It may also include phase-in information if you are currently under or over the recommended budget.

16 Frequently Asked Questions Why am I getting this letter? You and all other Innovations recipients in North Carolina will receive a letter like this in the coming year. The Innovations Waiver was recently updated and we are required to notify you of any changes. What does it mean to me? One of updates in the waiver is to use Individual Budgets as a planning tool to be sure everyone gets what they need. Budgets are based on (1) age, (2) whether you live in a group home, other Medicaid funded home or private home and (3) the kind of support needs measured by the Supports Intensity Scale (SIS). What Services will be included in my Individual Budget? Your Individualized Budget Tool will be used to help in planning for five Innovations services: (1) Day Supports, (2) Supported Employment, (3) Community Networking Service, (4) Respite and (5) Community Living and Support (new service that combines In-Home Skill Building, Personal Care and In-Home Intensive Support). All remaining services are not linked to Individualized Budget Tool (including Residential Supports and Supported Living).

17 Frequently Asked Questions (Cont d) How could this effect my services? The updates will start November 1, If current service costs fit in your Individual Budget (see enclosed letter), there should be no changes. If current service costs are more than your Individual Budget, you could see a change in services. This change will occur gradually over a 1-3 year period. What if I feel that I need more than my Individual Budget allows? You can always ask for what you believe is medically necessary. The Individual Budget is a guide for service planning that does allow for exceptions. Your budget can change as your need for supports changes.

18 Budget Letter Dear Member, On Date this Member received a Supports Intensity Scale ( SIS ) assessment. Based on their current support needs found during that assessment, as well as considering their age and living arrangement, their category, level, and base budget that match their current support needs are as follows: Individual Budget Category, Level, and Base Budget: Year 1, effective 11/1/2016 with an annual Base Budget amount of $X,XXX Year 2, effective «ISP_YR2_Date» with an annual Base Budget amount of $X,XXX Year 3, effective «ISP_YR3_Date with an annual Base Budget amount of $X,XXX The Base Budget and information related to the category and level are guidelines to be used when you are planning for your next plan year. The Base Budget is not a limit on the amount of services you can request or receive. When you are developing your Individual Support Plan, you should discuss with your Care Coordinator the services that are available and that you believe will meet this member s needs. If you believe that their needs cannot be met within $X,XXX you should request those services that you believe will meet their needs. We will review the request, and if we find that the services requested are needed to meet their support needs, we will approve those services. If any of the requested services are denied, we will provide written notice, along with information about how to appeal the decision. If you disagree with your category, level, or Base Budget, you may file a grievance with us. Please direct the grievance to: Alliance Behavioral Healthcare Attn: Access Department 4600 Emperor Blvd. Suite 200 Durham, NC (800) You may file a grievance by phone, in person or in writing. We must receive the grievance within ten (10) calendar days from the date on this notice. If the deadline falls on a weekend or holiday, then it is due the next business day. Someone from our office will respond to you within three (3) days of the receipt of the grievance. For further information on the grievance process, please contact us at (800) Sincerely, Alliance Behavioral Health Care

19 Five Services are included in Recommended Budget 1. Community Living and Supports (In-Home Skill Building, Personal Care & In-Home Intensive Supports) 2. Community Networking Services 3. Day Supports 4. Respite 5. Supported Employment

20 Phase-in Explanation Services Included within the Recommended Budget Phase-in Timelines What if my Support Needs Cannot Be Met Within Recommended Budget What if I disagree with my recommended budget 1. In-Home Skill Building/Personal Care/In-Home Intensive 2. Day Supports 3. Community Networking Service 4. Respite 5. Supported Employment Letters may include a phase-in of 0-3 years. The phase-in period allows gradual transition to the recommended budget Request the services you need (exceptions to recommended budget) You can file a grievance with Alliance within 10 days of receiving your letter

21 Are there Exceptions? 21

22 Yes, there are exceptions A Permanent Change is a change in support needs expected to last longer than six (6) months. Examples of a Permanent Change are changes in living arrangement and changes from the child to adult category A Temporary Change is an unexpected need that should resolve in six (6) months or less.

23 Implementation Intensive Review is a process that occurs when a person s needs cannot be met within her/his current recommended budget and will likely continue for the duration of the plan year. An Intensive Review will be based on the unique needs of the individual (based on medical and behavioral support needs).

24 Questions

25 Changes in Service Delivery

26 Important Changes Relative as Provider: It is recommended that a relative residing in the home of the beneficiary provide no more than 40 hours per week of service to the person. This should be noted in the ISP and effective 11/1/16 no longer requires prior approval from Alliance. If more than 40 hours are requested, prior approval from Alliance must be obtained. Justification must be provided: Why there is no other qualified provider Assurances of provider choice Isolation is not occurring

27 Important Changes Relative as Provider: Relatives who are providing more than 56 hours per week of service to a waiver beneficiary may continue to provide services at their current hours as long as there are: no health and safety concerns, including isolation the services continue to be medically necessary, and the beneficiary still wishes for them to provide the service. New requests will be limited to 56 hours per week.

28 Important Changes Relative as Provider: The only service that can be provided by a RAP is Community Living & Supports. Note: If the relative is also the legal guardian for the waiver participant, he/she must be legally able to provide services as defined in HB543 v4.pdf

29 Important Changes Services in the home of a Direct Service Employee: These circumstances need to be identified in the ISP Eligible only for Community Living and Supports, Respite Provider Agency, EOR or AWC is required to complete the Health & Safety Checklist prior to AND every six months afterwards, as long as the service continues to be provided in that location.

30 Other Changes Service Breaks: The requirement that Level 1 incidents for NC Innovations participants include reporting of failure to provide back-up staffing has been removed. Breaks in service are to be documented by the provider and monitored by the Care Coordinator.

31 Questions

32 Service Definitions

33 Service Now New plans (starting 11/1/2016) Community Living Supports 3 separate services (In-Home Skill Building, Personal Care and In-Home Intensive Supports) One blended service Supported Living Not available A new service for individuals who choose to rent or own their own home and receive services for up to 24 hours/day Base Budget Service? Yes No Day Supports 15-minute unit 1 hour unit Yes Respite Not available to people living in AFL (Alternate Family Living) homes. Available to people living in AFL (Alternate Family Living) homes. Yes Community Navigator Community Guide Expands advocacy role in ISP meetings and education about self- direction/self- No

34 Service Now New Plans (beginning 11/1/2016) Base Budget Service? Assistive Technology Equipment and Supplies Limit of $15, per 5 year waiver period Limit now combined with Home Modifications and new limit of $50, No Community Networking * Cannot be used to pay for membership to access inclusive structured activities * Can now be used to pay for membership dues so long as inclusive courses/activities are accessed Yes Community Transition * $5, lifetime limit * $5, per 5 year waiver period No Crisis Services Consultation must be provided by licensed psychologist Out of home services limited to 14 days Some consultation can be prevention planning and done by QDDP with supervision Out of home services expanded to 30 days No

35 Service Now New Plans (beginning 11/1/2016) Base Budget Service Home Modifications Exhaustive List $20, Limit per 5 year waiver period Exhaustive list removed Limit combined with Assistive Technology and expanded to $50, per 5 year waiver period No Residential Supports * AFL homes receive slightly enhanced rate to account for coordinating respite/caregiver relief * Individuals in AFL homes and their caregivers can now access per diem respite as a separate service No Specialized Consultative Services * Does not typically include psychological testing/evaluations * Can be used for psychological assessments once traditional Medicaid benefit is exhausted No

36 Service Now New Plans (beginning 11/1/2016) Base Budget Services Supported Employment Requires staff to have 3 years experience specific in employment support Transportation limited to times when service provided on site of employer Eliminates 3 year requirement to increase access to service Transportation may be provided to employment site Yes Vehicle Modifications Not available for people receiving residential supports Does not include lowering devices Can allow for people receiving residential supports so long as they own the van Includes lowering devices No

37 Questions

2016 Innovations Waiver Technical Amendment

10/26/2016 1 2016 Innovations Waiver Technical Amendment Presented by: Robin Winters, PhD, IDD Clinical Director Jesse Smathers, MSW, LCSW-A, LCAS-A, Director of Network Development Vaya Health Provider