Maryland Developmental Disabilities Administration Resource Coordination Provider Recruitment
Maryland Developmental Disabilities Administration Resource Coordination Provider Recruitment December 18, 2013 2 Agenda 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) 11) 12) 13) 14) Introduction/Overview DDA Service Delivery System Resource Coordination Services, Activities, and Data Provider Client Information System (PCIS2) Units Billing & Payments Working Capital Rates HIPAA Medicaid Fraud Application Submission Business Plan Timelines Questions 3 Introduction/Overview The Developmental Disabilities Administration (DDA) provides a coordinated service delivery system so that people with developmental/intellectual disabilities receive appropriate services oriented toward the goal of integration into the community. Services are provided through a combination of State Residential Centers (SRCs), Forensic Residential Facilities (FRC), and a wide array of community-based services delivered primarily through a network of non-profit providers licensed by the DDA. Resource Coordination (RC) is primarily a Medicaid rate-based service under Medicaid Targeted Case Management (TCM) in Maryland’s state plan. The same scope of services and rate structure is used for non-Medicaid eligible. 4 DDA Service Delivery System The DDA partners with people with developmental/intellectual disabilities to provide leadership and resources to live fulfilling lives. People with developmental/intellectual disabilities have the right to direct their lives and services. The DDA’s community-based service delivery systems includes various home and community-based services and supports provided through either a Medicaid State Plan or Waiver program or via DDA State funded services. 5 DDA Service Delivery System The DDA has organized its Service Delivery System into regions. Resource coordination providers need to provide services on a regional basis Region Counties Western Allegany, Carroll, Frederick, Garrett, Washington Central Anne Arundel, Baltimore City, Baltimore, Harford, Howard Southern Calvert, Charles, Montgomery, Price George’s, St. Mary’s Eastern Caroline, Cecil, Dorchester, Kent, Queen Anne’s, Somerset, Talbot, Wicomico, Worcester 6 People DDA Supports The DDA supports both children and adults with various ages, needs, and environments across the State. Some people have complex needs including: medically complex conditions; emotional and/or behavioral challenges and needs; court involvement; and transition from foster care and various institutions (e.g., out of State placements, State Residential Centers, State Psychiatric Hospitals, Nursing Facilities, etc.). 7 People DDA Supports Some people have involvement with multiple State service delivery systems, including: Maryland State Department of Education Division of Rehabilitative Services Special Education Department of Human Resources (DHR) foster care, Department of Juvenile Services (DJS) juvenile services, Mental Hygiene Administration (MHA) behavioral health services, Medicaid’s skilled care, and Other Medicaid Waiver programs such as the Autism, Model, and Living at Home Waiver programs. 8 Resource Coordination Services Resource coordination (RC), also known as Targeted Case Management (TCM) by Medicaid, plays a vital role in the delivery of services to people with developmental disabilities. Resource coordination covers a wide range of assessment, planning and coordination, referral, and monitoring activities to assist a person to obtain and retain services needed, including comprehensive assistance in gaining access to needed supports and services regardless of how the services are financed. Resource coordination is critical for connecting people with developmental disabilities and their families to services and supports within various other systems or community resources including medical services, educational services, housing assistance, food stamps, public transportation, social activities, etc. 9 Resource Coordination Services The DDA provides resource coordination services to: People applying for funding Comprehensive Assessment; People eligible for services on the DDA Waiting List in the crisis resolution, crisis prevention, and current request priority categories as defined COMAR 10.22.12.07 Waiting List Coordination; People currently receiving on-going community services regardless of program (i.e. Waiver or State Funded) Community Coordination; and People eligible for services transitioning into the community from an institution Transition Coordination. Resource coordinators assist people and families by applying, planning, coordinating, assessing and monitoring needs, services, and compliance with program rules and regulations and may be contacted to assist the DDA during emergencies outside of normal business hours. 10 Resource Coordination Services The DDA funds three types of ongoing RC services to eligible people, including Waiting List Coordination Services, Community Coordination Services, and Transition Coordination Services. Each of these services includes three RC activities: Development and periodic revision of the Individual Plan (Reference: COMAR 10.09.48.06B); Referral and related activities (Reference: COMAR 10.09.48.06C); and Monitoring and follow-up (Reference: COMAR 10.09.48.06D). Resource coordinators’ primary work should focus on Assuring that DDA-funded and other services are meeting the person’s needs, support outcomes, and goals, and are being delivered as specified in the individual plan; and Ensuring the person’s safety. 11 Comprehensive Assessment Face-to-face assessment of the person’s needs and supports to determine eligibility as noted in COMAR 10.09.48 and 10.22.12. Assistance with information gathering such as obtaining professional evaluations and assessments necessary to document and recommend eligibility and priority for services. Provide Referral and Related services including: Sharing information about relevant resources and making referrals, and Providing assistance with applications to generic community, local, state and federal programs for medical, social, educational and other necessary services. 12 Individual Plan Development of a “person centered” service plan referred to as the Individual Plan (IP); Facilitating and coordinating interim meetings based on the individual’s “person centered planning methodology” preference (i.e. Essential Lifestyles Plan, MAPS, Paths, etc.); Entering critical information from an individual’s IP into the DDA’s IT system; Update and revise the IP as circumstances change; and Facilitating and coordinating the annual IP update to be conducted within 365 days of the previous plan. 13 Referral and Related Share information about relevant resources and make referrals Assist with applications to generic community, local, state and federal programs for medical, social, educational and other necessary services. Complete National Core Indicators Pre-Survey 14 Monitoring and Follow-Up Assessment of: Services being rendered as specified in the Individual Plan; Current circumstances; Progress toward goals and intended outcomes; Referral status; Needs and supports to maintain eligibility for Medicaid, waivers, DDA services, and any other relevant benefits or services; Identification of new medical, health services, or other needs; Recommendation of priority category change (as applicable); Request for DDA service change; Identification of new support or resource options; Review and revisions to emergency plan; Monitoring of changes and actions items as a result of incidents; and Application or reapplication for necessary programs or services to prevent or remedy a gap ineligibility. 15 DDA Waiting List Coordination Monitoring Frequency Based on DDA Waiting List priority category Crisis Resolution–minimum monthly face-to-face contacts for first 90 days and then face-to-face quarterly meetings until priority category changes, unless otherwise authorized by DDA, or services offered; Crisis Prevention–minimum quarterly face-to-face contacts until priority category changes, unless otherwise authorized by DDA, or services offered; Current Request–minimum annual face-to-face contact until priority category changes, unless otherwise authorized by DDA, or services offered. 16 DDA Community Coordination Monitoring Frequency On a minimum quarterly basis: Face to face with the participant In different services delivery settings (employment site, residential program, etc.) At least one time in each service delivery setting 17 DDA IT System – PCIS2 The DDA’s Provider Client Information System (PCIS) is required for documentation of resource coordination services, activities, and billing. PCIS Modules 1. Individual Plan 2. Resource Coordination Notes Development of Plan Referral and Related Monitoring and Follow-Up 3. Incidents Auto generation of invoice based on certified notes All new providers must have resource coordinators directly input data into PCIS2. 18 Resource Coordination Population Estimated RC Counts By Region Region Western Central Southern Eastern Total Current 3,249 10,061 3,554 2,297 19,161 Currently Assigned Statewide Population Category Current Percentage Community Coordination 13,368 69.77% Transition Coordination 24 0.13% Crisis Resolution 66 0.34% Crisis Prevention 1,038 5.42% Current Request 4,665 24.35% Total 19,161 100.00% Available 3 112 3,709 32 3,856 Total Percentage 3,252 14.13% 10,173 44.20% 7,263 31.55% 2,329 10.12% 23,017 100.00% New Individuals Entering Service (FY2009 - FY2013 Average) Category Current Percentage Crisis Resolution 61 5.26% Crisis Prevention 191 16.48% Current Request 907 78.26% Total 1,159 100.00% 19 Resource Coordination Population Western Availability Category Community Coordination Transition Coordination Crisis Resolution Crisis Prevention Current Request Total Choice Available 91 2 0 0 0 0 7 0 32 1 130 3 New Central Availability Category Community Coordination Transition Coordination Crisis Resolution Crisis Prevention Current Request Total Choice Available 281 78 1 0 1 0 22 6 98 27 403 111 New 0 0 9 27 128 164 0 0 27 84 401 512 Total 93 0 9 34 161 297 Total 359 1 28 112 526 1,026 20 Resource Coordination Population Southern Availability Category Community Coordination Transition Coordination Crisis Resolution Crisis Prevention Current Request Total Choice 99 8 35 142 Available 2,588 5 13 201 903 3,710 New - Eastern Availability Category Community Coordination Transition Coordination Crisis Resolution Crisis Prevention Current Request Total Choice 64 5 22 91 Available 22 2 8 32 New - 19 60 286 365 6 19 92 117 Total 2,687 5 32 269 1,224 4,217 Total 86 6 26 122 240 21 Unit Allocation The DDA will allocate billing units annually per person based on the person’s eligibility for services. As outlined in regulations, billing units have been specified for each type of RC service to guide resource coordinators in the efficient use of units and constrain the costs to the system. Units Allocated by RC Service Type (per individual) RC Service Type Annual Units Annual Hours Expected Hours Community Coordination 212 53 39.75 Transition Coordination 208 52 39 Waiting List – Crisis Resolution 168 42 42 Waiting List – Crisis Prevention 112 28 28 Waiting List – Current Request 60 15 15 22 Unit Allocation Service requirements are outlined in COMAR 10.09.48.06 The regulations regarding service provision are not related to the payment unit limits outlined in COMAR 10.09.48.08: Payment Procedures. Unit limits are associated with payment; therefore, they do not restrict service delivery to people if excessive units are used by resource coordination providers. If all available units are used for an individual, a provider may request the approval of additional units in order to resolve an emergency or complete the required RC activities for the remainder of the fiscal year. 23 Unit Allocation Requests for additional units are reviewed to meet at least one of the following criteria: A crisis or emergency situation that meets the defined criteria for the crisis resolution priority (even if the individual is not currently in that category), including requests for individuals whose crisis occurred earlier in the fiscal year; Transitioning Youth (TY) who are new to the DDA and have been found eligible for TY funding in the current fiscal year; or Complex transfers between providers. Requests that do not meet those criteria will be reviewed on a caseby-case basis. 24 Billing Increments Units 1 2 3 4 5 6 7 8 A unit of service is paid if at least 8 minutes of service is provided. Data indicates that the paid time gained through the round up covers time lost by activities with a duration of less than 8 minutes. Despite this rounding, all activities should be entered in PCIS2. Minutes of Service Greater than or equal to 8 minutes, but less than 23 minutes (8-22 minutes) Greater than or equal to 23 minutes, but less than 38 minutes (23-37 minutes) Greater than or equal to 38 minutes, but less than 53 minutes (38-52 minutes) Greater than or equal to 53 minutes, but less than 68 minutes (53-67 minutes) Greater than or equal to 68 minutes, but less than 83 minutes (68-82 minutes) Greater than or equal to 83 minutes, but less than 98 minutes (83-97 minutes) Greater than or equal to 98 minutes, but less than 113 minutes (98-112 minutes) Greater than or equal to 113 minutes, but less than 128 minutes (113-127 minutes) Note: Units are cumulative minutes for all activities per day per person. 25 Billable Activities Billable activities involve: Face to face activities with the person eligible for services (direct contact); Telephone contacts with the person served and their supports (indirect); Collateral contacts such as face to face meetings, telephone, or email with family members, providers, etc.; Team meetings; Assessment, service planning, and reviews; and Critical or reportable incidents. 26 Billable Activities Examples Examples Include: Application and reapplication assistance Assisting the person in obtaining required supporting documentation Assistance completing the waiver application Developing and submitting the Medicaid waiver packet Information and referrals to various community resources to support goals and protect health and safety Eligibility confirmation and maintaining benefits Coordinating transitions from service providers or institutional settings Individual Plan -pre-planning, meeting coordination, development of IP, writing, etc. Telephone calls, emails, and site visits with person or team to monitor the IP Assessment of progress on goals and services as written in plan Assisting the person in identifying and overcoming barriers 27 Non-billable Time Examples include: Traveling time to and from site visits and meetings; Staff training; Supervisor management, oversight, supervision, evaluation, etc. of resource coordinator; Agency accounting processes and audits; Licensing processes, reviews, plan of corrections, etc. Community outreach; networking with providers Technical problems; correcting upload errors Caseload review Assisting colleagues; two coordinators serving the same individual in one day; supervision Transfers (only one agency can bill) Administrative activities (time sheets, general voicemails, etc.) Time spent after a death 28 Payment Rates Fiscal Year RC Rate $59.95 FY2016 $61.42 $472.41 FY2015 Rate Shown w/ Potential COLA FY2017 $62.94 $484.03 FY2016 Rate Shown w/ Potential COLA $70.16 FY2015 Notes The Rate of $70.16 only applies to FY2014 as $450.00 the Transition Year $58.51 Rate Shown w/ Potential COLA - Rate is $461.07 being reviewed. FY2014 CA Rate Comprehensive assessment shall be reimbursed per assessment. All other activities (i.e. referral and related, individual plan, and monitoring and follow up), providers shall be reimbursed at a per unit of service (billable activity). The FY 2014 is a transition rate to allow for ramp-up. FY 2015 – FY 2017 rates are shown with a potential COLA. The FY 2015 rate is currently being reviewed. All rate changes must be approved by the state budget office and CMS. 29 Payment Payment shall be made only to one approved provider for covered services rendered to a participant on a particular date of service. Invoices should be submitted by the 15th of the month following service and will be paid within 45 days following the review of the invoice. Payment for the services: Shall be considered as payment in full; and May not supplement or be supplemented by payment from other sources, such as the participant, family, a public program, or private agency. 30 Working Capital DDA will provide a Working Capital (WC) advance every year. Advance will be based on 33% of expected annual projected claims per census count (i.e. # of people receiving Waiting List, Community, and Transition Coordination resource coordination services). WC will be forwarded annually to providers on or about July 1 or at the start of service initiation. The payment of working capital for current providers will be dependent on the certification of the last invoice of the previous fiscal year. WC will be repaid via income earned in March, April, May, and June or during the last quarter of a partial year of service. Any remaining balance will be paid from the subsequent WC 31 Working Capital Working Capital: $100,000 Month of Service Month of Payment Amount Due as Payment for Service Amount Paid Working Capital Balance Owed July August $25,000 $25,000 $100,000 August September $25,000 $25,000 $100,000 September October $25,000 $25,000 $100,000 October November $25,000 $25,000 $100,000 November December $25,000 $25,000 $100,000 December January $25,000 $25,000 $100,000 January February $25,000 $25,000 $100,000 February March $25,000 $25,000 $100,000 March April $25,000 $0 $75,000 April May $25,000 $0 $50,000 May June $25,000 $0 $25,000 June July $25,000 $0 $0 32 Working Capital DDA may revoke the working capital advance based on: Quality of care deficiencies; Changes in business practice that are detrimental to service recipients; Impending bankruptcy; or Other good cause If the DDA revokes the working capital advance, the provider shall immediately repay the total amount of the advance to the DDA. 33 HIPAA Resource Coordination Agencies providing targeted case management services are considered Covered Entities under the Health Insurance Portability and Accountability Act (45 CFR parts160, 162 and 164). As healthcare providers to individuals, Agencies are responsible to safeguard Protected Health Information (PHI) through privacy and security policies and practices in accordance with all applicable regulations. 34 Medicaid Fraud MFU’s Jurisdiction Investigate and prosecute healthcare provider fraud in the Medicaid program Prosecute resident abuse and neglect in healthcare facilities receiving Medicaid funding or other long-term care facilities such as Assisted Living May review and prosecute complaints of the misappropriation of resident’s private funds in facilities receiving Medicaid funding 35 Medicaid Fraud There are criminal and civil penalties associated with Medicaid Fraud and there is a National Practitioner Data Bank (NPDB) - National Health Care Fraud database for the reporting of specific final adverse actions against health care practitioners, providers and suppliers. Criminal Prosecution Civil Prosecution General Maryland criminal statutes: Theft § 7-101 et. seq. Identity Fraud § 8-301 Assault § 3-202, 203 Specific Maryland criminal statutes: Medicaid Fraud § 8-508 Abuse or Neglect of a Vulnerable Adult § 3-604,605 Exploitation of Vulnerable Adults Prohibited § 8-801 Federal False Claims Act 31 U.S.C. § 3729-3733 Those who knowingly submit, or cause another person or entity to submit, false claims for payment of government funds are liable for three times the government’s damages plus civil penalties of $5,500 to $11,000 per false claim. Maryland False Claims Act (New) Health General § 2-601 et. seq. To recover damages and penalties from individuals who defraud the state by filing false claims against state health plans and programs, including Medicaid. 36 Application and Proposal The standardized application and business plan template must be used for submission Professional references are to submit the provided reference form directly to the DDA 37 Timelines Business Plan Webinar January 7, 2014 at 12 PM (Details will be forthcoming) Application Questions due by January 10, 2014 Applications are due January 21, 2014 by 12 PM Evaluation Decisions by February 3, 2014 New Provider Orientation for Management – February 10 & 11 Resource Coordinators Training (Mandatory) – February 18 & 19 PCIS2 Access and Module Training – February 20 – March 3, 2014 Service Referrals begin March 3, 2014 Questions 38
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