Disability Waiver Rates Management System Manual DRAFT December 2013 Lead agency workers use the Rates Management System (RMS) tool to calculate payment rates for specific authorized services that are then entered into MMIS. This manual will provide users of the RMS tool with operational information that will help them effectively use this tool. Table of contents • Introduction • RMS • How to use RMS (Steps to entering a rate agreement) • RMS information exchange • Day service fields • Unit-based fields • Residential fields • Customized Living, 24-Hour Customized Living and Residential Care Fields • Banding • Exceptions Request Process • Appendix A Rate Management Worksheets (data gathering worksheets) • Appendix B Shared staffing document Introduction: Disability Waiver Rate System The Disability Waiver Rate System (DWRS) determines individualized payment rates for the following Medical Assistance Home and Community Based Services for persons with disabilities: Community Alternatives for Disabled Individuals (CADI), Brain Injury (BI), Community Alternative Care (CAC) and Developmental Disability (DD) waivers. After the needs assessment and support planning have occurred, the Disability Waiver Rate System will be used to price individual services and provide the amount to authorize individual services. The Disability Waiver Rate System divides disability waiver services into three categories: • • • framework services market rate services pre-determined rate services The Rate Management System (RMS) tool determines the framework service rates. This occurs when lead agency staff enters information about an individual disability waiver recipient and the level of service into the RMS tool. The RMS tool runs an algorithm on the inputs and calculates the payment rate for the service. If approved by all parties, lead agency staff then authorizes the service in MMIS. This manual provides direction regarding Disability Waiver Rate System processes as defined in 2013 Minnesota Statutes, 256B.4914, instructions regarding the processes prescribed by the Commissioner and suggestions about how to accomplish these. Rate Management System (RMS) The Rate Management System is a secure, web-based application accessed by lead agencies through a Social Services Information System (SSIS) authentication portal. While RMS utilized research data prior to implementation of the DWRS, none of that information remains in the system for 2014. The Rate Management System (RMS) is a web-based application, it is important to note that you should not use the back button while in the system. If you need SSIS access, please see the DSD E-list link below: DSD Elist: Disability Waivers Rate System management reopens on Dec. 9 2013 If your SSIS access is not working, please contact SSIS via email [email protected] or phone at 651-431-4801. Or email the DSD Rates team: [email protected] How to use RMS Use the following action steps in the RMS tool to determine payment rates for individual services. Step 1 2 3 Action Log onto SSIS. Go to Tools and choose DWRS Under Client Information, click Search by PMI Enter PMI and DOB and click Search 4 Click Service Plan 5 6 7 To create a new plan, click Add On the box labeled Waiver click Select Select waiver type from options listed 8 9 10 11 12 Click Start Date box Use calendar to select start date or enter date Click End Date box Use calendar to select end date or enter end date Click Save 13 14 15 16 Click Show Services Check box of service being added to plan, then check Save Click on underlined service Enter NPI for provider of service being added to plan and click Find Use calendar to select service start/end dates Select County of Residence Enter info into all remaining boxes and/or use drop down menus to select from options listed. (See Day, Unit-Based, Residential, and Customized Living/24-Hour Customized Living, and Residential Care tables for info to obtain prior to RMS data entry. If not entering a Non-Framework/Rate Exception, click Calculate Right click anywhere on Rate Agreement and choose Print. Send printed copy to provider. If not adding providers, click Lock Record, and then Close. If adding providers, click Add, and follow steps 16-21. If entering Non-Framework/Rate Exception Information, enter county approved unit rate, select Type from options listed and briefly describe need in Reason box. Complete DHS 5820 and submit to DSD. Click Calculate again. Right click anywhere on Rate Agreement and choose Print. Send printed copy to provider. Click Lock Record, then Close to return to Select Services page. 17 18 19 20 21 22 23 Expected Result SSIS welcome page appears Client Information page appears Faint grey type appears on Name, DOB, and PMI boxes Manage Service Plan section appears containing any previously created plans Pop up box appears Waiver types appear Waiver box fills with waiver type that was selected Calendar feature appears Start date fills with date selected/entered Calendar feature appears End date fills with date selected/entered Manage Service Plan section showing newly created plan is displayed Available service selections are shown Service becomes underlined Rate Agreement appears Name of provider appears Start and end date boxes fill Selected county name appears Boxes fill with information Service Total displays Print box appears Return to Select Services page Boxes fill with information RMS information exchange The RMS tool generates payment rates using the following criteria: • • • • • • Service providers, with information from the Community Support Plan and oversight by lead agencies, initially generate the information needed to calculate payment rates. Providers may use the worksheets developed by DHS for this purpose, or may work with lead agencies to develop alternate methods for the sharing of this information. If the lead agency agrees that the information provided reflects the needs of the recipient and the negotiated level of service, lead agency staff enters the information into the RMS tool. If the lead agency does not agree, service planning continues until agreement is reached or a different decision is made. The lead agency must notify the service provider of the calculated payment rate produced by the RMS tool and the inputs associated with it. To accomplish this, lead agencies can take a screen shot and 1) Print and send it using the postal service, or 2) Save and send the screen shot electronically. Use this same screen shot as a reference in authorizing the service in MMIS. Day Service Fields A description of the fields you will see in the Day Service fields within the RMS tool. The day services include: Adult Day 15-Minute, Adult Day Bath, Adult Day Daily, DT&H 15-Minute, DT&H Daily, Prevocational Daily, Prevocational Hourly, Structured Day 15-Minute, Structured Day Daily Note: Not all services contain all the fields listed below. Information to obtain prior to entering RMS data Provider’s National Provider Identifier (NPI) or Unique Minnesota Provider Identifier (UMPI) Enter provider’s NPI or UMPI. Do not enter county UMPI. Service Start and End Date What day does service start and end? Enter start date and end date to match MMIS service agreement line Average Staffing Ratio Average daily ratio of direct care staff to recipients Number of units inclusive of service start and end date that person is authorized to receive service Select staffing ratio from drop down menu Field Provider NPI Total Units Individual RN Hours/Unit Action If Adult Day Daily, Prevocational Services Daily, or Structured Day Daily are not provided at least 6 hours per day (not including transportation to/from), go to Adult Day (15-minute), Prevocational Hourly, or Structured Day (15-minute). If DTH Daily is not provided at least 6 hours per day (including transportation time to/from when provided by DTH provider), go to DTH 15-minute Assessment and treatment provided on a 1:1 basis by RN during a unit of service Enter amount of time service will be provided during unit Individual LPN Hours/Unit Assessment and treatment provided on a 1:1 basis by LPN during a unit of service Enter amount of time service will be provided during unit Meals Per Day Number of meals per day of service Enter number of meals per unit of service AM Snacks Per Day Number of morning snacks per day Enter number of AM snacks per unit PM Snacks Per Day Number of afternoon snacks per day Enter number of PM snacks per unit CONT. on Pg 6 Field Customization Information to obtain prior to entering RMS data Does person meet criteria for deaf/hard of hearing customization? Action Review screening document to determine if person meets criteria and choose appropriate option from drop down box Total Daily To/From DT&H Transportation Obtain amount authorized on MMIS SA for T2002, DT&H Transportation Enter amount of DTH Transportation Rate Exception Unit Rate Rate that will be requested on DHS 5820 Exception-person will be discharged/service needs cannot be met Manual Banding NeededResidential-Change in Service Plan DTH Partial Day Brief description of why exception was needed Enter amount of requested rate Exception Type Exception Reason Use drop down menu to select type Choose reason from drop down box or enter narrative to describe “other” Exception Approval DHS entered field Leave blank Exception Approval Reason DHS entered field Leave blank Unit-Based Fields Here is a description of the fields you will see in the Unit-Based fields within the RMS tool. The Unit-Based services include: Behavioral Support, Companion Care, Housing Access Coordination, In-Home Family Support, Independent Living Skills Training, Night Supervision, Personal Support, Respite Care Services 15-Minute, Respite Care Daily Supported Employment Services, SLS 15-Minute Note: Not all services contain all the fields listed below Field Provider NPI Information to obtain prior to entering RMS data Provider’s National Provider Identifier (NPI) or Unique Minnesota Provider Identifier (UMPI) Action Enter provider’s NPI or UMPI. Do not enter county UMPI. Service Start and End Date What day does service start and end? Enter start date and end date to match MMIS service agreement line County of Residence County where person lives Staff to Recipient Ratio Number of individuals receiving ILS Training or Supported Employment Service at the same time from the same staff person Use drop down menu to select county of residence Use drop down menu to select 1:1 or 1:2 (ILS Training) or 1:1, 1:2, or 1:3 (Supported Employment Services). DD waiver SES is a 1:1 only service Total Units Number of units inclusive of service start and end date that person is authorized to receive service Enter number of units Customization Does person meet criteria for deaf/hard of hearing customization? Review screening document to determine if person meets criteria and choose appropriate option from drop down box Exception Unit Rate Rate that will be requested on DHS 5820 Enter amount of requested rate Exception Type Exception-person will be discharged/service needs cannot be met Manual Banding NeededResidential-Change in Service Plan DTH Partial Day Use drop down menu to select type Exception Reason Brief description of why exception was needed Choose reason from drop down box or enter narrative to describe “other” Exception Approval DHS entered field Leave blank Exception Approval Reason DHS entered field Leave blank Residential Fields Here is a description of the fields you will see in the Residential fields within the RMS tool. The Residential services include: Foster Care Corporate Daily, Foster Care Family Daily, SLS Corporate Daily, SLS Family Daily Note: Not all services contain all the fields listed below Provider NPI Information to obtain prior to entering RMS data Provider’s National Provider Identifier (NPI) or Unique Minnesota Provider Identifier (UMPI) County of Residence County where person lives Service Start and End Date What day does service start and end? On Site Awake Shared Staff Hours Average number of hours per day person shares the services of direct care staff Enter number of hours Asleep Shared Staff Hours Average number of hours per day person has shared asleep night staff Enter number of hours Shared Remote Awake Hours Number of hours per day that shared electronic monitoring is provided Enter number Number of Residents Licensed capacity Enter licensed capacity Number of Remote Monitored Residents On Site Awake Individual (1:1) Staff Hours Number of people in the home who Enter number share electronic monitoring Enter number Average number of hours per day person has a dedicated 1:1 direct care staff who is not available to others living in the home Asleep Individual (1:1) Staff Hours Average number of hours per day person has a dedicated 1:1 asleep staff who is not available to others living in the home Individual RN Hours Assessment and treatment provided on a 1:1 basis by RN during unit of service Field Action Enter provider’s NPI or UMPI. Do not enter county UMPI. Use drop down menu to select county of residence Enter start date and end date to match MMIS service agreement line Enter number How many of the Total Units will include 1:1 assessment and treatment by a RN? CONT. on Pg 9 Field Individual LPN Hours Information to obtain prior to entering RMS data Direct nursing provided on a 1:1 basis by LPN during unit of service Action How many of the Total Units will include 1:1 assessment and treatment by a LPN? Enter number Individual Remote Awake Hours Number of hours per day that remote electronic monitoring technology is provided to this person on a 1:1 basis Transportation Does person not need to have transportation is provided by residential provider, need transportation in a standard vehicle, or need transportation in an adapted vehicle with a lift Use drop down menu to choose from Customization Does person meet criteria for deaf/hard of hearing customization? Review screening document to determine if person meets criteria and choose appropriate option from drop down box Exception Unit Rate Rate that will be requested on DHS 5820 Exception-person will be discharged/service needs cannot be met Manual Banding NeededResidential-Change in Service Plan DTH Partial Day Brief description of why exception was needed Enter amount of requested rate Exception Type Exception Reason Use drop down menu to select type Choose reason from drop down box or enter narrative to describe “other” Exception Approval DHS entered field Leave blank Exception Approval Reason DHS entered field Leave blank Customized Living, 24-Hour Customized Living and Residential Care Fields A description of the fields you will see in these categories in the RMS tool: Field Provider NPI Information to obtain prior to entering RMS data Provider’s National Provider Identifier (NPI) or Unique Minnesota Provider Identifier (UMPI) Action Enter provider’s NPI or UMPI. Do not enter county UMPI. Service Start and End Date What day does service start and end? Enter start date and end date to match MMIS service agreement line County of Residence County where person lives Use drop down menu to select county of residence Select Group of Services, Service within that group, and enter Units per Day of Service Category of service that will be provided: • Meals • Home Management Socialization • ADL Assistance • Transportation • Mental Health Management • Health Related Use drop down menu to select Group (e.g., Meals, Home Management, Socialization). Use drop down menu to select Service (e.g., LaundryLinens (Hour)) from that Group. Enter units per day of service (e.g., 2 Hours of Laundry-Linens). Click Add Service to move to next Group (e.g., ADL Assistance). Use drop down menu to select Service (e.g., Assistance Dressing-Hour) from that group. Enter units per day of service (e.g., 2 hours of Assistance Dressing-Hour). Repeat for each Group of services person will receive and for each service within that group. After you have finished entering all groups/services within group, click Calculate. *If authorizing Summoning Device, be sure to enter 0.033 to reflect one charge per month as opposed to one charge per day. Exception Unit Rate Rate that will be requested on DHS 5820 Exception-person will be discharged/service needs cannot be met Manual Banding NeededResidential-Change in Service Plan DTH Partial Day Brief description of why exception was needed Enter amount of requested rate Exception Type Exception Reason Use drop down menu to select type Choose reason from drop down box or enter narrative to describe “other” Exception Approval DHS entered field Leave blank Exception Approval Reason DHS entered field Leave blank Banding Banding creates limits for changes in framework service payment rates that change because of DWRS implementation. A 0.5% rate stabilization adjustment (band) applying to the unit rate is in effect for all of 2014. This 0.5% band will take effect when you create a new waiver span or renew a waiver span. This means that in 2014, existing payment rates for framework services will not increase or decrease by more than 0.5%. Banding rules change depending upon the type of service and the circumstance. Most of the time, banding rules are built into the Rate Management System but, in some cases, manual banding or un-banding will be required. When banding rules are not built into the system for specific services or situations, we refer to them as Non-Framework Rates. Non-Framework rates require adjustments to get the correct banded rate. Non-Framework Rates Processes Below are scenarios, which explain the processes, needed to determine rates for services, which the RMS does not correctly band: 1. Manual Banding 2. Partial Day DT&H 3. Residential Change in a Service Plan. 1. MANUAL BANDING NEEDED Situation A: A Service Agreement renewal for individual receiving service in December 2013 with same provider but other changes (amount or intensity) to service agreement since December 2013. IF you have a service agreement renewal for an individual who was, in December 2013, receiving a residential service (adult foster care, customized living, 24 hour customized living, or residential care service), a daily unit of a day service (DT&H, adult day, structured day, prevocational service), a 15 minute unit of a day service (DT&H, structured day, or adult day), or hourly prevocational service, AND the intensity of the service has changed since December 2013, THEN you will need to complete the appropriate framework to reflect the service intensity before the change, AND THEN you will need to complete the appropriate framework to reflect the new service intensity, AND THEN complete the Non Framework Rate Information section, choosing “Manual Banding Needed” for type and filling in a unit rate for the service that is equal to the previously authorized unit rate, plus or minus 0.5% up to the rate produced by the framework, plus or minus the difference between the previous (before the intensity change) and current (reflecting the intensity change) framework rates. Service and Unit Types: • • • • Residential All Day Services with Day Units Prevocational with Hourly Units Adult Day with 15 Minute Units Process example to follow: Historic rate in MMIS of $247.50/Day Step 1: Calculate framework rate with previous level of intensity ($225) Step 2: Calculate framework rate with new level of intensity ($325) Step 3: Subtract (or add) RMS rate resulting from Step 2 from RMS rate resulting from Step 1 ($325-$225 = $100) Step 4: Add (or subtract) result from Step 3 to historic rate from Step 1 ($100 + $247.50 = $347.50) Step 5: Subtract (or add) 0.5% from result in Step 4 ($347.50 – $1.74 = $345.76) Step 6: Enter a Non Framework Rate in RMS for $345.76 with a type of Manual Banding Needed. Input details of calculation in notes sections. Situation B: All service Agreement renewals for individuals receiving DT&H Pilot or Structured Day services in 2013. IF you have a service agreement renewal for an individual who was receiving 15 minute DT&H or 15 minute structured day in December 2013 AND there have been no changes in service intensity, THEN you will need to complete the 15 minute DT&H or 15 minute structured day framework, AND THEN complete the Non Framework Rate Information section, choosing “Manual Banding Needed” for type and filling in a unit rate for the service that is equal to the previously authorized unit rate, plus or minus 0.5% up to the rate produced by the framework. Service and Unit Types: • • DT&H 15 Minutes Structured Day 15 Minutes Process example to follow: Historic rate in MMIS of $16.25/15 minute unit Step 1: Calculate framework rate in Rate Management System using DT&H 15 minute framework ($15.00) Step 2: Compare MMIS 2013 historic rate of $16.25 to the RMS framework rate of $15.00 Step 3: If MMIS 2013 historic rate is greater than RMS rate, subtract 0.5% from MMIS 2013 rate ($16.25-$.08 = $16.17)* Step 4: Enter a Non Framework Rate in RMS for $16.17 with a type of Manual Banding Needed. Input details of calculation in notes sections. *If MMIS 2013 historic rate is less than RMS rate, add 0.5% to MMIS 2013 rate. 2. PARTIAL DAY DT&H Situation: All service Agreement renewals for individuals receiving DT&H partial day services in 2013. IF you have a service agreement renewal for an individual who was receiving partial day DT&H service in December 2013, THEN you will need to complete the DT&H 15 minute framework, AND THEN complete the Non Framework Rate Information section, choosing “Partial Day DT&H” for type and fill in the (previously contracted) rate for the service. Service and Unit Types: • DT&H Partial Days Process example to follow: 2013 MMIS historic rate of $147.50/Day Step 1: Use DT&H 15 Minute framework in Rate Management System Step 2: Disregard the Rate Management System unit totals Step 3: Enter a Non Framework Rate in RMS for $147.50 (2013 unit rate) with a type of Partial Day DT&H. Input applicable details in notes sections. 3. RESIDENTIAL CHANGE IN SERVICE PLAN Situation: A service agreement is initiated for an individual who is receiving service on 12/1/2013 who changes to a different but existing provider on 12/1/2013. IF you have a service agreement initiated for an individual who was receiving a residential service in December 2013 but changes the provider for the same residential service, THEN you will need to complete the appropriate framework, AND THEN complete the Non Framework Rate Information section, choosing “Residential Change in Service Plan” for type and filling in a unit rate for the service as determined by the lead agency. Service and Unit Types: • Residential Process example to follow: Step 1: Complete appropriate framework in Rate Management System Step 2: Enter a Non Framework Rate in RMS using historical rate setting methodology used by county Step 3: Select a reason type of Residential Change in Service Plan. Input applicable details in notes sections. Exceptions Process Recipient Criteria Exceptions may be requested by recipients with exceptional needs that cannot be met by a DWRS framework rate. Lead agencies must submit exception requests to the state. Individual recipients may request lead agencies to submit an exception request. Exceptions are available to: • New recipients, or • Existing recipients who have a change (of provider or intensity) in service plan. Request Criteria An application should be made when: 1. An individual has service needs that cannot be met through additional units of service, or 2. A framework rate results in an individual being discharged Applications must include a thorough account and documentation of: 1. Summary of recipient need 2. Extraordinary program/service response (to meet need) that is not acknowledged by the framework 3. Price of extraordinary program/service response 4. The duration of the requested rate exception 5. ISP/CSSP and cost documentation 6. Any contingencies for approval An online Exceptions Request Application form (DHS-5820) has been developed and will be available. Exception requests may also be submitted to DHS by mail. Authorized Exception Rate • • • Exceptions are calculated from and apply to the framework rate Exceptions are not banded (neither increased nor decreased by +/- 0.5%) Exceptions are managed through lead agency allocations Process and Timelines • • • • • According to statute, lead agencies have 30 days to process an exception application, and DHS has 30 days to process an exception application. When all parties agree that an exception request is extremely urgent, an expedited process will be available. The expedited exception process gives lead agencies and DHS 3 business days each to process an application. Approved exceptions are effective upon initiation of the exceptional level of service, not to precede the date of the exception application to the lead agency, for the duration stated on the application. Approved Exceptions expire after 1 year. Recipients must reapply for an exception rate or revert to the framework rate. For new recipients who apply for an exception, are denied, and appeal; only the framework rate is authorized during the proceedings if the service is initiated. If the denial is overturned, the exception rate is authorized • • • retroactively to the date the exceptional service provision began, not to precede the date of the exception application to the lead agency. For existing recipients with a need change who apply for an exception, are denied, and appeal, the currently authorized rate will continue through the proceedings. If the denial is overturned, the exception rate will be authorized retroactively to the date the exceptional service provision began, not to precede the date of the exception application to the lead agency. Exceptions that have been approved by the lead agency will be approved by DHS unless one of the following is true: o The application fails to identify the recipient need o The application fails to identify exceptional service provision to meet the defined need o The application fails to identify cost information to quantify the cost of the exceptional service o The exceptional service provision is not a covered benefit, is a benefit covered by another payer or is incompliant with MA regulation. DHS may request further information or the revision of an application. If the request for further information not granted by the lead agency, provider, or recipient, DHS will render a denial of the exception. If the request is granted, DHS may consider new information presented and/or a revised application. Process Review • • • • DHS will perform random audits of exception applications, which are denied by lead agencies. The Exceptions internal approval process will be done by DHS staff. All Exceptions denials will be reviewed by two additional DHS staff with expertise in disability services policy. A quarterly report with exceptions request reasons, approvals, denials and appeals will be provided to an external review team. Appendix A Rate Management Worksheets 2013 legislation regarding the Disability Waiver Rate System suggests that rate-setting inputs originate with service providers who submit the information to lead agencies for review and entry into the Rate Management System. The Rate Management Worksheets are vehicles for service providers to organize that information and communicate it to lead agencies. Appendix B The following chart should be used to determine appropriate staffing ratios for entry into the Rates Management System: Disability Waiver Rate System: Residential Staff Hours Shared Monday Tuesday Wednesday Thursday Friday Saturday Sunday Total Weekly Average Daily On Site Awake Direct Care Staff /7= Remote Awake Direct Care Staff /7= Asleep Direct Care Staff /7= On Site Awake Direct Care Staff Remote Awake Direct Care Staff Asleep Direct Care Staff Individual Monday Tuesday Wednesday Thursday Friday Saturday Sunday Total Weekly On Site Awake Direct Care Staff Remote Awake Direct Care Staff Asleep Direct Care Staff RN Assessment and Treatment LPN Assessment and Treatment Average Daily /7= On Site Awake Direct Care Staff /7= Remote Awake Direct Care Staff /7= Asleep Direct Care Staff /7= RN Assessment and Treatment /7= LPN Assessment and Treatment Definitions Direct Care Staff: Provide direct support and assistance with activities of daily living, instrumental activities of daily living, and training to participants, in their home or during community activities, as directed in the individual service plan. Can be provided by nurses or supervisors acting as direct care staff. Can be shared or individual. Shared: Direct care staff serve or are available to all residents in a home. This includes many individual services provided to a resident in the home when these services are provided within the shared staffing pattern. Individual: Direct care staff brought in solely to provide support as a one-to-one interaction specific to an individual client’s needs. Awake: Direct care staff who must remain awake and engaged. Can be on site or remote. On Site: Direct care staff who are physically present in the setting. Can be awake or asleep. Remote: Direct care staff who are not physically present in the setting, but are engaged in real-time service provision. Only awake. Asleep: Direct Care Staff who are allowed to sleep, but are available to respond to planned or unplanned participant events. Only on site.
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