Managed care organization
panel discussion on
community living and
Community Living Supports
(CLS) services
October 29-30, 2014
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Tennessee Managed Care
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Overview of CHOICES
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TNPEC-0889-14
Guiding principles for CHOICES
• Focus on the whole person – coordination across medical,
behavioral, and long-term services and support (LTSS)
continuum
• Promote independence, choice, dignity and quality of life
• Reduce fragmentation – offer a seamless approach to needs,
including a one-stop shop for LTSS information and
assistance
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CHOICES benefits
•
•
•
•
Improves (and simplifies) access to the LTSS system
Increases options (choices) for members
Offers efficient utilization of limited resources
Improves quality of care
Provides the right care in the right place at the
right time.
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CHOICES member groups
• Group 1 – Members who are receiving Medicaid-reimbursed LTSS in a
nursing facility who meet nursing facility level of care (LOC).
• Group 2 – Members who are receiving Medicaid-reimbursed
home- and community-based services (HCBS) as an alternative to
nursing facility care who meet nursing facility LOC.
• Group 3 – Members in the community who are receiving
Medicaid-reimbursed HCBS to prevent or delay the need for nursing
facility care who meet at-risk LOC (effective July 1, 2012).
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CHOICES member eligibility
In order to be enrolled in CHOICES, a member must:
• Qualify for Medicaid
• Require nursing facility LOC or be at risk for nursing facility
care
• Need LTSS
• Actually be receiving LTSS*
* Satisfaction of the eligibility criteria for CHOICES is not sufficient for enrollment.
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CHOICES Community Living Support
(CLS) benefits
Benefits include:
• Hands-on assistance with activities of daily living,
including but not limited to toileting, transfers and
mobility, bathing, dressing, transportation, skilled care
services, etc.
• Personal emergency response system
• Pest control
• Minor home modifications
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Care coordination role
• Functions as the primary case manager for each CHOICES
member
• Conducts a comprehensive assessment addressing medical,
behavioral, environmental and psychosocial needs of each
CHOICES member
• Develops a plan of care inclusive of all member needs
• Coordinates service delivery to ensure safety, including
linkage to community resources
• Educates the member/member representative on CHOICES
benefits and other community resources
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New residential options for
CHOICES members
Community Living Supports (CLS) and
Community Living Supports - Family Model
(CLS-FM)
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New residential supports
CLS supports:
• Community-based residential alternative
• Up to four elderly or disabled Individuals (CHOICES
members only)
• Up to three elderly or disabled individuals in a Division of
Intellectual Disabilities Services (DIDDS) blended home
• Independence and integration in the community
• Includes hands-on assistance, supervision, transportation
and other supports as needed
• Member is responsible for room and board
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CLS
CLS1
• $1,100/monthly; T2032 UD, U1; or
• $36.16/day; T2033 UD, U1.
• This is available for members who:
• Are primarily independent or have other paid or unpaid
supports that can assist in meeting their needs
• Require limited intermittent care ‒ less than 21 hours per
week
• Do not require overnight assistance (staff is on call 24/7)
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CLS
CLS2
$100/day; T2033 UD, U3.
This is for members who:
• Can be left alone for several hours at a time
• Require minimal to moderate support on an ongoing basis
• Do not require overnight assistance (staff is on call 24/7)
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CLS
CLS3
• $139/day; T2033 UD, U4.
• This is available for members who:
•
•
•
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Have a higher acuity of needs
Require moderate to maximum assistance
Require overnight assistance or supervision for safety
Have significant physical disabilities requiring:
• Frequent intermittent hands-on assistance with activities of daily
living (ADL)
• Assistance with complex health conditions and compromised
health status
• Medication assistance and daily nurse oversight
• Monitoring and/or skilled nursing services
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CLS - Family Model (CLS-FM)
CLS-FM is a Community-based residential alternative with the
following features:
• Up to three elderly or disabled individuals live in a home with a
trained family who provides care and support (this is an unrelated
family)
• Supports independence and integration in the community
• Includes hands-on assistance, supervision, transportation and other
supports as needed
• Member is responsible for room and board
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CLS - FM
CLS – FM1
• $38/day; T2016 UD, U1.
• This is for members who:
• Are primarily independent
• Require limited intermittent care
• Do not require overnight assistance (family caretaker is on
call 24/7)
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CLS-FM
CLS – FM2
• $70/day; T2016 UD, U2.
• This is available for members who:
• Can be left alone for several hours at a time
• Require minimal to moderate support on an ongoing basis
• Do not require overnight assistance or supervision, but
family caretaker on call 24/7
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CLS-FM
CLS-FM3
• $115/day; T2016 UD, U3.
• This is available for members who:
•
•
•
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Have higher acuity of needs
Require moderate to maximum assistance
Require supports and/or supervision 24 hours per day
Have significant physical disabilities requiring frequent
intermittent hands-on assistance with:
•
•
•
•
ADLs
Complex health conditions and compromised health status
requiring medication assistance
Daily nurse oversight and monitoring
Skilled nursing services
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CLS LOC
• LOC is determined by a comprehensive individualized
assessment conducted by the MCO CHOICES care
coordinator.
• CHOICES group level does not equal a CLS level.
• Takes into account the individual needs of a member, which
will be included in the member’s Plan of Care.
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Discussion topics
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Billing for CLS services
• CLS will not be billed through the electronic verification
system.
• Agencies must submit electronic claims on the UB-04 form
using a clearinghouse.
• Managed Care Organizations (MCOs) will have a provider
representative assigned to your company to help with this
process and answer questions.
• Billing frequency would depend on the service in place and
the structure of the service.
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Program requirements for CLS
services
• MCOs are working to develop requirements that will align
with the provider’s current processes.
• Will address key documentation and quality standards.
• Will be developed collaboratively among the MCOs to
ensure consistency and ease for the providers.
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Does the Personal Support Services Agency
license cover CLS services?
No.
You will need to be licensed as a:
• Mental Retardation Semi-Independent Living Services
licensed provider by DIDDS for:
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•
•
•
CLS1
CLS2
CLS-FM1
CLS-FM2
• Mental retardation supported living and/or residential
habilitation facility provider by DIDDS for:
• CLS3
• CLS-FM3
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What type of quality
assurance will be in place?
• Critical incident reporting
• Monthly contacts with care coordinators by phone or
face to face
• Provider advocate annual HCBS audits
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Who develops the plan of
care?
• In CHOICES, the plan of care (POC) is a very similar
document to the individual support plan (ISP), including:
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Relevant information regarding the members’ services
Natural supports
Back-up plans
Disaster planning
A summary of the individual’s physical, social and emotional
needs
• Any self-directed care the member qualifies for
• Each MCO has a different format but all POCs contain the
same information.
• The CHOICES care coordinator is responsible for developing
the POC.
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How will medications be
administered?
• CHOICES members will be allowed to use self-direction for
medication administration if determined appropriate.
• A verbal order will be obtained from the member’s PCP and
included on the POC allowing a paid worker to assist in this
health care task.
• This is limited to the administration of oral, topical and
inhaled medications.
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Will the person’s MCO for
medical services be the only
choice he or she has for the
CLS service?
• Each MCO has the right to administer a single case
agreement with individual providers.
• We strongly encourage participation with all MCOs to
ensure continuity of care.
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Have MCOs started contracting with
DIDDS providers? What is the
process?
• Yes, we all have.
• The process is similar for each MCO.
• When a member is identified to move into a CLS
housing, a single case agreement will be completed.
• We will be moving to global contracts some time in
2015.
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Who to contact at each MCO?
• Each MCO has a different point of contact. We encourage
you to reach out to your provider representative if you
already have one.
• We also encourage you to meet with representatives that
are present from each MCO here today to exchange
information on how to reach out to them.
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Time frame from
identification of a member
until move-in day?
• This can range from seven to 45 days.
• Each case is different and specific to the member.
• Specific items that may impact this time frame are:
• A member’s physical status and need for additional care to
resolve acute conditions
• Need for a home modification
• Need for member & care coordinator to obtain needed
household items for community living
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Amerigroup contacts
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West Tennessee Grand Region:
Debra Phillips, RN
LTSS Manger I/Transitions-MFP
Email: debra.phillips@amerigroup.com
Cellphone: 615-948-1389
Office phone: 615-316-2400, ext. 22481
Middle Tennessee Grand Region:
Anita McClard, RN
LTSS Manager I/Transitions-MFP
Email: anita.mcclard@amerigroup.com
Cellphone: 615-670-0313
Office phone: 615-316-2400, ext. 22516
East Tennessee Grand Region:
Sharon Spontak
LTSS Manager I/ Transitions-MFP
Email: sharon.spontak@amerigroup.com
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UnitedHealthcare contacts
• West Tennessee Grand Region:
Lynn Sanders
Member Advocate
Email: lynn.sanders@uhc.com
Cell phone: 901-377-9197
• Middle Tennessee Grand Region:
Beth Zanolini
Member Advocate
Email: elizabeth_a_zanolini@uhc.com
Cell phone: 615-438-7148
• East Tennessee Grand Region:
Traci McKenzie
Member Advocate
Email: traci.mckenzie@uhc.com
Cell phone: 423-334-1016
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UnitedHealthcare Provider
contact for contracting:
• Deborah Stewart
Director, Provider Advocate
Email: Deborah_b_stewart@uhc.com
Phone: 615-589-3389
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BlueCare CLS Level of Care Determination
 BlueCare CHOICES Care Coordinators (CCs) complete
needs assessments for members prepared to transition to
community living
 Assessments are documented and submitted to TennCare
Medical Director for approval
 Once approval for level of care received, MCO Single
Points of Contacts initiate provider collaboration to
provide required member services and housing
BlueCare CLS Claims Submission and Billing
 BlueCare CHOICES Point of Contacts will conduct
a site visit with Provider and provide program
billing training
 Use of the CMS-1450 (UB-04)
 Electronic Funds/Electronic Payments
 HCPCS, rates and frequency driven by approved
services
BlueCare Contacts
Mary Gause
Manager, Statewide CHOICES Clinical Support
Email: Mary_Gause@bcbst.com
Phone: 615-565-1905
(member care coordination)
Phyllis White
Manager, Statewide Provider Relations
Email: Phyllis_White@bcbst.com
Phone: 615-386-8591
(credentialing and contracting)
Questions?
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