medicaid program enrollment rquirements

IDD Authority Manual MEDICAID Program Enrollment

Burke Center Revised, November 2011

MEDICAID PROGRAM ENROLLMENT RQUIREMENTS

As the Local Authority, Burke Center is responsible for the enrollment of individuals into the ICF, HCS and TxHmL Programs. Staff designated to complete enrollments into waiver programs will be required to complete on-line DADS enrollment training annually.

Designated enrollment staff may no perform provider functions. The training may be found at: http://www.dads.state.tx.us/providers/mra/training/index.html

.

I. Enrollment into the ICF Program

Prior to enrollment, staff will ensure the individual/LAR are provided information about the Medicaid Estate Recovery Program. It will also be determined whether the individual is a Medicare beneficiary. If the individual is a Medicare beneficiary and/or Medicare/Medicaid beneficiary , staff must do the following:

1.

Will verify the consumer: a.

is enrolled in a Medicare-sponsored prescription drug plan, which can be a stand alone drugs-only insurance plan or a Medicare Advantage prescription Drug (MA-PD) plan; and b.

has been deemed eligible for extra help and if not, assist the individual in applying for extra help using the SSA-1020 form found at www.socialsecurity.gov

.

2.

If the individual is not already enrolled in a drug plan, staff will explain to him/her and their LAR, if applicable, that the individual must enroll in a drug plan in order to receive prescription medications and that upon enrollment in the ICF Program he or she will be auto-enrolled in a drug plan, which may or may not be the drug plan that is most beneficial. Staff will: a.

encourage the individual to enroll in a drug plan before enrollment if

possible; and b.

offer assistance, and provide assistance if requested, to the consumer and LAR with evaluating the drug plans to identify the plan that is most beneficial to the consumer.

3.

Staff will explain to the individual and LAR, if applicable that: a.

the individual will get his or her prescription medications through a drug plan. Note: as Medicaid wrap-around services, MA will pay for a limited list of drugs that Medicare will not pay for, including benzodiazepines, barbiturates, and prescribed over the counter drugs;

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Burke Center Revised, November 2011 b.

the individual will be automatically deemed eligible for the extra help which will assist with his or her drug costs; c.

the individual will not have any cost-sharing responsibilities such as premiums, deductibles, co-payments, or co-insurance for drugs covered by the plan; and d.

the ICF Program provider can assist the consumer or LAR with changing drug plans and filing an exception, appeal, or grievance with the drug plan.

Again, steps 1 -3 only apply to individual who receive Medicare. An individual with Medicaid only is not affected by the Medicare Prescription Drug Program and will continue to receive his or her drugs through Medicaid.

II. Enrollment into the HCS and TxHmL Program

Staff will complete the enrollment process for each authorized individual into the

HCS Program within the following timeframe (enrollment process is complete when the consumer status in CARE screen C61 is active or denied.):

1.

For an individual residing in a nursing facility – 180 calendar days after the

Local Authority was notified of the program vacancy.

2.

For a consumer residing in a community ICF or being discharged from a state mental health facility – 90 calendar days after the Local Authority was notified of the program vacancy; and

3.

For a consumer residing in his or her own or family’s home – 75 calendar days after the Local Authority was notified of the program vacancy.

Upon receiving authorization to enroll an individual into the HCS Program the designated enrollment staff will access the Service Authorization Online (SASO) to determine if the individual is currently enrolled in a Medicaid waiver program, and if so, the local authority shall inform the individual or LAR of the requirement to choose either the program the consumer is currently enrolled in or the program that the Local Authority is offering. Staff will also provide comparison information to the individual which may be found by accessing: http://www.dads.state.tx.us/providers/waiver_comparisons/index.html

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Enrollment staff will review each individual’s status to determine if the individual is eligible for inclusion in the Money Follow the Person (MFP) Demonstration

Project as follows:

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1.

An individual is eligible for inclusion in the MFP Demonstration Project if the consumer meets all of the following criteria: a.

the individual must reside continuously in an institutional setting (ie:

ICF, nursing facility, hospital, or state hospital) for at least 90 days prior to the HCS enrollment date and be enrolled in HCS from a nursing facility, a large ICF (14 beds or more), or a medium ICF (9-13 beds); b.

the individual’s 90 day stay in the institutional setting as required by . above excludes any days funded by Medicare; c.

the individual must be Medicaid eligible under Title XIX of the Social

Security Act; and d.

the individual must transition from the nursing facility or large ICF into a qualifying residence, which is the individual’s own home or family home, a foster companion care home, a three-person group home, or a four person group home.

2.

An individual is eligible for inclusion in the MFP Demonstration Project if: a.

the individual is a resident of a medium ICF or large ICF; b.

the facility owner has an approved plan to participate in the MFP

Demonstration Voluntary Closure Pilot; and c.

the individual meets the eligibility criteria described above.

3.

An individual is eligible for inclusion in the MFP Demonstration Project if the individual is offered an HCS slot #39, which means the individual: a.

is under 22 years of age and a resident of a small or medium ICF; b.

is on the HCS interest list; and c.

meets the eligibility criteria described above except that the ICF may be a small facility.

4.

If the individual is eligible for the MFP Demonstration Project, staff will provide the consumer or LAR with a brief explanation of the project using the information on the Informed Consent for Participation (form 1580-IDD) and invite the consumer and LAR to participate in the project by signing the form.

If the consumer or LAR agrees, staff will follow the instructions on the form, including completion of the “For Official Use Only” section of the form.

Staff must complete the form as soon as possible and fax it to DADS immediately after completion, but no later than two weeks before the consumer is discharged from the facility. NOTE: A Local Authority is not required to comply with this provision for a resident of a state supported living center who is eligible for the MFP Demonstration Project. SSLC staff

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Burke Center Revised, November 2011 are responsible for the explanation and completion and faxing of Form 1580-

IDD.

5.

If the individual or LAR signs the form, staff must enter “Y” on the CARE screen L01 for the question MFP DEMO Y_ N_.

6. On a case by case basis, DADS may determine a consumer eligible for the

MFP Demonstration Project and direct the LA to comply with II.E.4 and 5. for that consumer or LAR.

If the individual being offered a program vacancy in HCS or TxHmL is enrolled in

STAR+PLUS:

1.

inform the individual/LAR that disenrollment in STAR+PLUS is required in order to enroll in HCS or TxHmL;

2.

ensure the individual’s Individual Plan of Care (IPC) begins on the first day of a month;

3.

ensure the individual’s enrollment data has been entered into CARE within seven (7) days prior to the end of the month before the individual’s scheduled enrollment date; and

4.

if staff anticipates the individual’ enrollment will not be completed within the timeframe required by DADS, request that DADS approve an extension to allow time for the enrollment.

A.

Enrollment Process

Upon notification from DADS regarding availability of waiver services,

Burke Center staff will begin the enrollment process as per DADS enrollment training guidelines:

A. Notification of availability of waiver enrollment for persons moving out of Large Community ICF Facilities:

1.

2.

DADS notifies the Local Authority when individuals served in Large ICF programs are authorized for enrollment into the HCS or TxHmL Program by letter with an attached

Provider Choice Form with assigned Slot Type.

Designated Authority staff notifies the individual/LAR, of the opportunity to enroll into the HCS Program after notification by DADS.

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3. When the offer of HCS Program services is made, the

Authority staff notifies the individual/LAR of the requirement to respond to the opportunity within 30 days of the notification.

4.

5.

Once the individual/LAR has responded to the Authority notification, staff schedules a time to discuss the opportunity in more detail.

If the individual/LAR does not respond to the offer of waiver services and: a. the individual is 22 years of age or older, individual’s

name is removed from the waiver interest list in

accordance with HCS rules; or b. the individual is under 22 years of age, the individual’s

interest list registration date is changed to the date of the

certified letter informing the individual/LAR of the offer of HCS Program services. In most cases, the Local

Authority is not able to change the date and should request the change from the DADS office of program enrollments.

B. Selection of Services:

1.

During the initial discussion with the individual/LAR, the staff reviews all available services with the Individual/LAR.

Staff will provides an oral and written description of the services and supports in the HCS Program to include

Consumer Directed Services and reviews other available services as outlined in the Explanation of IDD Services and

Supports Form. The Initial Identification of Preference Form and the appropriate forms regarding Consumer Directed

Services are completed.

2.

The Verification of Freedom of Choice form is the required documentation that indicates that the individual/LAR has selected the HCS Program or has not selected the HCS

Program. The Verification of Freedom of Choice Form must be signed within seven (7) days of the individual/LAR responding to the Authority notification of available services. If the individual/LAR does not sign the

Verification of Freedom of Choice form within seven days

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Burke Center Revised, November 2011 of responding to the notification of the opportunity to enroll in the HCS Program services the Authority must: a.

retain the applicant’s name on the HCS Program interest

list without change to the applicant’s date of registration;

and b.

notify the applicant/LAR in writing of the withdrawal of

the offer of the program vacancy and the retention of the

applicant’s name on the HCS interest list.

3. If at the time HCS Program services are offered, the individual declines HCS services and chooses to remain in the ICF facility, the offer for HCS Program services is withdrawn; and

4.

5.

Staff will fax the Verification of Freedom of Choice to

DADS program staff.

Staff will complete the rest of the pre-enrollment activities as described in detail later in this section. However, if the individual is under 22 years of age and seeking residential support or supervised living services, a description of his or her permanency planning outcome is included in the PDP.

Refer to Permanency Planning.

6. Staff will ensure the individual’s movement to HCS waiver

Program within 90 calendar days following the date the

Authority is informed of the availability of HCS services. If movement will not occur by the timeline, staff will request an extension from DADS enrollment staff.

4. Authorization to Enroll from Interest List

Please note that the enrollment process for individuals off the Interest List is the same except for the following:

A.

DADS notifies the Local Authority (LA) when HCS enrollments are authorized. HCS Program Services may be made available, as resources permit, for individuals registered on the HCS Interest list

(formerly known as a waiting list). DADS will automatically change interest status to pending upon notification.

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B.

Upon written notification by DADS of the availability of HCS Program services in the Authority’s Local Service Area (LSA), the LA will offer the services to the individual or the legally authorized representative

(LAR) of the individual whose name is first on the interest list within three days .

C.

Staff notifies the individual/LAR of the opportunity to enroll in the

HCS Program and that the individual/LAR must respond to the notice within 30 days of the date of the notification. The notification to the individual/LAR includes a statement that if the individual/LAR does not respond to the offer within 30 days , staff will withdraw the offer of the program services and remove the individual’s name from the

HCS Program interest list.

D.

If the individual/LAR does not respond to the notice of the opportunity to enroll within 20 days, staff takes steps to withdraw the offer and remove the individual’s name from the HCS Program Interest List.

E.

The Verification of Freedom of choice form is the required documentation that indicates if the individual/LAR has or has not selected the HCS Program. The Verification of Freedom of Choice form must be signed within seven (7) days of the individual/LAR responding to the Authority’s notification of available services.

F.

Ensure the completion of the initial IPC, recommendations for resource authorization based on the PDP, and all necessary enrollment assessments within 45 working days of the individual/LAR indicating his or her desire for HCS Program services by their signature on the

Verification of Freedom of Choice Form.

G.

Submit to DADS the necessary documentation for enrollment within

10 working days of the selection of an HCS Program provider by the individual or the LAR. The selection is documented on the Provider

Choice Form. Electronically transmit the enrollment information

(MR/RC and IPC) to DADS. DADS Program enrollment/Utilization

Review will complete CARE enrollment screen A28 and A05 upon receipt of this information.

5. Pre-Enrollment Activities

The designated staff will complete the following pre-enrollment activities and guidelines:

1. Complete the enrollment of an individual into the HCS Program and

TxHmL Program in accordance with DADS rules and within the

following time frames:

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Burke Center Revised, November 2011 a) 180 calendar days for an individual residing in a nursing facility or a state mental retardation facility b) 90 calendar days for an individual residing in a community

ICF/MR; and c) 75 calendar days for an individual residing in his/her own or family’s home.

2. Enter the individual’s enrollment information into

the CARE Automated Enrollment and Billing System screens LO1,

L23 (If applicable), LO2, LO3, LO9, and LO5.

3. If an individual on the IDD Services Interest List is currently

receiving general revenue-funded services from the LA,

inform the individual that in order to continue receiving the current

general revenue-funded services, the individual must seek enrollment

into the waiver program identified by the State (i.e. HCS or TxHmL).

4. Prior to enrollments to HCS, TxHmL and ICF Programs, designated

staff provides information to the individual and LAR about the

Medicaid Estate Recovery Program (MERP). In accordance with

Texas Administrative Code, Title 1, Part 15, Chapter 373, Medicaid

Estate Recovery Program (MERP), the designated staff will:

a) Provide the MERP overview to all individuals and their authorized representatives or legal guardians, who seek enrollment in a State

IDD Facility, a community ICF, the Home and Community Base

Services (HCS) Program, or the Texas Home Living (TxHmL)

Program. The MERP overview is part of the Medicaid Estate

Recovery Program Receipt Acknowledgement (Form 8001)

b) Facilitate completion of the Medicaid Estate Recovery Program

Receipt Acknowledgement (Form 8001) with the individual and authorized representative or legal guardian and provide a copy of the completed form to:

(1) The individual and authorized representative or legal guardian;

(2) The Medicaid provider who will provide services to the individual upon enrollment.

(3) File and maintain the completed MERP Receipt

Acknowledgement (Form 8001) in the individual’s record.

5. Prior to enrollment, determines whether the individual is a Medicare

beneficiary.

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Burke Center Revised, November 2011 a) If the individual is a Medicare beneficiary, staff must verify that the individual:

(1) is enrolled in a Medicare-sponsored prescription drug plan (PDP), which can be a stand alone drugsonly plan or a Medicare Advantage Prescription

Drug (MA-PD) plan; and

(2) has been deemed eligible for extra help and if not, assist the individual in applying for extra help using the SSA-1020 www.socialsecurity.gov

. form found at b) If the individual is not already enrolled in a PDP, staff shall explain to the individual (and LAR) that the individual must enroll in a Medicare Prescription Drug Program (PDP) in order to receive prescription medications and that upon enrollment in the waiver program he or she will be autoenrolled in a PDP, which may not be the PDP that is most beneficial. Staff will :

(1) encourage the individual to enroll in a PDP before enrollment if possible; and

(2) offer assistance, and provide assistance if requested, to the individual (and LAR) with evaluating the

PDP’s to identify the plan that is most beneficial to the individual. Information regarding Medicare

Prescription Drug Programs can be located on the www.medicare.gov

web page. c) Staff will explain to the individual (and LAR) that:

(1) the individual will get his or her prescription medications through a Medicare-sponsored PDP;

Note: as a Medicaid wrap-around service,

Medicaid will pay for a limited list of drugs that

Medicare will not pay for, including benzodiazepines, barbiturates, and prescribed over-the –counter drugs;

(2) the individual will be automatically deemed eligible for the extra help, which will assist with his or her drug costs;

(3) Until December 31, 2011, the individual will be responsible for paying minimum co-payments for his or her prescription medications, which will be:

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(a) $1 - $3, if the individual’s income is less than

100% of the federal poverty level; or

(c) $2 - $5, if the individual’s income is over

100% of the federal poverty level;

(4) beginning January 1, 2012, the individual will no longer be responsible for any cost sharing for his or her prescription medications;

(5) the individual will pay little or no premiums and no deductible.

(6) the individual will be responsible for paying for any prescription medications that are not covered by his or her PDP or the Medicaid wrap-around service (as noted in a. above);

(5) if the individual is enrolling in TxHmL, the service coordinator can assist him or her with changing

PDP’s and filling an exception, appeal, or grievance with the PDP; and

(6) if the individual is enrolling in HCS, the program provider can assist him or her with changing PDP’s and filing an exception, appeal, or grievance with the

PDP.

(d) Note:

(a) The information contained in 1 -3 above pertains to an individual with Medicare and Medicaid (referred to as “full dual eligible”). An individual with only

Medicaid is not affected by the Medicare

Prescription Drug Program and will continue to receive his or her drugs through Medicaid.

(b) If a full-dual eligible is being discharged from the

ICF Program in order to be enrolled in the HCS or

TxHmL Program, then upon enrollment the individual will be responsible for paying minimal copayments for prescription medications covered by his or her Medicare drug plan until December 31,

2011. Beginning January 1, 2012, the individual will no longer be responsible for any cost sharing for his or her prescription medications.

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In addition to the requirements above, staff will enroll into

Medicaid waiver programs an individual in the LA’s local service

Area who has been authorized by DADS for such enrollments based on refinancing of the individual’s general revenue-funded services as follows:

1. Enrollment staff is responsible for contacting each individual (or the individual’s LAR and, unless the LAR is not a family member, at least one family member if possible), who is receiving general revenue funded services and is identified by the State as potentially eligible for the

HCS Program or TxHmL Program. Staff must provide them with both an oral and written explanation of the services and supports offered in the waiver program for which the individual has been authorized to enroll (HCS or TxHmL) as well as the services and supports for which the individual may be eligible. Enrollment staff shall document the discussion took place by facilitating the completion of the

Home and Community-Base Services Refinance

Information (Form 8574) or the Texas Home Living

Program Refinance Information (Form 8585).

2. The designated staff must explain to the individual or LAR: a. He or she must document the following on the appropriate Verification of Freedom of Choice

Form:

1) That he or she chooses the TxHmL or HCS

Program; or

2) That he or she declines the TxHmL or HCS

Program and chooses instead the ICF Program

or other services (or program). If the individual

or LAR chooses “other services” (or program),

then the designated staff should encourage the

individual or LAR to identify the other services

(or programs); and c.

For individuals offered enrollment in the TxHmL

Program whose name is on the HCS Interest List as interested in receiving HCS services, that the

Individual’s name will remain on the Interest List regardless of whether the individual or LAR

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Burke Center Revised, November 2011 chooses or declines participation in the TxHmL Program.

3 For an individual who has declined to participate in the HCS or TxHmL Program, the designated staff shall: a. Submit to DADS a copy of the completed:

(1) Appropriate Verification of Freedom of Choice

Form; and

(2) Home and Community-Based Services Refinance

Information (form 8574) or Texas Home

Living Refinance Information (form 8585), as

appropriate.

(3) Enter the decline information in CARE if the individual’s name is on the HCS Interest List as interested in receiving HCS services by the completion & entry on the W21 form.

4. For an individual who has chosen to participate in the HCS or TxHmL Program, the designated staff must:

(a) Explain to the individual or LAR that he or she may choose any contracted HCS or TxHmL Program provider, as appropriate, in the local service area who has not reached its contracted capacity; and

(b) Must choose a provider within 14 calendar days after the Verification of Freedom of Choice form was assigned or the individual will be assigned to the provider of his or her current general revenue-funded services and that the individual or LAR would be free to transfer to another provider at any time following enrollment.

©

Provide the individual or LAR with a current list (i.e. dated within seven days) from CARE of all contracted TxHmL or HCS Program providers, as appropriate, in the Local Authority’s service area. If available, the list will also include local “applicant contact” information for use by the individual or

LAR. Staff will document this in the record along with a copy of the first page of the provider list showing the date it was printed.

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5. Document the selection of the program provider on the

Documentation of Provider Choice form and submit a copy of the form to DADS along with a copy of the completed

Home and community-Based Services Refinance


Program Refinance Information (Form 8585); and

Appropriate Verification of Freedom of Choice Form.

6.

The designated staff may not allow any of its program

provider staff to initiate contact with the individual or LAR

prior to the completion of the Documentation of Provider

Choice Form. However, the individual or LAR may request

to visit or tour the providers and possibly schedule a pre- placement visit prior to making a decision on which provider they choose for an individual who is being enrolled in the TxHmL Program, staff must facilitate the completion of the Texas Home Living Program Service

Coordination (Form 8586).

7. The designated staff shall maintain the original completed forms in the individual’s record:

(a) Home and Community-Base Services Refinance


Program Refinance Information (Form 8585);

(b) Verification of Freedom of Choice Form;

(c) Documentation of Provider of Choice Form; and

(d) Texas Home Living Program Service Coordination

Notification (Form 8586); if applicable.

(e) CDS Forms

In addition to the above activities designated staff will complete the following processes during the pre-enrollment phase of the HCS &

TxHmL waiver programs.

Determination of Eligibility: The Center’s licensed/DADS

Certified Psychologist will either review existing diagnosis or

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Burke Center Revised, November 2011 testing or will complete a new evaluation at their discretion. Please refer to Intake and Screening for more specifics regarding

Determination of Eligibility.

Assignment of Service Coordinator: The Continuity of Care worker will complete a Service Coordination Evaluation to determine eligibility and forward to the Essential Services Director for assignment. Continuity of Care worker will function in the role of

Service Coordinator until enrollment into HCS.

Verification of Freedom of Choice: The Continuity of Care Worker completes this form and documents the type of services the consumer/guardian has selected.

Changing Waiting List Status: The Continuity of Care Worker will change the status on the waiting list W21 Form for individuals who have been offered HCS or TxHmL services using the appropriate number as per the Interest List Manual if not automatically completed by DADS.

Medicaid Eligibility: One of the eligibility requirements for participating in the DADS Medicaid Waiver Programs

(HCS/TxHmL) is for the individual to be financially eligible for

Medicaid. This is accomplished by the individual receiving

Supplemental Security Income (SSI) from the Social Security

Administration (SSA) or Medical Assistance Only (MAO) form the

Texas Department of Human Services (TDHS). SSI recipients are categorically eligible for Medicaid. An individual can be receiving

Medicaid, but not be eligible for the DADS Waiver Medicaid

Program. The MRA can check the C63 screen in the CARE automated system to confirm Medicaid Eligibility. If it is determined that the consumer is not Medicaid Eligible, it is the responsibility of the Authority to assist the consumer/guardian in applying for Medicaid through the local SSA or TDHS office.

Initial Person Directed Plan: The Continuity of Care worker or designated staff along with the individual, family and/or guardian will complete an Initial Person Directed Plan. Information regarding the individual will be obtained from the individual, staff who work closely with the individual, and his/her family/guardian. The PDP is the working document, which addresses the needs and choices of

14


Burke Center Revised, November 2011 the individual in a format to enhance the person’s life and dreams.

The PDP will clearly identify the person’s desired outcomes and the resources available to meet his/her outcomes. The PDP must include information relevant to any issues concerning an individual’s heath, welfare and safety. An initial PDP is developed prior to entry into services and identifies community resources along with waiver services to meet these outcomes/needs. Please refer to the admission section of the program manual.

At a minimum, the PDP must include the following: a. b.

A description of the individual’s current services and supports, identifying those that will be available if the individual is enrolled in the HCS/TxHmL Program;

A description of individual outcomes to be achieved through HCS Program components and justifications for each service component to be included in the IPC: c. d. e.

Documentation that the type and amount of each service component included in the individual IPC;

Description of all determinations needed to establish the individuals eligibility for SSI or Medicaid benefits and for an ICF level-of-care; and

Description of actions and methods to be used to reach identified service outcomes, projected completion dates, and person(s) responsible for completion.

ICAP (Inventory for Client and Agency Planning: Staff will administer the ICAP and recommend an LON assignment to DADS in accordance with '409.507 of the Administrative Code. The

ICAP is administered in order to determine the appropriate Level of

Need (LON) for the individual. Rates for services are determined by the LON. If the individual has not had an ICAP completed in the past three years, someone who knows the individual will provide information to staff in order to complete the ICAP booklet.

If the individual has had an ICAP in the past three years, staff needs to review the ICAP to determine if it remains accurate. A LON for an individual must be requested by the Authority from the department by electronically transmitting a completed MR/RC assessment indicating the recommended LON. Documentation supporting the recommended LON must be maintained in the individual’s record. Such documentation may include but is not

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Burke Center Revised, November 2011 limited to the individual’s PDP, including the deliberations and conclusions of the individual’s service planning team, the individual’s ICAP assessment booklet, assessments and interventions by qualified professionals, behavioral intervention plans, and time sheets of the program provider staff. The department will assign a LON to an individual based on the individual’s ICAP service level score, information reported on the individual’s MR/RC ICAP service level score, information reported on the individual’s MR/RC Assessment and required supporting documentation. Documentation supporting a recommended LON must be submitted to the DADS by the Authority in accordance with department guidelines. For detailed instructions on completing the ICAP, please refer to the Examiner’s Manual for the Inventory for Client and Agency Planning Appendix D.

DADS will assign one of the five LON’s as follows:

1 -- An intermittent LON (LON 1) will be assigned if the individual’s ICAP service level score equals 7, 8, or 9.

2 -- A limited LON (LON 5) will be assigned if the individual’s

ICAP service level score equals 4, 5, or 6.

3 -- An extensive LON (LON 8) will be assigned if the individual’s ICAP service level score equals 2 or 3.

4 -- A pervasive LON (LON 6) will be assigned if the individual’s ICAP service level score equals 1;

5 -- Regardless of an individual’s ICAP service level score, a pervasive plus LON (LON 9) will be assigned if the individual meets the criteria described later in this section.

A LON 1, 5, or 8, determined by the ICAP, will be increased to the next LON by DADS due to an individual’s dangerous behavior, if supporting documentation submitted to the department proves that:

A LON 9 will be assigned by DADS if supporting documentation submitted by the Authority to DADS proves that: a the individual exhibits extremely dangerous behavior that could be life threatening to the individual or to others; b. a written behavior intervention plan has been implemented that meets department guidelines and is based on ongoing written data, targets the extremely dangerous behavior with

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Burke Center Revised, November 2011 c. d. e. individualized objectives, and specifies intervention procedures to be followed when the behavior occurs; management of the individual’s behavior requires a staff member to exclusively and constantly supervise the individual during the individual’s waking hours, which must be at least 16 hours per day; the staff member assigned to supervise the individual has no other duties during such assignment; and the individual’s MR/RC Assessment is correctly scored with a “2” in the “Behavior” section.

MR/RC (Mental Retardation/Related Condition Assessment): An

MR/RC is completed to establish eligibility for the HCS/TxHmL program and to designate a Level of Care and Level of Need for the individual. (Attachment #32A & 32B) The receiving Authority staff will use the CARE automated system 1160 screen to verify if a current

LOC/LON exists for the consumer. The receiving Authority staff must complete the MR/RC assessment if:

 the individual does not have a current LOC/LON;

 the previous assessment is within 45 days of the expiration date, or;

 the existing level of need is inaccurate.

If a new assessment must be completed, it must be electronically

entered into CARE automated system to be authorized by DADS before

the Individual Plan of Care (IPC) can be entered.

The Related Conditions Eligibility Screening Instrument is

completed when an individual does not have a diagnosis of mental

retardation, but may be eligible for a Level of Care/Level of Need based

on a related condition.

The hard copy of the MR/RC must be retained in the consumer’s

record and must match what is entered into the CARE automated

system. Staff should give a copy of the completed MR/RC to the

program provider selected by the individual and/or guardian.

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IDD Authority Manual Enrollment Into Medicaid Programs

Burke Center Revised – October 2011

Individual Plan of Care: (HCS IPC 3608 & 3608A)

(Attachment #34A & 34B)or TxHmL IPC 8582 & 8583 (Attachment

35A & 35B) The IPC form identifies the type and amount of

HCS/TxHmL services the individual will need for the current plan

year. The initial IPC’s for waiver and non-waiver services are

completed by the designated staff after the determination of needed

services through the PDP process. Designated staff should develop the

proposed IPC’s which reflects services

Based on needs identified in the PDP. The provider’s team and

Authority staff meets to negotiate the units to be reflected on the final

copy of the initial IPC for enrollment into services along with the

individual and/or guardian. Staff must ensure the development and

completion of the initial IPC, recommendations for resource

allocation based on the PDP and all necessary assessments within

45 days of the individual and/or guardian indication his/her desire

for HCS or TxHmL services if being enrolled on the interest list.

If documentation is necessary to establish the need for a specific type

or amount of service, the Service Coordinator may be able to obtain

this from the program provider. In some cases, if clarification of an

assessment or evaluation is necessary to justify a service, the Service

Coordinator will negotiate the requirement with the program provider,

e.g., additional hours on the IPC for a new assessment, etc.

Documentation of the type and amount of each service component

included in the individual’s IPC:

 are necessary for the individual to live in the community, to ensure the individual’s health and welfare in the community, and to prevent the need for institutional services;

 do not replace existing natural supports or other non-program sources for the service components; and

 when the proposed IPC includes residential support, the reasons the team concluded that supervision and assistance from awake service providers are required during normal sleeping hours to assure the

 individual’s health and welfare including but not limited to the individual’s demonstrated needs for staff intervention to respond to the individual’s medical condition, a behavior displayed by the individual

 that poses a danger to the individual or to others, or the individual’s need for assistance with activities of daily living during normal sleeping hours.

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Burke Center Revised – October 2011

Designated staff develops the proposed IPC based on an individual’s

PDP, after final negotiation with the individual, the guardian, and the

program provider. DADS Medicaid staff may conduct a utilization

review prior to authorization of services as described in §409.511 of the

Administrative code. The Service Coordinator signs the IPC, and

obtains the signatures of the individual, guardian and program provider.

Initial approval by phone contact with the individual’s guardian may be

obtained if necessary. This phone contact must be documented. The

Service Coordinator must then follow-up to obtain the actual signature

of the guardian on the IPC as soon as possible. The Service

Coordinator then submits the proposed IPC for data entry into CARE,

and provides a copy to the provider.

6.

Once all the pre-enrollment process is completed Burke Center

staff will complete that Data Entry into CARE as outlined in the DADS

enrollment guidelines. Staff may check the C61 CARE screen to

determine if the enrollment has been approved by DADS Program

Enrollment.

By the date of enrollment, the designated staff will provide the program

provider with the following information on each individual enrolled into

the program provider’s program:

1. IPC for waiver and non-waiver services;

2. Written justification for, and outcome of, each service identified

in the individual’s IPC, which is the PDP for Burke Center;

3.

Other consumer-related information (e.g., previous services plan, medical information, assessment results, DOE, PDP; enrollment forms) that will assist the program provider in serving the individual;

4.

MR/RC assessment; and

5.

ICAP Assessment booklet and scoring.

Extension Request

For an individual whose enrollment process is not complete within DADS timeframes staff must have, within the same timeframes: a.

submitted to DADS a Verification of Freedom of Choice form with the individual’s or LAR’s signature and date declining the HCS or

TxHmL Program as appropriate; b.

submitted to DADS documentation that the LA sent a letter of withdrawal in accordance to DADS rules; or

19


Burke Center Revised – October 2011 c.

submitted a request to extend to the time allowed for the enrollment (using a Request for HCS/TxHmL Enrollment

Extension (Form 1045)) that DADS has approved. NOTE:

A Request for HCS/TxHmL Enrollment Extension (Form 1045) received by DADS after the 15 th

day of the last month of a quarter will not be approved for that quarter.

If staff anticipate an individual will not be enrolled and listed as ‘active’ in

CARE by the required date, staff must request that DADS grant an extension (using form 1045) to the time allowed for the enrollment activities and data entry of all the enrollment screen in CARE, prior to submitting a request for extension.

7. Authorized Individuals Living In Other LA Area

FOR HCS ONLY: If staff attempt to contact an individual or LAR and learns that the individual or LAR has relocated to another local authority’s local service area, staff will determine the individual’s designate LA using the “Guidelines for Determining and Changing Designate LA” found in the Administrative Section of this Manual. If Burke Center is the designated LA, staff will continue with all enrollment activities. If the

Burke staff determines that another local authority is the designated LA, staff will forward to the designated LA a copy of the authorization letter, the Provider Choice form, and a copy of any extensions already obtained.

Staff will notify the appropriate staff at DADS LA section of the transfer.

Should Burke receive the information from an authorized LA, Burke

Center becomes the authored LA and is responsible for meeting required timeframes for enrollment or requesting an extension.

For TxHmL ONLY: If staff attempt to contact the individual or LAR and learns that the individual or LAR has relocated to another local authority’s local service area, staff will contact DADS for further instructions.

8. Individual Chooses Provider in Another LA Area

HCS ONLY: If staff contacts the individual or LAR and begins the enrollment process and the applicant or LAR selects a provider outside of

Burke Center’s service are, staff must conduct all pre-enrollment activities, such as explanation of services, obtaining signature on

Verification of Freedom of Choice, conducting diagnostic activities and

MR/RC, Medicaid eligibility information, enrollment person-directed plan, and proposed IPC. Staff must:

20


Burke Center Revised – October 2011 a.

request an extension on the enrollment if the enrollment will not be completed in the originally assigned or extended timeframe; b.

transfer the consumer to the local authority in which the selected provider operates; c.

provide the enrollment PDP to the provider and complete the IPC negotiations with the provider; and send hard copies of all enrollment documents, including the provider choice form and any enrollment extensions already obtained, to the receiving LA.

Once the receiving LA receives the information from the authorized LA, then the receiving LA is responsible for meeting required timeframes for enrollment. The receiving LA must complete the data entry of all enrollment screens in a timely manner and request an extension if enrollment is not expected to be approved by the required timeframe.

9.

Waiver Offer Declined

GR ONLY: If the individual being offered a program vacancy is currently receiving general revenue funded services, staff will inform the individual and LAR that if the consumer or LAR declines the offer of waiver services identified by DADS (ie: TxHmL or HCS) that Burke

Center will terminate the general revenue services.

21

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