Pennsylvania Department of Public Welfare Office of Developmental Programs
ODP Announcement Guidance: Fiscal Year (FY) 2017‐2018 ISP Renewal Period ODP Communication Number 036-17 The mission of the Office of Developmental Programs is to support Pennsylvanians with developmental disabilities to achieve greater independence, choice and opportunity in their lives.
AUDIENCE:
Administrative Entities (AEs), Supports Coordination Organizations (SCOs), All Direct Service Providers (Waiver and Base Providers), and Other Interested Parties
PURPOSE:
This Office of Developmental Program (ODP) communication is intended to provide guidance to AEs, SCOs, SCs and direct service providers for creating fiscal year (FY) 20172018 Individual Support Plans (ISPs). The following topical areas are included in this communication: Creating FY 2017/2018 ISPs Brief overview of anticipated changes; Additional Individual Staffing (AIS)/Supplemental Habilitation (SH) services; Needs Level/Needs Group Residential Habilitation services with and without day supports; Residential services effective dates on ISP Base rates in waiver settings P/FDS Cap Calculation and guidance for those anticipated to exceed cap Community Participation Supports Family/Caregiver Support-Training and Support (W7062) Provider Qualifications FY 2017-2018 Waiver Rate Loads Reserve to Encumbrance (R2E) Relevant Dates Appendix A: Anticipated Rules that will force a plan to go to the AE Dashboard for manual review by the AE Appendix B: Residential Services Reference. Includes Day Unit Definition and plan exclusions for Residential Habilitation, Life Sharing and Support Living
NOTE: If there are individual ISPs that will likely exceed the P/FDS cap of $33,000 for FY 17/18, ODP is advising to only authorize Community Participation Support services and In Home and Community Support services for a six (6) month period (July 1, 2017 through December 31, 2017). During this six (6) month period, ODP will be issuing further guidance to address the last six (6) months of the fiscal year. ISSUE DATE: May 2, 2017 ODP Communication Number: 036-17
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Pennsylvania Department of Public Welfare Office of Developmental Programs
WHEN TO CREATE FY 2017-2018 ISPS ODP recommends the following schedule for your fiscal year activities based on timeframe of activities occurring. The SCO may make a determination to organize their workload based on preference. SERVICE COMPOSITION IN PLAN SC Services Only Base services Base services funded with Base dollars but use waiver rates. P/FDS Consolidated without Residential
Consolidated w/existing Residential and Respite services that are end-dated in HCSIS 12/31/17 and do not have a Needs Group associated with them All ISPs that include services with a Needs Level/Needs Group: Licensed respite-day services Licensed Residential Habilitation Life Sharing > 30 hours Supported Living
ACTIVITIES OCCURRING
Rate Load Rate Load and following P/FDS Cap increase Provider service offerings visible in SSDs for the majority of CPS services, Unlicensed Respite, Residential Habilitation services and services that have been renamed which include “InHome and Community Supports (previously “Home and Community Habilitation”), Small Group Employment (previously “Transitional Work”) and Licensed and Unlicensed Life Sharing (previously “Family Living Homes). SCOs can choose to complete Consolidated ISPs by rolling over current residential services for time period of 7/1/17 – 12/31/17 and then complete Critical Revision in late fall to update the plan with new residential procedure codes that go into effect 1/1/2018. SCOs may choose to complete ISPs after rate load and after Needs Level/Needs Group Screen and values are visible in HCSIS. Licensed respiteday services and Support Living are effective 7/1/17 while Licensed Residential Habilitation and Life Sharing > 30 hours are effective 1/1/18.
WHEN Now Now May 22, 2017 May 22, 2017 May 1, 2017
May 1, 2017
May 22, 2017
BRIEF OVERVIEW OF ANTICIPATED CHANGES THAT IMPACT FY 2017-2018 RENEWALS Many changes in HCSIS are in the process of being developed. More information will be provided to all stakeholders/partners in future communications. Below is a high-level list of changes that will have a relationship and/or impact on FY 2017-2018 renewals:
Administrative Entity (AE) Dashboard: This new functionality is intended to assist AEs with managing their authorization role as it pertains to ISPs. Rules have been developed in HCSIS to allow the plan to be approved and services authorized without the need for AE review and approval when certain criteria are met. See Appendix A for the anticipated auto approval rules.
The benefits associated with the new auto approval/auto authorize functionality will likely be achieved during FY 2017-2018 and future fiscal year renewal periods but not during this year’s FY renewal period itself due to the high volume of service and rate changes. NOTE: If FY 2017-2018 renewals are completed before the May 20, 2017 HCSIS release, services on these ISPs will not be subject to the
ISSUE DATE: May 2, 2017 ODP Communication Number: 036-17
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Pennsylvania Department of Public Welfare Office of Developmental Programs
auto approval rules and will not appear on the AE Dashboard. The anticipated menu path in HCSIS for the AE Dashboard is as follows: Plan > Plan Admin > Plan Dashboard An “AE Plan Dashboard – Training and User Guide” is currently under development. When finalized it will be stored in the HCSIS LMS. This resource is anticipated to be available before July 1, 2017. See Appendix A for more information regarding the rules that were created that will force plans to be sent to the AE Dashboard for manual review by the AE. A SCO Dashboard is anticipated to be part of the November 2017 HCSIS release. There will be more information shared in the next few months regarding this project.
Creation of two (2) new windows in HCSIS. One window will identify the Needs Level/Needs Group of an individual and another window will display the current program capacity of applicable providers. These windows will not appear in HCSIS until Saturday, May 20, 2017. Once the Needs Level/Needs Group screen is visible in HCSIS, service Providers, SCOs, SCs and AEs will all be able to view individual’s Needs Level and Needs Group in this window. If the individual’s Needs Level/Needs Group is not present in this window, contact the ODP Fiscal mailbox:
[email protected]. Please include the MCI number of the individual associated with the Needs Level/Needs Group you are requesting. The anticipated menu path in HCSIS for both windows is as follows: o Needs Group/Needs Level: Individual > Evaluation > Needs Level/Needs Group o Program Capacity: Provider > Program Capacity
New/End-dated Services. On April 14, 2017, HCSIS was updated with 112 new discrete services/procedure codes. Service end dates were also added on this date. The Behavior Therapy procedure code (T2025, Modifiers HE and HQ) has been end dated as this service will no longer be offered in the waivers effective July 1, 2017. The procedure codes for InHome and Community Support and Companion, services at staff to individual ratios higher than 1:3, will also be end-dated effective July 1, 2017.
Provider Service Offerings and Service Contracts: ODP has created Service Offerings and Service Contracts (using a placeholder rate of $1.00) on behalf of providers for specific services. This activity occurred on April 27, 2017. Any provider that has an offering and contract at a service location for the services listed below for FY 16/17 should have been auto assigned an offering and contract unless a provider manually added these services to their SSD prior to the auto offering/service contract activity. If any of the services below are missing from provider’s SSDs, providers may manually add them if they are already qualified for the specialties associated with these services. o The majority of Community Participation Support (CPS) services. Provider’s previously qualified to render Day Habilitation and Prevocational services will continue to be qualified for CPS services. o Unlicensed Respite o Licensed Residential Habilitation services with the Needs Group (for services effective 1/1/2018)
ISSUE DATE: May 2, 2017 ODP Communication Number: 036-17
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Pennsylvania Department of Public Welfare Office of Developmental Programs
o Renamed services including “In-Home and Community Supports (previously “Home and Community Habilitation”), Small Group Employment (previously “Transitional Work”) and Licensed and Unlicensed Life Sharing (previously “Family Living Homes) and “Supported Employment – Career Assessment” (previously “Supported Employment”, procedure code W7235). ADDITIONAL INDIVIDUALIZED STAFFING (AIS) AND SUPPLEMENTAL HABILITATION (SH) SERVICES AIS or SH service requests for dates of service July 1, 2017 and forward will no longer require PROMISeTM prior authorization by ODP. Completion of a MA 97 and the Supplemental Habilitation and Additional Individualized Staffing Prior Authorization Request form (DP 1031) will no longer be required effective July 1, 2017. For AIS or SH requested during this six month period, providers must complete pages 1 and 2 of the ISP Review Checklist (DP 1050) and forward to SCOs in order to initiate a request; no other portion of the ISP Review Checklist needs to be completed. The SCO shall submit the DP 1050 to the authorizing AE at the time of submission of the ISP in accordance with current practice. The ISP review, approval and authorization will be conducted by the applicable AE just as they would authorize any waiver service that does not require prior authorization. Requests for AIS or SH, for dates of service prior to July 1, 2017, should continue to be made using the current process which includes completing the ISP Review Checklist, the MA97 and the Supplemental Habilitation & Additional Individualized Staffing Prior Authorization Request form (DP 1031). All requests for AIS or SH services that were rendered any time prior to July 1, 2017 must be received on or before July 28, 2017. Requests received after July 28, 2017 will not be processed. Effective January 1, 2018, the new residential service fee schedule rate methodology will incorporate AIS services. As a result, AIS services will be end dated December 31, 2017. SCOs and AEs should ensure the Service End Date for AIS, on the Service Details screen of the ISP, does not exceed December 31, 2017. Supplemental Habilitation (SH) services will continue to be made available after December 31, 2017; however, new criteria to receive SH will be in place. These criteria are currently under development and will be communicated at a later time. Providers who have been authorized by ODP (via PROMISeTM) for either SH or AIS for dates of service up to June 30, 2017, should continue to include the prior authorization number in the appropriate field on your claim transactions. For example, if SH was rendered on June 1, 2017 and the claim is submitted on August 2, 2017, that claim transaction must contain the PROMISeTM prior authorization number or the claim will deny. Note: Effective 7/1/2017, the ISP Checklist will only be used for AIS and SH requests. More information will follow regarding the future of the ISP Checklist. Service Name Supplemental Habilitation (SH) Additional Individualized Staffing (AIS)
7/1/2017 – 12/31/2017 Authorized via HCSIS like other services are authorized Authorized via HCSIS like other services are authorized
1/1/2018 – 6/30/2018 Do not authorize in HCSIS until ODP provides further guidance for this period. No longer available as a discrete service
A future communication will detail the new service authorization criteria for SH for the period January 1, 2017 and forward. ISSUE DATE: May 2, 2017 ODP Communication Number: 036-17
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Pennsylvania Department of Public Welfare Office of Developmental Programs
NEEDS GROUP AND NEEDS LEVEL The Needs Group (NG) and Needs Level are new terms for FY 2017-2018. The Needs Level represents the needs level of an individual derived from the Supports Intensity Scale, known as SIS. There are seven (7) Needs Levels. The Needs Group represents Needs Level groupings. After in-depth data analysis, certain Needs Levels were found to strongly correlate with one another and, thus, were placed in groupings. For example, individuals who have been assessed with a SIS Needs Level 3 or 4, have been found to have very similar levels of need and; therefore, are assigned to the same Needs Group, which, in this example, would be Needs Group 3. The relationship between the Needs Group and Needs Level is as follows:
Needs Level 1 2 3 and 4 5, 6 and 7
Needs Group 1 2 3 4
Represented in HCSIS Service Description NG 1 NG 2 NG 3 NG 4
Modifier U5 U6 U7 U8
Four modifiers will be used to represent the Needs Group associated with the individual. This means that each individual residing in the home could have a different modifier (and rate) based upon his or her specific Needs Group. These modifiers will be attached to the new Residential Habilitation, Life Sharing, Supported Living and licensed Respite day procedure codes and should be used when billing services that use a Needs Group. The modifiers will be visible on the Service Detail screen in HCSIS. Services that will be associated with the Needs Level/Needs Group include:
All Licensed Respite day services All Licensed and Unlicensed Residential Habilitation Eligible services (Ineligible component will not require a Needs Level/Needs Group) All licensed and unlicensed Life Sharing services when the individual needs over 30 hours per week of services on average. All Supported Living services. (This is a new service effective 7/1/17. See draft Consolidated Waiver Renewal for more details regarding this service).
Examples: W9029 U5: This combination represents “Res Hab-2 Person-NG 1-Elig” in HCSIS. This is translated to mean the eligible component of a two (2) person Residential Habilitation setting where the individual’s assessed needs are associated with Needs Group 1.
W9030: This discrete procedure code represents the ineligible component of a two (2) person Residential Habilitation service. The service description in HCSIS associated with this procedure code will be “Res Hab-Lic-2 Person-Inelig”. This procedure code will be associated with all two (2) person Residential Habilitation procedure codes regardless of Needs Group.
A new screen is being developed in HCSIS, which will identify the Needs Group and Needs Level. The window that will display the Needs Level/Needs Group values will not be visible in HCSIS until Saturday, May 20, 2017. The proposed window will contain an “Effective Begin Date” and an “Effective End Date” field. The first data load for these two windows, will show an “Effective Begin Date” as 7/1/17 and a blank “Effective End Date”. Future changes/updates to either the Program Capacity value or the Needs ISSUE DATE: May 2, 2017 ODP Communication Number: 036-17
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Pennsylvania Department of Public Welfare Office of Developmental Programs
Group value will be identified on the window by a change in “Effective Begin Date”. The communication process for ODP to notify impacted stakeholders of changes/updates made to either screen will be shared in a future ODP communication. Since the Needs Level/Needs Group window will not be available until May 20, 2017, SCs/SCOs will need to make sure they have access to an individual’s Needs Level/Needs Group in order to select the appropriate services in the Provider’s SSD. The Needs Level/Needs Group of each individual was shared with AEs and Providers in early April 2017. If you do not know an individual’s Needs Level/Needs Group, write to the ODP Fiscal mailbox:
[email protected]. Please include the MCI number of the individual associated with the Needs Group/Needs Level you are requesting.
Anticipated menu path in HCSIS for Needs Group/Needs Level window: Individual > Evaluation > Needs Level/Needs Group NOTE: Once the Needs Level/Needs Group screen is visible in HCSIS, authorized service Providers, SCOs, SCs and AEs will all be able to view this window.
RESIDENTIAL HABILITATION SERVICES WITH/WITHOUT DAY SUPPORTS The new licensed eligible and ineligible Residential Habilitation services (effective 1/1/2018) combine Adult Residential 6400, Community Residential Rehabilitation Services for the Mentally Ill Home (CRR Adult) 5310 and Child Residential 3800 into five (5) different procedure codes, each procedure code will represent five (5) different setting sizes (i.e., 1 person, 2 person, 3 person, 4 person and 5-8 persons). The provider’s enrolled specialty, associated with the procedure codes, will define which licensed setting the procedure code represents. Base Residential Habilitation services (9+) will continue to be available and will not receive a Needs Group modifier. Effective January 1, 2018, the new residential service fee schedule rate methodology and the new eligible Residential Habilitation services/procedure codes will take into account when an individual receives Residential Habilitation services and day supports. Residential Habilitation procedure codes with the modifier “HI” will represent Residential Habilitation WITHOUT day supports. The discrete procedure codes (without the “HI” modifier) will represent Residential Habilitation with day supports. For example, in HCSIS, you will see:
“Res Hab-1 Person-NG 3-Elig-w/Day Supports”: This service description in HCSIS represents a one (1) person Residential Habilitation setting. The individual associated with this service description is assigned a Needs Group 3 (represented by NG 3) and receives day/employment supports during the week and/or on the weekend. The procedure code/modifier combination associated with this service description is W9000 U7, where U7 represent Needs Level 3 or 4, which is equivalent to Needs Group 3.
“Res Hab-1 Person-NG 3-Elig”: This service description represents a one (1) person Residential Habilitation setting. The individual associated with this service description is assigned a Needs Group 3 (represented by NG 3) and does not receive day/employment supports either during the week and/or during weekend. The procedure/modifier combination for this service description is “W9000 U7 HI”, where “U7” represents Needs Group 3 and the “HI” modifier indicates that the person does not receive any day or employment supports.
ISSUE DATE: May 2, 2017 ODP Communication Number: 036-17
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Pennsylvania Department of Public Welfare Office of Developmental Programs
SCs/SCOs ACTION: Residential Habilitation Services with/without Day Supports 7/1/2017 - 12/31/2017
For FY 2017/2018 renewal ISPs and licensed Residential Habilitation1 services (55 Pa. Code Chapters 3800, 5310, 6400 and 6500), if an individual’s residential needs are anticipated to remain the same during the first six (6) months of the fiscal year, document current residential services in the ISP for the period 7/1/2017 through 12/31/17.
1/1/2018 - 06/30/2018
For the last six (6) months of FY 2017/2018 and licensed Residential Habilitation services (55 Pa. Code Chapters 3800, 5310 and 6400), individuals may use a combination of “with day supports” and “without day supports” during a calendar week throughout the fiscal year. For these situations, SCs should add two (2) service segments on the ISP, one for each of these services. The SC should utilize the tool provided by ODP to accurately reflect the number of days “with day supports” and “without day supports” for the individual for the period 1/1/2018 through 6/30/18. Life Sharing (6500) will not use the “with day” or “without day” model.
Total Residential Service Segments on FY 2017/2018 Renewal ISP
For individuals who will be receiving licensed Residential Habilitation services (55 Pa. Code Chapters 3800, 5310 and 6400) “with day supports” and “without day supports” during FY 2017/2018, the SC should add a total of five (5) service segments on the ISP for residential services. Two (2) segments will represent the eligible and ineligible residential service for the first six (6) months of the fiscal year. Three (3) additional segments will represent the last six (6) months of the fiscal year and should include one segment for the ineligible residential service, one segment for the “with day eligible residential service and one segment for the “without day” eligible residential service. See below/next page for example of unit break out.
Example for an individual that attends day program five (5) days per week:
Eligible Eligible with Day Eligible without Day Ineligible (existing code) Ineligible (new code)
7/1/2017 – 12/31/2017 184 ----184 ---
1/1/2018 – 6/30/2018 ---126 55 --181
Total units on FY 2017/2018 plan should reflect 365 total units of eligible residential services (184 + 126 + 55) and 365 total units of ineligible residential services (184 + 181). *ODP is currently in the process of developing a tool to address licensed Residential Habilitation services (55 Pa. Code Chapters 3800, 5310 and 6400) “with day supports” and “without day supports” to assist with the development of the ISP. This tool is anticipated to be available early May 2017.
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Effective 7/1/2017, Family Living Homes are referred to as Life Sharing.
ISSUE DATE: May 2, 2017 ODP Communication Number: 036-17
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Pennsylvania Department of Public Welfare Office of Developmental Programs
RESIDENTIAL SERVICE EFFECTIVE DATES ON THE ISP The following chart lists all residential services that exist in HCSIS and their begin/end-dates to support the waiver renewals. The word “None” in the End Date column indicates that there is no end date in HCSIS for this service. For FY Renewal ISP development purposes, SCs would enter an end date of 6/30/2017 on the Service Details screen in HCSIS for those services associated with an end date of “None”.
Residential Service Supported Living (+ Needs Group) Life Sharing (Licensed) (+ Needs Group) Life Sharing (Licensed) was called Family Living during FY
Needs Group (NG) Modifier Yes Yes No
7/1/2017 1/1/2018 Current Service
None None 12/31/17
No No Yes No
Current Service Current Service 1/1/2018 Current Service
None 12/31/17 None None
Start Date
End Date
16/17 and prior
Life Sharing (Unlicensed) Residential Habilitation (licensed 3800, 5310 and 6400) Residential Habilitation (licensed) (+ Needs Group) Residential Habilitation (unlicensed)
SC/SCO Action: Please take note of the dates in the chart on the previous page when adding residential services on an individual’s FY renewal plan. Date segments for residential services on the ISP should reflect the dates in the chart. For FY Renewal ISP development purposes, SCs would enter an end date of 6/30/2017 on the Service Details screen in HCSIS for those services associated with an end date of “None” that is seen in the chart on the last page. AE Action:
Prior to authorizing a service, AEs should ensure new services and end-dated services are accurately reflected in the FY 2017-2018 renewal ISPs, if applicable.
BASE RATES IN WAIVER SETTINGS Administrative Entities should comply with Chapter 51, sections § 51.43(e) and § 4300.115a, when assigning Base fees or rates in waiver HCBS settings. The Supports Intensity ScaleTM (SIS) needs assessment will be conducted for base funded individuals who reside in waiver funded residential habilitation settings. ODP recommends authorizing a six (6) month date segment on the ISP for base services rendered in waiver settings to ensure adequate time is provided for individuals to receive their SIS assessment.
P/FDS CAP CALCULATION EXCEEDING CAP
If there are individual ISPs that will likely exceed the P/FDS cap of $33,000 for FY 17/18, ODP is advising to only authorize Community Participation Support services and In Home and Community Support services for a six (6) month period (July 1, 2017 through December 31, 2017). During this six (6) month period, ODP will be issuing further guidance to address the last six (6) months of the fiscal year.
PRIORITIZING: SCs may want to consider only doing FY plans where an impact to the P/FDS cap is not anticipated. PLEASE NOTE: Currently the P/FDS cap is set to $30,000 and Supported Employment is included in the cap calculation in HCSIS. On Saturday, May 20, 2017, the new P/FDS cap amount will become active ISSUE DATE: May 2, 2017 ODP Communication Number: 036-17
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Pennsylvania Department of Public Welfare Office of Developmental Programs
at $33,000 and Supported Employment and Advanced Supported Employment will be excluded at that time from the P/FDS cap calculation. In Appendix C-4 of the P/FDS Waiver Renewal, ODP proposed an annual limit of $33,000 per person for P/FDS Waiver services. For FY 2017-2018, Supported Employment and Advanced Supported Employment services will be permitted to exceed the P/FDS cap up to $15,000 to equal a total of $48,000. For example, if the plan budget total for a P/FDS participant is $25,000, up to $23,000 worth of supported and advanced supported employment services are permitted to be added to the ISP. If the ISP is maxed out at $33,000 and contains no authorized Supported Employment and/or Advanced Supported Employment services, the individual may have up to a combined total of $15,000 worth of Supported Employment and Advanced Supported Employment services. See below examples for acceptable and unacceptable scenarios regarding the P/FDS cap.
P/FDS CAP EXAMPLES THAT ARE ACCEPTABLE 1. 2.
Individual A is authorized for $48,000 in Supported Employment Individual B is authorized for a. $30,000 of In-Home and Community Support b. $18,000 of Supported Employment
P/FDS CAP EXAMPLES THAT ARE UNACCEPTABLE 1.
Individual C is authorized for a. $35,000 of In-Home and Community Support (exceeds $33,000 service cap) b. $10,000 of Supported Employment 2. Individual D is authorized for a. $20,000 of Companion b. $20,000 of Community Participation (combination of Companion and Community Participation For 2017-2018, Supports Broker services exceeds $33,000 service cap) and Supports Coordination services will continue to be excluded from the P/FDS cap calculation. c. $8,000 of Supported Employment
FY 2017-2018 WAIVER RATE LOADS It is anticipated that there will be one waiver rate load during FY 2017-2018, which is scheduled to occur on May 22, 2017. The waiver rate load will contain rates for new services and existing services. Rates for existing residential services will be contained in the rate load and be effective until December 31, 2017. In addition, the new fee schedule rates for Residential Habilitation and licensed Life Sharing services will also be contained in the waiver rate load with an effective date of January 1, 2018 through June 30, 2018. Supported Living is effective July 1, 2017 and the rate will be assigned based on Needs Group. The new residential fee schedule rates will be associated with new residential procedure codes and modifiers that incorporate an individual’s Needs Level. Note: The P/FDS cap increase and will go into effect on Saturday, May 20, 2017, two days before the rate load, which is scheduled for Monday, May 22, 2017. Attention should be taken to ensure the cap is not exceeded if P/FDS FY plans are completed before the rate load. SCs/SCOs/AEs should plan accordingly. The estimated waiver rates are subject to the Centers for Medicare and Medicaid Services (CMS) approval of the Consolidated and P/FDS FY 2017-2018 waiver renewals and the final amounts appropriated by the General Assembly. A forthcoming communication will detail more specific timelines.
ISSUE DATE: May 2, 2017 ODP Communication Number: 036-17
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Pennsylvania Department of Public Welfare Office of Developmental Programs
COMMUNITY PARTICIPATION SUPPORTS (CPS) For guidance regarding CPS services, please see: ODP Communication 028-17: Crosswalk for Community Participation Supports for Individual Support Plan (ISP) Fiscal Year 17-18 Renewals for Consolidated and P/FDS Waivers
“FAMILY/CAREGIVER SUPPORT-TRAINING AND SUPPORT” (Procedure Code W7062) The service “Family/Caregiver Support – Training and Support” (procedure code W7062) is used to pay for training or registration fees at events, workshops, seminars or conferences and is considered an outcome based service in HCSIS. To add this service to a plan, the SC should use the vendor screens.
PROVIDER QUALIFICATIONS (PQ) Providers and AEs Providers and AEs should use the draft waiver renewal submitted by ODP to CMS on April 1, 2017 to review qualification standards for new services. Please note that qualification standards may have changed for existing services as well. Providers and AEs should be aware of these changes for future re-qualification. Providers can begin preparing qualification documents for new services in preparation for submission to Assigned AE upon CMS approval of the waivers. Enrollment applications for new services should not be submitted to ODP until CMS approves waiver and after completion of qualification. An updated PQ Documentation Record that will include updates to qualification standards that both providers and AEs can use during qualification process is forthcoming. ISP Teams Teams should use the draft waiver renewal submitted by ODP to CMS on April 1, 2017 to have discussions related to assessed service need of the new waiver services. Providers will need to be qualified and enrolled for these services before the services can be added to the ISP. Therefore, team discussions should take into consideration that the start date of the services will be based on when providers become qualified to render the services. The full Consolidated and P/FDS waiver applications submitted to CMS, as well as a side-by-side of substantive changes made as a result of public comment, are available at: http://dhs.pa.gov/provider/developmentalprograms/2017waiverrenewals/index.htm.
ISSUE DATE: May 2, 2017 ODP Communication Number: 036-17
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Pennsylvania Department of Public Welfare Office of Developmental Programs
RESERVE 2 ENCUMBRANCE (R2E) AE/COUNTY ACTION: Please note that the following actions are contingent upon ODP’s entry of the projected allocation which is anticipated to occur no later than May 22, 2017. ODP will communicate the R2E schedule and date County allocations will be entered into HCSIS via the AE Listserv. ODP regional staff will also notify applicable stakeholders using the same communication method employed during previous fiscal years. A. Preparation tasks before running the year end R2E process2 1. Run the Provider Service Status Report (contract types) for FY 2017-2018 and Provisional OnHold Contracts: Tools --> Reports --> Reports Request 2. Run the Provider Service Status Report for FY 2017-2018, Real Contracts: Tools --> Reports --> Reports Request 3. Review the base allocation amount by accessing the Funding Level screen. To make changes, navigate to the Non-Service Encumbrance, Overbooking and Revenue Adjustment screens. 4. Run the County Funding Level Report for the upcoming FY and all Funding Streams: Tools --> Reports --> Reports Request 5. Run R2E after: ODP communicates the R2E batch has been released There are no incorrect rates for real contracts in the upcoming FY Providers have service authorizations and can begin providing services B. Enter the Projected Plan Budget (PPB) for Base ISPs 1. Use the last year’s (FY 2016-2017) PPB amounts to populate the PPB amounts for FY 20172018. This task can be accomplished by doing one of the following: a. The county user can use the View / Update Budget Amount By Individual option from the Budget Management Menu screen to enter the PPB amount for one individual at a time - or b. The county user can use the Populate Future Fiscal Year Projected Plan Budget Amounts option to auto-populate future fiscal year (target fiscal year) PPB amounts for all the individuals within their scope using existing data from the previous fiscal year (source fiscal year). 2. If the user entered the PPB amounts by copying over the prior year’s funding before ODP entered the FY 2017-2018 funding streams, the FY 2016-2017 funding stream(s) would have been selected. Once the AE runs the Reserves to Encumbrance (R2E), the funding stream(s) will automatically be replaced by the corresponding funding stream applicable for FY 20172018. The request to copy over the PPB amounts is processed overnight. The next day, the Populate Future Fiscal Year Projected Plan Budget Amounts Report is made available on the Reports Inbox screen. 3. If manually entering the PPB amounts after ODP entered the FY 2017-2018 funding streams, select the “HUMAN SERVICE DEVELOPMENT FUND - Waiver Ineligible” funding stream. 2
Resource located in HCSIS > LMS > FM Guidebook and Supporting Materials > “Year End R2E Process Checklist v2.0 06/17/10”
ISSUE DATE: May 2, 2017 ODP Communication Number: 036-17
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Pennsylvania Department of Public Welfare Office of Developmental Programs
4. Run the Projected Plan Budget Amount Exceeded Report for FY 2017-2018: Tools --> Reports --> Reports Request NOTE: The R2E process may be run many times, however it must be run at least once AFTER 6/30 and BEFORE providers submit claims.
RELEVANT DATES ANTICIPATED DATE April 14, 2017 April 27, 2017
May 20, 2017
May 22, 2017
Before July 1, 2017
ACTIVITY New Service Definitions viewable in HCSIS Auto Offerings added to Provider’s SSD for the majority of CPS services, Unlicensed Respite, Residential Habilitation services and services that have been renamed which include “In-Home and Community Supports (previously “Home and Community Habilitation”), Small Group Employment (previously “Transitional Work”) and Licensed and Unlicensed Life Sharing (previously “Family Living Homes). Including, but not limited to, AE Dashboard, Auto Authorization Rules, Needs Level/Needs Group and Program Capacity windows and P/FDS cap calculation extended and modified for Supported Employment and Advanced Supported Employment services. FY 2017-2018 estimated Department established fees and fee schedule rates loaded in HCSIS. Rates visible on service contracts and the ISPs. AE Plan Dashboard Resource in LMS Needs Level/Needs Group Resource in LMS Program Capacity Resource in LMS Licensed Residential Habilitation “With Day” and “Without Day” tool
Inquiries regarding this communication should be sent to the ODP ISP Inquiries mailbox:
[email protected] The ISP Fiscal Year Renewal Webinar for AEs and SCOs is now posted and available on My ODP at: https://www.myodp.org/course/view.php?id=941 To access this webinar, please remember you must be registered, have an AE or SC role and log-in on My ODP to access the course.
ISSUE DATE: May 2, 2017 ODP Communication Number: 036-17
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APPENDIX A: Rule/Rule Descriptions that Prevent Auto Approval & Requires AE Manual Review
Rules/Rule Descriptions that Prevent Auto Approval and Requires AE Manual Review The following table identifies the Plan Category and waiver(s) subject to the “Rules” listed under the “Rule Name” column. When a rule is met, the plan will go to the AE Dashboard and the AE will be required to manual review and approve it. When a rule is not met, the plan will auto approve. All rules are effective July 1st 2017. Any plan category/waiver combination not listed below or where there is a blank space in the table will not be subject to the rules in the “Rule Name” column and will be auto approved. Requires AE Manual Review Plan Category FY Renewal Rule Name Service Addition Rule
Rule Description
Consld. P/FDS Consld. P/FDS
A service is added to the current plan that Yes was not on the previous plan and it does not satisfy an Old to New Service Definition Mapping. Service Removal A service is removed from the current plan Yes Rule that was on the previous plan. Unit Increase Rule The service units have increased by more Yes than 0% as compared to the previous plan. Unit Decrease Rule The service units have decreased by more Yes than 0% as compared to the previous plan. Base Services Rule Services mapped to only Base funding Yes streams exist on the current plan and service information has changed. Prior Plan Pending Future FY plan being submitted when there Yes Rule is a non-approved Critical Revision of the current FY plan. Missing Annual The Annual Review Update date has passed Yes Review Rule and no Annual Review Update was performed in the current FY. Waiver/Program The Waiver/Program of the individual has Yes Transfer Rule changed since the last approved plan. Service Combination Certain combination(s) of services exist Yes Rule concurrently on the plan and service information has changed. Multiple Funding Services are mapped to more than one Yes Stream Rule funding stream and an authorization decision has not yet been made. Requested for SC selected Request for Manual Approval Yes Manual Approval checkbox on Draft Plan screen. Rule System Exception Plan meets the error condition(s) of an Yes Rule* existing Plan Approval or Service Authorization screen validation.
ISSUE DATE: May 2, 2017 ODP Communication Number: 036-17
Annual Review Update
Yes
Yes
Yes
Yes
Yes
Yes
Critical Revision P/FDS Yes
Yes Yes Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
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APPENDIX B: RESIDENTIAL SERVICE TOPICS AND SERVICE EXCLUSIONS Definition of Day Unit: Effective July 1, 2017 through December 31, 2017, a day is defined as a period of a minimum of 12 hours of non-continuous care rendered by a residential provider within a 24-hour period beginning at 12:00 a.m. and ending at 11:59 p.m. Effective January 1, 2018, a day is defined as a period of a minimum of 8 hours of non-continuous care rendered by a residential provider within a 24- hour period beginning at 12:00 a.m. and ending at 11:59 p.m. These definitions apply to:
Licensed Residential Habilitation Licensed Life Sharing; Unlicensed Life Sharing for Individuals who need more than 30 hours per week of service; and Respite Day provided in Residential Habilitation, Life Sharing, private ICF/ID and nursing homes.
For residential services, that average less than 30 hours per week of direct support and assuming that the individual either does not require daily support or that some level of daily support is provided through natural supports (Supported Living, Unlicensed Life Sharing and Unlicensed Residential Habilitation), a day unit is defined as a period of a minimum of 8 hours of non-continuous care which may include on-call support or remote monitoring. The exception to the day unit rule is when an individual is admitted to a hospital or nursing facility. When this occurs the residential provider may not bill for the day the individual is admitted regardless of how many hours of care the residential provider has rendered during the 24-hour period. When an individual is discharged from a hospital or nursing facility the residential provider may bill for the discharge day of service regardless of how many hours of care the residential provider has rendered during the 24-hour period.
“Without Day”: “Licensed Residential Habilitation Without Day” (Modifier HI) is any day in which one of the following occurs:
An individual solely receives services that are part of the Residential Habilitation service; or An individual receives fewer than 5 hours of services and/or unpaid supports that are not included in the Residential Habilitation service.
“With Day”: “Licensed Residential Habilitation With Day” is any day in which an individual receives five (5) or more hours of services and/or unpaid supports that are not included the Residential Habilitation service.
ISSUE DATE: May 2, 2017 ODP Communication Number: 036-17
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APPENDIX B: RESIDENTIAL SERVICE TOPICS AND SERVICE EXCLUSIONS Residential Habilitation Service Exclusions Many of these exclusions will be enforced via the AE Dashboard under the “Service Combination Rule”. This rule will look for certain service combinations that have overlapping dates in the ISP. If combinations are found, the service(s) will be routed to the AE Dashboard for the AE to manual review and take action/adjust accordingly.
Effective July 1, 2017 – forward
Effective January 1, 2018 - forward
The following services may not be included in the plan with RESIDENTIAL HABILITATION
The services below may also not be included in the plan with RESIDENTIAL HABILITATION
Lifesharing
Additional Individualized Staffing (AIS) at a 1:1 or 2:1
Supported Living
In-Home and Community Support
Assistive Technology – Remote Monitoring
Behavioral Support (may only be authorized as a discrete service when it is used to support a participant to access Community Participation Support, Supported Employment, Transitional Work or Advanced Supported Employment). Additional guidance for Behavioral Support services to assist with understanding and Team discussion is currently under development and is forthcoming.
Supports Broker (unless the participant has a plan to self-direct services through a participant-directed services model in a private home)
Shift Nursing (except participants who receive nursing supports on a daily basis as part of Residential Habilitation can be authorized to receive Shift Nursing as a separate and discrete service solely for the hours of a home visit and as deemed necessary in accordance with the Shift Nursing service definition when there is documentation of the following:
Housing Transition and Tenancy Sustaining Services – Tenancy Support. (Housing Transition services may be authorized when the participant has a plan to move from the home where Residential Habilitation is provided into a private home that the participant will own, rent or lease. Transportation Companion Respite (15 minute or Day) Homemaker/Chore Music, Art and Equine Assisted Therapy Family/Caregiver Training and Support Specialized Supplies Home or Vehicle Accessibility Adaptations Consultative Nutritional Services Communication Specialist (only when authorized to support a participant with Community Participation Support services)
ISSUE DATE: May 2, 2017 ODP Communication Number: 036-17
The residential provider is unable to provide nursing supports; and The person(s) with whom the individual will have a home visit are unable to provide the nursing support during the visits. Transportation is included in the Residential Habilitation rate and may not be billed as a discrete service, unless the transportation is to or from a job that meets the definition of competitive integrated employment and that need is documented in the service plan.
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APPENDIX B: RESIDENTIAL SERVICE TOPICS AND SERVICE EXCLUSIONS Life Sharing Service Exclusions Effective July 1, 2017 – forward
Effective January 1, 2018 – forward
The following services may not be included in the plan with LIFE SHARING
The services below may also not be included in the plan with LIFE SHARING
Residential Habilitation Supported Living Assistive Technology – Remote Monitoring
Additional Individualized Staffing (AIS) at a 1:1 or 2:1 In-Home and Community Support Behavioral Support (may only be authorized as a discrete service when it is used to support a participant to access Community Participation Support, Supported Employment, Transitional Work or Advanced Supported Employment). Additional guidance for Behavioral Support services to assist with understanding and Team discussion is currently under development and is forthcoming. Shift Nursing (except participants who receive nursing supports on a daily basis as part of Life Sharing can be authorized to receive Shift Nursing as a separate and discrete service solely for the hours of a home visit and as deemed necessary in accordance with the Shift Nursing service definition when there is documentation of the following: • The Life Sharing provider is unable to provide nursing supports; and • The person(s) with whom the individual will have a home visit are unable to provide the nursing support during the visits.
Supports Broker (unless the participant has a plan to self-direct services through a participant-directed services model in a private home)
Housing Transition and Tenancy Sustaining Services – Tenancy Support. (Housing Transition services may be authorized when the participant has a plan to move from the home where Life Sharing is provided into a private home that the participant will own, rent or lease. Transportation Companion Respite (15 minute or Day) – EXCLUDED ONLY 7/1-12/31/2017 Homemaker/Chore Music, Art and Equine Assisted Therapy Family/Caregiver Training and Support Specialized Supplies Home Accessibility Adaptations when the home is owned, leased or rented by the Life Sharing provider. Consultative Nutritional Services Communication Specialist (only when authorized to support a participant with Community Participation Support services) Vehicle Accessibility Adaptations when the vehicle being adapted and utilized by the participant is owned, leased or rented by the Life Sharing provider. Transportation
ISSUE DATE: May 2, 2017 ODP Communication Number: 036-17
Transportation is included in the Life Sharing rate and may not be billed as a discrete service, unless the transportation is to or from a job that meets the definition of competitive integrated employment and that need is documented in the service plan.
Transportation is included in the Residential Habilitation rate and may not be billed as a discrete service, unless the transportation is to or from a job that meets the definition of competitive integrated employment and that need is documented in the service plan.
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APPENDIX B: RESIDENTIAL SERVICE TOPICS AND SERVICE EXCLUSIONS Supported Living Service Exclusions Effective July 1, 2017 – forward The following services may not be included in the plan with SUPPORTED LIVING Residential Habilitation Life Sharing Behavioral Support (may only be authorized as a discrete service when it is used to support a participant to access Community Participation Support, Supported Employment, Transitional Work or Advanced Supported Employment). Additional guidance for Behavioral Support services to assist with understanding and Team discussion is currently under development and is forthcoming. Housing Transition and Tenancy Sustaining Services In-Home and Community Support Assistive Technology – Remote Monitoring Supports Broker (unless the participant has a plan to self-direct services through a participant-directed services model in a private home) Transportation is included in the Supported Living rate and may not be billed as a discrete service, unless the transportation is to or from a job that meets the definition of competitive integrated employment and that need is documented in the service plan. Companion Respite (15 minute or Day) Homemaker/Chore Music, Art and Equine Assisted Therapy Family/Caregiver Training and Support Specialized Supplies Consultative Nutritional Services Communication Specialist (only when authorized to support a participant with Community Participation Support services) Vehicle Accessibility Adaptations when the vehicle being adapted and utilized by the participant is owned, leased or rented by the Supported Living provider.
ISSUE DATE: May 2, 2017 ODP Communication Number: 036-17
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