an introduction to consumer rights in the family care & iris programs 2013 1

An Introduction toConsumer Rights in the Family Care & IRIS Programs

2013

1

Plan for Today

Introduction to Family Care & IRIS Programs Plan Development Grievances & Appeals Q&A

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Adult LTC System OverviewEntry Point: Aging and Disability Resource Center

FAMILY CARE—Managed Care Organization (includes Family Care, Partnership or PACE)

Include, Respect, I Self-direct (IRIS)— Self-Directed Services

• Interdisciplinary Team determines “outcomes”

• Interdisciplinary Team manages care• Provider Network• Self-directed services (SDS) can be

used• No pre-determined budget amount

for services

• Participant (with IRIS Consultant) determines “outcomes”

• IRIS Consultant Agency (ICA) and Fiscal Services Agency (FSA) provide assistance

• Participant selects service providers and manages service plan

• Allocation (based on functional screen results) provides an estimate for cost of services (maximum)

Determines functional eligibility for adult LTC programs(and facilitates financial eligibility determination for Medicaid with Income Maintenance Consortium)

IF ELIGIBLE, THEN A PROGRAM IS SELECTED

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Functional Eligibility:The Adult LTC Functional Screen Adult Long-Term Care Functional Screen

determines functional eligibility Different from the children’s LTCFS

Inventory of activities people need to do every day

Gathers information about whether help is needed and if so, how much

Looks at individual’s ability to do:“ADLs” and “IADLs”

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Activities of Daily Living (ADLs)

Bathing Dressing Eating Mobility in the home Toileting Transferring

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Instrumental Activities of Daily Living (IADLs) Meal preparation Money management Medication management and administration Laundry and other chores Ability to use the telephone Arrange and use transportation Ability to function at a job site

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Other Components of LTCFS

Living situation Supports (natural/formal) Behavior Risk Factors Not all questions affect eligibility

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Financial Eligibility

Similar rules as Medical Assistance Low income and low assets Spousal Impoverishment rules apply Married people may have access to higher asset limits

Cost-share, if any, calculated by Income Maintenance agency

Do not assume you are or are not eligiblewithout talking with an expert.

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Goals of Family Care & IRIS

Cost-effective AND effective Member-centered Flexible Comprehensive services Provide “self-directed supports” End waiting lists

“The right services in the right amountat the right time for the right cost.”

Kitty Rhoades, Deputy Secretary of Department of Health Services(stated in presentation on Family Care to Assembly Committee on Aging and Long Term Care, March 10, 2011)

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Differences Between FC and IRIS Family Care is “managed

care” The MCO builds relationships

and negotiates and contracts with providers

The MCO manages the services and the cost and quality of those services

MCO receives a capitated rate and a portion of that is used to pay for services

Member has Interdisciplinary Team

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IRIS is “self directed supports” Participant builds relationships

and negotiates and contracts with providers

Participant has Budget Authority and Employer Authority

Participant uses an allocation derived from “fee for service” Medicaid funds

Participant has help from IRIS Consultant Agency (ICA) and Financial Services Agency FSA)

Family Care:Member-

Centered Plans

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MCO’s Comprehensive Assessment

First step in developing Member Centered Plan (MCP) Looks at member’s:

Needs – Builds on the LTCFS Strengths Resources Preferences

Conducted in-person May include others Includes a discussion about the options for self-direction Is the start of ongoing discussions about member’s

outcomes13

“Outcomes”

What is important to you?

What do you wantfrom life?

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12 Outcome Areas

1. I decide where and with whom I live2. I make my own decisions regarding my supports

and services3. I work or do other activities that are important

to me4. I have relationships with family and friends I

care about5. I decide how I spend my day

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12 Outcome Areas (continued)

6. I am involved in my community 7. My life is stable 8. I am respected and treated fairly 9. I have privacy10. I have the best possible health11. I feel safe12. I am free from abuse and neglect

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Outcomes are Individual

Each member’s outcomes are unique

Each member’s services will depend on each member’s outcomes

Different outcomes → Different supports

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The Member-Centered Plan

Comprehensive Assessment +

Outcomes+

“Resource Allocation Decision”(RAD) Method

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Individual Service Decisions:The RAD Method Service authorization policy developed by DHS and

adopted by MCOs Helps to identify cost-effective ways to meet

outcomes Creatively looks at options, including

natural/informal supports

DOES NOT EQUAL “cheapest”Should be cost-effective AND effective.

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Individual Service Decisions:The RAD Method (continued)

Completed by the Interdisciplinary Team: Member + anyone that the member chooses to

participate in the discussion Care Manager Nurse

Begins with the outcome, goal or problem and asks a series of questions to help identify the most appropriate option Available on DHS’ website

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The RAD Method

Six Questions:1. What is the need, goal, or problem?

2. Does it relate to member’s assessment, service plan, and desired outcome?

3. How could the need be met?

4. Are there policy guidelines to guide the choice of option?

5. Which option does the member (and/or family) prefer?

6. Which option is most effective and cost-effective in meeting desired outcome(s)?

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Member Centered Plan (MCP)

A record that documents a process by which the member and the IDT staff further identify, define and prioritize the member’s outcomes initially identified in the comprehensive assessment. Identifies the services and supports, paid or unpaid,

provided or arranged by the MCO including frequency and duration of each service (e.g. start & stop

date) provider(s) that will furnish each service.

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Member Centered Plan (MCP) (continued)

Identifies clinical and functional needs of the member identified by the IDT staff which the member may not want to receive assistance with at this time, but for health and safety reasons, the IDT staff need to recognize and attempt to mitigate.

Includes the plan for coordinating services outside the benefit package received by the member.

Members should be given a copy of their MCP by their Family Care team.

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IRIS: Individualized

Supports and Services Plan

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IRIS: ISSP Plan Development

OC helps participant identify outcomes Using outcomes, OC helps develop first plan Helps participant determine immediate needs for services

and supports Helps write initial plan (helps develop budget) Makes sure plan is within allocation and is compliant with

definition standards** Helps initiate separate budget for personal care services if

participant chooses to self-direct that service Submits plan to ICA for approval

**also need to meet criteria for “Customized Goods and Services” when that is used

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IRIS: ISSP Plan Development (continued)

Once plan is in place, IC makes regular connection with participant

Further explores outcomes and develops plan Helps participant consider who or what providers can offer

services, through paid or unpaid supports Helps trouble shoot difficulties participant is having with

plan Helps update plan for any changes needed and submits it to

ICA for approval FSA sends monthly reports showing budget usage Participants uses monthly report to ensure they are staying

within approved budget

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Allocation Adjustment Requests for an increase in IRIS allocation

This is a request to increase the “ceiling” when the participant cannot meet needs with given allocation

Exceptional Expense Requests for time-specific and/or one-time expenses

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Allocation Adjustment (AA)** If allocation is substantially insufficient to provide necessary

supports and services, OC or IC can help participant prepare and submit a request to increase allocation to meet needs

The AA is submitted to the ICA, where the AA Specialist reviews for completeness

The AA is submitted to DHS, which brings it to the AA/EE Committee for approval, denial or partial denial

**An AA is not permitted in certain circumstances, usually related to residential setting

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Requests NOT reviewed by AA/EE Committee Requests for funding for an individual not yet determined

eligible for IRIS** Requests that may be paid through Medicaid Card or other

payer Requests not submitted by IC

**However, committee may review requests from an individual who is eligible and considering IRIS prior to enrollment

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Member Rights: Grievances &

Appeals

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Appeal A decision was made that you don’t agree with

Usually an action taken to a plan (termination or reduction) or denial to a request, or a change in Level of Care determination

You want a reconsideration of that decisionGrievance There is something you are having a problem with (not a decision

that was made) Maybe you don’t like how your care team communicates with you Maybe you don’t feel safe with the transportation provider

You want help resolving that problem You can grieve a decision, rather than go through an appeal.

What are Grievances & Appeals?

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Family Care Grievances & Appeals

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Right to receive written notice of MCO decisions about denials, terminations, or reductions of services (called a “Notice of Action”) and denials for requests for payment. Terminations or reductions of services

Must receive Notice of Action (NOA) at least 10 days before the effective date of the action

Denials of requests for services MCO must authorize service or provide NOA within 14 days

of the request MCO may ask for additional 14 days to consider request


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Effective date Description Reasons Any applicable laws Right to appeal How to file an appeal Right to appear in person

at MCO appeal

Assistance with filing an appeal

Free copies of records relevant to appeal

Right to continuing benefits if MCO intends to terminate or reduce services

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Notice of Action Requirements

Appealing MCO Decisions If a member disagrees with a MCO’s decision, member

has the right to appeal the decision Members may also appeal decisions made by

Income Maintenance agencies If a member disagrees with an Income Maintenance

agency’s decision, member has the right to appeal by requesting a State Fair Hearing—Examples:

Financial eligibility Cost share amounts


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Right to continuing benefits Should request continuing benefits when you submit

your appeal Must request appeal on or before the effective date of

the intended action to obtain continuing benefits MCO must grant all timely requests Member may be liable for cost of continuing benefits if

appeal ends in adverse decision


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Appeal options in Family Care MCO Appeal Committee

A committee is arranged by the MCO. Includes at least one person eligible for the Family Care benefit

Can file for State Fair Hearing if decision is adverse State Fair Hearing

An Administrative Law Judge (ALJ) presides over a hearing Decision is final (can’t file for MCO Appeal if adverse)

Case review option in Family Care DHS Review

MetaStar does a record review and makes recommendations No ruling or decision is made


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MCO Grievance & Appeals Committee Committee made up of individuals selected by MCO and

include: no MCO employee involved in earlier decision at least one person (or guardian of a person) who is

functionally eligible for one of the target groups Individuals with appropriate medical or clinical expertise

for this member’s issue Member may bring advocate, friend/family member,

witnesses, and evidence Decision can be appealed through State Fair Hearing


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State Fair Hearing May file an appeal with the State—the “Division of

Hearings and Appeals” (DHA) Held in front of an Administrative Law Judge (ALJ) May bring advocate, friend/family member, witnesses,

and evidence Decision is final


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MCO Member Rights Specialist Can assist with:

problem solving resolving grievances obtaining records filing appeals

Will not represent member in appeal Will not gather evidence to support member’s case


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Right to request Department of Health Services review MetaStar is DHS’s external quality review organization Attempts to resolve concerns informally Cannot require MCO to change decision

But, MetaStar can make recommendation to DHS, and DHS can instruct MCO to change its decision

Automatically reviews requests for State Fair Hearings


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Do not have to appeal to the MCO Committee or request review by MetaStar in order to request a State Fair Hearing

But if member wants to appeal to the MCO Committee, he/she must do so prior to State Fair Hearing (though an appeal can be initiated with both at the same time)

Review by MetaStar will happen automatically if member requests a State Fair Hearing


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Deadline to file appeals File as soon as possible File no later than 45 calendar days from receipt of the

Notice of Action To request continuing benefits, must file appeal before

effective date of intended action


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IRIS:

Grievances & Appeals

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Right to receive written notice of IRIS decisions about terminations or reductions of services (called a “Notice of Action”) and denials for requests not already on plan (letter of denial). Terminations or reductions of existing services

Must receive Notice of Action (NOA) at least 10 days before the effective date of the action

Denials for requests not already on plan Letter of denial outlines grievance rights If not satisfied with results of grievance, can file an appeal

IRIS Grievances & Appeals

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Effective date Description Reasons Any applicable laws Right to appeal How to file an appeal

Assistance with filing an appeal

Free copies of records relevant to appeal

Right to continuing benefits if IRIS intends to terminate, reduce or suspend services

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Notice of Action Requirements

Appeal options in IRIS State Fair Hearing

AA/EE denials other appeals

Grievance options in IRIS All grievances are first submitted to ICA

If they involve issues with the ICA, they are taken care of by the ICA

If they involve issues with the FSA, a form is completed by the ICA and sent to the FSA


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Right to continuing benefits Should request continuing benefits when you submit

your appeal Must request appeal on or before the effective date of

the intended action to obtain continuing benefits IRIS must grant all timely requests Participant may be liable for cost of continuing benefits

if appeal ends in adverse decision


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IRIS Participant Services Specialists Can assist with:

problem solving resolving grievances obtaining records filing appeals

Will not represent participant in appeal Will not gather evidence to support participant’s case


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Appealing decisions based on Functional Screen ADRC conducts initial screen to determine functional

eligibility. Disputes with results of initial screen are appealed to the ADRC

ICA conducts annual rescreens and changes in condition thereafter

If found no longer eligible will receive NOA and can appeal to the ICA

Appealing decisions based on Financial Screen Financial Screen is conducted annually by Income

Maintenance Disputes with results (eligibility or cost share) can be appealed

through a State Fair Hearing


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Assistance with Appeals

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Disability Rights Wisconsin www.disabilityrightswi.org Members/potential members of Family Care, Partnership or

IRIS, age 18 to 59 Members/potential members of IRIS, age 60+ Madison 608-267-0214 Milwaukee 414-773-4646 Rice Lake 715-736-1232

Board on Aging and Long-Term Care www.longtermcare.state.wi.us

Members/potential members of Family Care or Partnership, age 60 and older

800-815-0015

Family Care/IRIS Program Ombudsman Agencies

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Members/Potential Enrollees Age 18-59 Types of Assistance

Information Investigation and informal negotiation with the Aging

and Disability Resource Center (ADRC), Managed Care Organizations (MCOs), and the IRIS Program

RepresentationCost All ombudsman services are provided at no charge to

you.

DRW’s Family Care & IRIS Ombudsman Program (FCIOP)

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When to call You can contact the ombudsman program at any point if you

are finding your situation challenging. The earlier FCIOP becomes involved, the more likely an issue can be resolved informally.

As Wisconsin’s protection and advocacy agency, Disability Rights Wisconsin (DRW) may assist Family Care, Partnership, IRIS, and PACE participants in cases/issues that are not in the scope of the FCIOP contract

DRW may be able to assist IRIS participants age 60+

DRW’s Family Care & IRIS Ombudsman Program (FCIOP) (continued)

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Questions?

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an introduction to consumer rights in the family care & iris programs 2013 1

Documents

family care iris programs2013

irisfamily care

long term care

financial services agency

liststhe right services

services sds

right cost

fiscal services agency