MMMMedicaid edicaid edicaid edicaid and Access to and Access to and Access to and Access to Community Living Services Community Living Services Community Living Services Community Living Services

AAAAUGUST UGUST UGUST UGUST 9, 20169, 20169, 20169, 2016

5555THTHTHTH ANNUAL CASE MANAGEMENT CONFERENCE FORANNUAL CASE MANAGEMENT CONFERENCE FORANNUAL CASE MANAGEMENT CONFERENCE FORANNUAL CASE MANAGEMENT CONFERENCE FOR

SERVICES COORDINATORS & PERSONAL AGENTS SERVICES COORDINATORS & PERSONAL AGENTS SERVICES COORDINATORS & PERSONAL AGENTS SERVICES COORDINATORS & PERSONAL AGENTS

Today’s FocusToday’s FocusToday’s FocusToday’s Focus

� Medicaid-funded in-home/community living services

� Specific program requirements – MAGI/CHIP/OSIPM

� Problem solving – common scenarios (change of benefits)

� Tools for the toolbox

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Today’s GoalToday’s GoalToday’s GoalToday’s Goal

Able to….

� Explain to individuals/families Medicaid in-home services available through ODDS

� Explain to individuals/families program requirements, including contact info

Have….

� Tools for problem solving with various DHS/OHA offices to ensure access to Medicaid in-home services for eligible individuals

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Supporting Individuals in their Own Home Supporting Individuals in their Own Home Supporting Individuals in their Own Home Supporting Individuals in their Own Home –––– SC’s/PA’s Role SC’s/PA’s Role SC’s/PA’s Role SC’s/PA’s Role

� Partner with individuals/families – create a vision for the individual’s future, and work with individuals/families to support the individual achieve his/her goals.

� Partner with service providers – prepare/support the individual for a full life in the community, and support families in their ability to care for their child in the family home. � Educational, health (mental/emotional/physical), employment, social services,

everyday activities in the community (i.e., leisure, social)

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InInInIn----Home Programs Home Programs Home Programs Home Programs Through ODDSThrough ODDSThrough ODDSThrough ODDS

� Family Support (for ages <18 only, OAR 411-305)

� State Plan Personal Care (OAR 411-034)

� Community Living Services (OAR 411-450) and

Ancillary Services (OAR 411-435)

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Programs OverviewPrograms OverviewPrograms OverviewPrograms Overview

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Planning for the Individual’s Future Planning for the Individual’s Future Planning for the Individual’s Future Planning for the Individual’s Future –––– What Does It Take?What Does It Take?What Does It Take?What Does It Take?

How much support….� does an individual need (as age appropriate and as related to the

individual’s disability)?� does a family need (to support the child with a disability in the family

home)?

What are the…. � existing supports naturally occurring, or being funded by other

sources/systems?� gaps on support possibly can be filled through CLS/in-home programs?

Are supports and services through the in-home/CLS programs making a difference and cost effective?

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Cost effective means being responsible and accountable with Department resources by offering less costly alternatives when providing choices that adequately meet the support needs of an individual. Less costly alternatives include other service settings available from the Department and the utilization of assistive devices, natural supports, environmental modifications, and alternative resources. Less costly alternatives may include

resources not paid for by the Department.

OAR 411-317-0000 (54)

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Making Best Use of Each Program Making Best Use of Each Program Making Best Use of Each Program Making Best Use of Each Program Services Services Services Services –––– Basic Steps Basic Steps Basic Steps Basic Steps

Assess/

Re-assess

PlanImplement

Monitor

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Assessing the Individual Assessing the Individual Assessing the Individual Assessing the Individual –––– Needs and Strengths Needs and Strengths Needs and Strengths Needs and Strengths

Gathering info directly….

� Level of care for ICF/IDD

� Functional Needs Assessment (CNA/ANA) – observation of and interviewing/consulting with the individual and family/responsible person

Gathering info indirectly….

� Reviewing files – i.e., school records, medical records

� Connecting with community partners – i.e., additional service assessments and support plans

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Planning for Best Utilization Planning for Best Utilization Planning for Best Utilization Planning for Best Utilization of Program Servicesof Program Servicesof Program Servicesof Program Services

Choice depending on….

� Institutional LOC/Level of assessed support needs -(program service/funding limitation)

� Medical coverage - (Medicaid/CHIP eligibility)

� Available informal support – (natural resources, age appropriate)

� Preferred formal support – (paid provider type, age appropriate)

� PSW vs. provider agency

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Type of Medical and Program ServicesType of Medical and Program ServicesType of Medical and Program ServicesType of Medical and Program Services

WHAT TYPE OF MEDICAL THE INDIVIDUAL WHAT TYPE OF MEDICAL THE INDIVIDUAL WHAT TYPE OF MEDICAL THE INDIVIDUAL WHAT TYPE OF MEDICAL THE INDIVIDUAL HAS DETERMINES WHAT TYPE OF SUPPORTS HAS DETERMINES WHAT TYPE OF SUPPORTS HAS DETERMINES WHAT TYPE OF SUPPORTS HAS DETERMINES WHAT TYPE OF SUPPORTS AND SERVICES UNDER WHICH PROGRAM THE AND SERVICES UNDER WHICH PROGRAM THE AND SERVICES UNDER WHICH PROGRAM THE AND SERVICES UNDER WHICH PROGRAM THE INDIVIDUAL MAY QUALIFY FOR.INDIVIDUAL MAY QUALIFY FOR.INDIVIDUAL MAY QUALIFY FOR.INDIVIDUAL MAY QUALIFY FOR.

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Assessing Type of Medical Assessing Type of Medical Assessing Type of Medical Assessing Type of Medical

What does the individual have?

� Private medical?

� OHP (MAGI/CHIP/OSIPM)?

� Private medical and OHP?

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Assessing Assessing Assessing Assessing Support NeedsSupport NeedsSupport NeedsSupport Needs

What are the individual’s long-term support needs?

For Children:

� Can Family Support services (GF) meet the child’s needs? (institutional LOC/level of support needs, available/natural supports & services)

� Can SPPC services (20 hours) meet the child’s needs?

� What is the child’s and family’s current circumstance?

For adults:

� Can SPPC services (20 hours) meet the individual’s needs?

� What is the individual’s current circumstance?

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Proceed with the Steps….Proceed with the Steps….Proceed with the Steps….Proceed with the Steps….� Functional Needs Assessment – CNA/ANA, LOC, SPPC

� Service planning -(what/when/where/how/who/why) – ISP/Annual Plan, Task List, Service Agreement

� Service authorization and documentation – eXPRS payment (ODDS), CEP payment (APD), progress notes

� Monitoring –What does/does not make a difference? Is it cost effective? How’s the individual participating in the community? What’s changing? How’s the individual/family prepared for the changes?

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Assessing Type of Medical Assessing Type of Medical Assessing Type of Medical Assessing Type of Medical –––– Potential Program Service Potential Program Service Potential Program Service Potential Program Service

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* The individual may qualify under the Former Foster Care Youth Program.

** See OAR 413-090-0100 to 413-090-0210 for Personal Care services through CW.

*** See Technical Guide for children under age 18 and residing in a CW-funded foster home.

� Check eXPRS How To document (benefit codes) (http://apps.state.or.us/exprsDocs/HowToViewClientInfoIneXPRS.pdf)

No OHP

CHIP

(age < 19)

MAGI-Child

(age < 19)

MAGI-Adult

(age=19-64)*

OSIPMCW

Medical

Family Support (age <18 only) √ √

State Plan Personal Care √ √ √ √ √**

Community Living Supports (K-Plan)

√ √ √ √***

Ancillary Services (K-Plan & Waiver)

√ √ √

CHIP CHIP CHIP CHIP –––– MAGI MAGI MAGI MAGI –––– OSIPMOSIPMOSIPMOSIPMType of MedicaType of MedicaType of MedicaType of Medical l l l

CHIP = Children’s Health Insurance Program � Income higher than Medicaid level

� ≤300% FPL, disregard resources

MAGI = Modified Adjusted Gross Income� Simplified Medicaid determination as of 1/1/14

� ≤138% FPL (MAGI-Child/Adult), disregard resources

OSIPM = Oregon Supplemental Income Program-Medical� SSI or ≤300% SSI income level, $2000 resources

� SSA disability criteria

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OSIPM Eligibility OSIPM Eligibility OSIPM Eligibility OSIPM Eligibility ---- RequirementsRequirementsRequirementsRequirements

Non-financial….

� Oregon resident

� U.S. citizen/qualified status

� Age ≥ 65, blind, or disabled (SSA criteria)

� Level of Care for ICF/IDD

� Receive/qualify for & has an active ISP for a waiver service

Financial….

� SSI or ≤300% SSI income level. Income cap trust if over.

� $2000 resource

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MAGI Eligibility MAGI Eligibility MAGI Eligibility MAGI Eligibility ---- RequirementsRequirementsRequirementsRequirements

Non-financial….

� Oregon resident

� U.S. citizen/qualified status

Financial….

� Modified Adjusted Gross Income (MAGI) –IRS tax household group

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CHIP Eligibility CHIP Eligibility CHIP Eligibility CHIP Eligibility ---- RequirementsRequirementsRequirementsRequirements

Non-financial….

� Oregon resident

� U.S. citizen/qualified status

Financial….

� Modified Adjusted Gross Income (MAGI) –IRS tax household group

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START 7210 is received in

processing at 5503

and loaded into

system.

Application is

screened for

APD and DD

services.

APD or

DDK?

Referral is sent

5503 DD

Services/APD for

Determination

Application

is

processed.

Application

is

processed

CMEU and

5503

Collaborate

conversion of

benefit plans,

if eligible.

CDDP Alerted to

begin PMDDT

referral. MAGI is

monitored

throughout

process.

MAGI

CMO or

AMO?

NO

YES

YESNO

Jill Jamieson/5503

Some Common Scenarios….Some Common Scenarios….Some Common Scenarios….Some Common Scenarios….

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Scenario 1: Scenario 1: Scenario 1: Scenario 1: Receiving Receiving Receiving Receiving SSISSISSISSI

An individual is/starts to receive SSI, is needing in-home/community living services, but has a medical case at OHP branch 5503.

�What are the required actions for a CDDP/brokerage to mitigate potential disruption of services?

�What’s the process for branch 5503 and for the APD/AAA office?

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Scenario 2: Scenario 2: Scenario 2: Scenario 2: Lost Lost Lost Lost SSISSISSISSI

An individual has recently lost SSI, and continues to need in-home/community living services.

�What are the required actions for a CDDP/brokerage to mitigate loss/potentially reduction of services?

�What’s the process for the APD/AAA office and for branch 5503?

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Scenario 3: Scenario 3: Scenario 3: Scenario 3: CHIP/loss MAGI CHIP/loss MAGI CHIP/loss MAGI CHIP/loss MAGI An individual has CHIP/lost MAGI, is needing institutional level of in-home/ community living services (beyond SPPC). � What are the required actions for a CDDP/brokerage to assist with the PMDDT process?� What’s the process for branch 5503 and for the APD/AAA office?

**Refer to the MAGI Conversion & PMDDT Due Process handout

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Where to Apply for Medical?Where to Apply for Medical?Where to Apply for Medical?Where to Apply for Medical?

MAGI application….

� (no medical/new applicants) Apply online or download a 7210 application (http://www.oregon.gov/oha/healthplan/Pages/apply.aspx) and fax to OHP branch 5503. Application is also available at the local Self

Sufficiency and APD/AAA office

� (conversion) Email application to 5503.DDServices@dhsoha.state.or.us

OSIPM application….

(Required only if has CHIP and needs Medicaid in-home services)

� Non-SSI and < 18 years old: apply through CMEU.

� SSI: apply through APD/AAA

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Tools for the Toolbox Tools for the Toolbox Tools for the Toolbox Tools for the Toolbox ---- WebsitesWebsitesWebsitesWebsites

Oregon Administrative Rules (OARs)

� http://www.dhs.state.or.us/policy/spd/alpha.htm

Transmittals (Policies and Procedures)

� http://www.dhs.state.or.us/policy/spd/transmit/transmit.htm

Brochures � https://apps.state.or.us/cf1/DHSforms/Forms/Served/ de0338.pdf (Choosing DD

Services for Children and Adults)

� https://apps.state.or.us/cf1/DHSforms/Forms/Served/de0339.pdf (Services for Children with I/DD)

� https://apps.state.or.us/cf1/DHSforms/Forms/Served/me9093.pdf (Estate Recovery Program)

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More Websites….More Websites….More Websites….More Websites….

Case Management (Expenditure Guidelines, FAQs, Technical Guidelines...)

� http://www.dhs.state.or.us/spd/tools/dd/cm/

Provider and Partner Resource (PSW brochure, PSW training, etc.)

� http://www.oregon.gov/DHS/SENIORS-DISABILITIES/DD/PROVIDERS-PARTNERS/Pages/index.aspx

� http://www.oregon.gov/dhs/spd/Pages/adv/hcc/training.aspx

OHP coverage questions/issues� http://www.oregon.gov/oha/healthplan/Pages/benefits.aspx (OHP Client

Handbook, FAQs…)

Oregon Consortium of Family Networks� http://ocdd.org/index.php/ocdd/resources/399

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Tools for the Toolbox Tools for the Toolbox Tools for the Toolbox Tools for the Toolbox ---- ContactsContactsContactsContacts

OHP coverage questions/issues� OHP Client Services, 1-800-273-0557

Medicaid & eligibility/service enrollment status� TAU staff assigned to your county

Medical application status� MAGI: OHP Customer Service, 1-800-699-9075 or

5503.DDServices@dhsoha.state.or.us (benefits conversion)

� OSIPM: CMEU staff or 5517.Inbox@state.or.us (new apps); APD/AAA staff

Contacts for local CW/APD/AAA branches� http://www.oregon.gov/DHS/Offices

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Questions?

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Presenters Presenters Presenters Presenters –––– Contacts Contacts Contacts Contacts � May Martin, ODDS may.martin@dhsoha.state.or.us

� Becky Smallwood, ODDS rebecca.smallwood@dhsoha.state.or.us

� Ada Osuna, APD ada.Osuna@dhsoha.state.or.us

� Jill Jamieson, OHA/5503 5503.DDServices@dhsoha.state.or.us

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