residential services in family care wahsa ltc managed care committee april 22, 2010
TRANSCRIPT
Room and Board
History of R&B in LTC Waivers Work to Standardize R&B in Waivers R&B Issues in FC MCO/ DHS R&B Workgroup Future of R&B in FC
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What is Room and Board
CMS Definition for all Waivers
Items related to room and board – NOT ALLOWABLE waiver costs
1. Rent, mortgage payments, title insurance, mortgage insurance.
2. Property and casualty insurance
3. Building and/or grounds maintenance costs
4. Resident's food
5. Household supplies and equipment necessary for the room and board of the
individual
6. Furnishings used by the individual (does not include office furnishings)
7. Utilities, resident phones, cable TV, etc.
8. Property taxes
9. Specific individual special dietary needs
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How R&B worked in Legacy Waivers Established via computation of facility rate
worksheet Based on audit allowable cost policy
guideline Cost – individual ability to pay= county levy,
state COP, unfunded, etc Wait lists, caps on proportion of COP W used
in substitute care
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What Happened with R&B at Expansion? Many MCOs “inherited” county strategies
without county levy, state COP, other public funding sources
Variation was magnified by one MCO in multiple counties & by multiple MCOs in one county
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Along Came “In Lieu of”
An in lieu of service must be:
1. Health related, and
2. Cost-effective, and
3. Like the covered Medicaid State plan service for which it is substituted.
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Rules and Responsibilities with In Lieu of DHS obligation to better clarity and
standardization of room and board Definition of R&B Rates paid for R&B Process of subsidization of R&B Cap on Room and Board
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MCO R&B Workgroup
Reviewed existing MCO R&B rate setting methods
Revitalized earlier DHS work with Counties and Providers on standardizing R&B
Explored existing methods and reached ‘consensus’ on HUD FMR R&B Rate Setting Method
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HUD FMR R&B Rate Method
Features Correlates typical facility size to R&B rates Recognizes county variation Standardized the rate across all MCOs
Things to note in HUD FMR Typically aligns facility size and R&B costs Additional specific exceptions in Draft Memo Being finalized during 2010 for full
implementation January 2011
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Scope of Services /Defining R&B
Physical Space- sleeping accommodations in compliance with facility regulations including, access to all areas of facility and grounds.
Furnishing - all common area furnishings and bedroom furnishings including all of the following: bed, mattress with pad, pillows, bedspreads, blankets, sheets, pillowcases, towels and washcloths, window coverings, floor coverings.
Equipment- all equipment that becomes a permanent part of the facility, such as grab bars, ramps and other accessibility modifications, door alarms, pull-stations and/or call lights.
Housekeeping services- including laundry services, household cleaning supplies, and bathroom toilet paper and paper towels.
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Scope of Services/ Defining R&B
Building Maintenance - including interior and exterior structure integrity and upkeep, pest control, and garbage and refuse disposal
Grounds Maintenance – including lawn, shrub, and plant maintenance, snow and ice removal.
Building Protective Equipment- carpet pads, wall protectors, baseboard protectors, etc.
Building Support Systems- including heating, cooling, air purifier, water and electrical systems installation, maintenance and utilization costs.
Fire and Safety Systems- including installation, inspection and maintenance costs.
Food- 3 meals plus snacks, including any special dietary accommodations, supplements, thickeners and consideration for individual preferences, cultural or religious customs of the individual resident.
Telephone and Media Access- access to make and receive calls and acquisition of information and news (e.g. television, newspaper, internet)
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Member Contribution April 2010
Standardizing Instructions for how member income is identified as available to contribute to R&B.
Areas of Attention Earned Income Medical and Remedial Expenses &
Specialized Medical Supplies and Equipment OTC, Supportive Home Care Services, & the
Kitchen Sink Corporate Guardian Fees- On Hold
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Residential Care and Services
Overview History of Residential Rates/ Service
Purchasing in Waivers Experiences in Family Care and Expansion
with residential services Work thus far and Next Steps
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Legacy Waivers
Multiple funding streams varying rules criteria amounts of money tied to each
Individually operated by 72 counties
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Family Care Expansion and Residential Service Rates MCOs inherited rates in many counties
Created challenges Blended benefit package – personal care, etc Program rules- bed size, county match, etc
Different Contracting Requirements for MCOs from the various legacy waivers
Identified need to align to Family Care Program
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Activities across MCO with Residential Service Purchasing Residential Care and Services Cost
2009 Residential Rate Workgroup Sharing& Brainstorming Products
Scope of services definition Contracting principles
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Current MCO Residential Service Purchasing Strategies 4- 5 using acuity based method 2-3 using rate bands 1-2 using cost based, audit allowable rates 2-3 using a combination of more than one
within method and across facility types
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Current Status of Residential Services in MCOs Standardized Instructions for Member
Contribution to R&B: April 1, 2010 Implementing standard R&B Rate Setting
Method: January 2011 Details being worked through now
DHS Residential Rate Setting Method Workplan: January 2011 Listening Sessions April 16 & 23
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Goals of Standard Methodology
Promote access to and quality of services for members,
Treat consistently providers offering similar services,
Establish predictability for purchasers and providers of residential services,
Maintain transparency and good stewardship of resources; and
Ensure consistency with CMS guidelines.
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Emerging Issues
Revising FC Service Definitions Including more standardization
Quality Management Systems in FC MCO Reporting Requirements
Critical Incidents – Definitions Draft white paper on AL & MCO Interface with
denials of physician orders Involuntary Discharge
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