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Service Rate Exceptions for Children’s 24-Hour Residential Service Settings
A Guide to Payment Category Service Rate Exceptions for the January 1, 2021 Rate Model Implementation
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This guide is intended as a manual to aid case managers, providers, and others supporting children in 24-Hour Residential Program Services on the policies and process related to requesting an exception to the child’s assigned service rate.
This guide will cover the following topics: New Rate Model Implementation Overview; When an Exceptional Service Rate Request May Be Appropriate; The Process for an Exceptional Service Rate Request; Roles and Responsibilities Related to the Exception Request Process; The Exceptional Rate Request form; Exceptional rate calculation; Notification, Authorization Periods, Expiration, and Exception Renewals; and Frequently Asked Questions
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New Rate Model Implementation Overview
Effective January 1, 2021, ODDS will be implementing a new rate model for Children’s 24-Hour Residential Service settings. The rates reflect payment categories that are assigned based on the child’s Service Group as determined by the Oregon Needs Assessment (ONA) tool.
Using the ONA Assessment, children and adolescents are placed into a service group corresponding to the child’s assessed support needs. Adolescents (age 12-17) may be assigned to one of five service groups while children (age 4-11) are assigned amongst three categories.
The Service Groups are then assigned a payment category. Payment categories consider both the Service Group and the capacity of the residential home site:
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When an exceptional service rate may be appropriate:
An exception may be requested when, due to a child’s individually assessed support needs, a greater amount of actively engaged direct support staffing to provide attendant care than is accounted for in the payment category associated with the child’s ONA-determined Service Group is necessary for basic health and safety.
The request may be made for additional 1:1 or 2:1 DSP support hours specific to an individual child on the basis of the following:
Exceptional behavior support needs; Exceptional medical support needs; The child experiences a situation where actively engaged direct care staffing is
needed in an exceptional amount to complete routine ADL/IADL or health-related tasks with or on behalf of the child; and/or
The child requires the support of more than one staff simultaneously delivering direct care and when the need for simultaneous staffing is intermittent, there is no reasonably available resource for staffing flexibility to adequately meet health and safety needs.
In order for the request for exceptional funding to address the exceptional support needs of a child, the following criteria apply:
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What is Covered (and not Covered) in an Exceptional Rate Request
Exceptions are specific to requests for DSP (Direct Support Professionals) staffing hours in an amount necessary beyond resources that are assumed in the payment category service rate assigned to the child.
ODDS will not grant exceptional rates for 24-hour residential service settings providers for the following:
Transportation; Home or Vehicle Modifications; Funding for property damage; Funding for equipment, supplies, or furnishing that are the responsibility of the
provider or a non-disability specific customary expense incurred as a general part of community living;
Funding to replace or supplement room and board or personal funds; Funding for state plan or waiver services not specifically identified as a
component of the bundled service rate, such as professional behavior services, direct nursing services, day support activities, and employment services;
Funding for services or support needs that may be met by an available alternative resource;
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Funding for increased staffing for a purpose other than an identified attendant care support necessary to address a significant health or safety risk. Increased funding will not be granted for travel, vacation, or other non-essential activities or excursions;
Funding to support an individual in a setting that is not Home and Community-Based, including hospitals, nursing care facilities, and school settings;
Service funding that is ineligible for Medicaid state plan or waiver match dollars; Temporary or singular events of increased support need lasting less than 30
days in duration; or Funding to address an individual’s extended or numerous absences from the
home.
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The process for an exceptional service rate request:
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Roles and responsibilities related to the exception request process:
The new exceptional rate, if granted, will be effective upon implementation of the new service rate model for Children’s 24-Hour Residential Settings on January 1, 2021.
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The Exceptional Rate Request form and submission:
ODDS will be piloting an update to the current DHS 0514DD “Funding Review and Exceptions Request” form. For the purposes of exceptional service group payment category rate exceptions for Children’s 24-Hour Residential Service settings, the word format document “Exceptional Payment Category Rate Request- Children’s 24-Hour Residential Service Settings” must be used.
The form will be located on the ODDS Staff Tools page for temporary use specifically for Children’s 24-Hour Residential Service setting rate exceptions submitted prior to January 1, 2021 as part of the transition to the new service rates.
Please note: The form for requesting a Children’s 24-Hour Residential Rate Exception is not available on ODHS form server.
You may also find a copy of this form at the end of this guide. Please complete the form electronically.
The exception request form and required documents shall be submitted to ODDS via secure email at: [email protected].
Requests for exceptions may be submitted beginning October 15, 2020. Case managers are asked to submit requests for exceptions prior to November 30, 2020 to allow for the ODDS exception review and determination to occur prior to the new rate model implementation on January 1, 2021.
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Begin Submission of Kids’ Residential Exception Requests
10/15/2020
Submit requests for exceptions by
11/30/2020
New Kids’ Residential Rates are Implemented
1/1/2021
Exceptional rate calculation:
Exceptional rates are based on a child’s individual exceptional needs for support. Requests will specifically consider the total amount of actively engaged 1:1 and/or 2:1 DSP hours necessary to address the child’s attendant care support needs.
The exceptional rate calculator will factor the contribution of shared staffing hours attributed to the child in the rate model assumption. Exceptional rates will calculate the amount of 1:1 and 2:1 DSP hours beyond the shared staffing and 1:1 support hours factored into the rate model assumptions for the child’s service group payment category.
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ODDS will request a summary of staffing of the home for information gathering and assessment in making an exceptional rate determination. ODDS will not be granting exceptions based on staffing patterns of a home or operational models adopted by a provider.
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Notification, authorization period, and expiration:
ODDS will issue notification of the exceptional rate request determination to the child’s ODDS Children’s Residential Case Manager and the 24-hour residential service setting provider. The exceptional rate identified in an approved exception request is effective January 1, 2021.
Exceptional rates will be effective until a new ONA assessment is completed by a certified ONA assessor, up to a maximum approval period of five years, unless an alternate expiration date is indicated on the notification letter.
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Exceptional rates must be reviewed by the child’s case manager on a minimum annual basis.
Whenever a child experiences a change in support needs, a new ONA assessment must be conducted by a certified ONA assessor- this includes an increase or decrease in support needs.
If the child is determined to still require an exceptional rate following the result of a new ONA assessment, a new exceptional rate request must be submitted to ODDS. If no new request for an exceptional rate is requested following an ONA completed by an assessor, the previously granted exceptional rate will expire on the last day of the month following the date the new assessment was completed.
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Questions?Providers:
Please contact your ODDS Children’s Residential Specialist
ODDS Children’s Residential Team:
Contact: Rose Herrera- [email protected] or
Dan Baker- [email protected]
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INDIVIDUAL INFORMATION
1. Child’s name: Prime number: Date of birth: 2. Name of parent or legal guardian: Email address:
Mailing Address: 3. ODDS Children’s Residential Case Manager:
Phone number: Email: 4. CDDP: SC name:
Phone number: E-mail: CDDP supervisor name:
Phone number: E-mail: 5. Are there any current legal orders that apply to the individual? (Check all that apply)
No Guardianship JPSRB/PSRB ORS 426/427 Commitment Parole/Probation Other:
6. Child’s Current ISP End Date: 7. Date of Most Recent ONA: Service Group: 8. Services Individual is Currently Receiving (in addition to attendant care in the home):
Professional Behavior Services Direct Nursing Services: amount (hrs/day): Other: Type/Amount:
SETTING/PROVIDER INFORMATION9. Physical Home Address: 10. Setting Provider: Provider email address: Provider Mailing Address (if different from home address): 11. Licensed Capacity: Current Number of Residents in the Home: 12. Staffing Pattern of the Home (Identify the average staffing ratio for the entire home- typically DAY/SWING/NIGHT, example: 2/2/1):
EXCEPTION REQUEST
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Exceptional Payment Category Rate Request Children’s 24-Hour Residential Service Settings
13. Intensive Supports Identified: (Identify the total of hours/day and days per week needed for the child. Community Access time addresses time in the community when the child is actively supported by the 24-hour provider. 1:1 or 2:1 staffing means the DSP is actively engaged and has no responsibilities assigned other than direct care to support the intensive needs of the child. The 1:1 or 2:1 staff may not be responsible for other tasks, including shared supervision or household tasks)
1:1 DSP Hours for Home Setting: 2:1 DSP Hours for Home Setting: 1:1 DSP Hours for Community Access: 2:1 DSP Hours for Community Access:
14. Requested start date of exceptional funding: Requested end date (if limited duration exception): If a start date is being requested prior to the submission date, provide an explanation:
15. Exception is being requested based on: (check all that apply) Exceptional Behavior Support Needs- Complete SECTION B Exceptional Medical Support Needs- Complete SECTION M ADL/IADL Supports Requiring Intensive Staffing (check areas of support):
(beyond resources in rate model- indicate ADL/IADL)- Complete SECTION A Transferring/Positioning Ambulation Food Prep/Eating Hygiene/Dressing
16. Provide a summary explanation of why the exception is needed? (Include explanation of identified assessed child need and how increased staffing or exceptional supports will be applied to address the need, including reactive and proactive supports)
EXCEPTION INFORMATIONPlease provide additional information about the child17. Diagnosis(es):
18. Describe the specific supervision and support the child requires during the daytime hours in the home:
19. Describe the specific supervision and support the child needs to access community settings away from the home:
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20. Describe the child’s sleeping pattern and nighttime support needs (describe typical sleep hours, including duration of sleep, and child-specific needs for support during sleep/nighttime hours):
21. Describe what has been previously tried to address the child’s exceptional support needs (include a description of what has been tried such as strategies, treatments, environmental modifications, natural resources, etc., and what has been considered, but ruled out and why):
SECTION B- NEW EXCEPTION BASED ON EXCEPTIONAL BEHAVIOR SUPPORT NEEDS(B1). Describe the challenging behavior(s) that requires exceptional support (include a description of the challenging behavior including frequency, severity, intensity, and duration. Describe the required proactive intervention(s) to prevent the challenging behavior from re-occurring, the negative consequences that have occurred as a result of the challenging behavior - including serious injury, property damage, law enforcement involvement, etc.):
(B2). Is the child currently utilizing, or has the individual previously utilized, Professional Behavior Services?
Yes- Date of PBSP or most recent update: No- Why are Professional Behavior Services not being used?:
(B3). Provide a summary description of the behavior tracking data (include a summary description of each type of challenging behavior and the frequency, intensity, severity, and duration of the specific behavior type over the last 3 months):
Description of Challenging Behavior
Intensity Severity Frequency DurationDescription of Most Common Support Provided
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(B4). Describe the proactive behavior strategies utilized to minimize the occurrence, frequency, duration, severity, or intensity of the challenging behavior(s)? (Describe what staff are doing to successfully address the challenging behavior. Describe what has occurred or is anticipated to occur if proactive supports are not in place):
(B5). If the request includes 2:1 or greater staffing for the child, describe how the 2:1 or greater staffing is being utilized (What does the support delivered by the 2nd staff (or more additional staff) look like)?:
SECTION M- NEW EXCEPTION BASED ON EXCEPTIONAL MEDICAL SUPPORT NEEDSM(1). Describe the medical condition(s) that require exceptional support (include a description of the medical support needs, including the frequency and duration of care tasks specific to the medical condition and if the care requires delegation):
M(2). Indicate the child’s current medical protocols: Aspiration Constipation Dehydration Diabetes Seizures Other:
(M3). If the request includes 2:1 or greater staffing, describe how the 2:1 or greater staffing is being utilized (What does the support delivered by the 2nd staff (or more additional staff) look like)?:
SECTION A- EXCEPTIONAL STAFFING TO COMPLETE ADL/IADL and HEALTH-RELATED TASKS(A1). Describe the specific support related ADL/IADL task(s). Clarify how these supports require intensive staffing to an extent that child’s attendant care needs are not able to be met by the resources allocated through the service group rate assigned to the child (include a description of the specific tasks, how staff provide support to the child, and the frequency and duration of the support related to each identified task):
(A2). Can the support for the which the additional hours are being requested be scheduled?
Daytime Supports: Yes No- why not?: Nighttime Supports: Yes No- why not?:
(A3). Describe the alternate resources and strategies considered to meet the attendant care needs of the child, including natural supports, and why they were deemed not
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adequate to meet the need:
(A4). Describe the plan to increase the child’s independence participating in and completing and ADL/IADL activity. Or describe the plan to reduce the need for assistance from caregivers to complete the ADL/IADL activity (Include a description of a plan for skill-building, efficiency in care provided, the use of assistive devices, etc., when possible):
(A5). If 2:1 or greater staffing is being requested, describe how the 2:1 or greater staffing is being utilized (What does the support delivered by the 2nd staff (or more additional staff) look like)?:
DOCUMENTATION REQUIRED- the following documents, dependent upon the reason for the exception request, must be submitted with the exception request:
Exceptional Behavior Support Needs ( SECTION B was completed ): ISP including support documents:
Risk Tracking Record Safety Plan when applicable FBA PBSP
Exceptional Medical Support Needs ( SECTION M was completed ): ISP including support documents:
Risk Tracking Record Safety Plan when applicable Nursing Assessment Nursing Care Plan
Exceptional Staffing to Complete ADL/IADL Support Needs ( SECTION A was completed) :
ISP including support documents: Risk Tracking Record Safety Plan when applicable
Protocols (relevant to the intensive staffing support need)
Requests submitted with exception forms that are incomplete, fail to include the required attached documents and lack a valid explanation why documents are not attached, or are hand-written will not be processed for an exception review.
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Submit forms electronically via email to: [email protected]
Cc: Residential provider noted above on form
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