Residential Services in Family Care WAHSA LTC Managed Care Committee April 22, 2010.

Residential Services in Family Care

WAHSA LTC Managed Care Committee

April 22, 2010

Three Buckets to Residential Services Room and

BoardMember

Contribution Care and

Services

2

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

3

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

4

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

5

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

6

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.

7

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

8

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

9

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

10

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.

11

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)

12

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

13

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

14

Legacy Waivers

Multiple funding streams varying rules criteria amounts of money tied to each

Individually operated by 72 counties

15

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

16

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

17

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

18

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

19

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.

20

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

21

Questions?

22