Embed Size (px)
Citation preview
Maine Department of Health and Human Services
Proposed Changes to MaineCare Personal Care Services
November 20, 2012
Bonnie Smith – Deputy Commissioner for Programs
Patty Dushuttle – Strategic Initiatives Coordinator
2
Details of Proposed Model
• Simplification and consolidation of reimbursement for Personal Care Services (PCS).• Reimbursement for medically eligible members regardless of setting.
• Member choice for in-home PCS.• Self-directed• PCS Agency
• Adult Family Care Homes or PCS Homes• Services provided by the licensed agency operating
the residence.
• Licensing regulation changes will be necessary.
3
Personal Care Services Model
•Personal Care
Services
• Personal Care and Private Duty
Nursing
• Adult Family Care Homes
• PNMI (APP C and F)
• Consumer Directed Services
4
Covered Personal Care Services
• 42 CFR § 440.167 Personal care services
• Unless defined differently by a State agency for purposes of a waiver granted under part 441, subpart G of this chapter—
• (a) Personal care services means services furnished to an individual who is not an inpatient or resident of a hospital, nursing facility, intermediate care facility for individuals with intellectual disabilities, or institution for mental disease that are—
• (1) Authorized for the individual by a physician in accordance with a plan of treatment or (at the option of the State) otherwise authorized for the individual in accordance with a service plan approved by the State;
• (2) Provided by an individual who is qualified to provide such services and who is not a member of the individual's family; and
• (3) Furnished in a home, and at the State's option, in another location.• (b) For purposes of this section, family member means a legally responsible
relative.
5
Covered Personal Care Services
• Activities of Daily Living (ADL):• Bed mobility, transfer and locomotion activities to get in and out of bed,
wheelchair or motor vehicle• Using the toilet and maintaining continence• Health maintenance activities• Bathing and Personal hygiene• Dressing• Eating and clean up
• Assistance • Cueing • Supervising• Provide limited or extensive physical assistance
6
Covered Personal Care Services
• Instrumental Activities of Daily Living (ADL)• Grocery and prepared food shopping• Assistance with obtaining medications• Routine housework• Laundry• Money management, • Meal preparation and clean up
• Assistance • Cueing • Supervising• Provide limited or extensive physical
assistance
7
Proposed Medical Eligibility for PCS Determined by Standardized Independent Assessment
• 12 Hours Per Week• Level I: A member meets the medical eligibility requirements for Level I if he or she requires at least limited assistance plus a one person physical assist with at least one (1) of the following ADLs: bed mobility,
transfer, locomotion, eating, toilet use, dressing, and bathing, plus physical assistance with at least two Instrumental Activities of Daily Living; OR cueing seven (7) days per week for eating, toilet use, bathing and dressing.
• 18 Hours Per Week • Level II: A member meets the medical eligibility requirements for Level II if he or she requires at least limited assistance and a one person physical assist with at least three (3) of the following ADLs: bed mobility, transfer, locomotion, eating, toilet use, dressing, and bathing.
• 28 Hours Per Week •Level III: A member meets the medical eligibility requirements for Level III if he or she requires at least extensive assistance and a one person physical assist with two of the following five ADLs: bed mobility, transfer, locomotion, eating, or toileting; and limited assistance and a one person physical assist with two (2) of the following additional ADLS: bed mobility, transfer, locomotion, eating, toilet use, dressing, and bathing.
8
Personal Care Services and Consumer Choice
• Requires PCS and chooses to remain at home
• Self Directs PCS• Choose PCS Agency to direct and
provide PCS
• Requires PCS, Requires 24/7
supported setting, and chooses another
residential setting
• Choose Adult Family Care Home• Choose PCS Home
• Choose another setting such as Nursing Facility
9
Current Guidance for Consumer Directed Personal Care Services
Activity Definitions Time Estimates Bed
MobilityHow person moves to and from lying position, turns side to side and positions body while in bed.
5 – 10 minutes
Transfer How person moves between surfaces – to/from: bed, chair, wheelchair, standing position (EXCLUDE to/from bath/toilet).
up to 15 minutes per time documented in Plan of Care
Locomotion How person moves between locations in his/her room and other areas on same floor. If in wheelchair, self-sufficiency once in chair.
5 - 15 minutes per (Document time and number of times done during Plan of Care)
Dressing & Undressing
How person puts on, fastens and takes off all items of street clothing, including donning/removing prosthesis.
20 - 45 minutes daily
Eating How person eats and drinks 30 minutes per meal Toilet Use How person uses the toilet (or commode, bedpan, urinal); transfers
on/off toilet, cleanses, changes pad, manages ostomy or catheter.5 -15 minutes/use
Personal Hygiene
How person maintains personal hygiene, (exclude bath and showers) add shampoo and nails
20 minutes per day, add 15 minutes/3 times per week for shampoo, 20 minutes per week for nails
Walking How person walks for exercise, How person walks around own room, How person walks within home
Document time and number of times in plan of care,
Bathing How person takes full-body bath/shower, sponge bath (EXCLUDE washing of back, hair), and transfers in/out of tub/shower
15 - 30 minutes daily
10
Proposed Time/Task for “Average” Adult Family Care Home or PCS Homes
Activity Definitions Time Estimates Avg Minutes Bed
MobilityHow person moves to and from lying position, turns side to side and positions body while in bed.
0 0
Transfer How person moves between surfaces – to/from: bed, chair, wheelchair, standing position (EXCLUDE to/from bath/toilet).
5 times, 5 minutes each = 25
Locomotion How person moves between locations in his/her room and other areas on same floor. If in wheelchair, self-sufficiency once in chair.
6 times, 5 minutes each = 30
Dressing & Undressing
How person puts on, fastens and takes off all items of street clothing, including donning/removing prosthesis.
15 minutes each, 2 x per day = 30
Eating How person eats and drinks 30 min per meal, 3 x per day = 90 Toilet Use How person uses the toilet (or commode, bedpan, urinal); transfers
on/off toilet, cleanses, changes pad, manages ostomy or catheter.
60 minutes per day= 60
Personal Hygiene
How person maintains personal hygiene, (exclude bath and showers) add shampoo and nails
30 minutes per day 30
Walking How person walks for exercise, How person walks around own room, How person walks within home
20 minutes per day 20
Bathing How person takes full-body bath/shower, sponge bath (EXCLUDE washing of back, hair), and transfers in/out of tub/shower
15 minutes per day 15
TOTAL= 5 Hours per Day
11
Proposed PCS Staffing Requirements
• Minimum staffing qualifications for all Personal Care Services. • May require DLRS and MaineCare rule changes.
• Requirements: • Be authorized to work in the United States• Contracted with the Medicaid Agency or its Designated Agent• Have a Medicaid Agency criminal background check• Department certification - Personal Support Specialist (PSS)
• The Department may approve licensed health care staff whose training or licensure exceeds these certifications. (CNA, CRMA, HHA)
• Medication administration must be done by qualified staff • CRMA cannot administer medications outside of a facility and without
nursing supervision
12
Rates for In-Home Personal Care Services
• Current: • Consumer Directed Services (Section 12) for Personal Support Specialists
• $10.44 per hour (15 minute units @ $2.61 per unit) • Staff are not typically agency employed
• Agency providers under Personal Care Services/Private Duty Nursing • $15 per hour (billed in 15 minute units @ $3.75 per unit) • Allows for added agency licensing requirements.
• Proposed: • $10.44 per hour for Independent and/or Consumer Directed providers• $15 per hour for Licensed PCS Agency providers
13
Adult Family Care Home Proposal
• Group setting allows 24/7 supervision without MaineCare reimbursement
• Grouping assessed and approved by Independent Assessor
• Current Per Diem Resource Grouping reimbursement maintained
• Base rate increased to be consistent with Independent Rate of $10.44/hr.
• Resource Groupings estimate “average” member unable to live alone requires 5 hours PCS
• Independent Provider rate applied to daily
per diem base rate• $10.44 x 5hrs = $52.20
14
Proposed Rates for Adult Family Care Home
• Licensed Adult Family Care Home Rates:
Group Case Mix Current Proposed Rate
– 1 1.657 $71.68 $86.50– 2 1.21 $52.34 $63.17– 3 1.36 $58.83 $71.00– 4 1.027 $44.43 $53.61– 5 0.924 $39.97 $48.24– 6 0.804 $34.78 $41.97– 7 0.551 $23.84 $28.77– 8 0.551 $23.84 $28.77
15
Proposed for PCS Homes
• Group setting allows 24/7 supervision without additional MaineCare reimbursement
• Grouping assessed and approved by Independent Assessor
• Current Per Diem Resource Grouping reimbursement maintained
• Base rate increased to be consistent with Licensed PCS Agency rate $15/hr.
• Resource Groupings estimate “average” member unable to live alone requires 5 hours of PCS
• Licensed Agency rate applied to daily per diem base rate • $15 x 5 hours = $75
16
Proposed Rates for PCS Homes
Resident Group Order Short description Weight Rate
IC1 1 IMPAIRED 15-28 2.25 $168.75IB1 2 IMPAIRED 12-14 1.568 $117.60IA1 3 IMPAIRED 0-11 1.144 $85.80CD1 4 COMPLEX 12+ 1.944 $145.80CC1 5 COMPLEX 7-11 1.593 $119.48CB1 6 COMPLEX 2-6 1.205 $90.38CA1 7 COMPLEX 0-1 0.938 $70.35MC1 8 BEHAV HEALTH 16+ 1.916 $143.70MB1 9 BEHAV HEALTH 5-15 1.377 $103.28MA1 10 BEHAV HEALTH 0-4 0.98 $73.50PD1 11 PHYSICAL 11+ 1.418 $106.35PC1 12 PHYSICAL 8-10 1.019 $76.43PB1 13 PHYSICAL 4-7 1.004 $75.30PA1 14 PHYSICAL 0-3 0.731 $54.83BC1 15 NOT CLASSIFIED 0.731 $54.83
17
Additional Considerations
• Service Plans and documentation• Provider responsibility
• Elimination of DHHS Audits • R&B negotiated between PCH and resident
• Staffing Impact• Training and certification may be necessary for some staff
• Medication Administration • Billed separately (currently $6.32 per administration)• Subject to staffing requirements
18
Projected Fiscal Impact
• Fiscal Impact assumes utilization is stable, which may need recalculation as eligibility changes
Current Costs Projected Cost of
PCS Model State Impact Fiscal Impact Fiscal Impact
State $ Federal $ Total $ State $ Federal $ Total $ State Federal Total
ACFH $ 1,647,182.16 $ 2,097,762.26 $ 3,744,944.42 $ 4,432,080.17 $ 7,464,524.78 $ 11,896,604.95 $ 2,784,898.01 $ 5,366,762.52 $ 8,151,660.53
CD $ 194,679.21 $ 332,200.57 $ 526,879.78 $ 194,679.21 $ 332,200.57 $ 526,879.78 $ - $ - $ -
PDN&PC
S $ 21,428,926.83 $ 36,758,685.06 $ 58,187,611.89 $ 21,428,926.83 $ 36,758,685.06 $ 58,187,611.89 $ - $ - $ -
App C $ 42,100,343.07 $ 71,221,247.38 $ 113,321,590.45 $ 41,271,783.11 $ 69,510,080.01 $ 110,781,863.12 $ (828,559.96) $ (1,711,167.37) $ (2,539,727.33)
App F $ 686,720.45 $ 1,181,172.61 $ 1,867,893.06 $ 690,258.69 $ 1,162,536.06 $ 1,852,794.75 $ 3,538.24 $ (18,636.55) $ (15,098.31)
TOTAL $ 66,057,851.72 $ 111,591,067.88 $ 177,648,919.60 $ 68,017,728.01 $ 115,228,026.48 $ 183,245,754.49 $ 1,959,876.29 $ 3,636,958.60 $ 5,596,834.89
Medication Administration
section State Federal $ Total
C 97 $ 6,886,358.90 $ 11,598,029.50 $ 18,484,388.40
F 97 $ 110,862.39 $ 186,714.81 $ 297,577.20
ACFH 2 $ 1,173,078.73 $ 1,975,703.27 $ 3,148,782.00
Med Admin T1502 visit 3 6.3 18.96
