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The Optional State Supplementation Program &
Optional Supplemental Care for Assisted Living Participants
Service SCDHHSDivision of Long Term Care Transformation
PO Box 8206
1801 Main Street
Columbia, SC 29202-8206
• The mission of the Optional State Supplementation (OSS) program is to enhance the quality of life for Medicaid consumers in licensed Community Residential Care Facilities (CRCFs). We are steadfastly committed to promoting and advancing high quality, evidence-based, efficient, innovative,
person-centered care and services.
MISSION STATEMENT
• OSS is an entitlement program that is a state supplement to a person’s Security Income (SSI/ SSA).
• The purpose of this program is to provide reimbursement to enrolled Community Residential Care Facilities (CRCFs; also known as assisted living facilities) who provide room and board and a degree of personal care for eligible consumers. OSS is NOT a Medicaid program; it is funded at 100% state funding.
WHAT IS OPTIONAL STATE SUPPLEMENTATION (OSS)?
• Be 65 years or older, or 18 years of age or older and blind or disabled
• Be a U.S. citizen or qualified noncitizen
• Have a Social Security number or file for one
• File for any other benefits to which they may be entitled
• Meet net income limit
• Can’t exceed resource limit of $2,000 for an individual
To be eligible for OSS, a person must
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Number of Consumers 3,557 (OSS & OSCAP)
54% Female & 46% Male
CRCF Medicaid enrolled facilities: 350
Consumer Payment Source :
SSA: 43%
SSI: 59% ($710)
Current OSS Rate: $1,393
Average yearly cost = $16,716 annual (single occupancy)
QUICK FACTS
Admission are approximately 93 residents per month. The referrals come from the community and the hospitals.
Terminations are approximately 73 residents per month and is attributed to changes in level of care (home, lesser level of care such as a boarding home, higher level of care such as a nursing facility, death)
OSS Monthly Admissions and Terminations
• Resident’s monthly income must fall below the Net Income Limit (NIL) set by the State Legislature, currently at $1,393.00 per month
• Resident’s resources $2,000 or less
• The maximum monthly amount a CRCF operator may charge an OSS recipient is $1,332.00 per month
OSS Program Funding
• OSS recipients are allowed to keep $61.00 per month for personal needs. These eligible consumers are SSI only and pay category 86.
• Eligible consumers who have income other than SSI are allowed to keep an extra $20.00 for personal needs, bringing their total to $81.00 This is due to a $20.00 general disregard allowed in the budgeting process. These eligible are pay category 85.
OSS Program Funding
The resident receives their Personal Needs Allowance (PNA) from their recurring income at the first of each month, not from the OSS amount that is paid on behalf of the resident.
PNA increase by $2 every time there is a Cost of Living Allowance Increase (COLA)
• Facilities must accept the OSS entitlement amount as payment in full. Residents may not be charged for any difference due to rounding in the computer payment system.
OSS Program
• Facilities may not charge a resident or a resident’s family for any difference over and above the OSS entitlement amount – even if the family is willing to pay the difference for a private room.
The additional payment would be considered income for the resident and could make them ineligible for OSS due to income limitations
OSS Program
The OSCAP service provides additional reimbursement to facilities to provide assistance with personal care for residents who meet the medical criteria required for participation
The assistance must be provided by a resident assistant that has been trained and determined competent to provide the service by a licensed nurse with weekly supervision by a licensed nurse contracted or employed by the CRCF.
Optional Supplemental Care of Assisted Living Participants (OSCAP)
• OSCAP employs four (4) registered nurses to evaluate residents’ needs and authorize the provision of services to the facility for OSS residents who meet the OSCAP service medical/functional criteria
• Residents are assessed by the SCDHHS RNs to establish the residents’ need for the service and the appropriateness of the care plan
OSCAP Service
• Criteria for coverage are two functional dependencies or one functional dependency combined with a form of cognitive impairment
• The RN employed or contracted by the facility develops the care plan, trains and determines competency of direct care staff
OSCAP Service
The intake process for the OSS program will ensure that all persons with long term care
needs that request placement in a community residential care facility are screened for
Medical necessity criteria, as well as financial eligibility, to ensure that persons can be
housed to maximize their personal well-being and health.
The intake process will incorporate data on all Medicaid LTC programs (CLTC, Home Again,
OSS, OSCAP, and SNF) for long range tracking and forecasting.
All current residents will be assessed:
1. Current OSS participants in newly contracted OSCAP providers
2. Current IPC participants in non-OSCAP contracted facilities
3. Current IPC residents in OSCAP contracted facilities
4. Current OSS only residents
Intake Process
OSS & OSCAP Billing & Payment
• OSS Consumers
• $1,393OSS
• Participants who meet NIL and Medical Necessity (1 functional dependency & 1 cognitive impairment, or 2 functional dependencies)
• Payment is $1,600
OSCAP
• Participants who qualified for CLTC waiver: OSCAP entitlement payment + services rate
• Payment is $2,038
OSCAP WAIVER
ThreeLevels of Payment (Tiers)
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Claims Receipt – CRCF
Claims Section
Post Office Box 67
Columbia, SC 29202-0067
TAD Mailing Address
• Net Income Limit: $1,393
• OSS resident income: 710
• Personal needs: 61
• OSS payment: $683
• Facility receives: $1,332
Payment Scenario - OSS
• Net Income Limit: $1,600
• OSS resident income: 870
• Personal needs: 61
• OSS payment: $730
• Facility receives: $1,539
Payment Scenario –OSCAP
Provider Requirements
• Licensure in good standing by DHEC
• Assurance of one composite electronic fund transfer
• Facility documentation of resident funds and personal needs allowance
• Facility underpayment or overpayment adjustments
• Facility notification to DHHS regional offices and the eligibility offices of admissions, discharges, transfers, and deaths within 72 hours
• Monthly processing of the OSS payments
• Approval of payment of new OSS beneficiaries
• Medical absences
• Quality and scope of services
• Annual rate determination
• Freedom of choice
• Record keeping
• Assurance of compliance with OSS program policies and procedures
• Sanctioning process
• Termination
• Appeals
1. The referral form can be accessed by following this website: https://phoenix.scdhhs.gov/initial_electronic_referrals/new
2. Enter the participant’s demographic information, address, facility information, contact information and physician’s name and phone number.
3. Be sure to fill all fields with a red arrow. These fields are required and the referral cannot be processed until the error is corrected. (The physician’s name, number and address are not required fields and the referral can be submitted without this information. Incontinence supplies referrals CANNOT be processed without the physician’s information.)
4. In the Referral Information section of the form select the desired service. If you are making an OSCAP referral select OSS as the desired service, then enter OSCAP inside the comment box in this section. (If OSCAP is not entered in the comment box the referral will be processed as just an OSS referral and not passed onto the appropriate nurse for your facility.)
5. Click the blue submit button. The referral has been successfully submitted.
Other ways to apply for OSS or OSCAP• By phone: 1-888-356-2197• Or at your Local Eligibility Office
How to make an OSS or OSCAP referral on the Internet ?
New Applicant CRCF-01 from process
OSS applications are made
electronically in Phoenix or at the
Local Eligibility Office
The eligibility department
determines financial eligibility
A CRCF-01 form is sent to the OSS department to
initiate the 02 slot letter
The OSS department sends the 02 slot letter to the resident or the
facility
Once the 02 letter is returned from the
facility the OSS department returns the CRCF 01 form to
the Eligibility department
Eligibility worker completes section III (A and B) on the CRCF-01 form, signs and dates the form, updates the MEDS system, and return the form to the CRCF
• For current OSS participants already living in a CRCF that have changes such as – Transfers, discharge, income changes, or termination.
– The CRCF should send their CRCF-01 form to the local eligibility office.
– The local eligibility worker approves changes and returns CRCF-01 form to facility.
• It a resident is discharged or terminated from a CRCF the facility must complete a terminating CRCF-01 form within 72 hours and send the information to the local eligibility office. Failure to provide terminating CRCF-01 forms can jeopardize your entire payment.
Billing Tips
Upcoming Changes
Electronic Billing and Reporting
Phoenix
• A web-based software system used to documenting prior authorization for service and track OSCAP and CTLC’s participants
Care Call
A system that contains
• Prior Authorizations For Service
• Documents Service Delivery
• Provides Service Monitoring
• Provides Billing to MMIS
• Care Call is a two part system
– IVRS
– Website
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Incontinence Supplies
To start the referral process for incontinence supplies, the beneficiary (or CRCF administrator) will contact CLTC centralized intake at 855-278-1637 or online at https://phoenix.cltc.state.sc.us/cltc_referrals/new to open a new referral.
A phone assessment will be conducted by a CLTC RN to determine if the beneficiary is eligible for incontinence supplies by meeting the medical necessity criteria. The CLTC RN will determine the frequency of incontinence and the amount of supplies authorized.
If the beneficiary is eligible, then the Physician Certification of Incontinence DHHS Form 168IS and a CLTC provider choice listing will be mailed out to the beneficiary.
Once the Physician Certification of Incontinence DHHS Form 168IS and the CLTC provider choice listing are received back to CLTC centralized intake the beneficiary will start to receive incontinence supplies.
Periodic recertification of incontinence supplies per beneficiary will be monitored by to guarantee that an updated Physician Certification of Incontinence DHHS Form 168IS is on file per beneficiary.
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• SCDHHS has an agreement with the Lieutenant Governor’s Office on Aging (LGoA) for the purposes of designing, implementing and maintaining a web-based nursing facility bed registry.
• The registry will provide current information on available Medicaid nursing facility and community residential care facilities beds throughout South Carolina. This information will be available to hospitals, consumers and anyone interested in identifying available Medicaid nursing facility beds.
Facility Bed Locator
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Facility Bed Locator
Facility Information
The NFBL website providers demographic information on Nursing Homes and Community Residential Care Facilities. This includes:
• Facility Name
• Facility Address
• Business Phone Number
• Business email address/ website
• Total number of Beds in the Facility
• Total Number of Private Pay Beds and Number of Available Private Pay Beds
• Total Number of Medicaid Beds and number of available Medicaid Beds
Nursing Facility Bed Locator (NFBL) website
www.nfbl.sc.gov
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Facility Bed LocatorFacility Information
• Alexis Martin, MBA
– OSS Program Coordinator II
– 803-898-1060
• Russell Morrison, LMSW
– Quality Assurance Coordinator
-803-898-1140
OSS Contact Information
• Mary Adams, R.N.– Statewide
• 803-240-9674• Donna Perry, R.N.
– Pee Dee and Coastal Region, • 843-616-2255
• Linda Thomas, R.N.– Piedmont Region (Upstate)
• 803-240-7526• Hope Hopkins, R.N
– Midlands• 803-542-6966
OSCAP Nurses
