ODP Review of AE Operating Agreement Comments

Transcription

1 ODP Review of AE Operating Agreement Comments Proposed Change by ODP: Annual Review Update - The category field in HCSIS used to document the results of an ISP annual review meeting. The annual review update date is the end date of the current ISP plan year. Comment: The annual review update date is the end date of the current ISP plan year. This is ambiguous as written and seems to define the ARU end date, however the term current ISP Plan Year is not a formal ISP classification, subject to misinterpretation as ARU Update or the Fiscal Year Plan. ODP Response: This has been changed to match the ISP Manual and read, The Annual Review Update Date is the end date of the current plan ISP. Proposed Change by ODP: Bi-Annual Review - The category field in HCSIS used to document the results of the six month review of services and supports. Comment: HCSIS used to document the results of the six month review of services and supports. Current requirements state that the six month review is required for special class members and/or specifically selected or required services and supports in the ISP check list. Consider rewriting so that the language is consistent with other ISP guiding documents, i.e. the ISP check list & manual. ODP Response: Added language to cover class member requirements. Proposed Change by ODP: Financial Management Services (FMS) - A type of Provider (either AWC or Vendor Fiscal/Employer Agent (VF/EA) that provides administrative support to a Waiver Participant who self-directs all or some of the Participant's services. An entity that fulfills specific employer or employer agent responsibilities for a participant that has elected to self-direct some or all of their HCBS. A FMS Provider process payments on behalf of a waiver participant who is not self-directing but requires a onetime payment. Comment: The definition begins using the term, Provider, to describe the type of organization that administers FMS, but later describes the type of organization more broadly by using the term entity. If this is intentional, we need additional context. If the intent is not to broaden the description, consider the following edit: "...support to a Waiver Participant who self-directs all or some of the Participant's services, and fulfills specific employer or employer agent responsibilities for a participant that has elected to selfdirect some or all of their HCBS. ODP Response: Change made to include the language suggested. Proposed Change by ODP: To remove the term Permanent vacancy. Comment: Agree with recommendation as per PACA MH/DS recommendation in November

2 ODP Response: None required Proposed Change by ODP: To remove the term Temporary Absence. Comment: Agree with recommendation as per PACA MH/DS recommendation in November ODP Response: None required Delegated or Purchased Administrative Functions Proposed Change by ODP: For all administrative functions performed by or subcontracted to an entity, the AE shall submit to the appropriate regional ODP on an annual basis, by April 1 of each year: 1. A list of the administrative functions the AE will continue or begin to delegate or purchase from an entity during the FY. 2. A brief statement describing each specific administrative function the AE will delegate to or purchase from an entity or proposes to delegate or purchase during the next FY and the current entity or proposed entity that will provide those administrative functions for the AE during the next FY. 3. Procedures the AE has or will put in place to monitor the completion of those delegated or purchased administrative functions during the next FY. 4. A list of related subcontracts or agreements to be effective during the next FY. This shall include a description of the tasks and functions delegated, the specific work requirements for each delegated function, reporting requirements and the process used to address any performance issues. The monitoring protocols must include 1. Frequency of AE review and the staff responsible for the review and 2. A description of the method to be used, which addressed all requirements of the delegated function Comment: Consider appending the phrase, by April 1 of each year with"...by next/upcoming fiscal year for clarity. ODP Response: Change made as requested Delegated or Purchased Administrative Functions Proposed additions by ODP: 13. ISP Review Checklists 14. Correspondence/documentation related to the transfer of a waiver participant to the AE 15. Money Follows the Person Comment: Recommend consistent citations. Items 13 and 14 and required documentation for Money Follows the Person to confirm consent are not included in AE Letter #6. ODP Response: The additions proposed are not all based on AE letter #6, as the side-by-side may have suggested. No change made in the amended list. The checklist is to be maintained per ODP information packet, # In order to receive MFP funding, a consent must be completed. This clarifies that a copy must be retained in the individual s file (Other Waiver Records) Proposed Change by ODP: The AE shall maintain the following other waiver records: 14. Records to substantiate administrative costs and methodology Comment: Clarify if #14 is intended for all funds spent by the AE on purchased administrative functions regardless of categorical funding. We recommend that the language be revised to specifically identify 2

3 funding applicable to # 14. ODP Response: We have added the word waiver to clarify that this applies to all waiver administrative activities, whether delegated or provided by the AE directly. 3.4 (Waiver Capacity Management) Proposed Change by ODP: The AE shall comply with the Waiver Capacity Management process as approved by the Department which includes the policies and procedures relating to Waiver Capacity Commitment (including management of reserved capacity), Waiver Residential Vacancy Management governing Temporary Absences and Permanent Vacancies in settings licensed under 55 Pa. Code Chapter 6400 and management of Unanticipated Emergencies. Comment: Consider editing as follows: Waiver Capacity Commitment (including management of reserved capacity), ["and"] Waiver Residential Vacancy Management ODP Response: Suggested change has been made (Permanent Vacancies) Proposed Change by ODP: When a permanent vacancy occurs because someone is dis-enrolled from the Consolidated waiver, the AE of registration for the Participant who created the Permanent Vacancy shall have the first opportunity to identify an alternative individual in need on the emergency PUNS or in reserved capacity and enroll that individual in the Consolidated Waiver (subject to available waiver capacity). Comment: Clarify the language and intent of ODP Response: This language/section has been removed since it does not reflect the right of current waiver participants have choice regarding the vacancy and, because providers are no longer reimbursed for any vacant bed days, they should have the ability to fill the vacancy in as efficient and prompt a manner as possible. 4.1 (PUNS) Proposed Change by ODP: Except as provided for through designation in reserved capacity status, The AE shall ensure that all Waiver applicants most in need with an emergency need identified in PUNS, within the Jurisdiction of the AE, are enrolled in one of the Waivers prior to investigating the enrollment of an applicant with a different PUNS assessed category status. Comment: Please define "Jurisdiction" as used in this context. PUNS needs to be reviewed and revised. ODP Response: No change. A definition is included in the Definition of Terms section. 4.4 (Offering Free Choice of Willing and Qualified Providers) Proposed Change by ODP: The AE shall validate that applicants individuals and Participants are offered free choice of Willing and Qualified Providers for each service or support the AE approves and authorizes on an ISP, including the free choice of a all SCOs willing to provide services in the geographic area by ensuring that the SCO Directory maintained by ODP is shared Comment: We recommend the language be clarified as follows: 1. Change Applicant to New Applicant. 2 Specify this refers to waiver applicants only 3

4 ODP Response: No change. This agreement applies to waiver only. Applicant is a term consistently used in the waivers and ODP policy when referring to new individuals not currently in a waiver. 4.5 FMS Proposed Change by ODP: The AE shall make information on FMS and Participant direction available to Waiver applicants at Waiver enrollment. The AE shall monitor to ensure that SCs provide FMS and Participant direction information during planning meetings and upon request. The AE shall ensure adherence to the requirements outlined in Written Policies and Procedures and Departmental Decisions relating to VF/EA and AWC FMS. When aware of or notified of concerns regarding the performance of a common law employer, the AE shall try to resolve the issue and provide technical assistance to avoid any recurrence. If these efforts are unsuccessful, the AE shall notify the regional office of ODP. Comment: The AE has few tools to identify problems between a common law employer and employee. There is limited access to FMS RECORDS by the AE. Time logs and travel are not readily available. Without options, tools and technical assistance available to the AE, they cannot ensure adherence. Recommend rewording accordingly identifying options for the AE to meet standard. Comment: Clarification of terminology of managing employer and common law employer is needed. ODP Response:The terms managing employer and common law employer are defined in the Definition of Terms section. ODP expects AEs to use the established provider monitoring tool and inform ODP if they become aware of an issue through, for example, a complaint (Statewide Needs Assessment Contractor) Proposed Change by ODP: The AE shall complete its required functions related to completion of the Statewide Needs Assessment in accordance with Written Policies and Procedures and Departmental Decisions relating to the Statewide Needs Assessment. The AE shall initiate an urgent request to have the Statewide Needs Assessment conducted prior to enrollment. If the Statewide Needs Assessment cannot be completed prior to enrollment because the individual requires the immediate initiation of waiver services to ensure their health and safety, notify the appropriate ODP regional program manager to request that the Assessment be completed within 30 days of the waiver effective start date. Comment: Make the need for a SIS prior to enrollment explicit, along with the conditions under which an exception can be made. ODP Response: The change recommended, regarding the need for a SIS prior to enrollment, has been added. The conditions for an exception have not been changed. (The person s health and safety requires the immediate initiation of waiver services.) (Review, Approval and Authorization of ISPs and Waiver Services) Proposed Change by ODP: The AE shall not authorize services to be funded through on of the Waivers which are provided under the state plan, private insurance or other third party payers, unless evidence that all other payers have been exhausted and other funding types are not available. The AE may only authorize therapy and nursing services through the Waivers if there is documentation that the service is medically necessary and not covered through the MA State Plan which includes EPSDT, Medicare and/or private insurance. Therapy Services must be provided under the MA State Plan including EPSDT, Medicare and/or private insurance plans until the plan limitations have been reached and documentation is secured by the 4

5 Supports Coordinator. Comments: Consider editing to read: "Therapy Services [and Nursing] must be provided under the MA State Plan including EPSDT, Medicare and/or private insurance plans until the plan limitations have been reached and documentation is secured by the Supports Coordinator. Please clarify "medically necessary", specifically identifying the documentation required. We recommend that the language be revised to identify the specific health care professional (i.e. Physician Assistant, Nurse Practitioner) able to designate medical necessity for services. Clarify documentation sufficient from Medicare to validate denial or exhaustion of benefit. ODP Response: No change made. The language is from the approved waivers. ODP will be issuing a bulletin to clarify the relationship of EPSDT services to services included in the approved waivers. This policy will also address the documentation needed from other insurance prior to provision through the waivers (Residential Services) Proposed Change by ODP: The AE shall only approve and authorize a service to be provided in a licensed or unlicensed residential setting when the Participant meets the residential habilitation service criteria and any applicable service location size guidelines or, if the criteria are not currently met, an action plan to revise supports is in place. Comment: Please clarify "applicable service location size guidelines". We are uncertain if this is referring to the approved waiver capacity, Labor and Industry standards, local codes and/or licensing requirement. ODP Response: Revised to clarify this refers to the waiver capacity limits and one person home guidelines, where applicable (Residential Services) Proposed Change by ODP: The AE shall review requests for clearance for new residential service settings Comment: Please clarify the approach with the new departmental policy and identify who is making the request that requires and AE response. ODP Response: This refers to the existing AE review process as outlined in AE letter #2. Added language to clarify that the AE shall review requests forwarded by ODP upon submission by a provider. 5.1 (Provider Recruitment and Enrollment) Proposed Change by ODP: The AE shall provide ongoing technical support to Providers utilizing ODP's Provider Handbook on enrollment, qualification and HCSIS and PROMISe processes. This support includes, but is not limited to: 1. The provision of information regarding the Provider application, enrollment and qualification processes. The information must be developed by ODP. 2. The provision of "hands-on" technical support or referral to the appropriate entity for enrollment support. 3. Communication to the appropriate regional ODP regarding issues related to Provider recruitment and enrollment processes. 4. Oversight of transition planning in the event of provider closure or notification that a provider is no longer willing to provide supports to a participant. This shall include actions to ensure that any affected waiver participant(s) are afforded choice of provider. 5. The provision of information 5

6 regarding ODP required provider orientation and training. 6. Orientation or training of providers when approved or requested by the Department. Comments: AEs provide a great deal of support to new and existing providers. More detail and resources are needed related to training, technical support and referral sources in addition to orientation and training materials. Need a standardized curriculum for AEs to support and guide new providers With no authority over able and willing providers, we recommend ODP train and orient new providers. ODP Response: No change. Work is currently underway to develop a standard curriculum for the orientation of new providers that will be required prior to enrollment and service provision. 5.2 (Qualification of Waiver Providers) Proposed Change by ODP: If a vendor is contracted through an OHCDS, the AE shall review subcontracts held with an OHCDS provider of the vendor service and monitor that the provider acting as the OHCDS and subcontracted vendor are qualified. Comment: Provider Handbook, pg 17 notes, "Entities that function as an OHCDS for vendor services are responsible to ensure that subcontracted entities meet all applicable provider qualification standards for the services they are rendering." This seems to indicate that the qualification would be the responsibility of the OHCDS and not the AE. ODP Response: No change. This refers to the AE s role during monitoring when the provider is functioning as an OHCDS. 6.1 (Monitoring of Waiver Providers) Comment: Note the Implementation of the monitoring cycle is a two year process. ODP Response: Language has been added to provide clarification, as recommended. 6.1 (Monitoring of Waiver Providers) Proposed Change by ODP: The AE shall notify the appropriate regional ODP if initial remediation efforts are unsuccessful relating to the following: 1. Failure the meet waiver qualification standards, 2. failure to comply with the provisions of the waiver provider agreement, 3. in a significant number or proportion of cases. The provider has furnished waiver services at a frequency or amount not consistent with the authorized ISPs, b. the provider has furnished waiver services of a quality that does not professional standards, c. the provider has failed to comply with departmental written policies and procedures, d. commission of a violation as listed in 55 Pa. Code and 77 (relating to provider prohibited acts), e. failure to complete provider qualification process or not achieving qualification status within the required timeframes, f. submission of false information for qualification and g. conviction of illegal business activities Comments: 6

7 We recommend the term "significant" be defined or clarified. We also recommend that the language include a contextual reference or otherwise clarify "professional standards". Same comment as 5.2 above: Provider Handbook, pg 17 notes, "Entities that function as an OHCDS for vendor services are responsible to ensure that subcontracted entities meet all applicable provider qualification standards for the services they are rendering." This would seem to indicate that the qualification would be the responsibility of the OHCDS and not the AE. ODP Response: No change has been made. The terms noted are in the current operating agreement. If the AE has specific questions or concerns, please contact your regional office. 6.3 (Annual Administrative Review) and (Correction of Issues Identified during the Annual Administrative Review) Proposed Changes by ODP: When directed by the Department due to performance concerns, The AE shall conduct at least an annual administrative review of the services provided using the monitoring procedures outlined in ODP s AE OM Process, with the exception of the sample size and interviews with Waiver Participants. The review shall include an analysis of the data collected and the implementation of procedures that assure Waiver compliance. The review shall include a minimum sample of five (5) percent of Waiver Participants under the Jurisdiction of the AE, but shall include not less than a minimum number of five (5) records and at least thirty (30) records per Waiver for each AE. In addition, selection of the sample must be proportionally represented by each SCO providing services to Participants under the Jurisdiction of the AE, but must include at least thirty (30) records per Waiver for each AE. If the SCO provides services to five (5) or less Participants under the Jurisdiction of the AE, every record shall be reviewed. The AE shall conduct all monitoring of Participants as specified in the current AE OM Process. The AE's monitoring must include a face to face interview with each Waiver Participant in the sample, to be conducted at the location where service(s) are rendered. In the conduct of the administrative review, the Department reserves the right to require that the AE conduct face-to-face interviews. The AE shall notify the appropriate regional ODP by July 1 of each year of its annual administrative review cycle. Upon completion of the annual administrative review, the AE shall promptly forward the summary results and analysis of the annual administrative review no later than thirty (30) calendar days after the completion of the review. The AE shall also submit any necessary CAP(s) no later than forty-five (45) fifteen (15) calendar days after the completion of the review to the appropriate regional ODP. Comments: Clarify annual administrative annual review cycle timeline for ODP directed administrative reviews and when the 15 day clock begins. Since analysis is a prerequisite to CAP development, additional time is recommended. The stated deadlines are consistent with Remediation. Define jurisdiction. Clarify if this standard applies to all SCOs serving AE registered waiver recipient. Sampling requirements do not match the instructions provided as part of AE oversight 7

8 ODP Response: This has been revised to clarify that if a full review is required, the sample selection must proportionately represent each SCO serving waiver participants from the AE. The 15 day clock is the standard corrective action plan timeline established by ODP for all monitoring processes. Clarified that the maximum is sample is 30 records per waiver. Comments on Delegated Functions Revised Language: Ensuring that eligible applicants having an emergency need, receive preference in waiver enrollment before those with a critical or planning need. Comment: Note that ODP has retained waiver slots for new initiatives. The PUNS does not consistently define emergency need statewide, and should be revised. ODP Response: The Agreement clarifies that people in a reserved capacity group may have a different PUNS status. As an interim step, we are revising the PUNS Manual and training is planned. Revised Language: Reviewing and approving ISPs in accordance with ODP policies and procedures and making authorization determinations about waiver-funded services using criteria established by ODP Comment: Will the clarification result in any change to current procedures? ODP Response: Changes are not planned at this time. Revised Language: Monitoring of waiver providers, excluding SCOs, using monitoring processes developed by ODP Comment: Is the AE responsible for fraud, waste and abuse or assuring the provider is implementing procedures? ODP Response: If a reviewer is concerned that a situation or findings may be the result fraud or abuse, they should consult with ODP regarding next steps. Removed - conducting desk reviews of providers cost reports and review provider financial audits, as per the AE Operating Agreement Comment: Clarify whether the AE remains responsible for Desk Reviews. ODP Response: Yes, this continues to be an AE requirement that is included in the revised Operating Agreement. The delegated function list only included those items/tasks from among the list of standard waiver functions specified in item A-7 of the waiver. Removed- Participation in ODP required trainings as per the AE Operating Agreement Comment: ODP should clearly specify management roles required to attend training and the AE assure appropriate participation ODP Response: ODP will designate required participants based on the content of the training. 8

9 Additional Edits There were some additional minor edits/changes made in the final version of the AE Operating Agreement that were not included in the side-by-side summary of changes initially proposed by ODP. We apologize that these items were not previously included. They are listed below, for your information: 1. Section 1.0 Definition of Terms a. Changed references to the Waiver Capacity Commitment Letter to Waiver Capacity Commitment Notification. 2. Subsection Waiver Capacity Commitment a. Added language to cover capacity that may be associated with reserved capacity groups that may not be typically considered part of the waiting list initiative. 3. Subsection 9.1 Agreement Remedies a. Removed reference to timeline for completion of the CAP as this should be based on the extent and impact of non- compliance. b. Changed records retention requirement from 4 to 5 years. 9