Provider Update: CMS Final Rule Implementation
July 2, 2014
CONFLICT FREE CASE MANAGEMENT (CFCM)
Beginning October 1st, 2014, all ADvantage Member Service Plans must be in compliance with the new CMS regulations. Please see the Federal Regulation quoted below.
- §441.301(1) (vi) Providers of HCBS for the individual, or those who have an interest in or are employed by a provider of HCBS for the individual, must not provide Case Management or develop the person-centered service plan, except when the State demonstrates that the only willing and qualified entity to provide case management and/or develop person-centered service plans in a geographic area also provides HCBS.
Due to this rule change, ADvantage Members receiving Case Management and Home Care services from the same agency must transfer to another agency for one or the other of these services. This prevents any potential conflict of interest between providers.
The ADvantage Administration has implemented a method for processing all New Service Plans, Reactivation Plans, Reassessment Service Plans and Transfer Addendums. This process is noted below.
NEW SERVICE PLANS
Effective July 1st, 2014, the MSU-AA will begin sending out all new cases in accordance with the new CMS Final Rule requirement for CFCM. This means the ADv6g you receive for new Members will have a case management provider from one agency and a home care provider from a different agency.
Due to immediate implementation, it is highly possible that new Members currently being processed may have already selected providers that do not meet the CFCM rule. In these situations, the MSU-AA will contact Members by phone to educate and obtain appropriate provider choices using the Member Consents and Rights form (02CB001E). This form will be included in the packets sent to Case Management providers.
PLEASE NOTE that when this process has been implemented, a condition will be placed on the T1016 Case Management service line stating “Submit Form 02CB001E for CFCM”. This condition is directing the Case Manager to obtain the Member’s signature on the Member Consents and Rights form included in the initial packet. This signed form must be returned to the MSU-AA along with the Service Plan packet in order for the Case Management service line to be authorized.
This process will only continue until the DHS County Nurses have had the opportunity to implement CFCM during eligibility determination and all existing cases have been appropriately processed.
REASSESSMENT SERVICE PLANS, REACTIVATIONS, AND TRANSFER ADDENDUMS
Effective
August 1st, 2014, the Service Plan Authorization Unit (SPA) will be conditionally authorizing the T1016 Case Management service lines for Reassessment Plans and Transfer Addendums that are out of compliance with the CFCM rule change. All home care lines will be authorized as appropriate. A condition will be placed on the T1016 Case Management service line stating “Please educate Members on the CFCM rule and submit a Transfer Addendum for either Case Management, Home Care, or both as Members select”.
Effective October 1st; 2014, the T1016 Case Management service line will NOT be authorized until the plan is in compliance with the rules. The Home care lines and all other ADvantage services will be authorized as appropriate. Case Managers will continue to be responsible for ensuring service delivery to Members is not affected due to the status of the Case Management service line. As stated above, a condition will be placed on the T1016 Case Management service line directing Case Managers to educate Members on the CFCM rule. The condition will instruct as follows; “Please educate Members on the CFCM rule and submit a Transfer Addendum for either Case Management, Home Care, or both as Members select”. PLEASE NOTE that Case Managers will be required to submit justification for service providers being out of compliance with the new Rule in order for Case Management services to be authorized for the timeframe required to bring the plan into compliance.
REMINDER ON REASSESSMENT SUBMISSIONS
For annual Service Plan renewals, the Case Manager should submit the Service Plan to the MSU-AA at least 30 to 60 days before the Member’s current Service Plan end date.
CHANGE IN STANDARD NAMING CONVENTION
In order to better be able to identify those entities providing more than one service to ADvantage members, the MSU-AA is revising provider names to include an alphanumeric code at the beginning of each name. The code uniquely identifies same providers, regardless of the actual business name. This change in naming convention will be occurring over the next several weeks, and will be picked up by the IVRA vendor as well as on the ADvantage Certified Agencies Report. As billing and claims submission at OHCA is a numeric process that relies on Provider IDs, Member IDs, etc., the claims process will not be affected.
BACK UP PLANS
Beginning July 15, 2014, all Service Plans are required to have a Back Up Plan per the CMS Final Rule requirement.
- §441.301(2) (vi) The Person-Centered Service Plan must reflect risk factors and measures in place to minimize them, including individualized back-up plans and strategies when needed.
The purpose and use of the Back Up Plan for our ADvantage Members is to assist with improving health and quality of life outcomes, and to ensure continuity of care. Additionally, this form will assist Case Managers with discussing life planning issues, and possibly even end of life planning issues, with our Members. In the event a Member becomes unstaffed or experiences an emergency situation, the individual(s) pre identified in the Back Up Plan can be contacted timely by the appropriate individual. The Back Up Plan is to be used by the Member, the Member’s informal supports, the Case Manager, and anyone else involved in caring for the Member.
The ADvantage Administration has implemented a method for processing all New Service Plans, Reactivation Plans, Reassessment Service Plans and Transfer Addendums. This process is noted below.
Effective July 15, 2014:
- All New, Reactivation and Reassessment Service Plans submitted to the MSU-AA must include the Services Backup Plan, form 02CB014E. In the event a Service Plan is submitted without the required Back Up Plan, the T1016 (Case Management) service line will not be authorized until the Back Up Plan has been received at the MSU-AA.
- All Case Management Transfer Addendums submitted to the MSU-AA must include an updated Services Backup Plan form.
GUIDELINES FOR USE OF THE BACK UP PLAN FORM
The Services Back Up Plan instructions list the information that is required for completion of the form, and include direction on who should be listed as the first, second and third back up for the Member.
In the event you have Members with no informal supports, document this on the form. Discuss with Members what they will do in the event they can no longer remain safely in their homes and include their plans on the Back Up Plan form. Please be sure there is no conflict with the documentation provided in the UCAT regarding available informal support assistance, as this may warrant a condition on the Case Management line for clarification.
The Case Manager is responsible to find alternative solutions to meet the Members need for Health and Welfare, and to discuss any concern(s) the Member may have. The form is required to be signed as noted on the instructions. Failure to have the form completed as directed may warrant conditions on the Case Management line as noted above.
If you have any questions regarding the information provided above, please feel free to contact us via Smarter Mail at: aauproviderquestion@aau.okdhs.org
