DLTC INFO MEMO 2009-01

Department of Health Services
Division of Long Term Care

DLTC Information Memo Series 2009-01
Date: March 26, 2009
Index Title: Policy Changes to the CIP 1A/1B and BIW
Medicaid Waivers

To: Listserv

For: Area Administrators
Human Service Area Coordinators
County Department of Community Programs Directors
County Department of Developmental Disabilities Services Directors
County Department of Human Services Directors
County Department of Social Services Directors
Long Term Support Planning Committee Chairs
Tribal Chairpersons/Human Service Facilitators
Regional Community Integration Specialists
DLTC Bureau Directors
DLTC Section Chiefs

From: Fredi-Ellen Bove
Interim Administrator

Subject: POLICY CHANGES TO THE CIP 1A/1B and BIW MEDICAID WAIVERS

Document Summary

This memo announces a number of significant changes that have been, or will soon be, made to the Community Integration Program (CIP) 1A/1B Waiver and the Brain Injury Waiver (BIW). The COP-W, CIP II and CLTS Medicaid Home and Community-Based Services Waivers may be affected in the future as those programs complete the renewal process or implement changes per federal requirements in advance of renewal, however for now the policy and operations changes described in this memo affect only the CIP 1A/1B and BIW Waivers. These changes are largely the result of new federal requirements for Medicaid Home and Community-Based Services Waiver operations disseminated by the Centers for Medicare and Medicaid Services (CMS) and communicated to the Department of Health Services (DHS) in the waiver renewal process.

The Department's commitment to address and adopt the new federal requirements is detailed in the state's renewal of the CIP 1 and BIW waivers. DHS agreed with CMS that some of these changes will have an effective date of January 1, 2009 while others will be phased in. The new requirements have a broad scope affecting county waiver agency operations, waiver program service providers and the state's management and oversight functions. This memo is intended to announce the new policy and operations requirements and describe what local agencies can expect as these changes are implemented. Additional details will be communicated via the DLTC numbered memo series and revisions to the Medicaid Waivers Manual.

Introduction

Beginning in September of 2007 and for all of 2008 Department staff have been working with the Centers for Medicare and Medicaid Services (CMS) to secure a renewal of the CIP 1A/1B and BI Waiver programs. Efforts have focused on a number of new waiver requirements as well as clarification from CMS that rules that applied to providers seeking reimbursement under the Medicaid State Plan also applied to the Home and Community-Based Services Waivers. Adopting these requirements will have the effect of changing the relationship between the state and the county agencies that operate the waivers locally in Wisconsin. Meeting the new requirements will also impact the way county agencies work with local waiver service providers and the way county staff interact with consumers, providers and the state.

This memo is the first of a series of memos and related communications that are intended to announce and implement these changes, focusing on the new expectations that apply to county waiver agencies and service providers.

A. Changes in DHS Waiver Monitoring Processes for CIP 1A/1B and BIW
The Developmental Disability Services (DDS) waiver unit will implement new methods for the collection and reporting of data. DHS expects that the information collected will enhance processes for the monitoring and measurement of waiver quality. The data is also expected to provide a means to track trends in service delivery using selected performance indicators. The new monitoring tools will be employed by both state and local waiver staff in the participant application, monitoring and recertification processes.

The enhanced monitoring systems will include:

• An application checklist for state staff reviewing new waiver applications;
• An applicant tracking form that will follow applicant status from the point of application, through the level of care eligibility determination including the outcome of the process as placement on a wait list, eligible and service planning processes to service delivery, or denial of eligibility;
• An upgrade to the existing database used to record the results of in-person participant field reviews conducted by state staff;
• The expanded record review process initiated in 2008, including the revised recertification assurance process;
• The implementation of a more comprehensive corrective action system;
• Enhancements to the program monitoring function of the single state audit; and
• Implementation of a new database to record the number, subject and outcome of all appeals and fair hearings.

The DHS will use other reporting forms and reports to monitor county and provider performance. These include enhancements to the incident reporting process, including:

• A revised version of the incident reporting form. The updated form and accompanying instructions will be available from the DHS forms library and the Medicaid Waivers Manual; and
• A new brochure, designed for family members and guardians, providing information and guidance about recognizing and reporting incidents.

These enhanced monitoring, reporting and recording processes will provide the DHS with systems to capture federally required information. The information database will record, track, and analyze trends in order to monitor performance, ultimately enhancing waiver quality.

B. Changes That Impact Service Providers and the Provider - Program Relationship
The expectations for counties and the county relationship with providers is an area with significant changes. DHS expects these new requirements will involve the most effort by county agencies and providers. The waiver policy context for some of the most substantial changes includes:

• Waiver participants must have free choice of any willing and qualified providers;
• The DHS must facilitate choice by ensuring that participants and their guardians, if any, are given access to information about all qualified or potentially qualified providers;
• All providers must be permitted to participate in the waiver program if they are qualified;
• All providers must have the opportunity to be determined qualified under the standards for the service established by the DHS prior to participation; and
• All providers must agree to the required conditions of participation and may not be subject to additional requirements.

To implement these policy principles:

1. ALL WAIVER SERVICE PROVIDERS MUST EXECUTE A PROVIDER AGREEMENT WITH THE STATE MEDICAID AGENCY
Like other Medicaid programs, the Medicaid waivers require that all providers execute an agreement with the State Medicaid Agency (DHS). The county waiver agencies will have responsibility to obtain such agreements with all current providers. This change will apply to all waivers.

2. THE STATE MUST PROVIDE A MEANS FOR PROVIDERS TO SIGNAL A WILLINGNESS TO PROVIDE WAIVER SERVICES
DHS will make a web-based provider registry available in order to assure that all willing providers have an opportunity to be selected to provide waiver service(s). The registry will become the basis for a provider directory, used to ensure that all waiver participants have access to all the information they need to choose their provider(s). This change will apply to all waivers.

3. PROVIDERS REQUIRED TO REPORT INCIDENTS TO COUNTY WAIVER AGENCIES
Service providers must now file incident reports with the county waiver agency. The county waiver agency will retain its current primary responsibility for incident reporting and resolution, including reporting to DHS per established criteria.

4. FOREIGN LANGUAGE TRANSLATORS MUST BE AVAILABLE
County waiver agencies and waiver service providers must ensure that qualified translators are provided to participants and guardians as needed to ensure that language is not a barrier to the process of application, plan development, service selection and service provision.

5. A NEW EMPHASIS ON MEDICATION MANAGEMENT
County waiver agencies and waiver service providers will assume more responsibility to assure that medication monitoring is an integral part of each service plan in order to ensure that participants are safe.

C. Changes Impacting County Control of Waiver Policy
There are two changes from the current waiver renewal and the DHS agreement with CMS that redefine the role of counties in the administration of the waivers. The State Medicaid Agency must be the sole source of policy and direction for waivers. This responsibility may not be shared with or delegated to any other entity including counties. This has resulted in two very significant changes detailed below.

1. COUNTIES MAY NOT INSERT LOCAL POLICY IN WAIVER PURCHASE OF SERVICE (POS) CONTRACTS
The State Medicaid Agency must act as the sole authority in waiver administration; all program policy must be promulgated by the DHS, and not local agencies. The waiver provider agreements are the vehicle by which providers officially relate to the program, not via county contracts as before. The county waiver agency will retain the role of detailing fiscal transactions needed to fund services as the only remaining function for the POS contact. The use of these contracts to impose local requirements will be barred. The Department has agreed with CMS that state staff will review all such contracts to assure this requirement has been met.

2. WAITING LIST PRIORITY- SETTING AND OTHER AREAS WHERE COUNTIES MADE POLICY ARE NOW STATE RESPONSIBILITIES
The State Medicaid Agency has the obligation to assure consistent waiver policy under the authority of the Medicaid Home and Community-Base Services Waiver. Therefore, a number of revisions to the Medicaid Waiver Manual will be made in the coming weeks. The revisions will focus on the centralization of waiver authority at the state level and this will include any practices where counties were permitted to establish local waiver policy. An example of this is the current practice where, within broad state guidelines, each county may set waiting list priority criteria. The Department will work with county waiver agencies to establish a consistent wait list priority criterion that will be applied statewide.

Summary

This information memo is intended to announce and provide a brief overview of changes that will be implemented as a result of the recent waiver renewal. More detailed policy instruction will be issued using the DLTC Numbered Memo process and through revisions to the Medicaid Waivers Manual. Agencies should be alert to these forthcoming policy announcements. There are other changes that are narrower in scope and significance which the department will detail in future communications.

DHS is aware of the significance of these changes and the workload involved. Adopting the new requirements and fulfilling the waiver renewal assurances to CMS will involve significant efforts at all program levels. These changes will affect all counties that haven't yet transitioned to Family Care as the Department has assured CMS that the current waiver programs will maintain high quality and compliance with federal requirements. CMS will monitor the state by reviewing evidence that demonstrates the follow through of these quality assurance activities and oversight responsibilities by the state and counties. Please contact your assigned Community Integration Specialist (CIS) if you have any questions about any of the subjects covered in this memo.

CENTRAL OFFICE CONTACT: Ken Golden

MEMO WEB SITE: http://www.dhs.wisconsin.gov/dsl_info/

Last Revised: September 13, 2010