DLTC INFO MEMO 2009-02
STATE OF WISCONSIN
Department of Health Services
Division of Long Term Care
DLTC Information Memo Series 2009-02
Date: May 4, 2009
Index Title: Wait List Criteria and First Come First Serve Requirements
To: Listserv
For: Area Administrators / Human Services Area Coordinators
Area Agencies on Aging
County Aging Units / Directors
County COP Coordinators
County Department of Community Program Directors
County Departments of Developmental Disabilities Services Directors
County Departments of Human Services Directors
County Departments of Social Services Directors
County Waiver Coordinators
County DD Coordinators
Children's Long-Term Support Lead Contacts
Independent Living Centers
Tribal Chairpersons
Human Services Facilitators
From: Fredi-Ellen Bove
Interim Administrator
Subject: PRELIMINARY REVISIONS TO THE STATEWIDE WAIT LIST CRITERIA AND
FIRST COME FIRST SERVE REQUIRMENTS RELATED TO THE MEDICAID HOME AND
COMMUNITY-BASED SERVICES WAIVERS
Document Summary
This memo modifies and rescinds any local policies related to wait
list management that were created under discretion previously delegated to
county waiver agencies for the Medicaid Home and Community-Based Services
Waivers. This includes the Brain Injury Waiver, the Children's Long-Term
Support Waivers, the Community Integration Program (CIP I); and the
Community Options Program-Waiver/Community Integration Program II
(COP-W/CIP II). This memo replaces these local policies with a single,
consistent statewide policy to manage Medicaid Waivers wait lists. These
preliminary changes are consistent with Centers for Medicare and Medicaid
Services (CMS) requirements for statewide policies and procedures related
to the Medicaid Waivers. State Quality Assurance staff for each of the
Medicaid Waivers are available to assist county waiver agencies with the
application of the revisions set forth in this memo, especially with
respect to the impact on an individual consumer.
This memo is one of a series of administrator's memos that detail
changes in the way the Medicaid Home and Community-Based Services Waiver
Programs will operate to comply with federal requirements for these
waivers. These policies apply to the Brain Injury, Children's Long-Term
Support, Community Integration Program and Community Options Program
Waivers. These changes are necessary to assure that Wisconsin's Medicaid
waivers comply with federal regulations and are part of a multi-year
effort mandated by the U.S. Congress to improve the quality and
accountability of federal oversight of Medicaid waiver programs.
State administrative authority is one of the six assurances applied by
CMS to all waiver programs. Local policies that were previously permitted
in response to unique local conditions are no longer permitted; instead,
policies must be consistent on a statewide basis. The remainder of this
memo details the statewide policy and effect of this change related to
wait lists for each of the Medicaid waivers.
WAIVER WAIT LIST MANAGEMENT POLICY CHANGES
CMS requires the State Medicaid Agency to assure consistent, statewide
policies under the authority of the Medicaid Home and Community-Base
Services Waiver. This means that the Department must establish a uniform
process and centralized, statewide priorities for the order of serving
people from waiver wait lists. Thus, the wait list policy requirements in
both the Medicaid Waivers Manual and the COP Guidelines have been
rescinded and replaced by policies that conform to the federal
requirements for the waivers. County policies established in County COP
Plans and approved by the Long Term Support Committee may no longer be
applied to individuals applying for waiver services from these waiver
programs.
The updated waiver wait list management policy incorporates most key
provisions that were developed by counties and long-term support
committees under previous policy options set forth in the Medicaid Waiver
Manual. In compliance with Federal regulation, the wait list will be
managed on a first come, first serve basis with exceptions made for crisis
and urgent situations as outlined in this document. There will also be a
variance process to address an individual's unique situation that is
comparable to crisis or urgent criteria. This will also provide a
transitional process for consumers promised services based on current
policies for the remainder of 2009.
Each county waiver agency is expected to make a good faith effort to
implement immediately these policy revisions and work with State quality
staff to address any unique consumer circumstances created as a result of
this change. State staff will work with all county waiver agencies still
operating Waiver programs to ensure an orderly transition to the new
policies.
The following describes further changes in wait list management policy.
These descriptions are also located in Section 1.06 of the Medicaid Waiver
Manual.
Wait lists for assessments and service plan development:
County waiver agencies are permitted to establish a wait list for
individual assessment and individualized service plan development when
the agency has expended all available funds. However, DHS reminds
county waiver agencies that all waiver applicants must be offered
timely Medicaid financial and functional eligibility determinations
using the appropriate Long-Term Care Functional Screen or Brain Injury
eligibility criteria.
Waiver agencies may estimate the likely cost of the services the
person needs and would receive if funds were available. If the person
is placed on the waiver wait list for this purpose, the cost of the
services needed must both be estimated and applied to this person.
Wait Lists for Waiver Service Funding:
The Manual discusses the permissible circumstances in which a wait
list for waiver funding may be established. The circumstances under
which a county waiver agency is permitted to place people on wait
lists are revised as follows:
The provisions of Section 1.06 A (1) which permit the person to
be placed on the wait list are:(1) if the cost of providing the
community services identified in the assessment will cause the
agency to exceed local, state and federal funds available and (2)
the provision permitting the waiver agency to not serve the person
in order for the county to comply with that county's significant
proportions quota. (Retained)
The provisions of Section 1.06 A permitting wait list placement
(1) if the person's costs exceed the allowable average of COP
costs with a denied variance and (2) in response to a locally
established limit on service expenditures. These policies on
allowable COP costs are incompatible with the CMS requirement that
the state must ensure that all assessed needs of each participant
served must be addressed. (Rescinded)
The provisions in Section 1.06 A (2) d. of the Waiver Manual
that permitted the county waiver agency to place a person on the
wait list if the cost of meeting the support and service needs
identified in the assessment would cause the agency to exceed a
locally established limit on service expenditures is rescinded.
Counties may not establish local policies that are not applied
statewide by the State Medicaid Agency. Local fiscal limits on the
cost of services may no longer be used as a reason for moving or
not moving people who are on the wait list. (Rescinded)
Section 1.06 B. of the Waiver Manual, the procedures for placing
persons on county wait lists is unchanged. Specifically, the need
to make a preliminary determination of financial and functional
eligibility, the requirement that the need for long term care
services must also be established, the need to document contact
with the person or other referral source, the need to document the
date the applicant was/is placed on the wait list, the requirement
to update the wait list every six months and the requirement to
provide each applicant/participant notification of her/his status
on the wait list. (Retained)
The policy provisions in Section 1.06 B (5) that requires that
waiver participants from one county who move into another county
must continue to be placed on the wait list for services of the
county to which he or she moved while funding for their service
plan from his or her county of origin continues. (See Chapter
II-Section 2.08). The funding that was used to finance that
person's services must move with him or her no matter where he or
she locates in Wisconsin. The money must follow the person so that
access to the waiver is not affected by a move. These individuals
must be given the same priority as all other individuals on the
wait list and cannot be passed over in favor of other county
residents on the basis of length of tenure. (Retained)
The provisions described above are the only permissible reasons
for someone to be placed on the waiver wait list. County waiver
agencies may not create any unique local reasons for placing
people on the waiver wait list. The requirement for people on the
list to be registered on HSRS, as described in Section 1.05, is
unchanged.
Changes in the Procedures used for Serving Persons from County Wait
Lists
This entire section of the Waiver Manual (Section 1.06 (C.)) is
rescinded. This is to address CMS-mandated changes related to
statewide policies. As previously stated, the Department is no longer
able to delegate substantial policy discretion to county waiver
agencies.
Specifically, there is no longer a need to seek guidance and approval
from the local COP or Long-Term Support Committee in establishing
priorities for movement off waiver wait lists. DHS has incorporated
key principles used by many counties in the policies for waiver wait
lists to avoid major disruptions in county operations and consumer
expectations. The most basic of these principles is the expectation
that people must be served on a first-come, first-serve basis unless
specific state-level criteria such as urgency/crisis situations are
met. Specifically, individuals are placed on the waiver wait list
based on the date of the person's application or referral for waiver
services.
When waiver resources become available to serve someone, the
individual who is the next person on the wait list must be offered the
opportunity to receive Medicaid Waiver Services, unless a person
meeting the urgent or crisis need criteria is served in advance of the
next person on the wait list. When serving persons from the wait list
the following requirements apply:
The individual must receive the services needed according to his
or her current assessment.
High cost of a person's needs cannot be used as a reason to
bypass the person to serve someone with lower projected costs.
When full funding is not available for the next person on the
list, the agency must wait for necessary funds to be available to
assure the health and safety of the participant.
Funds that are designated for a specific purpose such as one
time expenditures are exempt from this process.
Once service funds are available, the application, eligibility
and planning process as described in Chapter VI of the Manual
occurs for that person on the list.
Exceptions to the First Come, First Serve Requirements:
Urgent/Crisis Needs The only exception to the first come first serve
policy is when someone meets one of the urgent/crisis need criteria
that permit county waiver agencies to bypass others on the list. These
criteria are the only ones waiver agencies are permitted to use. The
permissible reasons a person can bypass the wait list and be served
out of first come, first serve order follow:
Emergency or crisis conditions are present in the person's life
situation. The need shall be classified as emergency if an urgent
need for as determined by any of the following: o Substantiated
abuse, neglect or exploitation of the individual in the person's
current living situation;
The death of the individual's primary caregiver or the
sudden inability of that care giver/ support person to provide
necessary supervision and support and lack of alternative
primary caregiver;
The lack of an appropriate residence or placement for the
individual due to the individual's loss of housing;
The person has a documented terminal illness and has a life
expectancy of less than six months based upon the medical
opinion of professionals appropriately qualified to make such
a determination; or
A sudden change in the individual's behavior or the
discovery that the individual has been behaving in a manner
that places the individual, the people with whom the
individual shares a residence or the community at large at
risk of harm.
A finding by the county waiver agency that there is jeopardy to
the health and safety of the individual due to the primary
caregiver's physical or mental health status;
A finding by the county waiver agency that other, emergency or
urgent conditions exist that place the individual at risk of harm
and a variance is approved by state quality assurance staff; or
The person is at imminent risk of a more restrictive placement
in an ICF-MR or nursing home.
When the waiver agency uses one of these criteria to bypass the
list, the county must request a variance and receive approval from
the appropriate state quality assurance staff prior to initiating
services and waiver eligibility. This can be done prior to, or as
part of, the service plan submission process. The county waiver
agency, with a wait list, must have documentation of the request
and the approval in the file. This will be a subject of monitoring
by auditors and state staff record reviews.
Summary and Effective Dates
This memo announces a change in the way that waiver wait lists are
managed in Wisconsin. It discusses the notable changes and the reasons for
these changes. This memo is supported by Waiver Manual releases detailing
how County waiver agencies must manage wait lists. County agencies should
begin to implement these changes upon receipt of this memo and must come
into full compliance within sixty (60) days of the Manual Release that
will follow this memo.
The Department is receptive to addressing questions and comments on
this policy. Please address comments to the contacts below.
REGIONAL OFFICE CONTACT:
Human Services Area Coordinators and Regional Waiver Quality Assurance
Staff
CENTRAL OFFICE CONTACT:
Beth Wroblewski (608) 267-5139 beth.wroblewski@wisconsin.gov
MEMO WEB SITE:
http://www.dhs.wisconsin.gov/dsl_info/
Last Revised: September 13, 2010 |
