DDES Memo Series 2006-07
Date: April 25, 2006
To: Area Administrators / Human Services Area Coordinators
Bureau Directors
County Departments of Community Programs Directors
County Departments of Developmental Disabilities Services Directors
County Departments of Human Services Directors
County Departments of Social Services Directors
County Waiver Contacts
Licensing Chiefs / Section Chiefs
Tribal Chairpersons / Human Services Facilitators
From: Sinikka Santala, Administrator
Subject: Special CIP II Nursing Home Diversion Funding
Document Summary
Effective on the date of this memo counties may apply for CIP II-
Nursing Home Diversion funding for up to 150 eligible individuals who are
at imminent risk of entering a nursing home. This memo provides guidelines
to counties on the process to apply for these resources.
Introduction
The 2005 Wisconsin Act 355 made changes in the statutes to allow for
the expansion of relocations from nursing homes under the Community
Integration Program II (CIP II) to include persons who are diverted from
imminent entry into nursing homes. To be eligible for these diversion
funds, a person is required to meet certain risk criteria as defined by
the Department in addition to meeting the usual functional and financial
eligibility criteria for CIP II. The statute authorizes the Department to
provide an enhanced CIP II rate for up to 150 individuals who are diverted
from imminent entry into a nursing home. This document describes the
initiative, conveys Department implementation policies related to the
initiative, and provides guidance to counties related to participation in
the program.
Background
The special Nursing Home Diversion funding will do the following:
- Modify and expand the current Community Integration Program II (CIP
II) Medicaid Waiver for elders and people with physical disabilities,
enabling the Department to provide enhanced funding above the standard
CIP II rate.
- Provide an opportunity for up to 150 individuals who are at imminent
risk of entering a nursing home to remain in the community and receive
the long-term care services they may need.
- Provide a tool for counties to serve people who would otherwise
enter a nursing home.
- Require that the Medicaid costs of serving individuals in the
community under this initiative are less than or equal to what they
would have cost if those individuals had been in a nursing home.
Participant Eligibility
To be eligible for diversion funding, an individual must meet all of
the following criteria:
- Belong to a target group served by CIP II (elderly age 65 or older
and/or have a physical disability)
- Be functionally and financially eligible for the CIP II program;
- Reside or intend to reside in a community setting that is eligible
for CIP II;
- Meet high risk criteria for imminent entry into a nursing home;
- The costs of the person's Medicaid funded community care plan must
be no greater than the Medicaid costs the person would have incurred
in the nursing home. The care must be cost-neutral.
High Risk Criteria
As a part of the diversion initiative, the Department is required to
develop and utilize criteria to determine who is at imminent risk of entry
into a nursing home. The attached High Risk Worksheet
(DDE-452)
(PDF, 78 KB) establishes that criteria. In developing the criteria, the Department
reviewed national studies, analyzed Wisconsin data and consulted with
county long-term support coordinators and staff. Factors that are
considered in the criteria include:
- Meeting an intensive skilled nursing (ISN) level of care;
- Facing an imminent loss of current living arrangement;
- Having a fragile or insufficient informal caregiver arrangement;
- Having a terminal illness;
- Having multiple other factors that are associated with nursing home
entry as specified in the attachment.
The criteria and worksheet to determine the imminent risk of entering a
nursing home is the same for these diversion funds as for the funding that
becomes available for diversions under the Community Relocation
Initiative.
Wait List Management Tool
While people are not required to be on the county's wait list, county
COP Waiver agencies are encouraged to use the attached high risk criteria
to determine whether there are people waiting for community services that
may meet the high risk criteria and may be at risk for entering a nursing
home.
Funding Availability
The availability of funding for nursing home diversions presumes that
the individual would be served by Medicaid in the nursing home. The
availability of funding will be limited to 150 persons on a first come
first served basis as long as cost neutrality can be maintained as
described above. If additional funding becomes available to serve more
than the 150 people, these same policies and procedures will apply.
1. First Come First Served. Funding will be awarded to the first 150
applications for individuals who are determined eligible and whose care
plan meets budget neutrality criteria. No requests for funding will be
accepted before the effective date in this memo.
2. Funding Available. The Department is using its experience with the
Community Relocation Initiative to establish the cost neutrality threshold
for this funding. The average nursing home daily Medicaid cost in the CIP
II - Community Relocation is $127 (includes nursing home per diem and
other Medicaid card costs). After allowing for Medicaid card costs in the
community and the seven percent waiver administration allowance, the
maximum waiver per diem is $85. Only waiver care plans that are less than
or equal to this per diem will be approved for this funding.
3. Room and Board Costs. Federal rules prevent the use of Medicaid
Waiver to pay for room and board costs in adult family homes (AFHs),
community based residential facilities (CBRFs), and residential care
apartment complexes (RCACs). These include costs associated with items
such as rent, building depreciation, building and/or grounds maintenance,
resident food, resident phone, cable, and utilities.
4. Covering Increased Costs. If the waiver care plan costs for an
individual increases, the county may request additional funds from the
Department. If the Department determines that the increased costs are
necessary for the individual's health and safety and if sufficient funds
are available at the state level within this program, the county may
receive increased funding for the individual.
Diversion Funding Approval Process
The following outlines the approval process for applications:
1. A person in the community expresses an interest in receiving their
long-term care services in the community in lieu of an imminent move to a
nursing home.
2. The county determines that the individual is both functionally and
financially eligible for CIP II, including the completion of a long-term
care functional screen and MA eligibility determination.
3. The county determines that the person meets the high risk criteria (DDE-452)
(PDF, 78 KB).
4. The county determines that the person satisfies all other funding
criteria, if applicable, including:
a. Five CBRF placement conditions, including the pre-admission assessment;
b. CBRF variance approval if facility is larger than 20 beds;
c. CBRF maximum amount;
d. RCAC maximum amount of waiver reimbursement;
e. County contract criteria.
5. The county submits to The Management Group (TMG):
a. The individual's community care plan (where waiver costs do not exceed
$85 per day); and
b. The High Risk Worksheet (Attachment #1) which provides documentation
that the individual meets the criteria for imminent entry into a nursing
home.
6. TMG will review the waiver application packet as it does for all
applications. In addition, it will look for consistency among the long
term care functional screen, assessment and the High Risk worksheet. If
approved, TMG will forward the request to the Community Options Section in
the Bureau of Long Term Support (BLTS).
7. BLTS reviews the submitted documentation to assure cost neutrality,
and if approved, will issue a letter indicating an intent to award
funding.
Disposition of Funding When Person Leaves the Program
If an individual funded under this initiative leaves the program
permanently (i.e., the person dies, moves into a nursing home permanently,
leaves the state or is no longer eligible), the funding will be returned
to the Department. The funding will be used for additional diversions not
to exceed 150 individuals at any one time. The Department will notify COP
Waiver agencies when community care plans for 150 individuals are approved
and whether additional funding will be available.
REGIONAL OFFICE CONTACT: OSF/Human Service Area Coordinators
CENTRAL OFFICE CONTACTS:
Lisa Kelly
Bureau of Long Term Support
P.O. Box 7851
Madison, WI 53707-7851
(608) 267-3659 phone
(608) 267-2913 fax
kellylm@wisconsin.gov
Irene Anderson, COP/Waiver Supervisor
Bureau of Long Term Support
P.O. Box 7851
Madison, WI 53707-7851
(608) 266-3884 phone
(608) 267-2913 fax
anderil@wisconsin.gov
MEMO WEB SITE: http://www.dhs.wisconsin.gov/partners/local.htm
Attachment: Criteria for High Risk of Nursing Home Admission-High
Risk Worksheet (DDE-452) (PDF, 78 KB)
cc: The Management Group (TMG)
Independent Living Center Directors
County/Tribal Aging Directors
Area Agency on Agency Executive Directors
Wisconsin Association of Homes and Services for the Aging, Inc.
Wisconsin Health Care Association
Wisconsin Assisted Living Association
Residential Services Association of Wisconsin
Board on Aging and Long Term Care
Coalition of Wisconsin Aging Groups
Disability Rights Wisconsin
PDF: The free Acrobat Reader® software is
needed to view and print portable document format (PDF) files. Learn
more.
Last Revised: September 13, 2010 |
