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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

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Last Revised: September 13, 2010