DDES Memo Series 2006-14
Date: July 25, 2006
To: Listserv
For: 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
Licensing Chiefs / Section Chiefs
Tribal Chairpersons / Human Services Facilitators
From: Sinikka Santala
Administrator
Subject: Charge
Back Rate for Individuals Residing at a State
Center for persons with a Developmental Disability
Supersedes 96-03, 97-05, 99-10, and 99-10A
Document Summary
This memo revises memo series 99-10A, and provides new procedures and
updated information regarding the $48.00 a day charge back rates for
individuals residing at a state center for persons with developmental
disabilities, and will be effective on June 1, 2006. It describes
increased expectations for guardian interaction, and expands criteria for
granting appeals based on guardian resistance to considering community
placement. Guardians are expected to be knowledgeable and involved in the
life of the person to be able to make decisions on their behalf, regarding
living in the most integrated setting. Guardians need to maintain active
involvement and annually state their reasons for being hesitant about
relocating the person to a community based setting. Counties may still
avoid charge back when guardians are resistive, if new criteria are met.
Background
The philosophical and programmatic approach of the Division of
Disability and Elder Services (DDES) is that individuals with
developmental disabilities and their guardians should have real choices
about where and with whom they live and what kind of services they
receive. It is also the legal obligation of the Division to ensure that
individuals with disabilities have opportunities to live in the most
integrated community settings. We want to ensure that individuals who
reside at the State Centers for persons with developmental disabilities
have these opportunities. One way to do this is to conduct regular reviews
of community care needs and costs of residents who still live at the
Developmental Disabilities (DD) Centers. Counties are expected to pursue
community placements of all state DD Center residents with cooperation and
involvement of parents/guardians. Previously, implementation of the
chargeback was waived upon evidence of guardian non-acceptance of
community placement. It is the intent of DDES to continue charging
counties $48 per day for individuals who remain in a state Center, unless
sufficient documentation is presented that demonstrates that the guardian
is actively involved in the life of their ward, and has current knowledge
of community residential options and available supports and services.
Authority
The Department of Health and Family Services has implemented a charge
back to the county agency for $48.00 a day, since 1996.
This applies to an individual residing at a state center for persons with
developmental disabilities who is also eligible to receive Home and
Community Based services and supports, and for whom there is adequate
state and federal funding to provide such community services. Authority
for this exists in s. 51.437(4rm) 3, Wis.Stats. The charge back is
considered in conjunction with each biannual Utilization Review conducted
at each Center by an independent professional review team.
(1) "County agency" means one of the following:
(a) A county department of developmental disabilities services
established under s. 51.437, Stats.
(b) A county department of community programs established under s.
51.42, Stats., or, if under s. 51.437(4g)(b), Stats., the county board
of supervisors has transferred the powers and duties of the county
department of developmental disabilities services to the county
department under s. 51.42, Stats.
(c) A county department of human services established under s.
46.23, Stats.
(2) "Department" means the Wisconsin Department of Health
and Family Services.
(3) "Independent professional review" means an on-site
utilization review that occurs at least every six months of each person
residing at a state center for persons with developmental disabilities
by one or more independent professional review teams under 42 USC
1396a(a)(31) and 42 CFR 456 Subpt. F.
(4) "Medical Assistance" (MA) means the assistance program
operated by the department under ss. 49.43 to 49.47 and 49.49 to 49.497,
Stats.
(5) "Eligible for home and community based waivers" means
an individual residing at a state center for persons with developmental
disabilities whose care needs are deemed by an independent professional
review as allowable for continuing to receive MA/Title XIX care and
treatment in the institution, while also being considered and eligible
to receive community based services and supports through the State's
Community Integration Program (CIP1A).
(6) "Secretary" means the head of the department or
designee.
(7) "State center for the developmentally disabled" or
"center" means a department-operated residential institution
or intermediate care facility (ICF) providing care of persons with a
developmental disability.
Independent Professional Review Process
The independent professional review is completed every six months at
each Center by an external team consisting of a physician and Qualified
Mental Retardation Professional (QMRP). The Division of Disability and
Elder Services' standardized Utilization Review (UR) system will generate
information to be reviewed by this external team in developing their
determination. The independent professional review team under 42 USC 1396
a (a)(31)(A) and 42 CFR 456 Subpt. B, determines whether a person is
appropriate for continued stay at the State Center, and because this
status also makes them eligible to receive home and community based
services through CIP1A waiver, implies the need for initiating
transitional planning.
Costing Out Process
Estimated support needs of each person currently living in the Center
is based on availability of county-specific services and historical
average costs, in specific program categories, as submitted to the Human
Services Reporting System (HSRS) by each county. Given the differences in
needs and costs among individuals, conservative cost estimates have been
made in order to focus on individuals who are clearly able to return to
their communities with available state and federal funding.
Counties may find it useful to update (or complete) a Long Term Care
Functional Screen for each person residing in a DD Center, in order to
arrive at a standardized description of each person's needs and
functioning levels, that are consistent with individuals residing in
community settings.
Notification to Counties
County agencies will receive written notification of each individual's
charge back status, as determined by the independent professional review
team, within 45 calendar days of the completion of each biannual
utilization review and when community support costs are projected to be
within the level of available state and federal funding. This "letter
of intent to chargeback" will serve as the formal notice to the
county agency of the intent to charge $48.00 a day. This notification will
occur each time an individual is found able to return to their community
with available state and federal funding.
Appeal Process
The process for appealing the determination of the independent
professional review is under Chapter HFS 86 of the Wisconsin
Administrative Code (Appealing Independent Professional Review
Determinations at the State Centers for persons with developmental
disabilities). This section provides the exclusive procedure through which
a county agency may appeal an independent professional review
determination that would result in billings. The appealed decision, under
this section, is final and not subject to further hearing, appeal or
judicial review.
A county agency must file a written appeal to the Administrator of the
Division of Disability and Elder Services (DDES) within 60 calendar days
of formal notice to the county agency of the intent to charge back $48.00
a day of the full Medical Assistance rate (100%). An appeal may be filed
by mailing it to: Administrator, DDES, 1 West Wilson Street, Room 418, P.
O. Box 7851, Madison, Wisconsin 53707-7851. An appeal is considered filed
upon receipt. No appeal will be considered if submitted later than the
prescribed 60-day appeal time period. Each county is responsible for
knowing each guardian's degree of involvement with the individual ward and
their preference for community placement for their ward and to proceed as
directed by that knowledge in a timely manner within this 60-day period.
DDES may grant extensions to appeals, under special circumstances. (For
example, lack of staff, due to significant turnover to prepare appeals,
would be an example of when a county could ask for a 60-day extension.)
Criteria for Appealing Chargebacks
Counties should submit associated documentation for each selected type
of appeal per individual per utilization review (UR) (charge back cycle).
Counties can appeal the chargeback based on parent(s)/guardian resistance
to placing the person in the most integrated community setting, or if the
community support plan cost exceeds the current available funding.
Every written appeal must contain all of the following:
- A copy of the court order from the most recent Watt's review;
- A written description of the basis upon which the county agency
contests the Independent Professional Review determination or the
daily $48.00 chargeback billing decision; and
- Any other documentary evidence the county agency wishes to submit in
support of the appeal.
Guidelines for Appealing Based on Guardian Resistance
The county agency must also provide the following additional
documentation at the time of an appeal based on the parent(s)/guardian
resistance to considering community placement:
A) A written statement, signed by the parent/guardian within the last
12 months, stating the reason(s) for their opposition and/or hesitancy
in considering community placement. This statement may be in any form
which a county deems appropriate;
B) Documented descriptions of actions taken by the county agency to
ensure that the parent(s)/guardian has current knowledge of community
service and support options; and
C) Documented descriptions of guardian involvement that is sufficient
to reasonably believe that they are well aware of their ward's needs and
strengths to make decisions that are related to that individual's
current needs.
The parent/guardian can make the best decisions and fulfill their
responsibilities when they have accurate and current knowledge of the full
range of possible residential options and community supports. Sufficient
knowledge is attained when the parents/guardians have current, appropriate
information about community options.
Written documentation/evidence of this knowledge would typically
include at least two of the following, which have occurred within
the previous 12 months:
- Parent/guardian (and, if appropriate, the individual consumer) has
visited one or more potential community residential settings.
- Parent/guardian (and, if appropriate, the individual consumer) is
aware of the current community supports and options available, to
allow the individual to successfully transition to community
residential living. Note: This may include such things as receiving
descriptions of health care options, lists of residential providers or
day service programs, which may be sent by counties or providers.
- Parent/guardian (and, if appropriate, the individual consumer) has
engaged in discussions with county personnel (e.g., direct caregivers,
support services coordinator, human service directors) about the
feasibility of any special environmental or personalized adaptations,
and individual's preferences that would be necessary for a successful
transition.
- Parent/guardian (and, if appropriate, the individual consumer) is
accompanied by officials from the State Center, the county and/or
community residential provider(s) when they visit any community
residential setting. The results of the visit are documented in county
files and included in the request to waive the county chargeback.
Written documentation that is sufficient evidence of parental/guardian
involvement would typically include at least two of the following,
which have occurred within the past 12 months:
- Parent/guardian has visited the individual at the DD Center.
- Parent/guardian has made telephone calls, emails, letters, and/or
meetings with the individual and/or professionals from the
Interdisciplinary Team.
- Individual has completed a home/family visit.
- Parent/guardian has participated in the person's most recent Annual
Review process.
- Parent/guardian has initiated contact with their ward at the time of
an important life event. Note: This may include the individual's
birthday, graduation, events of religious/spiritual significance, a
new job, a move, or other important life events that have been
acknowledged with a card, letter, call or some other appropriate form
of recognition. Documentation of the above can be in the form of
copies of informal case notes, email, and etc.
Appeal Review Process
The appeal will be reviewed by a team consisting of representatives of
DDES, as delegated by the Administrator. These individuals shall make a
recommendation relevant to the validity of the appeal to the Administrator
of the Division of DDES.
The appeal will be decided by the Administrator of DDES, or a designee.
The basis for the decision will be solely on any written material
submitted by the county agency; except that the Administrator, or
individual(s) delegated to the appeal review, may consult with one or more
members of the independent professional review team, center staff, or
other individuals familiar with the particular individual, regarding any
issue raised by the county agency. The Administrator will issue the appeal
decision in writing within 45 calendar days of receipt of appeal.
In cases where the Administrator does not grant the appeal, or if the
county agency did not appeal the decision, the Department shall proceed to
bill the county agency for $48.00 a day of the full (100%) rate paid by
Medical Assistance for the person residing at the Center.
The Department will notify the county by a formal notice of intent
to bill. Billing will begin 180 calendar days from the date the formal
notice is received by the county agency from the Department. (Note: the
180 calendar days does include the time covered during the actual
appeal process.)
In cases where the Administrator grants the county's appeal, the county
agency will not be billed, until the next UR cycle, at which time the
conditions for implementing a chargeback will be reviewed again, after a
determination is made by the individual review team.
An appeal based on parent(s)/guardian resistance to placement may be
postponed if the next Watts review will occur before the charge back
begins. If, at the hearing, the court orders the person to remain at a
Center, the appeal would be granted. If the court ordered the person to
return to the community, the 180-day period would begin on the date of the
court's notice to the county agency.
The county agency is expected to be proactive and ask for a court
hearing, if necessary (Watts review). The county agency is also
responsible to provide documentation to the Administrator, Division of
Disability and Elder Services, as to the results of the Watts review
within 30 calendar days following the Watts review. The county is
responsible to submit, in writing, any changes in the court date for the
Watts review. Without any type of notification to the Division, or
requests for a billing extension, billing will start 180 calendar days
from the county's originally submitted court date. This documentation will
be submitted to the Division of Disability and Elder Services, Bureau of
Long Term Support, Attn: Developmental Disabilities Services Section, 1 W.
Wilson Street Room 418, PO Box 7851, Madison, Wisconsin 53707-7851.
If the Watts review is scheduled to occur during the next UR charge
back cycle, no additional notice(s) will be sent to the county. No billing
responsibility is incurred by the county during that time until the Watts
review occurs.
Each county can choose to appeal or not appeal for one or both of the
appeal reasons, within the prescribed 60-day period following each UR
charge back cycle. If a county chooses not to appeal, that same county
could exercise its right to appeal following the receipt of the next
independent review determination regarding an individual, within the
60-day period.
If the "new" appeal is then upheld, the county's billing
responsibility for an individual will end on the date the appeal was
granted. If the "new" appeal is denied, the county's billing
responsibility would continue for as long as the individual remains at the
Center and there is no change in circumstances that would preclude or
contra-indicate continued transition planning.
Delay in Billing Start Date or Request for Extension of Billing
Period
The Department may delay the effective date of the $48.00 a day charge
back up to 60 calendar days (no additional extensions are allowed under
administrative rule) for a person whose plan for community services has
been approved by the Department, but is waiting implementation. The county
agency must make this request including the reason(s) for the delay, in
writing to the Administrator, Division of DESS, 1 West Wilson Street, Room
418, P.O. Box 7851, Madison, Wisconsin 53707-7851. Note: special
consideration may be given to situations in which a guardian has been
newly appointed within the last year or other similar situations.
Payment Process
No charges will be incurred by a county if a person is moved within 30
calendar days of the billing start date. No charges will be incurred by a
county for the month in which a person moves to their community. Payment
is due from the county agency within 60 calendar days of the billing date,
subject to provisions of the contract between the Department and the
county agency. The Department of Health and Family Services will begin
billing the county in the amount of $48 per day, as the specified charge
back penalty if a county has not moved the individual into a community
setting within the 180-day grace period.
If, within 60 calendar days of the receipt of the bill, the county has
not forwarded to the Department a check in the amount billed, the
Department will deduct the specified amount from the CARS funding that the
State provides to the county in question. Billing will continue until such
time as the individual is moved into the community or has estimated costs
that rise above the available CIP1A rate, or the individual's health
status changes significantly enough to warrant a delay in planning for
community transitioning.
REGIONAL OFFICE CONTACTS:
Assistant Area Administrators
CENTRAL OFFICE CONTACTS:
Michael Linak
DDES/BLTS/Developmental Disabilities Services Section
(608) 266-1140
cc: BLTS-CIS Field Staff
MEMO WEB SITE: http://www.dhs.wisconsin.gov/dsl_info/
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Last Revised: July 12, 2010 |
