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DDES Memo Series 2005-19

October 19, 2005

To: 
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 Child Welfare Supervisors
County Mental Health Supervisors
County Long Term Care Coordinators

From: 
Burnie Bridge
Administrator
Division of Children and Family Services

Sinikka Santala
Administrator
Division of Disability and Elder Services

Re: Policy Guidance on Serving Children in the Children’s Long Term Support Waivers and Child Welfare Services

Document Summary

This memo provides a synopsis of the Children’s Long Term Support Waivers (CLTS) and child welfare services, with programmatic and fiscal direction for administering case management services and exceptional placement cost claiming for children enrolled in both programs.

The purpose of this memo is to describe the requirements of and provide direction on state and local claiming for administrative and service expenditures associated with the Children's Long-Term Support Medicaid Home and Community-Based Services Waivers (CLTS Waivers) and child welfare services. Attachments A & B provide an overview of the program background and philosophy, service requirements and components, and a fiscal overview for each program respectively.

This memo was developed jointly by the Division of Disability and Elder Services (DDES) and the Division of Children and Family Services (DCFS), in collaboration with county representatives, Human Services Area Coordinators and the Division of Management and Technology (DMT). The memo briefly describes related federal requirements and provides state policy related to program operation and fiscal claiming for case management or service coordination activities and exceptional placement costs when children and their families are being served in both the CLTS Waivers and child welfare programs.

Case Management Claiming for Title IV-E and Support and Service Coordination for CLTS Waivers

The federal Centers for Medicaid and Medicare Services (CMS) has established a policy related to third party liability in cases where services can be claimed to Title IV-E. This requirement states that whenever a service can be claimed to Title IV-E, Title IV-E must be payor of first resort (an exception to this is noted in "Exceptional Placement Cost Claiming " below). As such, Medicaid, whether claimed through the CLTS Waivers or through some other Medicaid program, such as Targeted Case Management (TCM), may be claimed only if the service is not covered by Title IV-E.

The CLTS Waivers generally pay AFTER Medicaid Fee for Service, however TCM is paid first by the CLTS Waiver for Waiver clients and not through Medicaid Fee for Service (exception: Children in Community Support Program (CSP) and CLTS Waiver will bill TCM to CSP, NOT CLTS Waiver).

To ensure that duplicate billing for services does not occur, if a child is temporarily being served in the Child Welfare program AND the child has been determined eligible and received a CLTS Waiver slot for which the county is also providing Support and Service Coordination, the county agency should do one of the following:

  • Have two different staff persons provide Support and Service Coordination (case management) functions where one staff person is responsible for CLTS Waiver functions and the other staff person is responsible for child welfare functions. Ensuring that:

    a. Support and Service Coordination through the CLTS Wavier is related to disability or waiver services and is performed by a staff person who is not also providing child welfare case management to address child welfare concerns.

    b. Child welfare case management is performed by a staff person who is not also providing disability or waiver-related case management for the same client or client family. This staff person is to be included in the agency's staff roster submitted as required for the Department's Social Services Random Moment Time Study (SS RMTS).

OR

  • Have one staff person provide both CLTS Waiver Support and Service Coordination and child welfare case management functions. If child welfare and CLTS Waiver case management is performed by one staff person, the county agency must ensure that claims to the Medicaid program under the CLTS Waiver are consistent with Medicaid third party liability policy. Claiming practices which meet the Department's SS RMTS requirements and ensure consistency with Medicaid third party liability are as follows:

    a. The staff person is to be listed on the agency's staff roster per the Department's direction for SS RMTS requirements and;

    b. Support and Service Coordination activities are claimed as an allowable expense under the CLTS Waiver only when the activity is directly and solely related to one or more of the services covered under the CLTS Waiver program. A list of these services is provided in Attachment A of this memo.

    c. Activities that are related to child welfare case management are claimed as an allowable administrative activity to the Title IV-E program through the Department's Cost Allocation Methodology and may not be claimed by local county agencies to the Medicaid program under the CLTS Wiaver. A list of the general case management activities that are covered by and, therefore, claimed to Title IV-E by the Department is provided in Attachment B of this memo.

Documentation of all contacts on behalf of the child and his/her family is required for both programs. Documentation of contacts should be recorded in eWISACWIS Case Notes window for child welfare services and must be documented in the Support and Service Coordinator's case notes for CLTS Waiver services. This documentation is to include the date and time of contacts, the participants in the contact, the purpose of the contact and the results of the contact. Documentation must be kept in this manner regardless of whether a county has separate program support and service coordination/case management staff for each program, or a single individual performing support and service coordination/case management for both programs. This ensures accountability to the programs' respective federal regulations.

Exceptional Placement Cost Claiming

The CLTS Waivers list "Foster Care" as a possible service. Allowable services under Foster Care for the CLTS Waivers are those supports that are supplemental for supporting a child with a disability in a foster care setting, not basic or routine expenses for general foster care services. Exceptional and supplemental foster care service costs may be claimed to the waiver if the child meets specific needs as identified in the "Determination of Exceptional Care Needs for Children in a Child Care or Foster Care Setting" checklist (Attachment C).

If supplemental and/or exceptional placement costs are determined to be appropriate for the CLTS Waiver, Title IV-E does not need to be claimed first for these costs, as the Center for Medicare and Medicaid Services (CMS) has approved this CLTS Waiver allowable service to be billed under the CLTS Waiver first.

Medicaid reimbursement claimed by the county agency under one of the CLTS Waivers for supplemental and/or exceptional placement costs must be documented in eWiSACWIS in order to offset the DHS Title IV-E claim for placement costs and prevent double-billing to both Medicaid by the county and Title IV-E by the Department. Examples of when and how to document these claims are provided in the eWiSACWIS Placement Documentation Manual as noted below.

Related Policies

  • Medicaid Home and Community-Based Waiver Manual http://www.dhs.wisconsin.gov/bdds/waivermanual/app_b.pdf
  • Rate Structure Clarification for Intensive In-Home Autism Treatment Services Under the CLTS Waivers: http://www.dhs.wisconsin.gov/dsl_info/NumberedMemos/DDES/CY_2004/ Nmemo2004-08-DDES.htm
  • CPS Investigation Standards http://www.dhs.wisconsin.gov/dcfs_info/num_memos/2000/2000-02.HTM
  • Determination of Exceptional Care Needs - Children in Child Care/Foster Care Settings (Attachment C)
  • Ongoing Services Standards and Guidelines http://www.dhs.wisconsin.gov/dcfs_info/num_memos/2002/2002-08.htm
  • Claiming TCM on Child Welfare Cases http://www.dhs.wisconsin.gov/dcfs_info/num_memos/2002/2002-09.HTM
  • Title IV-E Policy Handbook:
     http://www.dhs.wisconsin.gov/Children/TitleIV-E/index.htm
  • eWiSACWIS Placement Documentation Manual

CENTRAL OFFICE CONTACT: 
Michelle Rawlings
DHS /DCFS/BPP 1 W. Wilson St. Rm. 550
Madison, WI 53707
608.264.9846
e-mail: rawlimm@wisconsin.gov

Kristina Stuart
DHS /DDES/BLTS 1 W. Wilson St. Rm. 418
Madison, WI 53707
608.235.6636
e-mail: stuarkc@wisconsin.gov

MEMO WEB SITE: 
http://www.dhs.wisconsin.gov/partners/local.htm

cc: 
Human Service Area Coordinators
Bureau Directors
Program Office Directors/Section Chiefs
Tribal Chairpersons/Human Services Facilitators
Division of Management and Technology, Don Warnke

ATTACHMENT A
Children's Long-Term Support Medicaid Home and 
Community-Based Services Waivers
(CLTS Waivers)

Program Background and Philosophy

  • The CLTS Waivers support an eligible child with disabilities and his or her family with services in the child's home and community.
  • The CLTS Waivers are Medicaid Home and Community-Based Services Waivers (HCBS Waivers). These HCBS Waivers were started as a method for Medicaid to fund the integration of people with disabilities into the society at large, instead of funding more restrictive and costly institutional placements.
  • The CLTS Waivers were developed to provide more appropriate services and supports for children with long-term care needs; previous HCBS Waivers had been developed for adult populations.
  • The CLTS Waivers took effect January 1, 2004.
  • Children enrolled in the CLTS Waivers may receive services up to age 22.
  • There are three CLTS Waivers, which differ primarily by target population: there is one for children with developmental disabilities, one for children with physical disabilities, and one for children with mental health disabilities.
  • CLTS Waivers are operated by Wisconsin Counties; some slots are available with State funds (called state matched slots), but counties also have the ability to contribute funds for CLTS Waiver Slots (called locally matched slots).

Local Eligibility Determinations and State Approval Process

  • The child meets Level of Care (criteria differ by age of child but essentially the child must have needs that substantially impair functioning in major life area based on assessed need).
  • For State matched slots, the child must have a Disability Determination by the Disability Determination Bureau (locally matched slots do not need a Disability Determination).
  • Form DDES 919 is used to verify the child's financial eligibility (see form at):  http://www.dhs.wisconsin.gov/forms1/F2/F20919.pdf
  • For Intensive In-Home Autism Treatment Services, the child and family must meet additional criteria. Please see the DHS HCBS Waiver Manual, Chapter 4, p. 68 - 72 for additional criteria at: http://www.dhs.wisconsin.gov/bdds/waivermanual/waiverch4.pdf

Services

  • Services are developed on an individualized, child and family-centered basis. A county Support and Service Coordinator works with the family to identify supports and services that would be most beneficial for the child and family. After a plan of services is developed, the Support and Service Coordinator works with the family to help implement services as well as to assess their ongoing effectiveness. (For a full description of Support and Service Coordinator functions, please see the DHS HCBS Waiver Manual, p. 88 at: http://www.dhs.wisconsin.gov/bdds/waivermanual/waiverch4.pdf)
  • Experimental or aversive services will not be funded under the CLTS Waivers.
  • Possible Services:
    • Adaptive Aids
    • Adult Family Home (after age 18)
    • Child Care and Foster Care Services
    • Communication Aids
    • Consumer and Family-Directed Supports
    • Consumer Education and Training
    • Counseling and Therapeutic Resources
    • Daily Living Skills Training
    • Day Services
    • Home Modifications
    • Intensive In-Home Autism Treatment Services
    • Personal Emergency Response System
    • Respite Care
    • Specialized Medical and Therapeutic Supplies
    • Specialized Transportation
    • Support and Service Coordination
    • Supported Employment
    • Supportive Home Care

Case Responsibility where the child is moving to another Wisconsin County

  • If a child has a CLTS Waiver slot with local match, and the child moves to another county in Wisconsin, the original county must continue to fund that child's slot as long as the child is eligible for services or until the new county is able to provide match; this is true regardless of court order.

Fiscal Overview

  • Federal Medicaid funds are available for CLTS Waiver slots, but state or local match must be provided. The match ratio changes from year to year, but is approximately 60% Federal funds to 40% State or local.
  • State funded slots currently are available only to children receiving Intensive In-Home Autism Treatment Services (and ongoing services after a child's Intensive Services end).
  • For Intensive In-Home Autism Treatment Services slots, there is a weekly rate paid to a provider based upon the number of hours authorized.
  • For local match slots or ongoing services, services are funded based on their Individual Service Plan (ISP) costs.
  • Counties may use unmatched state funds, such as those in the Family Support Program and Community Options Program, as match to the CLTS Waivers.
  • Some counties may have a waiting list for local match slots due to a lack of available state or local match.
  • Funds are paid to counties by the DHS based on Human Services Reporting System HSRS) data submission on clients served.

ATTACHMENT B
Child Welfare Services

Program Background and Philosophy

  • The primary purpose of child welfare is to identify, assess and respond to concerns within a family that negatively affect child safety or where the child's behavior negatively affects his/her safety.
  • Child welfare services are intended to be temporary, to be delivered in the least intrusive manner, and to be family-specific.

Child Welfare Case Types and Entry into Child Welfare Services

  • Child welfare cases include families and children where the children remain in the family home or where a child in the family has been removed from his/her family.
  • These children and their families may be served on a voluntary or court-ordered basis under Ch. 48 or Ch. 938 of Wisconsin Statutes. Agency involvement may be due to concerns related to child safety or child behaviors affecting his/her safety in the community.

Services

  • Child welfare services for which federal Title IV-E reimbursement can be claimed include both administrative services as well as placement, or maintenance, cases for children placed in out of home care.
  • These administrative activities are specified within the state's CPS Investigation Standards and the Ongoing Services Standards and Guidelines. Various Administrative Rules and Policy also govern additional activities related to the Child welfare services such as foster care licensing, adoption assistance and Title IV-E.

Case Responsibility

  • Child welfare services are to be delivered until the child can be safely cared for in the family home or is placed in a safe, permanent home outside the parental home or court-ordered conditions have been met.
  • If the family moves from one county to another, continuing services may be provided through a request for courtesy supervision from the new county or a venue change of the legally responsible agency to the new county.

Fiscal Overview

  • The primary funding sources for child welfare services are federal Title IV-E, Social Services Block Grant and state General Purpose Revenue (GPR) provided through the Basic County Allocation. The other primary funding source is local county funds including required match and county over-match.
  • Other federal funding sources used for child welfare services include Title IV-B (Parts 1 and 2), Title IV-E Income Augmentation Funds, Independent Living and Kinship Care (TANF) funds.
  • The DHS claims federal reimbursement under Title IV-E for activities related to foster care and preventing out-of-home placement and Medicaid Targeted Case Management (TCM) for non Title IV-E eligible children.
  • The Social Services Random Moment Time Study (SS RMTS) facilitates the allocation of staff time and costs eligible for federal reimbursement. The SS RMTS uses a quarterly random moment time study sampling process to identify the amount of time county staff spend on job activities throughout the workday. The results of the time study are used to allocate costs related to county and Bureau of Milwaukee Child Welfare (BMCW) human/social services workers. Counties report their social services costs using the Community Aids Reporting System (CARS).
  • County agencies may also claim TCM via a fee for service basis for allowable activities provided to eligible children by agency staff as permitted by federal and state policy. The Basic County Allocation (BCA) or county tax levy may be used as a local match for TCM claiming at the local levels (See Section III).
  • Administrative services allowable under Title IV-E include:
    • Implementing and monitoring a service plan to ensure child safety;
    • Developing, implementing and evaluating the child's case plan;
    • Finding, establishing and placing a child with a placement provider;
    • Setting the rate for payment to the placement provider;
    • Developing, implementing and reviewing the child's permanency plan and;
    • Participating in court proceedings related to ensuring child safety and achieving child permanency.
    • Maintenance costs or placement costs are covered for children who have been determined to be eligible for Title IV-E for costs associated with placement in Title IV-E reimbursable facilities.

ATTACHMENT C

DETERMINATION OF EXCEPTIONAL CARE NEEDS
FOR CHILDREN IN CHILD CARE OR FOSTER CARE SETTINGS

Directions: Place a checkmark in the box for each of the needs that a child exhibits that may affect the intensity or skill level required of the provider of child care or foster care services. A child must have at least one need in Category A or B in order to be considered as a child with exceptional care needs for the purpose of either child care or foster care services under the waiver. The child's record must include documentation of the need, as well as a comprehensive medical or personal care, or psychiatric/emotional treatment plan as a result of these needs.

Category A: Emotional and Behavioral Needs:
The child must display at least one of the following characteristics and require a psychiatric or behavioral intervention plan as a result.

The child has encoporisis or enuresis during daytime hours several times per week.

The child has severe hyperactivity to the point of frequent destructiveness or sleeplessness on a consistent basis.

The child is chronically withdrawn, depressed or anxious.

The child engages in bizarre or severely disturbed behavior.

The child has a conduct or attachment disorder resulting in significant acting out behaviors.

The child runs away for long periods of time returning only as a result of intervention of others.

The child habitually creates a disturbance in the classroom or on the school bus such that there is daily parent to school contact required, the child is frequently truant , or unable to complete the school day as a result.

The child exhibits high-risk behaviors including habitual alcohol or drug use, sexually promiscuous behavior, or sexual perpetrator behavior.

 The child engages in repeated and uncontrolled social behavior resulting in delinquency status such as property offenses, assault and arson.

The child has aggressive behavior on a daily basis including biting, scratching or throwing objects.

The child engages in self-injurious behavior such as head banging, eye poking, biting, picking, or cutting.

The child has a severe eating disorder including anorexia nervosa, pica, or polydipsia.

The child is severely withdrawn or has an extreme social phobia.

The child exhibits psychotic or delusional behaviors.

The child requires 24-hour awake supervision or care.

Category B: Physical and Personal Care Needs:
The child must display at least one of the following characteristics and require a medical or personal care intervention plan as a result.

The child requires assistance with multiple personal care needs including dressing, bathing and toileting.

The child requires catherization or ostomy care.

The child must be fed, require tube or gavage feedings, or require direct supervision while eating to prevent complications such as choking, aspiration or excessive intake.

The child requires frequent care to prevent or remedy serious skin conditions such as pressure sores or persistent wounds.

The child requires suctioning.

The child has a complex and unstable medical condition that requires constant and direct supervision.

The child requires two or more hours of therapy follow-through per day.

The child requires other complex medical, medication or treatment follow through throughout the day.

The child is not mobile and requires assistance with transfers and positioning throughout the day.

The child requires 24-hour awake supervision or care.

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