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DLTC Memo Series 2010-11

STATE OF WISCONSIN
Department of Health Services
Division of Long Term Care

DLTC Numbered Memo Series 2010-11
Date:
October 14, 2010
Index Title: Setting an MCO Enrollment Date for People Relocating from Nursing Homes

To: Listserv

For: Aging and Disability Resource Centers
Managed Care Organizations
IRIS consultant Agency

From: Susan Crowley
Administrator

Subject: Setting an MCO enrollment date for people relocating from nursing homes in counties with a waiting list

Document Summary

The purpose of this memo is to establish the policy that guides ADRC and MCO action when a resident of a nursing home requests to relocate before a Family Care county is at entitlement. This memo does not apply to ICF-MR relocations or to relocations necessitated by a facility closure, both of which follow other protocols.

Background
A basic premise of Wisconsin's community based long term care programs since their inception has been to foster consumer choice of living arrangement. The Community Relocation Initiative begun in 2005 provided the opportunity for over 3,000 institutionalized residents to return to the community by allowing Medicaid funding to "follow the person" to a "waiver-allowable" living arrangement. Family Care further improved the system by eliminating artificial barriers of setting by combining institutional and community based funding to support people wherever they chose or needed to live by including nursing home care within the Family Care and Partnership benefit package.

In addition, the Supreme Court Olmstead decision stated that residents in institutions be given the same opportunity for community care as community dwelling individuals in need of long term care. Further, the federal government expected that where there were waiting lists, people in institutions would be served at the same pace as those not in the institution. These principles are the basis for this policy regarding nursing home relocations in Family Care, Partnership and IRIS.

Applicability
This memo applies to the enrollment of nursing home residents in the following situation:

  • The nursing home is in a county served by Family Care, Partnership or IRIS programs where there is a waiting list while the county is in transition to entitlement;
  • Medicaid is paying for any part of the person's nursing home stay;
  • The person is eligible for his/her preferred program;
  • The person is not able to leave the nursing home without the long term care supports and services available from a managed long term care program or IRIS.
  • The person may or may not be on the waiting list.

Policy
Residents of nursing homes seeking to enroll in Family Care or Partnership will be enrolled in the Managed Care Organization (MCO) of their choice no later than four (4) weeks from the date of their enrollment counseling session with the Aging and Disability Resource Center (ADRC).

This policy allows an MCO to set a general policy of accepting enrollment dates for nursing home residents any time prior to four weeks. For example, an MCO may prefer the ADRC/consumer set the enrollment date for as soon as the day following the signing of the enrollment form.

Implementation
When a nursing home resident who meets the above criteria comes to the attention of the ADRC, the ADRC will confirm financial eligibility, determine functional eligibility, and provide enrollment counseling. When the person selects a benefit package (Family Care, Partnership, PACE) and a managed care organization, the ADRC will discuss with the consumer various factors that contribute to selecting an appropriate enrollment date for that individual. These factors might include the person's readiness to relocate (e.g., the person's medical condition is sufficiently stable); and, the financial implications of any date chosen (e.g., cost share).

The ADRC will indicate to the consumer that the MCO enrollment date will be four weeks from the date of the consumer/ADRC consultation (unless the MCO has chosen a different timeframe as a general policy). This advance notice is intended to give the MCO some time to prepare for the relocation before having to assume the cost of the nursing home care.

The ADRC will complete the enrollment form including the enrollment date. The ADRC notifies the MCO immediately of the new enrollee, the enrollment date and any other information helpful to relocation planning. Also, the ADRC is to notify the appropriate member care quality specialist within the Office of Family Care Expansion that a nursing home resident intends to become a member and relocate, the planned enrollment date and the facility where the person is residing.

If the nursing home resident prefers to relocate sooner, and if the MCO can arrange an earlier relocation date, the MCO will notify the individual and the ADRC, and the ADRC will revise the date on the enrollment form and re-submit the form to the local income maintenance agency or CAPO, whichever is processing the enrollment.

If the individual selects IRIS as his/her program choice, the standard IRIS referral process applies. In addition, the ADRC is to notify the Division's IRIS program manager of each nursing home resident referred to the IRIS Consultant Agency (ICA). The person will be able to relocate once their IRIS service plan is approved. IRIS is a home and community based waiver and cannot support a resident while in an institution.

When an MCO accepts an enrollment date four weeks from referral, the MCO is expected to contact the consumer as soon as possible to begin relocation planning. At a minimum, the MCO must have an initial in-person meeting with the resident within two weeks after the referral date. All other requirements for MCO activity remain the same as outlined in the MCO contract.

If a resident is seeking to relocate to a county outside the MCO service area serving the nursing home, the enrollment date would be the date the person established residency in the new county.

Effective Date
This policy and procedure is to be implemented no later than November 1, 2010.

The provisions contained in this numbered memo will be incorporated into subsequent contracts for MCOs and ADRCs.

REGIONAL OFFICE CONTACT: ADRCs - Contact ORCD Regional Quality Specialist
MCOs - Contact OFCE Contract Coordinator

MEMO WEB SITE: http://dhfs.wisconsin.gov/dsl_info/

cc: Area Administrators / Human Services Area Coordinators
Area Agencies on Aging
County Aging Unit 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
Independent Living Centers
Human Services Facilitators
Tribal Chairpersons

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