DODD Waiver Transition
Waiver Transition Memorandum
March 19, 2007
From: Tracy J. Williams, Deputy Director
Subject: Clarifications Regarding the Waiver Transition “Pause”
The Department first announced implementation of the “pause” in the February 21, 2007 issue of its on-line newsletter, Pipeline. The purpose of this memorandum is to clarify which activities should pause as the Department proposes possible improvements to the existing system. Any changes proposed by the Department must be approved by the federal government.
Information in this memorandum is intended to replace information contained in the ‘Pause’ Frequently Asked Questions website that was posted by ODMRDD in late February. A copy of this memo and any subsequent clarifications may be accessed via the Department’s homepage at www.mrdd.ohio.gov.
Purpose of the “Pause”
The MRDD system continues to wrestle with several significant issues related to the reimbursement transition that were not contemplated in the new system’s design and development. While possible in theory, the new system which requires providers to calculate homemaker/personal care service ratios for each 15-minute billing unit is proving to be complex and overwhelming to implement for individuals receiving services in congregate settings. This increases the risk for audit findings, stakeholder dissatisfaction and, ultimately, consumer access. This situation, coupled with several elements of the new system not yet approved by federal authorities (e.g., adult foster care service & daily rate, homemaker personal care daily rate), significantly mitigates the chance of a complete transition to the new system by June 30, 2007.
The Department seeks to make targeted modifications to the documentation requirements in order to build on areas that have been endorsed by CMS. We will not offer to CMS any proposals that fundamentally change the originally approved tenets of the reimbursement system, including the base rate or the Ohio Developmental Disabilities Profile (ODDP.) Rather, proposed changes will be focused on an alternative approach to ratios and the use of 15 minute units.
Individuals’ Rights Will Not Change
It is important to note that individuals and their guardians retain all existing rights to request prior authorization for additional services and also withdraw any prior authorization requests as they wish. Furthermore, individuals/guardians retain all existing rights to request an appeal when services are altered, decreased, added, etc.
The remainder of this memorandum is divided into three parts: the first part addresses situations where individuals receive homemaker/personal care services by themselves; the second part addressed situations where individuals share these services; and the third part addresses Adult Day Services.
Individuals who receive homemaker/personal care (HPC) services by themselves (i.e., do not share services)
Because the Department’s proposed improvements will focus on documentation requirements for services rendered for individuals who live in congregate settings, the “pause” should not affect the reimbursement transition of providers in single-person settings. In other words, people who receive HPC services by themselves (i.e., do not share services with others) will continue to transition. The Department is not seeking to make any changes that would affect reimbursement of these services.
If an individual/guardian wishes to object to the transition, the objection should be provided in writing to their County Board of MR/DD and should request that an approved ISP be developed that is calculated for cost using the “old” reimbursement system. Additionally, if a PA request or appeal is in process, the individual/guardian should submit in writing to the agencies involved requesting the withdrawal of the PA request or appeal.
For individuals in the following three situations, the pause is not applicable because transition has already occurred:
- The individual has already transitioned to the new waiver reimbursement system and has started to receive services. This includes individuals for whom a new PAWS has been submitted by the county board to the department.
- The individual has been newly enrolled to begin receiving Level 1 or I/O Wavier services as of July 1, 2005 and thus has not participated under the negotiated rate structure.
- The individual has received an approval or denial of their request for prior authorization (PA) from either ODMR/DD, ODJFS or from a State Hearing and the appeal process and timelines have elapsed for further appeal.
Individuals who share homemaker/personal care (HPC) waiver services
As noted earlier in this memo, the transition “pause” is focused on reimbursement for HPC services that are provided to individuals who share services. During the period of the “pause” individuals who share HPC services today or will share services after the transition should not transition to the new waiver reimbursement system.
For individuals who share HPC waiver services, the individual/guardian retains the right to object to the pause and may request that the individual be transitioned to the new reimbursement system. If this happens, the transition should continue for that individual’s services. Agencies will continue to process the prior authorization or
Hearing requests already submitted unless they receive a written request from the individual/guardian to withdraw the PA or appeal.
For individuals who share HPC services in the following three situations, the pause is not applicable because transition has already occurred:
- The individual has already transitioned to the new waiver reimbursement system and has started to receive services. This includes individuals for whom a new PAWS has been submitted by the county board to the department.
- The individual has been newly enrolled to begin receiving Level 1 or I/O Wavier services as of July 1, 2005 and thus has not participated under the negotiated rate structure.
- The individual has received an approval or denial of their request for prior authorization (PA) from either ODMR/DD, ODJFS or from a State Hearing and the appeal process and timelines have elapsed for further appeal.
Adult Day Waiver Services Transition
During the ISP planning process, Service and Support Administrators (SSA) should continue to advise individuals enrolled on IO or Level One waivers and their guardians of their option to receive one or more of the new Adult Day Waiver services that became available on January 1, 2007.
Questions
The ODMR/DD encourages all stakeholders to send questions to the following email address: waiver.support@odmrdd.state.oh.us. ODMR/DD staff will review questions sent to this email box at least twice per weekday throughout the duration of the ‘pause’ and will manage responses in one of two ways:
- For questions asked by more than one person, both the question and response will be posted on the ODMR/DD’s web page via http://mrdd.ohio.gov.
- For questions that are specific to an individual situation, ODMRDD staff will follow up directly with the person who poses the question. For this reason, it may help to include your name and a telephone number where you can be reached.
- The ODMRDD will make an attempt to respond to questions within three working days.
