iBudget Rule - APD

iBudget Rule - APD

iBudget Rule iBudget Rule There is no audio required for this presentation. Please set your PowerPoint to view the slides and notes. In presentation mode, click the mouse or press enter to advance to the next slide. In presentation mode, press the backspace to return to the previous slide.

iBudget Rule Send procedural questions by email to [email protected] WSCs may contact the Regional office for assistance on specific cases. Training Topics

iBudget Rule Introduction Key Terms Implementation/WSC Instructions Cost Plan Development Significant Additional Needs iBudget Rule Introduction

iBudget Rule iBudget Rules 65G-4.0213 through 4.0218, F.A.C. became effective July 2016. View rule at http:// apd.myflorida.com/ibudget/rules-regs.htm iBudget Rule Algorithm for new enrollees Algorithm, AIM, and Individual review at the time of the support plan for existing individuals enrolled on the waiver

Key Terms Rule 65G-4.0213 is a comprehensive list of definitions Some key terms included in the next several slides of the presentation Key Terms Individual: Person with a developmental disability, as defined by Section 393.063, F.S., and who is enrolled in iBudget.

Key Terms Individual representative: Individuals parent (for a minor), guardian, guardian advocate, a designated person holding a power of attorney for decisions regarding health care or public benefits, designated attorney or a healthcare surrogate, or in the absence of any of the above, a medical proxy as determined under Section 765.401, F.S. The individuals Waiver Support Coordinator shall ascertain whether an individual has any of these

representatives and inform the agency of the identity and contact information. Key Terms Allocation Algorithm: The mathematical formula based upon statistically validated relationships between individual characteristics (variables) and the individuals level of need for services provided through the Waiver . Allocation Algorithm Amount: Result of

the Allocation Algorithm apportioned according to available funding. Key Terms Amount Implementation Meeting Worksheet (AIM): A form used by the Agency for new waiver enrollees, and upon recalculation of an individuals algorithm, to (a) communicate an individuals Allocation Algorithm Amount, (b) identify proposed services based upon the Allocation Algorithm Amount, and (c) identify additional services, if any,

should the individual or their representative feel that any Significant Additional Needs of the individual cannot be met within the Allocation Algorithm Amount. Key Terms iBudget Amount: Total amount of funds that have been approved by the agency, pursuant to the iBudget Rules, for an individual to expend for waiver services during a fiscal year

Key Terms iBudget Amount Algorithm + Significant Additional Needs = iBudget Amount Key Terms Individual Review Agency review of information submitted by a WSC, to determine if the request meets significant additional needs criteria.

Implementation Implementation Old and New Allocation Algorithm New Enrollees At the time of support plan for individuals presently receiving waiver services For new enrollees with AIMs from the old algorithm in process or individuals with pending SANs, APD will contact the WSCs with further

direction Refer to the iBudget Rule Implementation WSC Process Steps document Implementation at the time of the Support Plan 60 days prior to support plan, WSC receives the Allocation Algorithm from APD via email with the EZ Budget Calculator attached Implementation at the Time of the Support

Plan Date Algorithm Provided November 1, 2016 December 1, 2016 January 1, 2017 February 1, 2017 March 1, 2017 April 1, 2017 May 1, 2017 June 1, 2017 July 1, 2017

August 1, 2017 September 1, 2017 October 1, 2017 Support Plan Date in ABC January 2017 February 2017 March 2017 April 2017 May 2017 June 2017

July 2017 August 2017 September 2017 October 2017 November 2017 December 2017 Implementation/WSC Instructions The WSC will meet with the individual and conduct the Allocation Implementation Meeting and document this using the AIM

Worksheet. The AIM Worksheet is located at http:// apd.myflorida.com/ibudget/users.htm Implementation/WSC Instructions AIM Meeting Requirements: Communicate Allocation Algorithm Amount Identify proposed services Identify additional services if there are Significant Additional Needs. Document with the AIM Worksheet

Implementation/WSC Instructions Implementation/WSC Instructions Implementation/WSC Instructions Implementation/WSC Instructions WSC submits AIM within 30 calendar days of receipt of the Allocation Algorithm Amount APD will issue a notice of the decision of

iBudget Amount within 30 days of receipt of AIM Worksheet or 60 days if additional documentation is requested Implementation/WSC Instructions If the individual is satisfied with the algorithm amount, the WSC can submit the AIM Worksheet to APD Regional office using email addresses for AIM submission. [email protected] [email protected]

[email protected] [email protected] [email protected] [email protected] Implementation/WSC Instructions If the individual is requesting services that exceed the algorithm amount due to significant additional needs, the WSC must submit the AIM Worksheet and documentation to APD on the iBudget SAN

system. Implementation/WSC Instructions Implementation/WSC Instructions The WSC is responsible for ensuring that the individual and their individual representative understand the iBudget notice. This includes: 1. Reviewing the notice content 2. Explaining information in the notice 3. Answering questions or following up on

concerns Implementation/WSC Instructions WSC receives Algorithm Amount from APD WSC facilitates AIM Meeting with Individual and Individual Representative

WSC provides AIM Worksheet to APD Regional Office WSC discuss iBudget Amount with Individual and Individual Representative APD Regional office finalize Individual

Review and issues Notice of iBudget Amount SANS During Implementation During statewide implementation of the new algorithm, if the WSC needs to submit a new SAN request prior to the individuals support plan annual date, the WSC will request the new algorithm from the Region via email. The Region will run the new algorithm and provide

it to the WSC. The WSC will complete the AIM process with the consumer and document on the AIM Worksheet, which must be included in the SAN Request. SANs During Implementation The WSC must complete the AIM process within 30 days. If the new algorithm meets the individuals needs submit the AIM to the Regional Office. If the individual is requesting additional funds,

submit the AIM Worksheet online through the SAN Process. SANS During Implementation WSC requests new Algorithm Amount from APD APD provides algorithm to WSC

WSC facilitates AIM Meeting with Individual and Individual Representative WSC discuss iBudget Amount with Individual and Individual Representative APD Regional office

finalize Individual Review and issues Notice of iBudget Amount WSC provides AIM Worksheet to APD Regional Office through the SAN system if over algorithm

SANS during Implementation For additional information, please refer to the iBudget Rule Implementation Waiver Support Coordinator (WSC) Process Steps document posted with this training. Allocation Algorithm Living Setting

3 Age 2 1. Allocation Algorithm QSI

Allocation Algorithm Age Living Setting 0-20 21-30 31 and older

Family Home Independent Living, Supported Living, or licensed residential

facility without residential habilitation Standard or Live-In Residential Habilitation Behavior Focus Residential habilitation Intensive Behavior Residential Habilitation Comprehensive Training and Education Program (CTEP) or Special

Medical Home Care QSI Used QSI behavioral sum

of scores of all questions for all consumers. Used functional sum of scores of all questions for consumers in family home and supported living. Used behavioral sum of scores of all questions for consumers in supported living.

Questions 16, 18, 20, 21, 23, 28, 33, 34, 36 and 43 were additionally weighted Allocation Algorithm QSI WSC notify APD in writing if there is an error with the QSI APD will review the QSI to determine if adjustments are needed

APD will inform the WSC of the review and revised the Allocation Algorithm WSCs must notify the individual Allocation Algorithm QSI Individual/WSC may request reassessment if there is a significant change related to variables impacted in the algorithm APD will complete the assessment and notify the individual and WSC of the results within 60 days.

APD and WSC must address any emergency needs regardless of the QSI completion. Cost Plan Development Cost Plan Development Medical Necessity 1. Necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain

2. Individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the patients needs Cost Plan Development Medical Necessity (continued) 3. Consistent with generally accepted professional medical standards as determined by the Medicaid program, and not experimental or investigational

Cost Plan Development Medical Necessity (continued) 4. Be reflective of the level of service that can be safely furnished, and for which no equally effective and more conservative or less costly treatment is available statewide Cost Plan Development Medical Necessity (continued) 5. Furnished in a manner not primarily intended

for the convenience of the individual, the individuals caretaker, or the provider. 6. The fact that a provider has prescribed, recommended, or approved medical or allied care, goods, or services does not, in itself, make such care, goods or services medically necessary or a medical necessity or a covered service. Waiver coverage and

limitations Allocation Algorithm Amount Medicaid State Plan Schools Private insurance Natural Supports

Waiver Requirements Payer of Last Resort Cost Plan Development Within algorithm amount unless

there are Significant Additional Needs Cost Plan Development WSCs must coordinate to obtain services from all available resources Natural/ Community Supports

School Medicaid State Plan Private Insurance Cost Plan Development WSC Flexibility to adjust service authorizations

Life Skills Development 1 Life Skills Development 2 Life Skills Development 3 (within approved ratio) Durable Medical Equipment Adult Dental Personal Emergency Response System Consumable Medical

Supplies Personal Supports up to $16,000 Respite up to $10,000 Environmental Accessibility Adaptations Cost Plan Development Flexibility to change services within the cost plan if medically necessary and health/safety needs met. Examples might include:

Using unallocated funds or unused funds to meet a one-time need such as dental or equipment Moving funds between meaningful day activities Moving unused previously allocated funds forward to meet a temporary increased need for Personal Supports Cost Plan Development WSC ensure that sufficient funds remain allocated for services not yet billed by the provider

It is required for WSCs to populate the notes section of the service authorization to clarify service provision. Example: 5 hours/day M-F; 10 hours weekends, etc. Cost Plan Development Services not listed on Slide 47 require additional review by APD When the WSC inputs services into the cost plan, the iBudget system has

controls in place to facilitate the authorization process Cost Plan Development REMEMBER! Services must be medically necessary Services must meet waiver coverage and limitations Significant Additional Needs

Significant Additional Needs Funds can be approved above the Allocation Algorithm Amount if the individual has Significant Additional Needs that meet the criteria of the iBudget Rule. Request at any time, including: a. During the AIM process b. Anytime after the iBudget Amount is established

Significant Additional Needs Need for additional funding that if not provided would place the health and safety of the individual, caregiver, or public in serious jeopardy Extraordinary needs Significant need for one time or temporary services Significant need to increase services after the beginning of the year Significant need for transportation

Significant Additional Needs EXAMPLES Significant, potentially life-threatening behaviors Complex medical conditions Significant Additional Needs EXAMPLES Chronic comorbid condition Need for total physical assistance

Significant Additional Needs EXAMPLES Permanent or long term loss or incapacity of a caregiver Loss of services authorized through Medicaid State Plan Significant change in medical, behavioral, or functional status Significant Additional Needs EXAMPLES

Lack of meaningful day activity needed to foster mental health, prevent regression or engage in meaningful community life Crisis situation: Homeless, danger to self and others, caregiver unable to provide care Risk of abuse, neglect, exploitation, or abandonment Significant Additional Needs One Time

Temporary Long Term Significant Additional Needs Extraordinary Needs One time/temporary

needs Need for increase after the cost plan year due to change Transportation to waiver funded services Significant Additional Need

Extraordinary Need significant, potentially life-threatening behaviors, such as recent attempts at suicide, arson, nonconsensual sexual behavior, or self-injurious behavior requiring medical attention Significant Additional Need Extraordinary Need (continued) A complex medical condition that requires active intervention by a

licensed nurse on an ongoing basis that cannot be taught or delegated to a nonlicensed person Significant Additional Needs Extraordinary Need (continued) A chronic comorbid condition. As used in this subparagraph, the term comorbid condition means a medical condition existing simultaneously but independently with another medical

condition in a patient Significant Additional Need Extraordinary Need (Continued) A need for total physical assistance with activities such as eating, bathing, toileting, grooming, personal hygiene, lifting, transferring or ambulation. Significant Additional Needs

Extraordinary Need (continued) The presence of an extraordinary need alone does not warrant an increase in the amount of funds allocated to a clients iBudget as determined by the algorithm. Ensure all available options are accessed first. Significant Additional Needs Significant need for one-time or temporary support or services that, if not provided, would place the

health and safety of the client, the clients caregiver, or the public in serious jeopardy, unless the increase is approved. Examples: Environmental modifications, durable medical equipment, services to address the temporary loss of support from a caregiver, or special services or treatment for a serious temporary condition when the service or treatment is expected to ameliorate the underlying condition. Significant Additional Needs

Significant increase in the need for services after the beginning of the service plan year that would place the health and safety of the client, the clients caregiver, or the public in serious jeopardy because of substantial changes in the clients circumstances, including, but not limited to, permanent or long-term loss or incapacity of a caregiver, loss of services authorized under the state Medicaid plan due to a change in age, or a significant change in medical or functional status which requires the provision of additional services on a permanent or long-term basis that cannot be

accommodated within the clients current iBudget. Significant Additional Needs Transportation services to waiver-funded adult day training program or to a waiver funded supported employment when: - this cannot be addressed within funding without impacting health and safety - Public transportation is not an option - Other resources are not available

How to submit a request for Significant Additional Needs Can services be moved around to address the need? Can unused services be moved to address the need? Is the entire budget allocated to services? Significant Additional Needs Implementation of Allocation Algorithm

Amount Identify any Significant Additional Needs during AIM process Document on AIM Worksheet After iBudget Amount Established Identify Significant

Additional Needs at times after the iBudget Amount is established Follow normal SAN Request protocol and request online. AIM required anytime the algorithm is recalculated How to submit a request for Significant Additional Needs WSC submit proposed cost plan:

Use AIM Worksheet if needs are being identified during the AIM process or when the algorithm is calculated Use online SAN system How to submit a request for Significant Additional Needs Explain why additional funds are needed with supporting documentation Identify issues/concerns with the QSI Document attempts to access services

through other resources How to submit a request for Significant Additional Needs Documentation Requirements The iBudget rule specifies the documentation required for each service. Please refer to the attachment entitled Documentation Requirements for SAN for a complete list.

How to submit a request for Significant Additional Needs The iBudget rule specifies the documentation required for each service. Please refer to the attachment entitled Documentation Requirements for SAN for a complete list. How to submit a request for Significant

Additional Needs APD has 30 days to approve, deny (in whole or in part), or request additional documentation If the request does not include all necessary documentation, the APD will send written notice to the individual and WSC. The individual or WSC shall provide the documentation within 10 days, or notify APD if they want APD to render its decision based upon the documentation provided. If additional documentation is requested, the deadline for the APD is 60 days following the receipt of the

original request. How to submit a request for Significant Additional Needs The WSC must notify the Region office if there is an emergency need that must be met prior to the timeframes. The Region may authorize temporary non-waiver funds to assist while Significant Additional Needs requests are processed.

Questions? Send procedural questions by email to [email protected] WSCs may contact the Regional office for assistance on specific cases. Additional information can be found in the iBudget Rule Implementation Waiver Support Coordinator (WSC) Process Steps document posted with this training.

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