1.00 Introduction
Home and Community Based Services Manual
Department of Health and Senior Services’ (DHSS) Vision
Optimal health and safety for all Missourians, in all communities, for life.
DHSS Mission
To promote health and safety through prevention, collaboration, education, innovation, and response.
Division of Senior and Disability Services’ (DSDS) Vision
Missourians regardless of their age or abilities can live their optimal life.
DSDS Mission
To protect, support, and empower seniors and individuals with disabilities through assessment and connection to community resources to age with dignity.
Role
DSDS is the designated state agency, carrying out mandates of the state, regarding programs and services for seniors and individuals with disabilities.
DSDS is responsible for the administration and operation of the Medicaid Funded Home and Community Based Services [Needs Link] (HCBS) programs. HCBS provides services that meet the unmet needs of individuals with disabilities allowing them to remain in their least restrictive environment. HCBS DSDS staff and/or its designee process initial referrals, assessments, reassessments, person centered care plans (PCCP), and PCCP maintenance services for the HCBS program.
DSDS investigates reports of abuse, neglect, and financial exploitation, provides crisis intervention, and Adult Protective Services for eligible adults. The Central Registry Unit (CRU) operates the state’s toll-free hotline for reporting alleged abuse, neglect, or financial exploitation of adults with disabilities and seniors aged 60 and above. CRU also registers complaints against hospitals, licensed long-term care facilities, and home-health agencies.
Legal Authority
Home and Community Based Services Manual
| Chapter 192: Department of Health and Senior Services | |
|---|---|
| 192.2000 | DSDS Duties |
| 192.2005 | Definitions |
| 192.2400 - 192.2505 | Protective Services for Adults: Reporting, Investigations, Employee Disqualification, Criminal Background Check |
| Chapter 208: Old Age Assistance, Aid to Dependent Children and General Relief | |
|---|---|
| 208.865 | Definitions – Personal Care Attendant and Vendor |
| 208.895 - 208.896 | HCBS Referrals – Department Duties, Assessments, Care Plans, Structured Family Caregiving Waiver |
| 208.900 - 208.930 | Personal Care Assistance Services – Eligibility, Consumer and Vendor Responsibilities/Requirements, Electronic Visit Verification (EVV), Denial of Services, Discontinuation of Services |
| Chapter 660: Department of Social Services | |
|---|---|
| 660.023 | In-Home Service Providers, Telephone Tracking System |
| Chapter 7 - Service Standards | |
|---|---|
| 19 CSR 15-7.021 | In-Home Service Standards |
| Chapter 8 - Consumer-Directed Services | |
|---|---|
| 19 CSR 15-8.100 | Definitions |
| 19 CSR 15-8.200 | Eligibility |
| 19 CSR 15-8.400 | Vendors |
| 19 CSR 15-8.500 | Hearing Rights |
| Division 30 – Division of Regulation and Licensure | |
| Chapter 81 – Certification | |
| 19 CSR 30-81.030 | 19 CSR 30-81.030 Evaluation and Assessment Measures for Title XIX Recipients and Applicants in Long-Term Care Facilities |
| Division 70 – MO HealthNet Division | |
|---|---|
| Chapter 91 – Personal Care Program | |
| 13 CSR 70-3.320 | Electronic Visit Verification (EVV) |
| 13 CSR 70-91.010 | Personal Care Program |
Helpful Links
Home and Community Based Services Manual
A link to the current approved waivers on file with the Centers for Medicare & Medicaid Services (CMS) can be found at the following website:
Current Approved Waivers:
1.05 Abbreviations
Home and Community Based Services Manual
Programmatic Terms/Services
| Abbreviation | Term |
|---|---|
| AAA | Area Agency on Aging |
| ADC | Adult Day Care |
| ADCW | Adult Day Care Waiver |
| ADW | Aged and Disabled Waiver |
| AFL | Assisted Living Facility |
| ANE | Abuse, Neglect, and Exploitation |
| APC | Advanced Personal Care |
| AR | Advanced Respite |
| ASA | Administrative Support Assistant |
| BR | Basic Respite |
| CDS | Consumer Directed Services |
| CFR | Code of Federal Regulations |
| CIL | Center for Independent Living |
| CM | Case Management |
| CSR | Code of State Regulation |
| EAA | Environmental Accessibility Adaptations |
| F2F | Face to Face |
| FMS | Financial Management Service |
| GHE | General Health Evaluation |
| H&I | Hourly and Intermittent |
| HC | Homemaker/Chore Services |
| HCB | Home and Community Based Medicaid |
| HCBS | Home and Community Based Services |
| HDM | Home Delivered Meals |
| Hh, hh | Household |
| IA | Initial Assessment |
| IHS | In-Home Services |
| ILW | Independent Living Waiver |
| ITP | Individualized Treatment Plan |
| LASA | Lead Administrative Support Assistant |
| LOC | Level of Care |
| LTC | Long Term Care |
| ME | Medicaid Eligibility |
| MFP | Money Follows the Person |
| MSP | Medicaid State Plan |
| ORA | Online Reporting Application |
| PA | Prior Authorization |
| PC | Personal Care |
| PCCP | Person Centered Care Plan |
| Pt/pt | Participant |
| R&R | Rights and Responsibilities |
| RM | Regional Manager |
| SME | Specialized Medical Equipment |
| SMS | Specialized Medical Supplies |
| SNF | Skilled Nursing Facility |
| SSS | Social Service Specialist |
| SSUS | Social Service Unit Supervisor |
| TC | Track Changes |
State and Federal Entities
Home and Community Based Services Manual
| Abbreviation | Term |
|---|---|
| APS | Adult Protective Services |
| CMS | Centers for Medicare and Medicaid Services |
| CO | Central Office |
| CRU | Central Registry Unit |
| DCN | Departmental Client Number (MO HealthNet Number) |
| DDD | Division of Developmental Disabilities |
| DHSS | Department of Health and Senior Services |
| DLS | Division of Legal Services |
| DMH | Department of Mental Health |
| DSDS | Division of Senior and Disability Services |
| DSS | Department of Social Services |
| EVV | Electronic Visit Verification |
| FAMIS | Family Assistance Management Information System |
| FSD | Family Support Division |
| HCY | Healthy Children and Youth Program |
| HH | Home Health |
| HIPAA | Health Insurance Portability and Accountability |
| MHD | MO HealthNet Division |
| MMAC | Missouri Medicaid Audit and Compliance Unit |
| OAA | Older Americans Act |
| RCF | Residential Care Facility |
| Reg | Region |
| RSMo | Revised Statutes of the State of Missouri |
| SD | Spenddown |
| SIU | Special Investigations Unit |
| SLUMS | St. Louis Mental Status Exam |
| SS | Social Security |
| SSN | Social Security Number |
| WT | WebTool |
Medical
Home and Community Based Services Manual
| Abbreviation | Term |
|---|---|
| AD | Alzheimer’s disease |
| ADL | Activities of daily living |
| AIDS | Acquired immunodeficiency syndrome |
| ALS | Amyotrophic lateral sclerosis (Lou Gehrig’s Disease) |
| AMA | Against medical advice |
| Appt/appt | Appointment |
| bid, b.i.d. | Twice a day |
| BM | Bowel movement |
| BP | Blood pressure |
| c/o | Complains of |
| CAD | Coronary artery disease |
| CHF | Congestive heart failure |
| COPD | Chronic obstructive pulmonary disease |
| CP | Cerebral palsy |
| CVA | Cerebral vascular accident (stroke) |
| CXR | Chest x-ray |
| DM | Diabetes mellitus |
| DO | Doctor of osteopathic medicine |
| Dr | Doctor |
| Dx | Diagnosis |
| ECG or EKG | Electrocardiogram |
| ED | Emergency department |
| ER | Emergency room |
| Fr | Fracture |
| GERD | Gastroesophageal reflux disease |
| gtt, gtts | Drop(s) |
| H&P | History and physical |
| HIV | Human immunodeficiency virus |
| HOH | Hard of hearing |
| HR | Heart rate |
| HTN | Hypertension (high blood pressure) |
| Hx, hx | History |
| IADL | Instrumental activities of daily living |
| IDDM | Insulin dependent diabetes mellitus |
| IM | Intramuscular |
| IV | Intravenous |
| L | Liter |
| MD | Medical doctor |
| mg | Milligram |
| ml | Milliliter |
| MS | Multiple sclerosis |
| MVA | Motor vehicle accident |
| N/V, N&V | Nausea and vomiting |
| NG, ng | Nasogastric |
| NPO, n.p.o | Nothing by mouth |
| O2 | Oxygen |
| OT | Occupational therapy |
| PCP | Primary care physician |
| PO, po | By mouth |
| Post-op, post-op | Postoperative (after surgery) |
| Pre-op, pre-op | Preoperative (before surgery |
| prn | as needed |
| PROM | Passive range of motion |
| PT | Physical therapy |
| PTSD | Post-traumatic stress disorder |
| Q2h, q.2h (number can vary) | Every two hours (number can vary) |
| qd, q.d. | Every day |
| qh, q.h. | Every hour |
| qid, q.i.d. | Four times a day |
| RA | Rheumatoid arthritis |
| RN | Registered nurse |
| ROM | Range of motion |
| Rx | Prescriptions |
| S/S, s/s, | Signs and symptoms |
| SLP | Speech-language pathology (Speech Therapy) |
| SOB | Shortness of breath |
| sub-q | Subcutaneous |
| tab | Tablet |
| TB | Tuberculosis |
| TBI | Traumatic brain injury |
| TID, tid, t.i.d | Three times a day |
| Tx, tx | Treatment |
| Vs | Vital signs |
Other
Home and Community Based Services Manual
| Abbreviation | Term |
|---|---|
| AKA | Also known as |
| ATC | Attempt to contact |
| d/t | due to |
| DOB | Date of Birth |
| DPOA | Durable power of attorney |
| E: | |
| F: | Fax |
| hr | Hour |
| LKA | Last known addres |
| LM | Left message |
| mn | Minutes |
| Mo, mo | Month |
| Msg, msg | Message |
| OV | Office Visit |
| POA | Power of attorney |
| Rcvd | Received |
| TCF/TF | Telephone call from |
| TCT/TT | Telephone call to |
| VM | Voice mail |
| Wk, wk | Week |
1.15 Code of Ethics
Home and Community Based Services Manual
Division of Senior and Disability Services (DSDS) is charged with the responsibility to provide aid and assistance to the elderly and adults with disabilities living in the state. One component of DSDS’ operational responsibilities is the administration of Home and Community Based Services (HCBS) which align with the ethical and culturally competent standards of the Department of Health and Senior Services (DHSS).
In coordination with the Department Director, the Division Director, and Deputy Division Director, DSDS staff have the opportunity to serve vulnerable individuals and have a positive impact on their quality of life. Understanding and adhering to ethical and culturally competent standards helps to ensure quality services are delivered.
It is the responsibility of DSDS staff to understand and follow the policies outlined in the HCBS Manual and the DHSS Administrative Policies (http://dhssnet/policiesprocedures/ [Needs Link]). The National Association of Social Workers (NASW) Code of Ethics (https://www.socialworkers.org/About/Ethics/Code-of-Ethics) is an additional resource for DSDS staff.
DSDS staff shall implement the following ethical principles while interacting with participants, stakeholders and coworkers. DSDS staff shall:
Work to serve in the best interest of the participant;
Ensure a participant’s rights of privacy, dignity, respect, and freedom from coercion and restraint;
Ensure a participant’s HCBS optimizes individual initiative, autonomy, and independence in making life choices;
Ensure a participant is able to facilitate individual choice regarding services and supports, and who provides them;
Maintain professional interactions with participants and recognize potential placement of personal bias and values upon participant, stakeholders or coworkers;
Attain informed consent from the participant prior to assessing for HCBS;
Respect, verbalize, and explain the participant’s right to confidentiality by utilizing the DHSS Notice of Privacy Practices form (see Policy 9.00, Appendix 1 [Needs Link]);
Endeavor to understand the vast cultural and linguistic diversity among participants and ensure proper cultural considerations are implemented;
Interact and communicate with participants in a clear, concise and easy to understand manner;
Encourage the inclusion of family or other informal support systems in the development of the Person Centered Care Plan (PCCP) or other decisions regarding HCBS;
Maintain professional boundaries by refraining from personal relationships, business arrangements or other possible conflicts with participants, stakeholders and coworkers;
Do no harm. Communication and interaction with participants, stakeholders and coworkers shall be conducted in a way that promotes the professional relationship and builds upon a strengths based perspective.
DSDS staff shall understand, acknowledge and adhere to the DSDS Code of Ethics in conducting all state business. Any deviation from the Code of Ethics shall be subject to supervisory approval, up and including to the Division Director.
1.20 Final Rule Medicaid HCBS
Home and Community Based Services Manual
The Home and Community Based Services (HCBS) Final Rule established by the Centers for Medicare and Medicaid Services (CMS) defines HCBS settings and Person Centered Care Planning (PCCP) (Policy 4.20 [Needs Link]) requirements in Medicaid HCBS Waiver programs. The purpose of the rule is to ensure individuals receive HCBS in settings that are integrated in and support full access to the greater community. This includes opportunities to seek employment and work in competitive and integrated settings, engage in community life, control personal resources, and receive services in the community to the same degree as individuals who do not receive HCBS.
Home and Community Based (HCBS) Setting
The Final Rule establishes mandatory requirements for the qualities of HCBS settings and identifies settings that are not HCBS. All HCBS settings must meet the following requirements:
- Be integrated in and support access to the greater community;
- Provide opportunities to seek employment and work in competitive integrated settings, engage in community life, and control personal resources;
- Ensure the individual receives services in the community to the same degree of access as individuals not receiving HCBS;
- Is selected by the individual from among setting options, including non-disability specific settings;
- Ensure an individual’s rights of privacy, dignity, respect, and freedom from coercion and restraint;
- Optimizes individual initiative, autonomy, and independence in making life choices;
- Facilitates individual choice regarding services and supports; and who provides them.
Each participant is informed of their right to receive services in a setting in the above requirements through the HCBS Care Plan and Participant Choice Statement (HCBS-3).
1.25 Electronic Visit Verification
Home and Community Based Services Manual
The 21st Century Cures Act mandates the use of Electronic Visit Verification (EVV) for all Medicaid personal care services (PCS). This applies to PCS provided under sections 1905(a) (24), 1915(c), 1915(j), 1915(k), and Section 1115.
Missouri Code of State Regulations (CSR) 13 70-3.320 sets forth additional requirements for use of EVV for services identified by MO HealthNet Division and provided to a MO HealthNet participant with a prior authorization or care plan as approved by the Department of Health and Senior Services.
Purpose
EVV improves the quality of care provided to individuals and enhances quality control by utilizing technology to capture point-of-service information related to the delivery of in-home services.
Requirement
Home and Community Based Services Manual
EVV is required for the following services authorized by the Division of Senior and Disability Services (DSDS):
EVV is not required for the following services authorized by DSDS:
Neither the 21st Century Cures Act nor MO CSR 13 70-3.320 provides HCBS participants the opportunity to opt out of these requirements. Refusal to comply with EVV requirements will result in closure of authorized HCBS through DSDS. DSDS shall initiate the Adverse Action process when a participant refuses to comply with EVV requirements. Participants not utilizing EVV, but who wish to comply with EVV requirements, shall be directed to contact their HCBS provider to ensure compliance. If a participant’s provider cannot accommodate the participant’s EVV needs, a provider change shall be initiated.
Providers and/or participants identified as noncompliant with EVV requirements by Missouri Medicaid Audit and Compliance (MMAC) will be forwarded to DSDS for a provider change or closure of HCBS.
Policy Manual Index
Home and Community Based Services Manual
| Chapter | Policy | Policy Number |
|---|---|---|
| 1. Introduction | Index | |
| Introduction | 1.00 [NEEDS LINK] | |
| Abbreviations | 1.05 [BROKEN LINK] | |
| Code of Ethics | 1.15 [NEEDS LINK] | |
| Final Rule Medicaid HCBS | 1.20 [NEEDS LINK] | |
| Electronic Visit Verification | 1.25 [NEEDS LINK] | |
| 2. Medicaid Funding | Medicaid Eligibility | 2.00 [NEEDS LINK] |
| General Requirements | 2.00 Appendix 1 [NEEDS LINK] | |
| Medicaid Income Charts | 2.00 Appendix 2 [NEEDS LINK] | |
| Medicaid Eligibility Codes | 2.00 Appendix 3 [NEEDS LINK] | |
| 3. Available Home and Community Based Services | Home and Community Based Service (HCBS) Introduction | 3.00 [NEEDS LINK] |
| Basic Personal Care – State Plan (Agency Model) | 3.05 [NEEDS LINK] | |
| Advanced Personal Care - State Plan (Agency Model) | 3.10 [NEEDS LINK] | |
| Authorized Nurse Visits State Plan (Agency Model) | 3.15 [NEEDS LINK] | |
| Personal Care Services in a Residential Care Facility/Assisted Living Facility (RCF/ALF) – State Plan | 3.20 [NEEDS LINK] | |
| Personal Care Assistance – State Plan (ConsumerDirected Model) | 3.25 [NEEDS LINK] | |
| Adult Day Care Waiver (ADCW) | 3.31 [NEEDS LINK] | |
| Chore (Aged and Disabled Waiver) (ADW) | 3.35 [BROKEN LINK] | |
| Home Delivered Meals (ADW) | 3.40 [NEEDS LINK] | |
| Homemaker (ADW) | 3.45 [NEEDS LINK] | |
| Respite Care (ADW) | 3.50 [NEEDS LINK] | |
| Adult Day Care (ADW) | 3.51 [NEEDS LINK] | |
| Independent Living Waiver | 3.55 [NEEDS LINK] | |
| Structured Family Caregiving Waiver | 3.60 [NEEDS LINK] | |
| Non-Medicaid Eligibility (NME) | 3.65 [BROKEN LINK] | |
| Social Services Grant General Revenue Protective Services Participants | 3.70 [NEEDS LINK] | |
| Home and Community Based Service Units and Rates | 3.00 Appendix 1 [NEEDS LINK] | |
| Home and Community Based Services Cost Maximums | 3.00 Appendix 2 NEEDS LINK] | |
| Consumer Directed Services Tax Information | 3.25 Appendix 1 [NEEDS LINK] | |
| Waiting List Notice for Independent Living Waiver Services | 3.55 Appendix 2 | |
| 4. Home and Community Based Assessment, Care Planning and Authorization Process | HCBS Processes Introduction | 4.00 [NEEDS LINK] |
| Intake Process | 4.05 [NEEDS LINK] | |
| Explanation of the Level of Care Determination | 4.10 [BROKEN LINK] | |
| Assessment Process | 4.15 [BROKEN LINK] | |
| Person Centered Care Planning and Maintenance | 4.20 [NEEDS LINK] | |
| Provider Reassessment Process | 4.25 [BROKEN LINK] | |
| Case Notes Documentation | 4.30 [NEEDS LINK] | |
| Service Coordination | 4.35 [NEEDS LINK] | |
| Department of Mental Health (DMH) Service Coordination | 4.35.1 [BROKEN LINK] | |
| Healthy Children and Youth (HCY) Service Coordination | 4.35.2 [NEEDS LINK] | |
| Program of All-Inclusive Care for the Elderly (PACE) | 4.35.3 [NEEDS LINK] | |
| Case Closure | 4.40 [NEEDS LINK] | |
| Collateral Contacts | 4.00 Appendix 1 [NEEDS LINK] | |
| Participant Choice Statement and Instructions HCBS-3 | 4.00 Appendix 2 | |
| Adult Day Care Participant Rights and Responsibilities | 4.00 Appendix 2c [BROKEN LINK] | |
| Agency Model Participant Rights and Responsibilities | 4.00 Appendix 2d [BROKEN LINK] | |
| CDS Participant Rights and Responsibilities | 4.00 Appendix 2e [BROKEN LINK] | |
| RCF/ALF Personal Care Participant Rights and Responsibilities | 4.00 Appendix 2f [NEEDS LINK] | |
| Structured Family Caregiving Waiver Rights and Responsibilities | 4.00 Appendix 2g [NEEDS LINK] | |
| In-Home Services Worksheet Form/Instructions HCBS-3a | 4.00 Appendix 3 | |
| Consumer-Directed Services Worksheet Form/Instructions HCBS-3c | 4.00 Appendix 4 | |
| Physician Notification of Care Plan Form/Instructions HCBS-11 | 4.00 Appendix 5 | |
| Department of Mental Health’s (DMH) Consumer Information Management, Outcomes, and Reporting (CIMOR) | 4.00 Appendix 6 [NEEDS LINK] | |
| Department of Mental Health, Division of Developmental Disabilities Contact Information | 4.00 Appendix 7 [NEEDS LINK] | |
| SLUMS Form/Instructions | 4.00 Appendix 8 | |
| Home and Community Based Options Information | 4.00 Appendix 9 [BROKEN LINK] | |
| Self-Direction Assessment Questions | 4.00 Appendix 10 | |
| Participant Contact Letter | 4.00 Appendix 11 | |
| Participant Communication – Reason for Contact | 4.00 Appendix 12 [BROKEN LINK] | |
| Healthcare Professional Inquiry | 4.00 Appendix 13 | |
| Healthcare Information Request | 4.00 Appendix 15 | |
| Structured Family Caregiving Waiver Diagnosis Verification Form HCBS-11a | Appendix 16 | |
| 5. Adverse Action | Adverse Action | 5.00 [NEEDS LINK] |
| Legal References for Adverse Action | 5.00 Appendix 1 [BROKEN LINK] | |
| Adverse Action Notice for Home and Community Based Services HCBS-12 | 5.00 Appendix 3 | |
| Application for State Hearing for Home and Community Based Services HCBS-12a | 5.00 Appendix 4 | |
| Reversal of Adverse Action Notice for Home and Community Based Services HCBS-12b | 5.00 Appendix 5 | |
| Notice of Closure for Home and Community Based Services HCBS-12m | 5.00 Appendix 6 | |
| 6. Appeals and Hearing Process | Appeal and Hearing Process | 6.00 [NEEDS LINK] |
| Department of Social Services, Division of Legal Services Regional Offices | 6.00 Appendix 1 [NEEDS LINK] | |
| HCBS Witness Information | 6.00 Appendix 2 [NEEDS LINK] | |
| Qualifying Witness Statement | 6.00 Appendix 3 [BROKEN LINK] | |
| Centers for Medicare & Medicaid Services (CMS) Letter | 6.00 Appendix 6 [NEEDS LINK] | |
| Cover Letter for Hearing Request HCBS-12h | 6.00 Appendix 7 [NEEDS LINK] | |
| Agency Witness List | 6.00 Appendix 8 | |
| 7. Show-Me Home | Show-Me Home (SMH) | 7.00 [NEEDS LINK] |
| Show-Me Home Regional Staff Contacts | 7.00 Appendix 1 [NEEDS LINK] | |
| Show-Me Home Option Counseling Transition Coordination Contractors Map | 7.00 Appendix 2 [NEEDS LINK] | |
| Show-Me Home HCBS Referral Assessment Form HCBS-1b | 7.00 Appendix 3 | |
| Show-Me Home Participation Agreement | 7.00 Appendix 4 | |
| Show-Me Home Transition Plan | 7.00 Appendix 5 | |
| Show-Me Home Approval Notice Plan | 7.00 Appendix 6 | |
| Show-Me Home Ombudsman Referral | 7.00 Appendix 7 | |
| Health, Safety and Welfare Assessment for Show-Me Home | 7.00 Appendix 8 | |
| Show-Me Home Referral Notification | 7.00 Appendix 9 | |
| Request for Show-Me Home Funds | 7.00 Appendix 10 | |
| Show-Me Home Funds Notification | 7.00 Appendix 11 | |
| 8. Miscellaneous and Forms | Abuse, Neglect, and Exploitation | 8.00 [BROKEN LINK] |
| Participant Case Records | 8.05 [NEEDS LINK] | |
| Provider Complaint Process | 8.15 [NEEDS LINK] | |
| Abuse, Neglect, and Exploitation Indicators | 8.00 Appendix 1 [BROKEN LINK] | |
| Abuse, Neglect, and Exploitation Alleged Perpetrators Indicator List | 8.00 Appendix 2 [BROKEN LINK] | |
| HCBS Referral Form HCBS-1 | 8.00 Appendix 3 | |
| General Health Evaluation and Level of Care Recommendation | 8.00 Appendix 4 | |
| Physician Prescription for Personal Care Services | 8.00 Appendix 5 | |
| Family Support Division HCB Medicaid Referral Form IM-54A | 8.00 Appendix 6 | |
| Provider Complaint Communication | 8.00 Appendix 7 | |
| Eligibility Letter | 8.00 Appendix 8 [BROKEN LINK] | |
| Person Centered Care Plan (PCCP) Form HCBS-5 | 8.00 Appendix 9 | |
| 9. Confidentiality and HIPAA | Confidentiality Requirements | 9.00 [BROKEN LINK] |
| DHSS Notice of Privacy Policies | 9.00 Appendix 1 [BROKEN LINK] | |
| Administrative Manual Chapter 11 Code of Conduct – Confidential Information | 9.00 Appendix 2 [BROKEN LINK] | |
| Administrative Manual Chapter 19 HIPAA and Confidentiality | 9.00 Appendix 3 [BROKEN LINK] | |
| Administrative Manual Chapter 22 Security Policies and Rules | 9.00 Appendix 4 [BROKEN LINK] | |
| Acknowledgement Form/Instructions | 9.00 Appendix 5 | |
| Authorization for Disclosure Form/Instructions | 9.00 Appendix 6 | |
| HCBS Memos | HCBS Memos | |
| Policy Clarification Questions (PCQ’s) | PCQ's [NEEDS LINK] |
2.0 Medicaid Eligibility
Home and Community Based Services Manual
The Medicaid program was authorized by federal legislation in 1965 through Title XIX of the Social Security Act. Medicaid provides health care access to low-income persons who are age 65 or over, blind, an adult with a disability, families with dependent children, pregnant women in poverty, refugees and children in state care. Missouri’s Medicaid program is funded by multiple sources: the Federal Government, Department of Health and Human Services (DHHS), Centers for Medicare & Medicaid Services (CMS) and Missouri taxes. The Department of Social Services (DSS), MO HealthNet Division (MHD), is the designated state agency that administers the Medicaid program in Missouri.
Purpose
A Home and Community Based Services (HCBS) participant must have Medicaid benefits to qualify for HCBS. This policy will explain eligibility, special circumstances, definitions and Medicaid Eligibility (ME) codes related to various Medicaid benefits.
Eligibility
Individual eligibility for Medicaid benefits is determined by DSS, Family Support Division (FSD) based on specific program eligibility requirements.
HCBS is authorized by the Department of Health and Senior Services (DHSS), Division of Senior and Disability Services (DSDS). HCBS is available to individuals who meet specific eligibility requirements including, but not limited to:
- Determined eligible for Medicaid benefits that reimburse for HCBS
- Agreeable to participate in a face-to-face assessment and development of a person-centered care plan (PCCP)
Determined to meet nursing facility
- Assessed to have an unmet need(s) which can be met through the authorization of HCBS
Assessed to meet the eligibility requirements for authorized service(s) as described in
Potential participants must have active Medicaid benefits before an initial referral can be made for HCBS with the following exceptions provided under the
Special Circumstances [Needs Link] section:
- Unmet spenddown liability if eligible for Home and Community Based (HCB) Medicaid
- Qualified Income Trust (QIT)
- Division of Assets Specified
- Low Income Medicare Beneficiary 2 (SLMB 2)
Special Circumstances
Home and Community Based Services Manual
Home and Community Based Medicaid (HCB Medicaid)
HCB Medicaid eligibility rules provide for a higher income threshold for individuals who meet the requirements for and have a need for Aged and Disabled Waiver (ADW) services. Determination of HCB Medicaid eligibility requires coordination between FSD and DSDS. The FSD HCB Medicaid Referral (IM54a) shall be used as communication between the agencies regarding HCB Medicaid eligibility requirements. The IM-54a shall be uploaded into the participant’s electronic case record. DSDS staff shall review HCB Medicaid eligibility during the initial assessment, reassessment and PCCP maintenance process.
Spenddown Coverage
Individuals who meet Medicaid eligibility requirements, but have income over the monthly limit, may meet eligibility for spenddown coverage [Needs Link]. A spenddown is a monthly premium payment that participants must meet before Medicaid benefits become active.
At Initial Assessment
The spenddown liability must be met for the current date before a referral for HCBS can be processed except for a participant that appears to be HCB Medicaid eligible. Upon receipt of a referral for a potential participant that is not HCB Medicaid eligible with an unmet spenddown, DSDS staff shall inform the individual:
- A referral cannot be completed because the spenddown liability has not been met for the current date
- To contact FSD for information on Medicaid benefits
- To contact the HCBS Intake Customer Service Center to initiate a referral once Medicaid benefits are active
Upon receipt of a referral for a potential participant that has met the spenddown for the current date, DSDS staff shall complete the initial assessment in the participant’s electronic case record.
- If LOC is met, DSDS staff shall proceed with developing a PCCP and coordinating with the selected HCBS provider. DSDS staff shall inform the participant that Medicaid will only reimburse for HCBS during periods when the monthly spenddown liability has been met. The participant will be responsible to pay for the cost of any HCBS provided during periods when the monthly spenddown liability has not been met.
- If LOC is not met, DSDS staff shall proceed with the adverse action [Needs Link] process.
At Reassessment
A participant with spenddown coverage must have met the spenddown liability at least once within the previous three (3) months to continue with the reassessment process. DSDS staff shall:
- Review the Medicaid eligibility within the participant’s electronic case record and/or DSS systems to verify that Medicaid benefits are currently active.
- If the spenddown liability has been met at least once within the previous three (3) months, DSDS Staff or designee shall complete the reassessment process within the participant’s electronic case record.
- If the spenddown liability has not been met for the current date and has not been met at least once within the previous three (3) months, DSDS Staff shall initiate the adverse action process.
NOTE: At the time of reassessment, DSDS staff shall determine if a participant with spenddown coverage meets the eligibility criteria for HCB Medicaid. If a participant meets HCB Medicaid eligibility criteria, DSDS staff should initiate the FSD HCBFSD HCB Medicaid Referral (IM-54a).
Unmet Spenddown HCB Referral
Potential or current participants must meet the age, income and ADW criteria, as outlined in Missouri’s Medicaid Program policy.
Initial Referral
If a potential participant has not met spenddown at initial referral, they are referred to FSD.
- FSD will initiate HCBS referrals for participants who have not met their spenddown but meet the HCB criteria.
If LOC and/or ADW eligibility is not met, DSDS staff shall:
- Proceed with the adverse action process
- Complete and upload an IM-54a into the participant’s electronic case record
- If FSD initiated the IM-54a, submit the IM-54 to FSD HCB Processing Center
NOTE: If FSD initiated the IM-54a and DSDS staff did not conduct the initial assessment, DSDS staff shall return the original IM54a to the FSD HCB Processing Center, explaining why an assessment was not completed. The updated form should be uploaded into the electronic case record system.
Reassessment and PCCP Maintenance
At reassessment or PCCP maintenance if DSDS staff or its designee identifies that a current participant with spenddown coverage meets HCB Medicaid eligibility criteria outlined in HCB Medicaid policy, DSDS staff shall:
- Initiate the FSD HCB referral (IM-54a)
- Upload the IM-54a
- Submit the IM-54a to the FSD HCB Processing Center
When DSDS staff or its designee identifies that a current participant with HCB Medicaid no longer meets criteria or requires an ADW, DSDS staff shall:
- Proceed with the adverse action [Needs Link] process if appropriate
- Complete and upload the IM-54a into the participant’s electronic case record
- Submit the IM-54a to the FSD HCB Processing Center
Qualified Income Trust (QIT)
Individuals with income more than HCB Medicaid requirements may still qualify for HCB Medicaid by diverting a portion of their income into a QIT (a.k.a. Miller Trust). QIT is limited to persons needing Medicaid for nursing facility care or for services provided through the ADW.
Division of Assets
Division of Assets may be used to prevent spousal impoverishment. Federal law provides a way to protect a portion of assets and income for a “community spouse” whose spouse is receiving vendor nursing care or HCBS.
Specified Low Income Medicare Beneficiary 2 (SLMB2)
SLMB2 is a program that can aid with Medicare premiums, co-insurance and deductibles for qualifying individuals. SLMB2 beneficiaries may be HCB Medicaid eligible if all requirements are met, however, the participant must choose which coverage (HCB Medicaid or SLMB coverage) to have.
QIT, Division of Assets, or SLMB2 Referral Process
The HCB referral process may be initiated for potential participants pursuing QIT, Division of Assets, or SLMB2.
At initial assessment, if the participant meets LOC and ADW requirements, DSDS shall:
- Complete and return the IM-54a to the FSD HCB Processing Center
- If FSD returns the IM-54a approving HCB Medicaid benefits:
- Enter all assessment and authorization activity into the participant’s electronic case record
- Coordinate service delivery with the selected HCBS provider(s)
- If FSD returns the IM-54a denying HCB Medicaid benefits:
- Proceed with the adverse action process
- If LOC and/or ADW eligibility is not met:
- Proceed with the adverse action process
- Complete and return the IM-54a to FSD HCB Processing Center
NOTE: If an initial assessment was not conducted, DSDS staff shall explain why there was not an assessment completed on the original IM-54a, upload the updated form and submit the form to FSD HCB Processing Center.
At reassessment or PCCP maintenance, if DSDS staff or its designee identifies that a current participant with HCB Medicaid no longer meets criteria or refuses an ADW, DSDS staff shall proceed with the adverse action [Needs Link] process to close HCB Medicaid.
- DSDS staff shall complete and upload the IM54a regarding ineligibility for HCB Medicaid and send to the FSD HCB Processing Center.
Blind Pension (ME Code 02)
Blind Pension provides assistance to blind individuals who do not qualify under the Supplemental Aid to the Blind law and who are not eligible for Supplemental Security Income benefits. Eligible individuals receive a monthly cash grant, as well as MO HealthNet coverage. ME Code 02 [Needs Link] will only reimburse for state plan services. Participants with ME Code 02 are not eligible for any waivered services. The electronic case record will only display the services the participant is eligible for.
If a participant has a waivered service that was previously authorized, but Medicaid eligibility changes to ME Code 02, DSDS staff shall:
- Initiate the adverse action [Needs Link] process to close the waiver service
- Close all prior authorized waivered services
Ticket to Work Health Assurance (ME Code 85)
The Ticket to Work Health Assurance (TWHA) program provides Medicaid coverage, including HCBS, for persons with disabilities ages 16 through 64 who are employed. Like spenddown coverage, TWHA coverage has a monthly premium payment that participants must meet before Medicaid benefits become active.
At Initial Assessment
The TWHA premium liability must be met for the current date before a referral for HCBS can be processed. Upon receipt of a referral for a potential participant with an unmet TWHA premium liability, DSDS staff shall inform the participant:
- A referral cannot be completed because the TWHA premium has not been met for the current date
- To contact FSD for information on Medicaid benefits
- To contact the HCBS Customer Service Center to initiate a referral once Medicaid benefits are active
Upon receipt of a referral for a potential participant that has met the TWHA premium for the current date, DSDS staff shall complete the initial assessment in the participant’s electronic case record.
- If LOC is met, DSDS staff shall proceed with developing a PCCP and coordinating with the selected HCBS provider(s). DSDS staff shall inform the participant that Medicaid will only reimburse for HCBS during periods when the monthly TWHA premium liability has been met. The participant will be responsible to pay for the cost of any HCBS provided during periods when the monthly liability has not been met.
- If LOC is not met, DSDS staff shall proceed with the adverse action [Needs Link] process.
At Reassessment
A participant with TWHA coverage must have met the TWHA premium liability at least once within the previous three (3) months to continue with the reassessment process. DSDS staff shall review Medicaid eligibility within the participant’s electronic case record and/or DSS systems to verify that Medicaid benefits are currently active.
- If the TWHA premium has been met for the current date or has been met at least once within the previous three (3) months, DSDS Staff or designee shall complete the reassessment process within the participant’s electronic case record.
- If the TWHA premium has not been met for the current date and has not been met at least once within the previous three (3) months, DSDS Staff shall initiate the adverse action [Needs Link] process.
Transfer of Property Penalty
Participants with a transfer of property penalty have limited Medicaid benefits and are not entitled to ADW services. FSD determines the length of the penalty if a participant has sold, traded, or given away property for which fair and valuable consideration was not received.
The transfer of property penalty does not apply to State Plan, Independent Living Waiver (ILW), Structured Family Caregiving Waiver (SFCW) or Adult Day Care Waiver (ADCW) services; therefore, Medicaid eligible participants may be authorized for those services as identified through the assessment and PCCP.
NOTE: Transferring of income into a QIT does not constitute a Transfer of Property Penalty.
Managed Care
Individuals enrolled in certain Managed Care Health Plans are ineligible to receive HCBS except for State Plan Consumer Directed Services (CDS). Upon receipt of a referral for an individual enrolled in a Managed Care Health Plan where requested services cannot be authorized, DSDS staff shall refer the individual to the Managed Care Health Plan via the Notice of Closure form.
When an individual displays as having dual codes and one is Managed Care, DSDS staff needs to determine if the individual is “opted in” or “locked in” with a Managed Care provider before proceeding with any assessment, authorization or adverse action.
ME CODE 05 (Adult Family): Individual cannot receive HCBS. The participant will need to contact FSD to “opt out” of Managed Care Medicaid or change their Medicaid eligibility code altogether to request or receive HCBS.
Participants may “opt out” of Adult Family Medicaid (ME 05) if they meet one of the following criteria:
- Eligible for Supplemental Security Income (SSI)
- Enrolled in Special Health Care Needs Program
- Disabled and 18 years of age or younger
NOTE: This information also pertains to the ME Codes of 10, 18, 19, 21, 24, 26, 36, 37, 38, 43, 44, 45, 56, 61, 73, 74, & 75
NOTE: The electronic case record system will not allow further action on individuals who receive Managed Care on the date of request.
ME Code E2 (Medicaid Expansion) – Individual can only receive CDS. The participant will need to contact FSD to un-enroll from E2 in situations where there are dual codes and one code is E2, and the participant is requesting or authorized for services that E2 restricts.
Individuals with the following criteria are restricted to receive E2:
- Have active Medicare
- Age 65 or greater
- Eligible for non-spenddown Medicaid (ME codes: 05, 11, 12, 13, or 18)
- Determined as disabled through FSD Medical Review Team or Social Security Administration
Participants may “opt out” of Medicaid Expansion (ME 02) if they meet one of the following criteria:
- Eligible for SSI
- Enrolled in Special Health Care Needs Program
- Disabled and 18 years in age or younger
Electronic Case Record
The participant’s Electronic Case Record provides information to assist with Medicaid eligibility status determination. The eligibility status will display in the participant’s electronic case record. It may take up to 48 hours for the latest information to display. DSDS staff or designee shall utilize the appropriate DSS eligibility systems to verify Medicaid benefits when questions arise regarding the messages displayed within the electronic case record.
HCBS Eligibility
- Medicaid Eligibility (ME) Code [Needs Link]
- Prior to all HCBS (re)authorizations, the ME Code shall be reviewed to ensure the participant is eligible for specific service(s).
- Spenddown Indicator
- The spenddown indicator only displays for spenddown participants.
- If no is displayed, the participant has not met the monthly liability amount and is not currently eligible for Medicaid benefits.
- If yes is displayed, the participant has met their spenddown liability amount and is currently eligible for Medicaid benefits.
- MMIS tab and will eligibility period
- The spenddown indicator only displays for spenddown participants.
- Transfer of Property
- This field is not functional in the electronic case record. Staff shall review the LXIX screen in the DSS Network to determine Transfer of Property.
- Gross Income
- This data is not consistently updated in the electronic case record. Staff shall access the DSS Network to determine a participant’s income when needed.
- Ticket to Work Premium
- This field will display only for ME Code 85 participants and will show either paid or not paid.
- Participant Age
- Date of Death
2.0 Appendix 1 Missouri's Medicaid Program
Home and Community Based Services Manual
Missouri’s Medicaid program, also known as MO HealthNet, provides health care access to low income individuals who are elderly, disabled, members of families with dependent children, low-income children, uninsured children, pregnant women, refugees, or children in state custody. Missouri Medicaid determinations are made by the Department of Social Services (DSS), Family Support Division (FSD). Complete information regarding eligibility and how to apply for benefits can be obtained by accessing the following web site https://mydss.mo.gov/healthcare . In addition, this web site provides a link to locate a specific Resource Center and FSD’s Information Call Center.
Medicaid (non-spenddown)
Medicaid benefits are available to persons who:
- Are United States citizens or eligible qualified non-citizen;
- Are residents of Missouri and intend to maintain residency in Missouri;
- Provide (or apply for) a Social Security Number (SSN);
- Are determined medically eligible based on:
- Age (65 years of age), or
- Disabled (determined to be permanently and totally disabled), or
- Blind; and
- Do not own resources which exceed the Medicaid limit:
- $5,000 for an individual; or
- $10,000 for a couple; and
- Married couples who have resources exceeding the $10,000 maximum may be eligible for a Division of Assets - when only one of the couple needs Medicaid funded Home and Community Based Services (HCBS) through a Home and Community Based Waiver i.e., Aged and Disabled Waiver (ADW) or is institutionalized.
- Have monthly income which does not exceed the non-spenddown income limit (Medicaid Income Information [Needs Link]). Participants whose adjusted income exceeds the established guidelines as determined by FSD may be eligible for Medicaid benefits with a spenddown (see information included in this policy), and/or if age 63 or older, may be eligible for HCB Medicaid or Miller Trust benefits (see information included in this policy).
Medicaid (spenddown)
Benefit eligibility is the same as above for non-spenddown Medicaid except participants with income in excess of the income limit will have an amount of monthly medical expenses, similar to an insurance premium or deductible, that are the participant’s financial responsibility before Medicaid benefits are active. The spenddown liability is the amount by which an individual's or couple's net income exceeds the non-spenddown income limit (Medicaid Income Information [Needs Link]). Medicaid spenddown eligibility is determined initially by FSD. Upon determination of eligibility, the participant shall continue to be Medicaid eligible until a change in the participant’s situation causes ineligibility. The participant does not have to make reapplication. Active Medicaid coverage, however, is determined on a monthly basis.
- Participants may meet their spenddown obligation by:
- Paying the spenddown liability directly to the MO HealthNet Division (MHD) on a monthly basis which will provide active coverage for the entire month. A timely monthly payment provides the participant with ongoing Medicaid coverage; or
- Submitting medical bills that reach the participant’s spenddown liability, to the local FSD office. Active coverage will start the day the participant meets the spenddown liability and continue during the remainder of that month. On the day that the participant reaches their spenddown liability, MHD will only pay for medical services over the spenddown liability. Individuals do NOT have to pay their medical expenses before being considered as meeting their spenddown liability.
- Once determined eligible for Medicaid spenddown, a participant will be “locked-in” to receive Medicaid coverage.
Blind Pension
The Blind Pension (BP) program was established in 1921 and is financed entirely by state funds. This program provides assistance for blind persons who do not qualify under the Supplemental Aid to the Blind (SAB) law and who are not eligible for Supplemental Security Income (SSI) benefits. Each eligible person receives a monthly cash grant as well as state funded, rather than federally funded, Medicaid coverage. Additional information regarding the BP program can be found by accessing the following link: http://dss.mo.gov/fsd/blind-pension.htm.
Benefits are available under the BP program to persons who:
- Are 18 years of age or older;
- Are living in Missouri and intends to remain;
- Are United States citizens or eligible non-citizens;
- Have not given away, sold, or transferred real or personal property in order to be eligible for BP;
- Are single, or married and living with spouse, and do not own real or personal property worth more than $20,000. In determining the value of real or personal property, the real estate occupied by the blind person or spouse as the home shall be excluded;
- Is of good moral character;
- Have no sighted spouse living in Missouri who can provide support;
- Do not publicly solicit alms;
- Are determined to be totally blind as defined by law (up to 5/200 or visual field of less than 5 degrees);
- Are found to be ineligible for SAB (http://dss.mo.gov/fsd/sblind.htm);
- Are willing to have a medical treatment or an operation to cure their blindness, unless they are 75 years old or older;
- Are not a resident of a public, private, or endowed institution except a public medical institution; and
- Are found ineligible to receive federal SSI benefits.
Home and Community Based (HCB) Medicaid
Medicaid eligibility rules provide for a higher income threshold for individuals who meet the requirements for and have a need for services in the ADW (HCBS Introduction). A determination must be made for need and the availability of ADW services before FSD can apply the higher HCB income. Therefore determination of HCB Medicaid requires the inter-agency cooperation between FSD and the Department of Health and Senior Services (DHSS), Division of Senior and Disability Services (DSDS) or its designee. HCB Medicaid coverage does not have any direct cash benefits.
- HCB Medicaid application requirements are:
- 63 years of age or older;
- Monthly income at or below the current HCB income standard (Medicaid Income Information [Needs Link]).
- Meet nursing facility level of care;
- Is eligible to be authorized for an ADW service;
- Meets the other eligibility requirements as outlined under Medicaid for the Aged, Blind, and Disabled.
Qualified Income Trust (i.e., Miller Trust)
A qualifying income trust, such as a Miller Trust, allows an individual to place income into a trust in order to meet income eligibility guidelines for Medicaid. The trust must consist solely of the individual’s income, such as monthly Social Security or pension benefits, but not resources, and must be used solely for the benefit of the individual. There are no limits on how much income can be placed in the qualifying trust. However, if amounts paid out of the trust exceed the fair market value of goods and services on behalf of the individual, then the individual may be at risk of a penalty for an uncompensated asset transfer, resulting in loss of Medicaid coverage for needed services. Additionally, amounts paid out of the trust may count as income – whether paid directly to the beneficiary or paid to purchase something on their behalf (other than medical care). This “income” must be under the eligibility level in the state and is subject to post-eligibility share-of-cost rules. Finally, the trust must specify the state will receive any amounts remaining in the trust, after the person no longer receives Medicaid benefits; up to the amount the state paid in Medicaid benefits for the Miller Trust owner.
Ticket to Work Health Assurance (TWHA)
- The Ticket to Work Health Assurance (TWHA) program provides Medicaid coverage, including some HCBS, for persons with disabilities, age 16 through 64, who are employed. Resource limits are the same as for Medicaid coverage. However, the TWHA Program allows earnings.
- Participants with income above 100% of the Federal Poverty Level (FPL) will pay a premium to receive coverage. The income of the spouse is included when determining eligibility for the TWHA program. A participant whose computed gross income exceeds 100% of the Federal Poverty Level (FPL) must pay a monthly premium to participate in the TWHA program.
- TWHA eligible participants will be locked into eligibility when all requirements have been met for Medicaid coverage.
- TWHA has two components, a Basic Coverage Group and a Medically Improved Group. The Basic Coverage Group is for persons who have earnings but are determined to be permanently and totally disabled. The Medically Improved Group is for persons who have lost their eligibility for the Basic Coverage Group solely due to medical improvement. Both groups provide full Medicaid benefits.
- Upon approval, MHD will send an Initial Invoice letter, billing the participant for the premium amount for any past coverage selected through the month following approval. Coverage will not begin until the premium payment is received. If the participant does not send in the complete amount, they will be credited for any full month premium amount received starting with the month after approval and going back as far as the amount of premium paid allows.
- MHD will send a Recurring Invoice on the second working day of each month for the next month's premium. If the premium is not received prior to the beginning of the new month, the person's coverage ends on the day of the last paid month.
- MHD will not send a recurring invoice to the participant after six months of nonpayment of premium. The participant's eligibility for TWHA will remain open but the individual will not receive coverage until the premium is paid.
MO HealthNet Managed Care
- MO HealthNet Managed Care refers to the statewide medical assistance program for low-income families, pregnant women, and children under the age of 19 or, in some cases, until the age of 21. Managed Care participants receive their health care through either the Fee-for-Service delivery system or the Managed Care Health Plan delivery system, depending on where the individual lives. For Managed Care participants who are enrolled in a MO HealthNet Managed Care Health Plan, the health plan is responsible for meeting their personal care needs. These services are not prior authorized within the electronic case record. The electronic case record will provide contact information for the MO HealthNet Managed Care Health Plan. Although Missouri’s managed care system has expanded statewide, Missourians who receive aged, blind, or disabled Medicaid benefits will not be included in the managed care system and will continue to receive services through the traditional Fee-for-Service delivery system.
Supplemental Nursing Care (SNC)
- The Supplemental Nursing Care (SNC) program is available primarily for residents of licensed residential care facilities (RCF) and assisted living facilities (ALF). The SNC program provides an actual cash payment to the resident of up to $156 per month for RCF residents and $292 per month for ALF residents. SNC recipients also get a $50 personal needs allowance.
2.00 Appendix 2 Medicaid Income Information
Home and Community Based Services Manual
| Individual Medical Assistance, non-spenddown income limit | Couple Medical Assistance, non-spenddown income limit |
|---|---|---|
| Effective April 01, 2025 | $1,109.00 | $1,499.00 |
Effective January 1, 2025 | ||
| SSI Maximum | $967.00 | $1,450.00 |
| HCB Income Standard | $1,690.00 |
|
Spousal Share – Minimum | $31,584.00 |
|
Spousal Share – Maximum | $157,920.00 |
|
| Maximum Allotment to Community Spouse | $3,984.00 |
|
2.00 Appendix 3 Medical Eligibility (ME) Category Chart
Home and Community Based Services Manual
Eligibility for:
| ME | Description | State Plan | ADW | ILW | ADCW | SFCW |
|---|---|---|---|---|---|---|
| 02 | Blind Pension | Yes | No | No | No | No |
| 03 | Aid to the Blind | Yes | Yes | Yes | Yes | Yes |
| 04 | Permanently and Totally Disabled | Yes | Yes | Yes | Yes | Yes |
| *05 | MO HealthNet for Families - Adult | Yes | No | Yes | Yes | Yes |
| *10 | Refugees other than Cuban, Haitian, Russian J | Yes | No | No | No | No |
| 11 | MO HealthNet Old Age Assistance | Yes | Yes | Yes | Yes | Yes |
| 12 | MO HealthNet - Aid to the Blind | Yes | Yes | Yes | Yes | Yes |
| 13 | MO HealthNet - Permanently and Totally Disabled | Yes | Yes | Yes | Yes | Yes |
| 14 | Supplemental Nursing Care - Old Age Ai | Yes** | No | No | No | No |
| 15 | Supplemental Nursing Care - Aid to the Blind | Yes** | No | No | No | No |
| 16 | Supplemental Nursing Care-Permanently and Totally Disabled | Yes** | No | No | No | No |
| *18 | MO HealthNet for Pregnant Women | Yes | No | Yes | Yes | Yes |
| *19 | Cuban Refugee | Yes | No | No | No | No |
| *21 | Haitian Refugee | Yes | No | No | No | No |
| *24 | Russian Jew | Yes | No | No | No | No |
| *26 | Ethiopian Refugee | Yes | No | No | No | No |
| *36 | Adoption Subsidy – Federal Financial Participation | Yes | No | No | No | No |
| *37 | Title XIX - Homeless, Dependent, Neglected | Yes | No | Yes | Yes | Yes |
| *38 | Independent Foster Care Children Ages 18-26 | Yes | No | Yes | Yes | Yes |
| *43 | Pregnant Woman - 60 Day Assistance (MHN criteria) | Yes | No | Yes | Yes | Yes |
| *44 | Pregnant Woman - 60 Day Assistance-Poverty | Yes | No | Yes | Yes | Yes |
| *45 | Pregnant Woman - Poverty | Yes | No | Yes | Yes | Yes |
| 55 | Qualified Medicare Beneficiary (QMB) | No | No | No | No | No |
| *56 | Adoption Subsidy – Title IV-E | Yes | No | No | No | No |
| *61 | MO HealthNet for Pregnant Women (HIF) | Yes | No | Yes | Yes | Yes |
| *73,7475 | Children Ages 0-18 | Yes | No | No | No | No |
| 82 | MoRx (Medicare Part D Wrap-Around Benefits) | No | No | No | No | No |
| 83 | Breast or Cervical Cancer Control Project -Presumptive | Yes | No | No | No | No |
| 84 | Breast or Cervical Cancer Control Project - Regular | Yes | Yes | Yes | Yes | Yes |
| 85 | Ticket to Work Health Assurance - Premium | Yes | Yes | Yes | Yes | Yes |
| 86 | Ticket to Work Health Assurance - Non-Pi | Yes | Yes | Yes | Yes | Yes |
| 91 | Gateway to Better Health | No | No | No | No | No |
| ***E2 | Adult Expansion Group (Medicaid Expansion) | Yes*** | No | No | No | No |
* Participants enrolled in a Managed Care Health Plan are not eligible to receive services authorized by the Division of Senior and Disability Services (DSDS) and need to be directed to their health plan.
** PC in RCF/ALF authorizations only.
*** Participants with an ME code E2 are only eligible for Consumer-Directed Services authorized by DSDS.
3.0 Available Home and Community Based Services
Home and Community Based Services Manual
Home and Community Based Services (HCBS) are designed to assist in meeting the unmet needs of the participant and provide the necessary assistance to remain in the least restrictive environment. As part of the development of a Person Centered Care Plan (PCCP), services shall be authorized which appropriately relate to the unmet needs of the participant, in accordance with provider availability and program eligibility. Individuals are not eligible to receive HCBS while residing in hospitals, Intermediate Care Facilities (ICF), or Skilled Nursing Facilities (SNF). HCBS are authorized for reimbursement through Medicaid for participants who meet specific program eligibility requirements. Medicaid funded HCBS are available through either State Plan services or through a Home and Community Based Waiver. States can choose to include certain HCBS in the State Plan Medicaid program or through a Waiver with the United States Department of Health and Human Services (DHHS), Centers for Medicare and Medicaid Services (CMS).
- State Plan Services are administered under the authority of TXIX of the Social Security Act.
- Home and Community Based Waivers are authorized under the authority in §1915(c) of the Social Security Act. Waivers give states the flexibility to develop and implement alternatives for individuals at risk of being institutionalized. States can design each Waiver program and select the mix of services that best meets the needs of the population they wish to serve. HCBS, with oversight responsibility within the Department of Health and Senior Services (DHSS), Division of Senior and Disability Services (DSDS), are available through the Aged and Disabled Waiver, Adult Day Care Waiver, and the Independent Living Waiver. Medicaid participants can receive services through only one Medicaid Home and Community Based Waiver at a time, regardless of the state agency administering the Waiver.
- A complete listing of HCBS limits, units, and rates is located in the Services Units and Rates [Needs Link] policy.
The Department of Social Services (DSS), MO HealthNet Division (MHD) is the single state Medicaid agency charged with the overall management and oversight of Medicaid programs in Missouri. MHD grants administrative program authority through cooperative agreements with other state agencies.
The following policies shall assist in determining the appropriate HCBS:
Personal Care – State Plan (Agency Model) - Policy
Basic Personal Care - State Plan (Agency Model) - 3.05 [Needs Link]
Advanced Personal Care – State Plan (Agency Model) - 3.10 [Needs Link]
Authorized Nurse Visit – State Plan (Agency Model) - 3.15 [Needs Link]
Residential Care Facility/Assisted Living Facility (RCF/ALF) Personal - 3.20 [Needs Link]
Care – State Plan
Personal Care Assistance – State Plan (Consumer-Directed Model) - 3.25 [Needs Link]
Adult Day Care Waiver - 3.31 [Needs Link]
Aged and Disable Waiver
- Chore - 3.35 [Needs Link]
- Home Delivered Meals - 3.40 [Needs Link]
- Homemaker - 3.45 [Needs Link]
- Respite (Basic and Advanced) - 3.50 [Needs Link]
- Adult Day Care - 3.51 [Needs Link]
Independent Living Waiver - 3.55 [Needs Link]
- Personal Care Assistance – Consumer-Directed Model
- Financial Management Services
- Case Management
- Environmental Accessibility
- Specialized Medical Equipment
- Specialized Medical Supplies
Structured Family Caregiving Waiver - 3.60 [Needs Link]
Social Services Grant General Revenue Protective Services Participants - 3.70 [Needs Link]
Home and Community Based Services Units and Rates - 3.00 Appendix 1 [Needs Link]
Home and Community Based Services Cost Maximums - 3.00 Appendix 2 [Needs Link]
Consumer Directed Services Tax Information - 3.25 Appendix 1 [Needs Link]
Waiting List Notice for Independent Living Waiver Services - 3.55 Appendix 2 (Forms and Instructions [Needs Link])
3.05 Basic Personal Care – State Plan (Agency Model)
Home and Community Based Services Manual
Introduction
Agency Model Personal Care (PC) services are medically oriented tasks provided as an alternative to nursing facility care and designed to meet the maintenance needs of individuals with chronic health conditions. PC services must be reasonable according to the participant's condition and functional capacity. Home and Community Based Services (HCBS) providers enrolled as PC providers with the Department of Social Services (DSS), Missouri Medicaid Audit and Compliance Unit (MMAC) deliver the services.
Purpose
Agency Model PC services are funded through the Medicaid State Plan and are designed to assist with activities of daily living (ADL) and/or instrumental activities of daily living (IADL). They are provided as an alternative to nursing facility placement to persons for adults and individuals with disabilities. PC is also provided in a Residential Care Facility (RCF) or Assisted Living Facility (ALF) [Needs Link].
Eligibility
All participants must meet the following eligibility criteria:
- At least 18 years of age
- In active Medicaid status (Medicaid Eligibility)
- Participants who are eligible for Medicaid on a spenddown basis may be authorized to receive PC during periods when they meet their spenddown liability.
- A participant is responsible for the cost of services received during periods of time when they have not met their spenddown liability.
- Participants who receive Medicaid due to eligibility for Blind Pension (BP) may be authorized for PC.
- Participants in a ‘Transfer of Property penalty’ may be authorized for PC.
- Authorization of PC does not meet the requirements for an individual to be eligible for Home and Community Based (HCB) Medicaid.
- Have an appropriate Medicaid Eligibility (ME) code [Needs Link].
Meet nursing facility level of care.
Authorization
PC units shall be authorized as outlined below:
- Authorized in 15-minute units
- Consistent with the PC tasks to be completed on a regular basis
Reasonable for the amount of PC units authorized
When developing a Person Centered Care Plan (PCCP) the following shall be taken into consideration:
- PC shall be included in the overall cost of care for the participant as referenced in the HCBS Cost Maximums policy
- PC services shall not exceed 60% of the cost maximum
- The combination of agency model PC and CDS shall not exceed 60% of the cost maximum.
- The 60% cost maximum can be exceeded by the cost of APC and RN visits, but only up to the full monthly cost of 100%.
NOTE: When the PCCP includes an authorization for RN services, the cost of one RN visit shall be excluded from the calculation of a PCCP’s cost.
- When the combination of PC, other State Plan services, and an HCBS Waiver e.g., Aged and Disabled Waiver (ADW) or Independent Living Waiver (ILW) exceeds 100% of the monthly cost maximum, approval is required from the Bureau of Federal Programs (BFP).
- The appropriate supervisor for the Division of Senior and Disability Services (DSDS) staff shall review all PCCP requests over the 100% cost maximum to ensure the participant’s unmet needs require the amount of service requested.
- If documentation supports the request, the case shall be forwarded to BFP for consideration and approval prior to authorization over 100% of the cost cap.
- Pending the approval from BFP to exceed the cost maximum, PC services in combination with other State Plan or ADW or ILW services can be authorized up to 100% of the cost maximum.
- When a PCCP includes Adult Day Care authorized through the ADW or the Adult Day Care Waiver (ADCW), the total cost of care cannot exceed 100% of the cost maximum.
NOTE: Pursuant to federal guidelines, a participant can only be enrolled in one HCBS waiver at a time, regardless of which department administers the waiver program.
Restrictions
The following outlines guidance to adhere to:
- The individual providing the service is an employee of the HCBS provider and cannot be a member of the immediate family of the participant. An immediate family member is defined as a parent, sibling, child by blood, adoption, or marriage (step-child), spouse, grandparent or grandchild.
- Participants authorized for certain services through the Department of Mental Health (DMH) may not be eligible for services as outlined in this policy. Staff shall refer to the DMH Service Coordination policy [Needs Link] for guidance on coordination of services for participants authorized for DMH services.
Tasks
Home and Community Based Services Manual
Suggested times and frequencies have been developed with the care needs of an average or typical participant in mind. In the development of the PCCP, consideration shall be given regarding the size of the home, geographic location, specific participant limitations, formal and informal supports, and other factors that might affect the amount of time necessary to complete required tasks.
PC services may include any of the following tasks:
Dietary
- Assistance with meal preparation and cleanup and assistance with eating/feeding. Consideration shall also be given to the participant’s ability to prepare a light meal such as sandwiches, soups, and salads and/or the availability of home-delivered meals. (Suggested time 10-60 minutes – Suggested frequency 1-7 x/week)
Dressing/Grooming
- Assistance with dressing and grooming including help with dressing and undressing, combing hair, nail care, oral hygiene and denture care, and shaving. (Suggested time 15 minutes – Suggested frequency 1-7 x/week)
Bathing
- Assistance with bathing, including shampooing hair. (Suggested time 30-45 minutes – Suggested frequency 1-7 x/week)
Toileting/Continence
- Assistance in going to the bathroom and changing bed linen. May also include the changing of bed linens for participants with medically related limitations that prohibit the completion of this task. Mobility and transfer to the bathroom should be included and delivered as needed. (Suggested time 5-10 minutes – Suggested frequency as needed)
Mobility/Transfer
- Assistance with transfer and ambulation when the participant can at least partially bear their own weight. Actual lifting of the participant is not an appropriate task. (Suggested time 5-10 minutes – Suggested frequency as needed).
Self-Administration of Medications
- Assistance with self-administration of medication and applying nonprescription topical ointments or lotions.
- Self-administration of medication is defined in 19 CSR 30-83.010 (46) as the act of actually taking or applying medication to oneself. For example, the time spent handing the medication container and water to the participant so the participant can self-administer their medications would be appropriately calculated in the time for this task. (Suggested time 1 unit/day for self-administration of medications taken up to 3 times daily; 2 units/day for medications taken 4 or more times daily)
- Refer to the RCF/ALF Personal Care – State Plan (Agency Model) [Needs Link] policy for self-administration of medication in a RCF/ALF setting.
Medically Related Household Tasks
- Includes the tasks outlined under Homemaker (ADW) [Needs Link] services.
NOTE: Encouragement (prompting and cueing) and instruction of participants in self-care may be a component of the tasks described above; however, encouragement and instruction do not constitute a task in and of themselves.
3.10 Advanced Personal Care - State Plan (Agency Model)
Home and Community Based Services Manual
Introduction
Advanced Personal Care (APC) (Agency Model) services are maintenance services provided in a participant’s home to assist with activities of daily living (ADL) when this assistance requires devices and procedures related to altered body functions.
Purpose
The authorization of APC services is funded through the Medicaid State Plan. These medically oriented services are designed to meet the physical and maintenance needs of participants with chronic and stable conditions. APC may also be provided in a Residential Care Facility (RCF) or Assisted Living Facility (ALF) through State Plan [Needs Link] (Agency Model).
Eligibility
All APC participants must meet the following eligibility criteria:
- At least 18 years of age
- Meet nursing facility level of care (LOC)
- In active Medicaid status [Needs Link]:
- Participants eligible for Medicaid on a spenddown basis may be authorized to receive APC when they meet their spenddown liability.
- A participant is responsible for the cost of services received during periods of time when they have not met their spenddown liability.
- Participants who receive Medicaid due to eligibility for Blind Pension (BP) may be authorized for APC.
- Participants in a ‘Transfer of Property penalty’ may be authorized for APC.
- Authorization of APC does not meet the eligibility requirements for an individual for Home and Community Based (HCB) Medicaid.
- Have an appropriate Medicaid Eligibility (ME) Code [Needs Link]
Authorization of APC
When authorizing APC, the following shall apply:
- APC shall be authorized in increments of 15-minute units
- APC units shall be consistent with the APC tasks to be completed regularly
- The number of APC tasks identified shall be reasonable for authorized APC units
- APC shall be included in the overall monthly cost [Needs Link] of care
- APC is provided by HCBS providers enrolled as a Personal Care-Agency Model provider.
- The APC staff is an employee of the HCBS provider and cannot be a member of the immediate family of the participant. An immediate family member is defined as a parent, sibling, child by blood, adoption, or marriage (stepchild), spouse, grandparent, or grandchild.
Cost Maximus
APC authorized together with other Medicaid State Plan Home and Community Based Services (HCBS) and Aged and Disabled Waiver (ADW), services shall not exceed 100% of the average statewide monthly cost for care in a nursing facility without prior approval of the Bureau of Federal Programs (BFP).
- If the documentation supports the request, the case shall be forwarded to BFP for consideration and approval before authorization over 100% of the cost cap
- Pending BFP approval to exceed the cost cap, APC services, combined with other State Plan or ADW services, can be authorized up to 100% of the cost cap
- When a PCCP includes Adult Day Care authorized through the ADW or the Adult Day Care Waiver (ADCW), the total cost of care cannot exceed 100% of the cost cap
NOTE: When the care plan includes RN services, the cost of one RN visit shall be excluded from calculating a care plan’s cost. When the combination of State Plan and ADW services exceeds the 100% cost maximum, the appropriate supervisor for the Division of Senior and Disability Services (DSDS) staff shall review all person-centered care plan (PCCP) requests over the 100% cost cap to address the participant’s unmet needs.
Restrictions
Participants authorized for certain services through the Department of Mental Health (DMH) may not be eligible for services as outlined in this policy. Staff shall refer to the Service Coordination Policy [Needs Link] for guidance on coordinating services for participants authorized for DMH services.
Allowable Services
Participants who meet eligibility requirements may be authorized for any of the following services:
- Aseptic Dressings: (Suggested time 15 minutes per ordered instance)
- Application of dressings to superficial skin breaks or abrasions as directed by a licensed nurse
- Application of medicated (prescription) lotions and ointments to unbroken skin, including stage 1 decubitus
- Assistance with Transfer Device: (Suggested time 15 minutes per instance)
- Use of an assistive device for transfers
- Bowel/Bladder Program: (Suggested time 15 minutes per ordered instance)
- Administration of prescribed bowel programs, including suppositories and sphincter stimulation per protocol and prepackaged enemas for participants without contraindicating rectal or intestinal conditions
- Catheter Hygiene: (Suggested time 15 minutes per instance)
- Changing of bags, soap and water hygiene around the site of external, indwelling, and suprapubic catheters
- Removal of external catheters, skin inspection, and catheter reapplication
- Non-Injectable Medications: (Suggested time 15 minutes per ordered instance)
- Manual assistance with non-injectable medications may include opening a medicine lockbox, steadying the participant’s hand/arm for ear and eye drops, finger sticks for blood sugar monitoring and reading levels and when prompting is required to take medication
- Ostomy Hygiene: (Suggested time 15 minutes per instance)
- Changing of bags, soap and water hygiene around a well-healed ostomy site (including tracheostomies, gastrostomies, and colostomies)
- Passive Range of Motion: (Suggested time 15 minutes per ordered instance)
- Administration of movement of a joint through its full range of motion, delivered by the care plan
NOTE: Encouragement (prompting and cueing) and instruction of participants in self-care may be a component of the task; however, encouragement and instruction do not constitute a task in and of themselves.
3.15 Authorized Nurse Visits – State Plan (Agency Model)
Home and Community Based Services Manual
Introduction
Authorized nurse visits are provided by Home and Community Based Services (HCBS) providers who are enrolled in the HCBS personal care agency model program. The nurse visits are for enhanced supervision of the personal care aide and maintenance, or preventative services provided by a Registered Nurse (RN) or a Licensed Practical Nurse (LPN), or a Graduate Nurse (GN) under the direction of an RN or physician. The visits shall also include an assessment of the participant’s health and the adequacy of the care plan to meet the participant’s needs.
Purpose
Authorized nurse visits are funded through Medicaid State Plan. They are provided to participants with stable, chronic conditions and are NOT typically intended as a treatment for an acute health care condition as normally provided through home health services.
Eligibility
All participants authorized for nurse visits must meet the following eligibility criteria:
- At least 18 years of age
- Meet nursing facility level of care
- In active Medicaid status (Medicaid Eligibility)
- Participants who are eligible for Medicaid on a spenddown basis may be authorized to receive nurse visits during periods when they meet their spenddown liability.
A participant is responsible for the cost of services received during periods of time when they have not met their spenddown liability. - Participants who receive Medicaid due to eligibility for Blind Pension (BP) may be authorized for nurse visits.
- Participants in a ‘Transfer of Property penalty’ may be authorized for nurse visits.
- The authorization of nurse visits does not meet the requirement for an individual to be eligible for Home and Community Based (HCB) Medicaid.
- Participants who are eligible for Medicaid on a spenddown basis may be authorized to receive nurse visits during periods when they meet their spenddown liability.
- Have an appropriate Medicaid Eligibility (ME) code
NOTE: Participants must be receiving other Personal Care Services (PC) - Agency Model or ConsumerDirected Model (CDS) to be eligible for nurse visits.
Authorization
The following guidelines outline the process for authorizing nurse visits:
- Nurse visits shall be authorized by the visit, not in 15-minute increments. No minimum or maximum time is required to constitute a visit.
- Nurse visits are typically authorized by combining individual nursing tasks into the same nurse visit; however, they can be separated if there is a justified need.
- The nurse is an employee of the HCBS provider and cannot be a member of the immediate family of the participant. An immediate family member is defined as a parent, sibling, child by blood, adoption, or marriage (stepchild), spouse, grandparent or grandchild.
- A maximum of 26 nurse visits will only be provided in a six-month authorization period.
- Authorized nurse visits shall NOT include services considered reimbursable as skilled nursing care under the home health program or when the visit is to determine whether an individual is eligible for HCBS.
- When a service need is detected that would require skilled nursing care, the provider shall forward information to the participant's physician. The physician may then issue home health orders as appropriate.
- Participants authorized for certain services through the Department of Mental Health (DMH) may not be eligible for services as outlined in this policy. Division of Senior and Disability (DSDS) staff shall refer to the DMH Service Coordination policy for guidance on coordinating services for participants authorized for DMH services.
NOTE: When a provider change occurs, the new provider shall only be authorized for the nurse visit(s) remaining within an existing authorization period.
Cost Maximum
Authorized nurse visitsshall be included in the overall cost of care (HCBS Cost Maximums) with the following exceptions:
- The cost of authorized nurse visits is not included in the 60% monthly maximum cost for basic PC
- The cost of one (1) authorized nurse visit is not included in the 100% monthly cost for basic PC
- Participants who only receive authorized nurse visits for General Health Evaluations (GHE), the cost of two nurse visits shall be excluded from the calculation of a PCCP cost
NOTE: The electronic case record system will automatically exclude the nurse visit(s) from the calculation of the PCCP.
- Nurse visits authorized together with other Medicaid State Plan HCBS, i.e., agency model PC, CDS, Advanced Personal Care (APC) and Aged and Disabled Waiver Services (ADW) shall not exceed 100% of the monthly cost for care in a nursing facility without prior approval from the Bureau of Federal Programs (BFP).
- When the combination of State Plan and ADW services (excluding Adult Day Care) exceeds the 100% cost maximum:
- The appropriate supervisor for DSDS staff shall review all PCCP requests to ensure unmet needs require the amount of service requested.
- If documentation supports the request, it shall be forwarded to BFP for consideration and approval prior to authorizing over 100% of the cost maximum.
- Pending approval from BFP, authorized nurse visits in combination with other state plan or ADW services can be authorized up to 100% of the cost maximum.
- When the combination of State Plan and ADW services (excluding Adult Day Care) exceeds the 100% cost maximum:
NOTE: When a PCCP includes Adult Day Care authorized through the ADW or the Adult Day Care Waiver (ADCW), the total cost of care cannot exceed 100% of the cost maximum.
General Health Evaluations
All participants receiving agency model PC and APC shall be authorized a minimum of two (2) nurse visits annually to perform General Health Evaluations (GHE) as required by MO State Statute 192.2475.14 RSMo. The semi-annual nurse visits are necessary for the delivery and supervision of the individual providing the services to ensure quality of care, assessment of the participant’s health and adequacy of the participant’s PCCP.
When no other nursing need is identified, GHEs shall be authorized as a task on separate lines in the 4th and 10th months following the (re)assessment as outlined below in the General Health Evaluation Chart.
General Health Evaluation Chart | ||
|---|---|---|
Month of Assessment | 4th Month | 10th Month |
| January | April | October |
| February | May | November |
| March | June | December |
| April | July | January |
| May | August | February |
| June | September | March |
| July | October | April |
| August | November | May |
| September | December | June |
| October | January | July |
| November | February | August |
| December | March | September |
Excluded from the requirement for semi-annual nurse visits are those participants authorized for:
- Personal Care Services (Agency Model) in a Residential Care Facility (RCF) or Assisted Living Facility (ALF)
- Aged and Disabled Waiver services only
- Personal Care Assistance (Consumer-Directed Model) only
- Independent Living Waiver only
- Adult Day Care Waiver only
- Structured Family Caregiving Waiver
Participants with a documented need for other nurse tasks shall not be authorized for separate semi-annual nurse visits. The 4th and 10th months following a (re)assessment, during which the GHE is to be completed, shall be documented in the electronic case record. DSDS or its designee shall communicate to the provider that the General Health Evaluation (GHE) and Level of Care Recommendation form is to be completed as part of a regularly scheduled nurse visit during those months. GHEs shall not be selected as a task when a participant has a need for nursing tasks. When selecting nurse visits in the electronic case record, only enter the first month of the GHE. The second month will automatically populate.
DSDS or its designee shall be aware of and review documentation/information submitted by the provider nurse and take appropriate action. This includes:
- The General Health Evaluation and Level of Care Recommendation
- Notification that a participant has refused a General Health Evaluation and Level of Care Recommendation visit
NOTE: Critical issues identified during any provider nurse visit shall be communicated immediately to DSDS via telephone, email or fax as required by the Code of State Regulation(s). This notification may require an immediate care plan change.
Regular Nurse Visits
For authorized nurse visits excluding the required semi-annual GHE visits, DSDS or its designee must establish and document that no other person is available who is willing and able to provide the service. Such documentation may include, but is not limited to:
- Participant lives alone
- Incapability of available family members
- Unwillingness/incapability of other available individuals to provide the needed services
Resident of RCF or ALF requires services beyond what is normally included in the monthly room and board reimbursement to the facility, RCF/ALF PC
In addition to increased supervision of the HCBS provider employee and assessment of the participant’s health and adequacy of the care plan, authorized nurse visits may include the following:
- Medications
- Filling insulin syringes weekly for diabetics who can self-inject the medication but cannot fill their own syringes.
- Documentation must be sufficient to establish the participant has a diabetic condition impairment that prevents the participant from independently filling syringes.
- Oral medication set-ups in divided daily compartments for participants who self-administer prescribed medications but need assistance and monitoring due to confusion or disorientation.
- Documentation must be sufficient to establish the need for medication and that the participant is disoriented or confused. Although self-control of prescription and over-the-counter medications may be allowed in an RCF or ALF with written permission from the resident’s physician and allowed by facility policy. This task would not be applicable for RCF and ALF residents who are authorized for Personal Care in an RCF or ALF.
- Filling insulin syringes weekly for diabetics who can self-inject the medication but cannot fill their own syringes.
- Monitoring Skin Condition
- Check for possible skin breakdown due to immobility, incontinence, or other needs as described below.
- Unable to turn and position self
- Limited ability to ambulate, with long periods of time sitting or lying in one position, or is documented to be incontinent
- History of decubitus ulcers, poor circulation evidenced by edema or discolored extremities, and diabetes
- Documentation must be sufficient to establish the participant is at risk of skin breakdown.
- Check for possible skin breakdown due to immobility, incontinence, or other needs as described below.
- Nail Care
- Monthly visits to provide nail care for diabetic participants or participants with other medically contraindicating conditions, including but not limited to participants:
- Taking anticoagulant medication, such as Coumadin
- Diagnosed with peripheral vascular disease
- Diagnosed with a compromised immune system (e.g. HIV and chemotherapy patients)
- Documentation shall be sufficient to establish the participant has a medical condition such as diabetes AND is unable to perform this task.
- Monthly visits to provide nail care for diabetic participants or participants with other medically contraindicating conditions, including but not limited to participants:
Other Nursing Care
Participants may be authorized for nurse visits for specific tasks when the needs of the participant cannot be met and are not reimbursable through the home health program. DSDS or its designee shall approve nurse visits for “other” non-routine nursing tasks after consultation with the participant, provider nurse, DSDS supervisor and, as necessary, the physician.
The “other” nursing tasks may include, but are not limited to:
- Administration of injectable medications (other than insulin)
- Venipunctures
- Catheter changes
- Enemas (only when not utilizing a prepackaged enema)
- Wound dressing changes
- Central line dressing/flush/blood draws
Providers with written documentation should upload it to the participant’s electronic case record and include documentation in case notes.
NOTE: It is not necessary for DSDS or its designee to obtain copies of physician’s orders prior to the authorization of a nurse visit or adding a task to a nurse visit.
Advanced Personal Care
All APC participants shall be authorized for a monthly nurse visit to evaluate the adequacy of service delivery and ensure the participant's needs and conditions are met. During the visit, the nurse assesses the APC aide’s ability to carry out the authorized services.
APC aides shall be trained on the APC tasks delivered. For participants not authorized for weekly nurse visits, an additional nurse visit shall be authorized through the first full month of the authorization for on-the-job training of the APC aide. DSDS staff or its designee shall select the Train APC task for those one-time visits.
The Train APC task shall not be selected for participants authorized for weekly nurse visits. In these circumstances, the Train APC should be authorized as an RN visit for the one-month authorization period. The task should be performed by the nurse during the regular nurse visit as needed.
The Train APC task is to be completed as follows:
- Once during the first full month of an initial authorization of APC, following the addition of an APC task to the care plan
- At the time of an APC provider change
- When requested by the provider (such as when aides change), to provide on-the-job training of the APC aide
When developing the PCCP, two (2) RN visits will be added. One (1) unit will be entered for Train APC, and two (2) units will be entered for Evaluate APC. Eval APC must be authorized for two units in the first month, so the provider can bill for both the training and evaluation of the APC aide later in the same month, since this will be two different visits.
NOTE: To prevent duplicate prior authorizations, the end date and start date of each authorization must not overlap.
Example Of APC Authorization With A Once-A-Month RN Task
1st RN Authorization
2nd RN Authorization
Example Of APC Authorization With Weekly RN Task Included
1st RN Authorization
2nd RN Authorization
Example Of APC Authorization With No Monthly Or Weekly Nurse Visits
1st RN Authorization
2nd RN Authorization
3.20 RCF/ALF Personal Care – State Plan (Agency Model)
Home and Community Based Services Manual
Introduction
Personal Care (PC) services are maintenance services provided to residents of Residential Care Facilities (RCF) or Assisted Living Facilities (ALF) to assist with activities of daily living (ADL). Services are authorized to eligible residents when the resident's needs exceed the facility's minimum obligations as established in the licensure requirements.
RCFs or ALFs are responsible, at a minimum, for the basic human needs of its residents. The facilities are also responsible for assuring the resident's PC needs are met through the resident's resources or other available resources. The facilities are responsible for 24-hour protective oversight of residents and room and board. The reimbursement the facility receives from the resident (Supplemental Security Income (SSI), Social Security Administration (SSA), etc.) and a supplemental cash grant from the Department of Social Services (DSS) is intended to cover safe shelter needs (including housekeeping, basic linens, and the maintenance thereof) and nutritional needs (food and food preparation).
Purpose
RCF/ALF Personal Care services are designed to support residents' additional needs in this setting and are funded through Medicaid State Plan. Basic Personal Care, Advanced Personal Care and Authorized Nurse Visits are all allowable service types offered to residents with an identified need that goes above and beyond the facility's basic requirements.
Eligibility
All PC participants must meet the following eligibility criteria to receive services in an RCF/ALF:
- At least 18 years of age
- In active Medicaid status:
- Participants eligible for Medicaid on a spenddown basis may be authorized to receive services during periods they meet their spenddown liability.
- A participant is responsible for the cost of services received during periods of time when they have not met their spenddown liability.
- Participants who receive Medicaid due to eligibility for Blind Pension (BP) may be authorized for services in the RCF or ALF.
- Participants in a ‘Transfer of Property penalty’ may be authorized for services in the RCF or ALF.
- Have an appropriate Medicaid Eligibility (ME) Code.
- Meet nursing facility level of care (LOC)
Referrals
Referrals for PC services shall be made to the Department of Health and Senior Services (DHSS), Division of Senior and Disability Services (DSDS). DSDS shall screen and process the referral as appropriate, utilizing the same timeframes as all other HCBS.
HCBS participants requesting PC services may make a referral by contacting the HCBS Customer Service Center. Providers should initiate referrals by utilizing the Online HCBS Referral Form. In instances when referrals cannot be submitted online, referrals can be submitted by completing the Home and Community Based Services Referral Form. In addition to the referral forms, referrals may include a Physician’s Prescription for Personal Care.
Assessment
When arriving at an RCF/ALF and completing a (re)assessment, DSDS staff or its designee shall:
- Announce themselves to facility staff and indicate the intent of the visit before meeting with the current or potential participant
- Document the room condition where the current or potential participant resides in case notes
- DSDS or its designee must review the participant’s facility chart to verify information that will assist in determining the (LOC) and assistance needed. Items to verify include but are not limited to:
- Diagnosis and frequency of mental health physician visits
- Physician-ordered treatments, medications, or special diets the participant receives
- Make other collateral contacts, including, but not limited to, RCF or ALF staff (Administrator/manager, licensed nurse, PC aide who provides daily services), family, friends, legal representatives, or physicians to obtain information to complete the assessment process
- Make decisions regarding the authorization of PC services in consultation and agreement with the participant, the participant’s legal representative (if applicable), and the participant’s physician
- Ensure the services authorized shall reinforce and enhance the participant's current formal and informal support system
- Reimbursement for PC services cannot duplicate what is covered in other reimbursements to the facility (e.g., routine linen changes and meal preparation).
Authorization
RCF/ALF PC services are also governed by the average statewide monthly cost for care in a nursing facility. PC units shall be authorized as outlined below:
- PC services shall not exceed 60% of the cost maximum
- The 60% cost maximum can be exceeded by the cost of APC and RN visits, but only up to the full monthly cost of 100%
- All combined PC services shall not exceed 100% of the average statewide monthly cost for care in a nursing facility
NOTE: When the care plan includes authorization for RN services, the cost of one RN visit shall be excluded from the calculation of a care plan’s cost.
Tasks
Residents who meet the necessary Medicaid eligibility requirements may be authorized for any of the following combinations of services provided.
Basic Personal Care
Basic Personal Care (PC) services in RCF/ALF shall be authorized in 15-minute units and are generally medically oriented tasks designed to meet the physical and maintenance needs of participants with chronic, stable conditions. PC may include the following tasks:
- Bathing
- Direct assistance with bathing and shampooing hair that requires active participation by the aide. (e.g. hands-on washing assistance, assistance in or out of the bath, gathering supplies/clean clothing, etc.) (Suggested time 15-45 minutes per bath)
- Dietary
- Direct assistance with meal preparation, feeding and clean up. Dietary shall be authorized when the participant has a physician-ordered specialized diet. Dietary may also be authorized if the participant needs assistance with feeding, cutting up food, carrying a tray to the table, opening containers, etc. Authorization of service units must be based on the participant’s specific needs. (Suggested time 15- minutes per meal)
- DSDS or its designee shall review any physician-ordered diet before authorizing units for dietary needs. No units shall be authorized for meal preparation and clean-up unless facility staff exceeds licensure requirements.
- Dressing/Grooming
- Direct assistance with dressing and undressing, combing hair, nail care, oral hygiene, shaving, and assisting with prosthetics. (Suggested time 15 minutes per dressing instance)
- Medically Related Household Tasks
- Assistance with required cleaning that goes above and beyond the minimum housekeeping requirements of the facility. Time may be authorized if the participant has a medically related need that requires the facility staff to clean a resident’s living area more often than usual (e.g. profuse bodily secretions, excess bodily fluids from incontinence, destructive tendencies, hoarding, etc.). DSDS or its designee can authorize services to clean the resident’s living area and launder the resident’s clothes and linens. (Suggested time 15-minutes per instance)
- Mobility and Transfer
- Direct assistance with mobility, transfer, and ambulation when the participant can at least partially bear their weight. (Suggested time 5-10 minutes per instance)
- Self-Administration of Medications
- Direct assistance with medications and applying nonprescription topical ointments or lotions (e.g. the time spent handling the medication container, including inhalers, medicines for nebulizers, ointments/lotions, steadying the participant’s hand/arm to get oral medication and inhalants to mouth, and water to the participant. (Suggested time 1 unit/day for self-administration of medications taken up to 3 times daily; 2 units/day for medications taken 4 or more times daily)
- Medication administration is not a covered task within the PC program. The self-administration of medication task does not include the time required by facility staff to administer the medication. Administration of medication is defined in 19 CSR 30-86.042(51) as delivered to a resident their prescription medication either in the original pharmacy container or for internal medication, removing an individual dose from the pharmacy container and placing it in a small container or liquid medium for the resident to remove from the container and self-administer.
- Direct assistance with medications and applying nonprescription topical ointments or lotions (e.g. the time spent handling the medication container, including inhalers, medicines for nebulizers, ointments/lotions, steadying the participant’s hand/arm to get oral medication and inhalants to mouth, and water to the participant. (Suggested time 1 unit/day for self-administration of medications taken up to 3 times daily; 2 units/day for medications taken 4 or more times daily)
- Toileting
- Direct assistance with toileting tasks. This may include assistance using or transferring to/from the toilet, commode, bedpan, urinal, cleansing after use and assistance with incontinence episode(s) (The suggested time is 5 minutes multiplied by times per day based upon the suggested frequency needed).
- Encouragement (prompting and cueing) and instruction of participants in self-care may be a component of the services; however, encouragement and instruction do not constitute a task in and of themselves.
- Direct assistance with toileting tasks. This may include assistance using or transferring to/from the toilet, commode, bedpan, urinal, cleansing after use and assistance with incontinence episode(s) (The suggested time is 5 minutes multiplied by times per day based upon the suggested frequency needed).
Advanced Personal Care
Advanced Personal Care (APC) services shall be authorized in 15-minute units and are medically oriented tasks designed to meet the physical and maintenance needs of participants with a chronic, stable condition when such assistance requires devices and procedures related to altered body functions. APC may include the following tasks:
- Aseptic Dressings
- Application of dressings to superficial skin breaks or abrasions as directed by a licensed nurse. (Suggested time 15 minutes per ordered instance)
- Application of medicated (prescription) lotions and ointments to unbroken skin, including stage 1 decubitus. (Suggested time 15 minutes per ordered instance)
- Bowel Program
- Administration of prescribed bowel programs, including suppositories and sphincter stimulation per protocol and prepackaged enemas for participants without contraindicating rectal or intestinal conditions. (Suggested time 15 minutes per ordered instance)
- Catheter Hygiene
- Changing of bags, soap and water hygiene around the site of external, indwelling, and suprapubic catheters. (Suggested time 15- minutes per instance)
- Removal of external catheters, skin inspection, and catheter reapplication. (Suggested time 15- minutes per instance)
- Non-Injectable Medications
- Manual assistance with non-injectable medications, as set up by a licensed nurse, may include opening a medicine lockbox, steadying the participant’s hand/arm for ear and eye drops, finger sticks for blood sugar monitoring and reading levels and when prompting is required to take medication. (Suggested time 15 minutes per ordered instance)
- Ostomy Hygiene
- Changing of bags, soap and water hygiene around a well healed ostomy site (including tracheostomies, gastrostomies, and colostomies). (Suggested time 15- minutes per instance)
- Passive Range of Motion
- Administration of movement of a joint through its full range of motion, delivered in accordance with the care plan. (Suggested time 15 minutes per ordered instance)
Authorized Nurse Visits
Authorized Nurse Visits (RN) are authorized by the visit. No minimum or maximum time is required to constitute a visit. RN services are maintenance or preventative services provided by a Registered Nurse (RN) or a Licensed Practical Nurse (LPN) under an RN's or physician's direction.
Authorized Nurse Visit tasks may include:
- Evaluate APC Care Plan
- All APC participants shall be authorized for an RN visit monthly to evaluate the adequacy of the authorized services to meet the participant’s needs and assess the APC aide’s ability to carry out the authorized services.
- Other RN Care
- Monitor skin condition(s)
- Nail care: Monthly visits to provide nail care for diabetic participants or participants with other medically contraindicating conditions, including but not limited to participants:
- Taking anticoagulant medication
- Diagnosed with peripheral vascular disease
- Diagnosed with a compromised immune system
- Administration of injectable medications (other than insulin)
- Venipunctures
- Catheter changes
- Enemas (only when not utilizing a prepackaged enema)
- Central line dressing/flush/blood draws
3.25 Personal Care Assistance – State Plan (Consumer-directed Model)
Home and Community Based Services Manual
Introduction
Personal Care Assistance Consumer Directed Services (CDS) is a Home and Community Based Services (HCBS) program offered through the Division of Senior and Disability Services (DSDS). CDS is available to participants who can direct their own care and can live independently. CDS participants select an HCBS provider that is enrolled as a CDS provider with the Department of Social Services (DSS), Missouri Medicaid Audit and Compliance (MMAC) Unit. Payment is made to the HCBS provider on behalf of the participant. The HCBS provider processes payroll, on behalf of the participant, to the individual providing the services.
Authorization of Personal Care Assistance is funded through both the Consumer-Directed Model Medicaid State Plan and the Independent Living Waiver (ILW). This policy addresses State Plan services only. Refer to the ILW Policy [Needs Link] for additional information regarding services through the ILW.
Purpose
CDS provides assistance with activities of daily living (ADL) and/or instrumental activities of daily living (IADL) provided as an alternative to nursing facility placement to persons with a physical disability.
Eligibility
All CDS participants must meet the following eligibility criteria:
- Be at least eighteen (18) years of age
- Be physically disabled, as defined by 19 CSR 15-8.100
- Loss of, or loss of use of, all or part of the body's neurological, muscular, or skeletal functions to the extent the person requires the assistance of another person to accomplish routine tasks.
- Be able to self-direct their CDS
- In active Medicaid [Needs Link] status
- Participants eligible for Medicaid on a spenddown basis may be authorized to receive CDS during periods when they meet their spenddown liability.
- During periods when the participant has not met their monthly spenddown liability amount, the participant and provider may make a private arrangement for the continued delivery of services. In these instances, the participant is responsible for the cost of services received.
- Participants who receive Medicaid due to eligibility for Blind Pension (BP) may be authorized for CDS.
- Participants in a ‘Transfer of Property penalty’ may be authorized for CDS.
- Authorization of CDS does not meet the requirements for an individual to be eligible for Home and Community Based (HCB) Medicaid.
- Participants eligible for Medicaid on a spenddown basis may be authorized to receive CDS during periods when they meet their spenddown liability.
- Have an appropriate Medicaid Eligibility (ME) Code [NEEDS LINK]
- Meet nursing facility level of care (LOC)
- Have not been previously involved in Medicaid fraud
Self Direction Determination
Home and Community Based Services Manual
A current or potential CDS participant is required to have the ability to direct their care per 208.903.1.(4), RS Mo. Consumer directed is defined as the hiring, training, supervising, and directing of the personal care attendant. Section 208.909.1, RSMo states that current or potential participants must be able to fulfill the following responsibilities:
- Supervise the personal care attendant
- Verify the wages to be paid to the personal care attendant
- Monitor proper Electronic Visit Verification (EVV) usage
- Notify DSDS staff or its designee of any changes affecting the CDS Person-Centered Care Plan (PCCP) or the participant’s place of residence
- Report any problems resulting from the quality of services rendered by the personal care attendant to the participant’s provider
- It shall be reported to DSDS staff or its designee if the problem cannot be resolved through the provider.
- Report to DSDS significant changes in participant’s health and/or ability to self-direct their care
Documentation shall be provided in the participant’s electronic case record if it is determined that a current or potential participant requesting CDS cannot direct their care or fulfill the responsibilities of a CDS participant. Examples of documentation may include, but are not limited to:
- Responses to questions from the current or potential participant during the assessment process that need further clarification. Questions are to be posed to the current or potential participant.
- If another individual responds on behalf of the current or potential participant, this must be documented in the case notes.
- Completion of the Self Direction Assessment questions
- If the Self Direction Assessment Questions are utilized, answers to the questions shall be provided as an exhibit if the current or potential participant appeals the decision that they cannot self-direct services.
- Completion of the St. Louis University Mental Status (SLUMS) exam. This may be utilized when there is a concern regarding an individual’s ability to self-direct.
- The instructions to the SLUMS provide background information on the exam, clarifies when the exam shall be utilized, and defines further evaluation which must be pursued.
- Statements or medical records from the current or potential participant’s healthcare professional documenting any functional limitations preventing the individual from self-directing
- The Healthcare Professional Inquiry may be utilized when there are concerns regarding the current or potential participant’s ability to self-direct. The response received from the Healthcare Professional Inquiry shall be documented and uploaded to the electronic case record along with other self-direction determination documents if utilized.
If a thorough review of all available information has taken place and the current or potential participant cannot self-direct, Adverse Action [Needs Link] procedures shall be followed, and DSDS staff or its designee shall advise that individual and/or the authorized representative of other available options. The Collateral Contacts Policy [Needs Link], outlines the various services available through alternative HCBS. Current or potential participants shall be advised that Personal Care (PC) and Advanced Personal Care (APC) services are comparable to services available through the CDS program.
- DSDS staff or its designee shall document the discussions held regarding the availability of other services.
Restrictions and Limitations
Home and Community Based Services Manual
CDS shall not be authorized to pay for services when:
- The primary benefit is to a household unit.
- The task is one that household members may reasonably be expected to share or do for one another unless the task is above and beyond typical activities provided for a household member without a disability.
- CDS does not include any task that must be performed/ trained by a licensed professional (i.e., skilled nursing, therapies ordered by a physician, etc.).
- A physically disabled person who can direct their care but has a cognitive impairment that requires a designated person to assist with the administration of the program can only be authorized through the ILW.
- Participants authorized for self-directed services through the Department of Mental Health (DMH) are not eligible for services as outlined in this policy. Staff shall refer to the Service Coordination Policy [Needs Link] for guidance on coordinating services for participants authorized for DMH services.
- Individuals who reside in a nursing facility, Residential Care Facility (RCF) or Assisted Living Facility (ALF) licensed by DHSS, Division of Regulation and Licensure (DRL) are not eligible for CDS.
- The ‘CDS Restricted’ checkbox in the participant’s electronic case record has been checked. This box can be checked when:
- DSDS staff followed the procedures outlined in the Adverse Action [Needs Link] policy and Appeal and Hearing Process [Needs Link]. Services shall not be closed until the 10-day appeal time frame has passed, and the participant has not appealed, or until the Department of Social Services (DSS), Division of Legal Services (DLS) has made its final decision for the appeal hearing affirming the adverse action.
- As appropriate, all current authorization(s) for CDS shall be closed, and other HCBS that may meet the participant's needs have been offered to the participant, e.g., Agency Model.
- The attendant shall not:
- Have been involved in Medicaid fraud previously
- Be a current CDS participant
- Participants can exercise individual choice in deciding who provides their CDS. The CDS participant is the attendant’s employer-of-record.
- The attendant may be a family member. However, the attendant cannot be the participant’s spouse or legal guardian.
NOTE: An individual with a guardian or conservator cannot be rejected for CDS solely for that reason. Explanation for the need of a guardian or conservatorship can justify the reason to reject CDS due to cognitive inabilities to self-direct. DSDS staff or its designee shall obtain a copy of the appointment order.
Authorization
Home and Community Based Services Manual
The following is an overview of CDS authorizations and tasks:
- CDS shall be authorized in 15-minute units
- CDS shall be included in the overall cost of care for the participant as referenced in the HCBS Cost Maximums policy
- CDS shall not exceed 60% of the cost maximum
- The combination of CDS and agency model PC shall not exceed 60% of the cost maximum.
- The 60% cost maximum can be exceeded by the cost of APC and RN visits, but only up to the full monthly cost of 100%.
NOTE: When the care plan includes RN services, the cost of one RN visit shall be excluded from the overall care plan cost.
- When the combination of CDS, other State Plan services, and an HCBS Waiver (e.g., Aged and Disabled Waiver (ADW) or ILW) services exceed the cost maximum by the cost of the waiver services:
- The appropriate supervisor for the DSDS staff shall review all PCCP requests over the 100% cost maximum to ensure the participant’s unmet needs require the amount of service requested.
- If documentation supports the request, the case shall be forwarded to the Bureau of Federal Programs (BFP) for consideration and approval prior to authorization over 100% of the cost maximum.
- Pending the approval from BFP to exceed the cost maximum, CDS in combination with other State Plan or ADW services can be authorized up to 100% of the cost maximum, excluding PC and/or CDS, which may never exceed 60% of the cost maximum.
NOTE: When a PCCP includes Adult Day Care authorized through the ADW or the Adult Day Care Waiver (ADCW), the total cost of care cannot exceed 100% of the cost maximum.
Under federal guidelines, a participant can only enroll in one (1) HCBS Waiver at a time, regardless of what agency administers the waiver program.
Tasks
Home and Community Based Services Manual
CDS provides “hands-on” assistance with physical tasks that benefit the participant and are based on the participant's physical limitations. No time can be authorized for the following:
- Stand-by assistance, prompting, or cueing
- Respite care or for time spent waiting for a participant at any appointment
CDS may include any of the following tasks:
- Assistance with Transfer Device
- Use an assistive device for transfers
- Bathing
- Direct assistance with bathing and shampooing hair that requires active participation by the aide (e.g., hands-on washing assistance, assistance in or out of the bath, gathering supplies/clean clothing, etc.)
- Bowel/bladder
- o Administration of prescribed bowel programs, including the use of suppositories and sphincter stimulation per protocol and pre-packaged enemas for participants without contraindicating rectal or intestinal conditions
- Catheter hygiene:
- Changing bags and soap and water hygiene around the site of external, indwelling, and suprapubic catheters.
- Removal of external catheters, inspect skin, and reapply catheter
- Change linens
- Clean bath
- Clean floors
- Clean kitchen
- Cleaning/maintaining equipment
- Wheelchairs, bedside commodes, shower chairs and nebulizer machines, etc
- Dressing/grooming:
- Direct assistance with dressing and undressing, combing hair, nail care, oral hygiene, shaving, and assisting with prosthetics
- Essential correspondence
- Essential transportation, including all essential shopping/errands (regardless if the participant is with the CDS attendant), medical appointments, school, or employment, etc.
- For the participant to be eligible for transportation assistance, there must also be an identified need for personal care assistance, even if that need is met by supports other than CDS.
- CDS Transportation does not include transporting to medical appointments when that appointment is covered under the Non-Emergency Medical Transportation (NEMT) program. To determine if NEMT covers the medical appointment, contact the NEMT provider at 1-866-269-5927.
- Laundry (home)
- Laundry (off-site)
- Make bed
- Meal prep/eating
- Direct assistance with meal preparation, feeding and clean up.
- Medications
- Direct assistance with medications (e.g., the time spent handling the medication container, including inhalers, medication for nebulizers, ointments/lotions, steadying the participant’s hand/arm to get oral medication and inhalants to mouth, and water to the participant)
- Mobility/transfer
- Direct assistance with mobility, transfer, and ambulation when the participant can at least partially bear their weight
- Ostomy hygiene
- Changing bags and soap and water hygiene around an ostomy site (including tracheostomies, gastrostomies, and colostomies, all with a well-healed stoma)
- Passive Range of Motion
- Passive range of motion (non-resistive flexion of joint within normal range) delivered in accordance with the care plan
- Tidy and Dust
- Toileting
- Direct assistance with toileting tasks. This may include assistance using or transferring to/from the toilet, commode, bedpan, urinal, cleansing after use and assistance with incontinence episode(s). (The suggested time is 5 minutes multiplied by the number of times assistance is given per day based upon the suggested frequency needed)
- Trash
- Treatments
- Eye drops, rubbing creams or lotions that are prescribed or non-prescribed
- Turning/positioning
- Wash dishes
Calculating Essential Transportation
Home and Community Based Services Manual
Essential transportation is entered on the care plan as minutes per month. To calculate essential transportation, the total number of minutes needed per day is multiplied by the number of days per month. Utilize the chart below to determine the number of days per month based on the frequency per week.
| # of Days/Week | 1 | 2 | 3 | 4 | 5 | 6 | 7 |
| # Days/Month | *5 | 10 | 15 | 19 | 23 | 27 | 31 |
Calculation Formula: number of minutes per day x number of days per month = number of minutes per month
NOTE: To account for months with 5 weeks, the formula always calculates based on a five-week month.
The total number of minutes should be entered on the care plan.
Example: 90 minutes, once a week: 90 x 5 = 450 minutes
Example: 60 minutes, twice a week: 60 x 10 = 600 minutes
Example: 60 minutes, three times a week: 60 x 15 = 900 minutes
Example: If there is an unexpected outing, such as a medical appointment not covered by NEMT, the additional time for the appointment should be calculated and added to the current authorization for essential transportation.
3.25 Appendix 1 Consumer Directed Services Tax Information
Home and Community Based Services Manual
Overview
Home and Community Based Services Manual
Directive
Consumer Directed Services (CDS) vendors shall take steps to promote the health, safety, and welfare of participants receiving CDS through their agency.
As part of this responsibility, CDS vendors shall submit verification of the assigned Federal or Missouri Employer Identification Number (EIN) and Missouri Tax ID for each CDS participant. CDS vendors shall enter the information on the participant page and upload this information to the participant’s electronic case record.1
For new CDS participants2, verification shall be uploaded into the participant’s electronic case record no later than ninety (90) days following the start date of CDS.
Verification shall be uploaded as attachments using the ‘EIN Tax Documents’ category selection from the dropdown in the electronic case record.
Resources for FUSION [Needs Link] are available for users who need assistance navigating through the electronic case record.
CDS vendors should contact the Bureau of Systems and Data Reporting at HCBS.Systems@health.mo.gov for all issues related to the FUSION user account maintenance, including enrollment, access, password issues and adding or deleting user accounts.
The following documents are acceptable for verification of the assignment of a Federal EIN:
- CP 575 or 147C Letter
- 940 Employer’s Annual Federal Unemployment (FUTA) Tax Return
- 941 Employers Quarterly Federal Tax Return
- 8109 Tax Coupon
- A letter from the IRS with the Tax ID number and legal name
- Any IRS document that has the legal name and TAX number preprinted
NOTE: A W-9 or computer printed forms are not acceptable.
1Verification does not need to be uploaded if documents were previously uploaded into a participant’s electronic case record by another CDs vendor.
2A participant is considered a new CDS participant if they have not yet been authorized for CDS in their current case. Participants who have had CDS authorized in previous cases, but not their current case, are considered new. Please refer to the participant's electronic case record to determine if a participant is to be considered a new CDS participant.
The following documents are acceptable for verification of the assignment of a Missouri EIN/TIN:
- A copy of the notice from the MO Department of Revenue
- MO 941 Employer’s Return of Income Taxes Withheld
- MO W-3 Transmittal of Tax Statements
NOTE: Additional documentation is not required if a document has both the FEIN and MO EIN/TIN, or if a previous provider has uploaded verification of the FEIN and MO EIN/TIN.
3.31 Adult Day Care Waiver
Home and Community Based Services Manual
Adult Day Care Waiver (ADCW) is the continuous care and supervision of a disabled adult in a licensed adult day care setting. Services include but are not limited to assistance with activities of daily living, planned group activities, food services, client observation, skilled nursing services as specified in the plan of care, and transportation. Planned group activities include socialization, recreation and cultural activities that stimulate the individual and help the participant maintain optimal functioning. The provider must arrange or provide transportation to the adult day care facility at no cost to the participant. Reimbursement will be made for up to 120 minutes per day of transportation related to transporting an individual to and from the Adult Day Care (ADC) setting. Meals provided as part of ADC shall not constitute a "full nutritional regimen" (3 meals per day).
- Authorization of the ADC is funded through the Adult Day Care Waiver (ADCW).
- All ADCW participants must meet the following eligibility criteria:
- Between the ages of eighteen (18) to sixty-three (63) years of age;
- Initial authorizations are restricted to those participants between the ages of eighteen (18) to sixty-two (62). Those participants age sixty-three shall be authorized for ADC [Needs Link] services through the Aged and Disabled Waiver (ADW).
- In active Medicaid status (Medicaid Eligibility).
- Participants who are eligible for Medicaid on a spenddown basis may be authorized to receive the ADCW during periods when they meet their spenddown liability.
- A participant is responsible for the cost of services received during periods of time when they have not met their spenddown liability.
- Participants who receive Medicaid due to eligibility for Blind Pension (BP) may not be authorized for the ADCW.
- Participants in a ‘Transfer of Property penalty’ may be authorized for the ADCW.
- Authorization of the ADCW does not meet the requirements for an individual to be eligible for Home and Community Based (HCB) Medicaid.
- Have an appropriate Medicaid Eligibility (ME) [Needs Link] code; and
- Meet nursing facility level of care.
- Between the ages of eighteen (18) to sixty-three (63) years of age;
- ADCW services shall be authorized for:
- Up to 10 hours per day for a maximum of 5 days per week of which no more than 120 minutes, or eight (8), 15 minute units per day may be related to transporting an individual to and from the ADC setting.
ADCW shall be included in the overall cost of care, HCBS Cost Maximums, for the participant.
ADCW authorized together with other Medicaid State Plan HCBS [i.e., Basic Personal Care (PC), Advanced Personal Care (APC), Authorized Nurse Visits (RN), and Consumer-Directed Model Personal Care (CDS)] shall not exceed 100% of the average statewide monthly cost for care in a nursing facility.
NOTE: When the care plan includes an authorization for RN services, the cost of one RN visit shall be excluded from the calculation of a care plan’s cost.
- ADCW is provided by ADC settings licensed by DHSS, Division of Regulation and Licensure (DRL) with a Medicaid provider agreement with the Department of Social Services (DSS), Missouri Medicaid Audit and Compliance Unit (MMAC). Payment is made to the ADCW provider on behalf of the participant.
- Restrictions:
- Individuals who reside in a nursing facility, Residential Care Facility (RCF) or Assisted Living Facility (ALF) licensed by DHSS DRL, are not eligible for ADCW.
- Participants authorized for certain services through the Department of Mental Health (DMH) may not be eligible for services as outlined in this policy. Staff shall refer to the DMH Service Coordination Policy [Needs Link] for guidance on coordination of services for participants authorized for DMH services.
- Services received from the ADC are determined by the individual plan of care developed by the participant, ADC personnel, and the participant’s physician. The individual plan of care is developed every six (6) months by the ADC and includes the amount, duration, and scope of treatment and services to be provided. The individual plan of care shall be available to Division of Senior and Disability Services (DSDS) staff or its designee upon request. Depending on the individual plan of care, the participant may receive the following organized services as a component of receiving the ADCW:
- Leisure-time and exercise activities - planned recreational and social activities;
- Counseling services - assistance to participants and families with personal, social, family or adjustment problems;
- Rehabilitative services - occupational, physical, and speech therapy;
- Activities of daily living - such as assistance with walking, toileting, or feeding;
- Medication management and nursing services - by a licensed nurse;
- Meals - to include physician ordered special or modified diets and snacks; and
- Up to 10 hours per day for a maximum of 5 days per week of which no more than eight (8), 15 minute units per day may be related to transporting an individual to and from the adult day care setting.
3.35 Chore (Aged and Disabled Waiver)
Home and Community Based Services Manual
Chore services are short-term, intermittent tasks necessary to maintain a clean, sanitary and safe home environment as determined by the Assessor to be critical in maintaining the participant’s health and safety. Chore services must be reasonable and necessary according to the condition of the functional capacity of the participant. Limited ability of the participant to perform necessary tasks shall be thoroughly documented. Chore services are mutually identified as necessary by the participant and the Assessor and based on information obtained during the assessment process.
- Authorization for Chore is funded through the Aged and Disabled Waiver (ADW) only.
- All Chore participants must meet the following eligibility criteria:
- At least 63 years of age;
- In active Medicaid status (Medicaid Eligibility)
- Participants who are eligible for Medicaid on a spenddown basis may be authorized to receive Chore services during periods when they meet their spenddown liability.
- A participant is responsible for the cost of services received during periods of time when they have not met their spenddown liability.
- Authorization of Chore does meet the requirement for an individual to be eligible for Home and Community Based (HCB) Medicaid.
- Have an appropriate Medicaid Eligibility (ME) Codes; and
- Meet nursing facility level of care.
- Chore Services shall be provided only when the participant and other household members are incapable of performing and when no other relative, caregiver, landlord, community or volunteer agency, or third party payor is capable of or responsible for providing such tasks.
- In the case of rental property, the responsibility of the landlord shall be explored prior to any authorization of services.
- Chore services shall be authorized in 15 minute units.
- Chore units authorized shall be consistent with the identified Chore tasks to be completed for the short term or intermittent authorization period to ensure the participant’s health and safety.
- Chore services shall be included in the overall cost of care (HCBS Cost Maximums) for the participant.
- Chore services authorized together with other Home and Community Based Services (HCBS) shall not exceed 100% of the average statewide monthly cost for care in a nursing facility, without prior approval of the state agency.
NOTE: The cost of one RN, when RN is authorized on a monthly basis, shall be excluded from the calculation of a care plan’s cost.
- When the combination of State Plan and Aged and Disabled Waiver services exceed the 100% cost maximum:
- The Assessor’s nurse shall review all person centered care plan requests over the 100% cost cap to ensure the participant’s unmet needs require the amount of service requested.
- If documentation supports the request, the case shall be forwarded to the state agency for approval prior to authorization over the 100% of the cost cap.
- Pending the approval from the state agency, to exceed the cost cap, HCBS can be authorized up to the 100% of the cost cap.
- Chores services are provided by HCBS providers that are enrolled as an ADW provider with the Department of Social Services (DSS), Missouri Medicaid Audit and Compliance Unit (MMAC). Payment is made to the HCBS provider on behalf of the participant.
- The individual providing the service is an employee of the HCBS provider and cannot be a member of the immediate family of the participant. An immediate family member is defined as a parent; sibling; child by blood, adoption, or marriage (step-child); spouse; grandparent or grandchild.
- Restrictions:
- Individuals who reside in a nursing facility, Residential Care Facility (RCF) or Assisted Living Facility (ALF) licensed by DHSS, Division of Regulation and Licensure, or any group home or residential type facility, licensed by the Department of Mental Health (DMH), are not eligible for Chore services.
- Participants who receive Medicaid due to eligibility for Blind Pension (BP) are not eligible for Chore services.
- Participants in a ‘Transfer of Property penalty’ are not eligible for Chore services.
- Participants receiving services through any other HCBS waiver are not eligible for Chore services funded through the Aged and Disabled Waiver.
- Chore services may include any of the following activities:
- Wash walls and woodwork;
- Clean closets, basement and attics;
- Shampoo rugs;
- Air mattresses and bedding;
- Spray for insects within the home, using over-the-counter supplies; and
- Provide rodent control within the home (setting traps or using over-the-counter supplies).
3.40 Home Delivered Meals (Aged and Disabled Waiver)
Home and Community Based Services Manual
Home Delivered Meals (HDM) can be an authorized service when determined necessary by the Department of Health and Senior Services (DHSS), Division of Senior and Disability Services (DSDS) to assist in meeting the nutritional needs of the participant. HDM can be authorized to individuals who are unable to prepare a balanced meal, or who otherwise need HDM to meet their individual care needs. HDM are authorized to provide participants with one or two meals per day, each of which shall contain at least 1/3 of the recommended daily nutritional requirements.
- Authorization for HDM is funded through the Aged and Disabled Waiver (ADW) only.
- All HDM participants must meet the following eligibility criteria:
- At least 63 years of age;
- In active Medicaid status (Medicaid Eligibility);
- Participants who are eligible for Medicaid on a spenddown basis may be authorized to receive HDM during periods when they meet their spenddown liability.
- A participant may be asked for a donation for the cost of HDM received during periods of time when they have not met their spenddown liability.
- Authorization of HDM does meet the requirements for an individual to be eligible for Home and Community Based (HCB) Medicaid.
- Have an appropriate Medicaid Eligibility (ME) code; and
- Meet nursing facility level of care.
- A unit of HDM is considered one meal. A maximum of two meals (units) per day may be authorized. The number of HDM shall be appropriate to the participant’s individual situation. The participant’s need for HDM must be assessed and prior authorized considering the frequency, time, and variety of other services and assistance available within the home.
- It may be necessary to authorize an HDM in conjunction with other Home and Community Based Services (HCBS) in order to meet the dietary needs of the participant.
- HDM shall be included in the overall HCBS Cost Maximums of care for the participant.
- HDM authorized together with other HCBS shall not exceed 100% of the average statewide monthly cost for care in a nursing facility, without prior approval of the Bureau of Long Term Services and Supports (BLTSS).
NOTE: When the care plan includes an authorization for RN services, the cost of one RN visit shall be excluded from the calculation of a care plan’s cost - When the combination of State Plan and ADW services exceed the 100% cost maximum:
- The appropriate supervisor for the Division of Senior and Disability Services (DSDS) review all person centered care plan requests over the 100% cost cap to ensure the participant’s unmet needs require the amount of service requested.
- If documentation supports the request, the case shall be forwarded to the BLTSS for consideration and approval, prior to authorization over 100% of the cost cap.
- Pending the approval from BLTSS to exceed the cost cap, HDM services in combination with other State Plan or ADW services can be authorized up to 100% of the cost cap.
- HDM authorized together with other HCBS shall not exceed 100% of the average statewide monthly cost for care in a nursing facility, without prior approval of the Bureau of Long Term Services and Supports (BLTSS).
- HDM are provided by the Area Agencies on Aging (AAA) enrolled as an ADW provider with the Department of Social Services (DSS), Missouri Medicaid Audit and Compliance Unit (MMAC). The AAA may sub-contract with Senior Centers throughout the state. Payment is made to the AAA on behalf of the participant.
- Restrictions:
- Individuals who reside in a nursing facility, Residential Care Facility (RCF) or Assisted Living Facility (ALF) licensed by DHSS, Division of Regulation and Licensure are not eligible for HDM.
- Participants authorized for certain services through the Department of Mental Health (DMH) may not be eligible for services as outlined in this policy. Staff shall refer to the DMH Service Coordination Policy for guidance on coordination of services for participants authorized for DMH services.
- Participants who receive Medicaid due to eligibility for Blind Pension (BP) are not eligible for Medicaid funded HDM.
- Participants in a ‘Transfer of Property penalty’ are not eligible for Medicaid funded HDM.
- Participants receiving services through any other HCBS waiver are not eligible for HDM funded through the ADW.
3.45 Homemaker (Aged and Disabled Waiver)
Home and Community Based Services Manual
Homemaker (HC) services are general household tasks for the participant as an alternative to nursing facility care. Homemaker services must be reasonable and necessary according to the condition and functional capacity of the participant.
- Authorization of HC is funded through the Medicaid Aged and Disabled Waiver (ADW) only. As it is a federal requirement that State Plan services be utilized before authorizing comparable services in a Home and Community Based Waiver, all appropriate State Plan Personal Care (PC), Medically Related Household Tasks must be utilized before the authorization of Homemaker (HC) services to the Person Centered Care Plan (PCCP). An exception to this requirement is for the provision of Home and Community Based (HCB) Medicaid (Medicaid Eligibility). ADW services can be authorized before utilizing comparable State Plan services if the ADW services are being authorized in order for the participant to qualify for HCB Medicaid or a Miller Trust.
- All HC participants must meet the following eligibility criteria:
- At least 63 years of age;
- In active Medicaid status (Medicaid Eligibility);
- Participants who are eligible for Medicaid on a spenddown basis may be authorized to receive HC services during periods when they meet their spenddown liability.
- A participant is responsible for the cost of services received during periods of time when they have not met their spenddown liability.
- Authorization of HC does meet the requirement for an individual to be eligible for HCB Medicaid.
- Have an appropriate Medicaid Eligibility (ME) code; and
- Meet nursing facility level of care.
- HC services shall not be authorized when the participant lives with other persons who are able to perform these tasks. If necessary, HC may be authorized to perform only those tasksessential for the participant, such as cleaning the participant’s room, changing the participant’s bed linens or cleaning the bathroom after bathing the participant. Any HC services authorized in this type of living arrangement shall not include cleaning common areas used by all members of the household.
- HC services shall be authorized in 15-minute units.
- HC units authorized shall be consistent with the HC tasks to be completed on a regular basis.
- The amount of HC tasks identified shall be reasonable for the amount of HC units authorized.
- HC shall be included in the overall HCBS Cost Maximums of care for the participant.
- HC authorized together with other Home and Community Based Services (HCBS) shall not exceed 100% of the average statewide monthly cost for care in a nursing facility, without prior approval of the Bureau of Long Term Services and Supports (BLTSS).
NOTE: When the care plan includes an authorization for RN services, the cost of one RNvisitshall be excluded from the calculation of a care plan’s cost.- When the combination of State Plan and ADW services exceed the 100% cost maximum:
- The appropriate supervisor for the Division of Senior and Disability Services(DSDS) staff shall review all person centered care plan requests over the 100% cost cap to ensure the participant’s unmet needs require the amount of service requested.
- If documentation supports the request, the case shall be forwarded to BLTSS for consideration and approval prior to authorization over the 100% of the cost cap.
- Pending the approval from BLTSS to exceed the cost cap, HC services in combination with other State Plan or ADW services shall be authorized up to the 100% of the cost cap.
- When the combination of State Plan and ADW services exceed the 100% cost maximum:
- HC is provided by HCBS providers enrolled as an ADW provider with the Department of Social Services (DSS), Missouri Medicaid Audit and Compliance Unit (MMAC). Payment is made to the HCBS provider on behalf of the participant.
- The individual providing the homemaker service is an employee of the HCBS provider and cannot be a member of the immediate family of the participant. An immediate family member is defined as a parent; sibling; child by blood, adoption, or marriage (step-child); spouse; grandparent or grandchild.
- Restrictions:
- Individuals who reside in a nursing facility, Residential Care Facility (RCF) or Assisted Living Facility (ALF) licensed by DHSS, Division of Regulation and Licensure are not eligible for HC.
- Participants authorized for certain services though the Department of Mental Health Services (DMH) may not be eligible for services as outlined in this policy. Staff shall refer to the DMH Service Coordination Policy for guidance on coordination of services for participants authorized for DMH services.
- Participants who receive Medicaid due to eligibility for Blind Pension (BP) are not eligible for HC services. o Participants in a ‘Transfer of Property penalty’ are not eligible for HC services.
- Participants receiving services through any other HCBS waiver are not eligible for HC services funded through the ADW.
- Homemaker services may include any of the following tasks:
NOTE: Suggested times and frequencies have been developed with the care needs of an average or typical participant in mind. In the development of the (PCCP), consideration shall be given regarding the size of the home, geographic location, specific participant limitations, formal and informal supports, and other factors that might affect the amount of time necessary to complete required tasks.- Meals/Dishes: Consideration shall be given the participant’s ability to prepare a light meal such as sandwiches, soups, and salads and/or the availability of home-delivered meals. Many participants will not need meal preparation on a daily basis, regardless of the type of meal. Includes washing, drying and putting away participant’s dishes. (Suggested time 10 - 60 minutes – Suggested frequency 1-7 x/week)
- Clean Kitchen: Includes cleaning counter tops, tabletop, and sweeping and mopping floors. (Suggested time 30 - 45 minutes – Suggested frequency 1x/week)
- Clean Bath: Includes sweeping and mopping the floor and cleaning the tub, toilet, and sink. (Suggested time 30 - 45 minutes – Suggested frequency 1 x/week)
- Clean Living Area: Includes sweeping/vacuuming/mopping all floors as necessary and tidying and dusting. (Suggested time 10 - 45 minutes – Suggested frequency 1 x/week)
- Make Bed/Change Linens: Linens are generally changed once a week and the bed made on days the employee is there. (Suggested time 10 minutes – Suggested frequency as needed)
- Laundry (Home/Off Site): Includes washing, folding, and putting away clothing. An off- site facility will require additional time for completion. (Suggested time 30 – 150 minutes – Suggested frequency 1 x/week)
- Iron/Mend: Includes ironing and mending clothing as directed by participant. (Suggestedtime 10 - 15 minutes – Suggested frequency 1 x/week)
- Wash Windows/Blinds: Includes washing inside windows and cleaning blinds that are within reach without climbing. (Suggested time 10 - 15 minutes – Suggested frequency 1 x/week)
- Trash: Includes bagging and carrying trash out to receptacle. (Suggested time 5 minutes – Suggested frequency 1 x/week)
- Shopping/Errands: Includes travel time to and from the store and putting items away upon return to participant’s home. If shopping is required more than once a week, the amount of time should generally be decreased. Shopping does not include going to multiple stores, unless necessary. The store should be a reasonable distance from participant’s home. Essential errands include banking, post office, bill paying, etc. (Suggested time 60 - 120 minutes – Suggested frequency 1-2 x/week)
- Essential Correspondence: Includes reading/writing essential correspondence for blind, someone who is unable to read or write, or physically impaired participants. (Suggested time 30 minutes – Suggested frequency 1 x/week)
3.5 Respite Care (Aged and Disabled Waiver)
Home and Community Based Services Manual
Respite Care (RC) services are maintenance and supervisory services provided to a participant in the individual’s residence to provide relief to the caregiver(s) that normally provides and/or arranges care. RC can be authorized in two (2) categories: basic and advanced.
- Authorization of RC is funded through the Medicaid Aged and Disabled Waiver (ADW) only.
- All RC participants must meet the following eligibility criteria:
- At least 63 years of age;
- In active Medicaid status (Medicaid Eligibility);
- Participants who are eligible for Medicaid on a spenddown basis may be authorized to receive RC services during periods when they meet their spenddown liability.
- A participant is responsible for the cost of services received during periods of time when they have not met their spenddown liability.
- Authorization of RC does meet the requirement for an individual to be eligible for Home and Community Based (HCB) Medicaid.
- Have an appropriate Medicaid Eligibility (ME) Code; and
- Meet nursing facility level of care;
- RC participants must have a designated caregiver(s), regularly responsible for providing and/or arranging the care of the participant.
- RC shall be included in the overall cost of care (HCBS Cost Maximums) for the participant.
- RC has no cost cap, but prior approval is needed from the Bureau of Long Term Services and Supports (BLTSS) if the overall cost of care will exceed 100% of the average statewide monthly cost for care in a nursing facility.
NOTE: When the care plan includes an authorization for RN services, the cost of one RN visit shall be excluded from the calculation of a care plan’s cost.- When the combination of State Plan and Aged and Disabled Waiver services exceed the 100% cost maximum:
- The appropriate supervisor for the Division of Senior and Disability Services (DSDS) staff shall review all Person Centered Care Plan requests over the 100% cost cap to ensure the participant’s unmet needs require the amount of service requested.
- If documentation supports the request, the case shall be forwarded to the BLTSS for consideration and approval prior to authorization over the 100% of the cost cap.
- Pending the approval from BLTSS to exceed the cost cap, RC services in combination with other State Plan or ADW services can be authorized up to the 100% of the cost cap.
- Once approval from BLTSS is given, the ADW portion of the care plan may be authorized to exceed the 100% of the cost cap while all other State Plan services are subject to the cost cap or their respective requirements.
- While it is a requirement to get approval from BLTSS of an initial request to exceed the monthly cost maximum by the amount of the waiver services, there is no requirement to request BLTSS approval for an increase in the ADW service.
- When the combination of State Plan and Aged and Disabled Waiver services exceed the 100% cost maximum:
- RC has no cost cap, but prior approval is needed from the Bureau of Long Term Services and Supports (BLTSS) if the overall cost of care will exceed 100% of the average statewide monthly cost for care in a nursing facility.
- RC is provided by HCBS providers that are enrolled as an Aged and Disabled Waiver provider with the Department of Social Services (DSS), Missouri Medicaid Audit and Compliance Unit (MMAC). Payment is made to the HCBS provider on behalf of the participant.
- Caregivers are broadly defined as family members, friends or neighbors who provide unpaid assistance to a person with a chronic illness or disabling condition.
- The individual providing services is an employee of the HCBS provider and cannot be a member of the immediate family of the participant. An immediate family member is defined as a parent; sibling; child by blood, adoption, or marriage (stepchild); spouse; grandparent or grandchild.
- Restrictions:
- Individuals who reside in a nursing facility, Residential Care Facility (RCF), or Assisted Living Facility (ALF) licensed by DHSS, Division of Regulation and Licensure (DRL), are not eligible for RC.
- Participants authorized for certain services through the Department of Mental Health (DMH) may not be eligible for services as outlined in this policy. Staff shall refer to the DMH Service Coordination policy for guidance on coordination of services for participants authorized for DMH services.
- Participants who receive Medicaid due to eligibility for Blind Pension (BP) are not eligible for RC services.
- Participants in a ‘Transfer of Property penalty’ are not eligible for RC services.
- Participants receiving services through any other HCBS waiver are not eligible for RC services funded through the ADW.
- RC cannot be authorized to relieve a paid caregiver e.g. aide, attendant, home health staff, private pay staff.
- RC services shall include the following activities:
- Supervision - Personal oversight of the participant for the duration of the service period including making a reasonable effort to assure the safety of the participant and to assist the participant in meeting his/her own essential human needs. Sleeping is permitted when the participant is asleep, provided there is no indication that the condition of the participant would pose a risk if the participant awoke while the RC worker was sleeping. The RC worker must be in close proximity to the participant during a sleeping period.
- Companionship - Provided during the participant’s waking hours to make the participant as comfortable as possible.
- Direct participant assistance - Provided to meet needs usually provided by the regular caregiver.
Basic Respite service is provided to participants with non-skilled needs who are unable to perform their activities of daily living (ADL’s) and are intended to offer periods of caregiver relief. Basic Respite services shall not be authorized when the more appropriate HCBS required on a regular basis is Personal Care (PC) and Homemaker services.
- Basic Respite Care: is a unit that is defined as fifteen (15) minutes.
Advanced Respite service is provided to participants with special care needs, requiring a higher level of personal oversight. Advanced Respite care is provided in that individual’s residence for the purpose of relief to a caregiver.
- Participants appropriate for Advanced Respite care include, but are not limited to:
- Participants who are essentially bedfast, and require specialized care involving turning and positioning, including assistance with mechanical transfer equipment; and/or assistance with elimination, including the use of a urinal, bedpan, catheter, and/or ostomy.
- Participants who have behavior disorders resulting in disruptive behavior especially due to dementia/Alzheimer’s disease which requires close monitoring.
- Participants who have health problems requiring manual assistance with oral medications; and/or participants who have special monitoring and assistance needs due to swallowing problems.
Advanced Respite Care: A unit is defined as fifteen (15) minutes.
NOTE: In summary, additional HCBS may be authorized on the same day as Basic Respite Care and/or Advanced Respite Care. However, the additional HCBS shall not be authorized during the same time as the authorized RC services.
RC shall never be authorized in place of a more appropriate service, e.g. Personal Care or Homemaker.
3.51 Adult Day Care (Aged and Disabled Waiver)
Home and Community Based Services Manual
Adult Day Care (ADC) is the continuous care and supervision of a disabled adult in a licensed adult day care setting. Services include but are not limited to assistance with activities of daily living, planned group activities, food services, client observation, skilled nursing services as specified in the plan of care, and transportation. Planned group activities include socialization, recreation and cultural activities that stimulate the individual and help the participant maintain optimal functioning. The provider must arrange or provide transportation to the adult day care facility at no cost to the participant. Reimbursement will be made for up to 120 minutes per day of transportation related to transporting an individual to and from the Adult Day Care setting. Meals provided as part of ADC shall not constitute a "full nutritional regimen" (3 meals per day).
- Authorization of ADC is funded through the Aged and Disabled Waiver.
- All ADC participants must meet the following eligibility criteria:
- At least sixty-three (63) years of age;
- In active Medicaid status (Medicaid Eligibility).
- Participants who are eligible for Medicaid on a spenddown basis may be authorized to receive the ADC during periods when they meet their spenddown liability.
- A participant is responsible for the cost of services received during periods of time when they have not met their spenddown liability.
- Participants who receive Medicaid due to eligibility for Blind Pension (BP) may not be authorized for the ADC.
- Participants in a ‘Transfer of Property penalty’ may not be authorized for the ADC.
- Authorization of the ADC does meet the requirements for an individual to be eligible for Home and Community Based (HCB) Medicaid.
- Have an appropriate Medicaid Eligibility (ME) Codes [Needs Link]; and
- Meet nursing facility level of care.
- ADC services shall be authorized for:
- Up to 10 hours per day for a maximum of 5 days per week of which no more than 120 minutes, or eight (8), 15 minute units per day may be related to transporting an individual to and from the adult day care setting.
- ADC shall be included in the overall HCBS Cost Maximums cost of care for the participant.
ADC authorized together with other Aged and Disabled Services and Medicaid State Plan HCBS [i.e., Basic Personal Care (PC), Advanced Personal Care (APC), Authorized Nurse Visits (RN), and Consumer-Directed Model Personal Care (CDS)] shall not exceed 100% of the average statewide monthly cost for care in a nursing facility.
NOTE: When the care plan includes an authorization for RN services, the cost of one RN visit shall be excluded from the calculation of a care plan’s cost.
- ADC is provided by Adult Day Care facilities licensed by DHSS, Division of Regulation and Licensure (DRL) with a Medicaid provider agreement with the Department of Social Services (DSS), Missouri Medicaid Audit and Compliance Unit (MMAC). Payment is made to the ADC provider on behalf of the participant.
- Restrictions:
- Individuals who reside in a nursing facility, Residential Care Facility (RCF) or Assisted Living Facility (ALF) licensed by DHSS, DRL are not eligible for ADC.
- Participants authorized for certain services through the Department of Mental Health (DMH) may not be eligible for services as outlined in this policy. Staff shall refer to the DMH Service Coordination Policy [Needs Link]for guidance on coordination of services for participants authorized for DMH services.
- Services received from the ADC are determined by the individual plan of care developed by the participant, ADC personnel, and the participant’s physician. The individual plan of care is developed every six (6) months by the ADC and includes the amount, duration and scope of treatment and services to be provided. The individual plan of care shall be available to Division of Senior and Disability Services (DSDS) staff or its designee upon request. Depending on the individual plan of care, the participant may receive the following organized services as a component of receiving the ADC:
- Leisure-time and exercise activities - planned recreational and social activities;
- Counseling services - assistance to participants and families with personal, social, family or adjustment problems;
- Rehabilitative services - occupational, physical, and speech therapy;
- Activities of daily living - such as assistance with walking, toileting, or feeding;
- Medication management and nursing services - by a licensed nurse;
- Meals - to include physician ordered special or modified diets and snacks; and
- Up to 10 hours per day for a maximum of 5 days per week of which no more than eight (8), 15 minute units per day may be related to transporting an individual to and from the adult day care setting.
3.55 Independent Living Waiver
Home and Community Based Services Manual
Introduction
The Independent Living Waiver (ILW) is a Home and Community Based Services (HCBS) 1915c waiver offered through the Division of Senior and Disability Services (DSDS) to participants receiving Consumer Directed Services (CDS), with a need for additional assistance to remain in the least restrictive environment.
The ILW offers several services, including additional CDS Personal Care, Case Management (CM), Environmental Accessibility Adaptations (EAA), Specialized Medical Equipment (SME), Specialized Medical Supplies (SMS), and Financial Management Services (FMS).
ILW expenditures must be cost effective in comparison to nursing facility costs based on the aggregate of all ILW participants’ services. Cost effectiveness of the ILW is managed by Division of Senior and Disability Services (DSDS), Bureau of Federal Programs (BFP) as an administrative function.
Purpose
The ILW aims to establish and maintain a community-based system of care for individuals 18 years of age and older with disabilities. These individuals live in and wish to continue living independently in their homes and/or communities and self-direct their services.
Eligibility
All ILW participants must meet the following criteria:
- Initial entry into the ILW is limited to individuals 18 years of age to 64 years of age
- Individuals who are enrolled in the ILW when they turn sixty-five (65) may remain enrolled in the ILW for as long as they maintain the ability and the desire to self-direct their personal care attendant services.
- Be physically disabled, as defined by 19 CSR 15-8
- Loss of, or loss of use of, all or part of the neurological, muscular, or skeletal functions of the body to the extent that the person requires the assistance of another person to accomplish routine tasks
- Individuals with a cognitive impairment must have had the onset of the cognitive impairment on or after age twenty-two (22)
- Be able to self-direct their own CDS
- Be in active Medicaid status (Medicaid Eligibility)
- Participants eligible for Medicaid on a spenddown basis may be authorized to receive ILW during periods when spenddown liability is met.
- When the participant has not met their monthly spenddown liability amount, the participant and provider may make a private arrangement for the continued delivery of services. In these instances, the participant is responsible for the cost of services received.
- Participants who receive Medicaid due to eligibility for Blind Pension (BP) are not eligible and shall not be authorized for ILW.
- Participants in a ‘Transfer of Property’ penalty period may be authorized for ILW.
- Authorization of ILW does not meet the requirements for an individual to be eligible for Home and Community Based (HCB) Medicaid.
- Participants eligible for Medicaid on a spenddown basis may be authorized to receive ILW during periods when spenddown liability is met.
- Have an appropriate Medicaid Eligibility (ME) code
- Meet nursing facility level of care
Restrictions
The ILW has the following restrictions:
- Must not reside in a facility of any kind, group home, or boarding home
- Must not be enrolled in any other waiver program, regardless of which state agency administers the waiver
- Shall not be selected as ‘CDS Restricted’ in the participant’s electronic case record
Participants authorized for certain services through the Department of Mental Health (DMH) may not be eligible for services as outlined in this policy. Staff shall review DMH Service Coordination guidelines to ensure appropriate service authorization for participants receiving DMH services.
Limitations And Waitlist
The ILW is limited to the following:
- A specific number of unduplicated participants during any waiver year
- The ILW year runs from July 1 of each year through June 30 of the following year
- If a participant leaves the ILW during a waiver year for any reason, the slot remains occupied for the duration of the waiver year
- If all available slots are full when a participant is determined eligible for the ILW, the participant will be placed on the ILW Waiting List
- BFP will notify DSDS staff when slots are available.
The ILW Waiting List is managed and maintained by designated staff in BFP as part of the required waiver oversight functions. At the beginning of each ILW year, BFP shall:
- Notify each region of any available slots and provide a list of participants from the ILW Waiting List to be contacted
- DSDS staff shall contact participant(s) at that time to re-verify eligibility for ILW enrollment and confirm the continued need for ILW services.
Service Description
CDS Personal Care
The scope and nature of the ILW do not differ from CDS State Plan except for the ability of the participant to designate another individual to direct their care. The ILW provides additional CDS when approved state plan limits are exhausted. Additional services under the ILW are not limited in amount or frequency.
- Any participant who opts to delegate self-direction responsibilities (while still possessing the ability to self-direct) shall have all CDS authorized through the ILW. Participants who choose to delegate selfdirection cannot be authorized through State Plan CDS.
- A physically disabled participant with a cognitive impairment that does not affect their ability to selfdirect is authorized through the ILW only. Participants who choose to delegate self-direction cannot be authorized through State Plan CDS.
Financial Management Services (FMS)
FMS is provided to participants who receive CDS through the ILW to facilitate employment of attendants by the participant and assist with access to other ILW services, when needed. FMS providers perform the following functions:
- Assist participant in verifying the attendant’s citizenship status
- Collect and process Electronic Visit Verification (EVV) records of attendants
- Process payroll, withholding, filing and payment of applicable federal, state, and local employmentrelated taxes and insurance
- Ensure all funds paid for attendants are used to pay the attendant’s wages and all employment related taxes and insurance
- Ensure attendant is registered with the Family Care Safety Registry (FCSR)
- Provide information and assistance to the participant or designee in arranging for, directing, and managing services
- Assist in identifying immediate and long-term needs, developing options to meet those needs, and accessing identified supports and services
- Offer practical skills training to enable families and participants to independently direct and manage waiver services, including:
- Providing information on recruiting, hiring, and managing attendants.
- Providing information on effective communication and problem-solving.
- Providing information to ensure that participants understand the responsibilities involved with directing their services.
- Assist in the acquisition of necessary assistive technology services and/or devices such as:
- Advocating for the participant by arranging for services with individuals, businesses, and agencies for the best available service within existing resources.
- Assist participant in obtaining three (3) cost statements for the authorization of SME, SMS, and EAA, including:
- Assuring the purchase price includes the cost of training the participant in the operation and maintenance of equipment. The purchase price must also cover the cost of maintenance and upkeep of equipment:
- Ensuring that providers of equipment and supplies are enrolled with the MO HealthNet Division (MHD) as a State Plan Durable Medical Equipment (DME) provider, or be registered and in good standing with the Missouri Secretary of State’s Office; and
- Ensuring providers for EAA are qualified and meet all state and local licensure and/or certification requirements. Contractors must have any required business licenses and meet all applicable building codes.
Case Management (CM)
CM assists participants in gaining access to needed waiver and other State Plan services, as well as medical, social, educational, and other services, regardless of the funding source for the services needed.
All participants enrolled in the ILW shall be authorized for CM. Case managers employed by the HCBS provider must deliver and document at least 12 hours of CM per year, which includes at least monthly contact with the participant. Case Management is authorized as 1 unit per month.
- CM may include any of the following activities:
- Identification of abuse, neglect, and/or exploitation
- Monitoring the provision of services in the participant’s care plan
- Review of the care plan and the participant’s needs, which shall include monthly contacts and faceto-face visits with the participant as deemed necessary
- Assisting participants with full access to a variety of services and service providers to meet their specific needs, regardless of funding source
Environmental Accessibility Adaptations (EAA)
EAA are physical adaptations to the participant’s home necessary to ensure the health and safety of the participant, and/or enable the participant to function with greater independence in the home and community. Authorization of EAA is limited to $5,000 in a five-year period. A unit is based on the actual cost of work (Services Units and Rates).
- Examples of appropriate modifications include:
- The installation of ramps and grab-bars, widening of doorways, and the modification of bathroom facilities
- Installation of specialized electric and plumbing systems that are necessary for the safety of the participant
- Other modifications that directly impact health and safety of the participant
- Excluded are adaptations or improvements to the home which are of general utility and are not of direct medical or remedial benefit to the participant, such as carpeting, roof repair, central air conditioning, etc.
- Authorizations of EAA may only be authorized when the FMS provider has verified and documented that no other resources are available to meet the need
- Participants who live in rental property shall first request the landlord make any necessary modifications and/or give permission for the work to be done
Specialized Medical Equipment (SME)
SME includes devices, controls, or appliances that enable participants to increase their ability to perform activities of daily living. Authorization of SME is limited to $5,000 in a five-year period. A unit is based on the actual cost of the device (Service Rates and Units). Examples include:
- Lift chairs, commode chairs, patient lifts, trapeze equipment, oxygen, respiratory equipment, shower benches, augmentative communication devices, canes, walkers, or wheelchairs
Specialized Medical Supplies (SMS)
SME include items that will enable a participant to increase their ability to perform activities of daily living. A unit is based on the actual cost of supplies (Services Units and Rates). Examples include:
- Incontinence supplies, such as adult diapers and disposable bed pads
- When a participant currently receives incontinence supplies through the Medicaid exception process, and the participant is being enrolled in the ILW, staff shall request authorization of SMS through the ILW.
NOTE: EAA, SME, and SMS shall only be authorized when it can be documented that such authorization will decrease the current authorization of or future need for personal care assistance services, either through the State Plan or the ILW.
SME and SMS shall be authorized only when it can be documented that these services cannot be covered by another source, such as Medicaid or Medicare covered Durable Medical Equipment.
Process
When the potential need for an ILW service is identified during an assessment or other participant contact, DSDS staff shall complete the following as part of the Person Centered Care Planning (PCCP) process:
- Verify participant’s age, Medicaid eligibility status, and ME code
- Ensure participant is or will be enrolled in State Plan CDS
- Persons with a cognitive impairment who choose to designate another person to direct their services shall be enrolled for CDS in the ILW (when a slot is available), as they are not eligible for State Plan CDS.
- Verify that participants already receiving State Plan CDS are consistently utilizing those services
- Verify that the participant is not enrolled in any other waiver
- Ensure the participant’s electronic case record contains a Participant Choice Statement signed within the last 365 days
- Review the participant’s electronic case record to ensure that information regarding the participant’s needs is consistent throughout (e.g. needs identified during the assessment coordinate with the services and tasks to be authorized)
- Update existing case information as needed to reflect correct marital status/living arrangement, physician, responsible party, safety concerns, and other information relevant to care planning
- Verify and document the participant’s ability to self-direct their care
- Verify and document with the provider and/or participant that services requested are not available from any other resource
- Complete and upload a draft CDS Worksheet that reflects all State Plan CDS and ILW services and tasks needed.
- The worksheet shall provide a clear explanation of why each task is being requested and why the amount of time requested is appropriate.
- When other services are or will be authorized, DSDS staff shall complete an In Home Services Worksheet to indicate which services and tasks will be included.
- Document all contacts and actions in the participant’s electronic case record, including any changes since the last assessment, unmet needs, support systems, a reference to the uploaded worksheet(s), and other issues that impact the need for services not already outlined in the worksheet.
Provider Choice
ILW participants must select a Home and Community Based Service (HCBS) provider that is enrolled as a CDS provider with the Department of Social Services (DSS), the Missouri Medicaid Audit and Compliance Unit (MMAC). The provider must also be approved to provide ILW and the services under the waiver.
Payment is made to the HCBS provider, as Medicaid only pays contracted providers. However, the participant is still considered the employer of the attendant.
Approval
DSDS staff shall submit all requests for ILW services to their supervisor for review. The supervisor shall:
- Review to ensure all steps are complete and the participant’s unmet needs require the service(s) requested
- After review, forward the request to BFP for approval, along with documentation that supports the request for the authorization of ILW
NOTE: Pending approval from BFP to authorize ILW, State Plan CDS shall be authorized up to 60% of the current cost maximum, depending on participant need.
BFP will review the ILW request and shall:
- Request clarification or additional details for approval if necessary
- Determine if an ILW slot is available and shall notify the supervisor to enroll the participant upon approval
- If an ILW slot is not available, BFP shall:
- Complete an Acuity-Based Worksheet to determine the participant’s needs and placement on the ILW Wait List, upload the form to the participant’s electronic case record and notify the supervisor of the decision.
- The Acuity Total is determined by transferring the times and tasks from the Care Plan Supplement for CDS, developed with the participant, to the priority categories listed on the Acuity Based Worksheet.
- Any changes to the participant’s Acuity Total shall be updated on the ILW Waiting List.
- Participants with the highest Acuity Total will be considered first for any available slots.
- A participant’s position on the ILW Waiting List may change from day-to-day based on the addition or deletion of other participants to the list.
When a participant is placed on the ILW Waiting List, they have ninety (90) calendar days to appeal their position on the list. DSDS staff shall:
- Complete a Waiting List Notice for ILW Services and forward it to the participant, along with a copy of the Acuity-Based Worksheet
- Lack of an available slot in the ILW is not subject to adverse action and appeal rights.
When a participant has been placed on the ILW Waiting List, DSDS staff shall notify BFP of all changes made to the participant’s PCCP. BFP will update the Acuity-Based Worksheet and the participant’s information on the ILW Waiting List as necessary. Changes may include:
- Addition or deletion of services and tasks, whether during reassessment or resulting from other contacts
- Suspension of services
- Case closing
- Any action affecting the participant’s eligibility or need for ILW services
The supervisor will be notified if the request is not approved for any reason. Denial of a request for ILW enrollment requires DSDS staff to send a Notice of Adverse Action to the participant and is subject to appeal rights (Adverse Action and Appeal and Hearing Process).
NOTE: When a DSDS designee completes a reassessment and identifies a need for ILW services, DSDS staff shall follow the same process to verify eligibility and need for ILW services before submitting the request to BFP.
Authorization
The following will guide prior authorization in the electronic case management system for both State Plan CDS and ILW services upon approval from BFP.
CDS State Plan Personal Care
- On the Care Plan Builder Page, select ‘Add Service’
- From the ‘Service Type’ drop down select ‘Personal Care Assistance – CDS’
- Select ‘Add Task’
- Choose all the tasks to be authorized as CDS Personal Care
- Add tasks up to the 60% cost maximum; tasks beyond the 60% cost maximum will be authorized under Independent Living Waiver
- Select the Provider
- Adjust the start date, as needed
ILW Personal Care
- On the Care Plan Builder Page, select ‘Add Service’
- From the ‘Service Type’ drop down select ‘Personal Care Assistance – ILW’
- Select ‘Add Task’
- Choose all tasks to be authorized as Personal Care – ILW
- Be careful not to duplicate tasks already authorized under Personal Care Assistance – CDS
- Select the Provider
- Adjust the start date, as needed
Case Management
- CM will populate automatically when ‘Personal Care – Independent Living Waiver’ is selected on the Care Plan Builder
- Case Management will auto populate 1 unit per month with the same date range as Personal Care - Independent Living Waiver
- If Personal Care Assistance – Independent Living Waiver is deleted, CM will be deleted
- Select the Provider
- Adjust the start date, as needed
- In rare instances a participant can be authorized for Case Management without the need for personal care above the 60% cost maximum. In these instances, CM can be added to the care plan manually
- On the Care Plan Builder Page, select ‘Add Service’
- From the ‘Service Type’ drop down select ‘Case Management’
- Select ‘Add Task’
Financial Management Services
- FMS will populate automatically when ‘Personal Care – Independent Living Waiver’ is selected on the Care Plan Builder
- FMS will auto populate 1 unit with the same date range as Personal Care -Independent Living Waiver
- If Personal Care Assistance – Independent Living Waiver is deleted, FMS will be deleted
- Select the Provider
- Adjust the start date, as needed
- When CM is added to the care plan without the need for additional Personal Care, Financial Management will also be required.
- On the Care Plan Builder Page, select ‘Add Service’
- From the ‘Service Type’ drop down select ‘Financial Management’
- Select ‘Add Task’
Provider Service Delivery
Providers should deliver all tasks outlined under both State Plan and ILW as State Plan until the 60% cost maximum has been exhausted. Once the 60% has been exhausted, providers should transition to delivering all tasks under ILW for the remaining portion of the month. This delivery method should be consistent for electronic visit verification entries and billing claims.
3.60 Structured Family Caregiving Waiver
Home and Community Based Services Manual
INTRODUCTION
The Structured Family Caregiving Waiver (SFCW) is a Home and Community Based Services (HCBS) waiver service offered through the Division of Senior and Disability Services (DSDS) available to participants with a diagnosis of Alzheimer’s disease or related dementia disorders. The goal of the SFCW is to provide necessary care to participants in a home environment by fostering the participant’s independence while preserving dignity, self-respect, and privacy in a non-institutional setting.
PURPOSE
SFCW is designed to provide long-term care to those whose needs can be met within the SFCW. Participant needs shall be addressed in a manner that support and enable the individual to maximize their ability to function at the highest level of independence possible. The participant’s needs are met by a cooperative relationship between the participant and/or legal guardian, the primary and substitute caregivers, and the SFCW provider.
The participant’s right of self-determination shall be sought and respected throughout the Person-Centered Care Planning (PCCP) process and delivery of the SFCW. The participant shall participate and approve of the services being delivered or when appropriate, the legal guardian may communicate this approval.
- The SFCW service shall be administered and received in the participants' or primary caregivers' home and community. The primary caregiver must be the live-in caregiver already providing care to the participant prior to authorization of SFCW.
- The primary and substitute caregivers may be a non-family member, family member, or legal guardian.
ELIGIBILITY
All SFCW participants must meet the following eligibility criteria:
- Be 21 years of age and over at initial entry
- Diagnosed with Alzheimer's or related dementia disorders as defined by state statute 172.800 RSMo by a physician licensed in the State of Missouri
- Reside full time in the same household as the primary caregiver
- Have an established backup plan
- A qualified substitute caregiver familiar with the participant’s needs, chosen by the participant or legal guardian and employed by the provider, must be identified and available to provide services at times when the primary caregiver is not available.
- Meet Nursing Facility Level of Care (LOC)
- Have an appropriate Medicaid Eligibility (ME) [Needs Link] code
- Be in active Medicaid status
- Participants eligible for Medicaid on a spenddown basis may be authorized to receive SFCW during periods when spenddown liability is met.
- When the participant has not met their monthly spenddown liability amount, the participant and provider may make a private arrangement for the continued delivery of services. In these instances, the participant is responsible for the cost of services received.
- Authorization of the SFCW does not meet the requirements for an individual to be eligible for Home and Community Based (HCB) Medicaid.
- Participants in a ‘Transfer of Property penalty’ are eligible for Medicaid funded SFCW
- Participants who receive Medicaid due to eligibility for Blind Pension (BP) are not eligible for the SFCW.
RESTRICTIONS
The SFCW has the following restrictions:
- The participant must not be enrolled in any other HCBS state plan or waiver service, regardless of which state agency administers the waiver
- Individuals who reside in a facility of any kind, group home, or boarding home are not eligible for the SFCW.
- The hiring of more than one primary caregiver is not allowed.
SERVICE DESCRIPTION
The SFCW provider is required to develop, implement, and provide a Person-Centered Care Plan (PCCP) that addresses the participant’s needs and ensures the primary and substitute caregivers are properly qualified to meet the participant’s needs.
Allowable Services and Supports
These are supportive and health-related attendant and homemaker services that substitute for the absence, loss, reduction, or impairment of a physical or cognitive function. The following are services related to needed Instrumental Activities of Daily Living (IADLs) and Activities of Daily Living (ADLs) .
- Homemaker which includes general household tasks like cleaning and laundry.
- Attendant care to provide assistance with ADLs such as bathing, dressing, and other personal care tasks.
- Medication oversight to manage medications and doses (to the extent permitted under State law).
- Escorting for necessary appointments, whenever possible, such as transporting individuals to doctor appointments and community activities that are therapeutic in nature or assists with maintaining natural supports.
PROVIDER CHOICE
The HCBS provider must be enrolled as a SFCW provider with the Department of Social Services (DSS), MO HealthNet Division, and Missouri Medicaid Audit and Compliance (MMAC) Unit. The SFCW provider is selected through the participant's choice and provider availability. A list of all qualified providers is available to the participant or legal guardian upon request, at reassessment, or anytime a provider change request is made.
COST MAXIMUM
Unit Rate: The SFCW unit of service is one-day, which equals a 24-hour period. The per diem unit rate is based upon 60% of the nursing facility daily rate. The SFCW unit shall never be authorized with any other HCBS.
The SFCW provider can take no more than 35% of the SFCW unit rate. The provider must pay the primary caregiver and substitute caregiver for services rendered.
PROCESS
The SFCW is limited to a specific number of unduplicated participants during any waiver year.
- The SFCW year runs from July 1 of each year through June 30 of the following year.
- Once a slot has been filled during the current waiver year, it cannot be used again in the same waiver year if the original participant leaves the SFCW for any reason.
When requested, services available through the SFCW shall be discussed with the participant and/or legal guardian, and anyone requested by the participant. DSDS staff shall confirm that the live-in caregiver already providing care to the participant will be the primary caregiver delivering SFCW. DSDS staff shall then document the identity of the primary and substitute caregivers.
DSDS staff shall confirm the diagnosis that meets the criteria outlined by state statute 172.800 RSMo by contacting the physician identified by the participant or legal guardian. If unable to reach by phone, DSDS staff shall utilize the SFCW Diagnosis Verification form. DSDS staff shall upload the completed form upon receipt.
Following confirmation of the appropriate diagnosis, DSDS staff shall provide the participant and/or legal guardian with information on SFCW providers for selection.
DSDS staff shall submit the request for SFCW to their supervisor for review. The supervisor shall review all requests for SFCW to ensure all steps are complete and the participant’s unmet needs require the SFCW. If documentation supports the request, the supervisor shall forward the request to the Bureau of Federal Programs (BFP) for review prior to authorization of SFCW. Pending approval from BFP to authorize SFCW, the SFCW unit and provider selection may be entered in pending status in the participants electronic case record.
BFP will review the SFCW request, and if necessary, request additional clarification or details.
- The supervisor will be notified if the request is not approved for any reason.
- Denial of a request for SFCW enrollment requires an adverse action [Needs Link]. DSDS staff shall send a Notice of Adverse Action to the participant and/or legal guardian which is subject to appeal rights [Needs Link].
- Upon approval of a request, BFP will determine if a SFCW slot is available and notify the supervisor to enroll the participant.
NOTE: Participants receiving other HCBS or waiver services that want to enroll in SFCW, must have the other HCBS state plan or waiver services’ end-dated prior to the authorization of SFCW.
3.70 Social Services Block Grant/general Revenue Protective Services Participants
Home and Community Based Services Manual
Social Services Block Grant (SSBG) funds are federal funds allocated to states through Title XX of the Social Security Act. General Revenue (GR) funds are state funds appropriated by the Missouri Legislature. Each year the legislature appropriates an amount of GR funds and authorizes a portion of SSBG funds to the Department of Health and Senior Services (DHSS), Division of Senior and Disability Services (DSDS), for use in the delivery of social and protective services.
Certain Home and Community Based Services (HCBS) may be authorized temporarily through SSBG/GR funds to an eligible adult receiving Adult Protective Services (APS) or in an active Hotline situation. SSBG/GR authorizations may include any of the services and tasks in State Plan-Agency Personal Care or the Aged and Disabled Waiver (ADW).
A written recommendation for HCBS shall be made by the Protective Service Unit (PSU) staff to their supervisor. The written recommendation shall include, but not be limited to, a summary of the eligible adult’s APS need, met and unmet needs, and a draft care plan utilizing the In-Home Service Worksheet (HCBS-3a). The PSU staff shall collaborate with the eligible adult to choose a qualifying HCBS provider from the list of providers enrolled with the Department of Social Services (DSS), Missouri Medicaid Audit and Compliance Unit (MMAC) to deliver the HCBS.
Approval must be obtained by the PSU Supervisor, through the Regional Manager. Upon receipt of written approval from the Regional Manager, a paper prior authorization request shall be completed by the appropriate Regional staff and emailed to the Bureau of HCBS Systems & Data Reporting and DSDS Financial Support Unit. The request shall include:
- Written approval from the appropriate Regional Manager;
- In-Home Service Worksheet
- Proposed dates of service; and
- HCBS provider name.
After review of the request and verification of the HCBS providers direct deposit information, the Bureau of HCBS Systems & Data Reporting will create a paper prior authorization and billing form and forward it to the appropriate PSU staff. The PSU staff shall contact and coordinate with the HCBS provider to ensure they receive the information and understand the funding source. The HCBS provider shall be advised to contact the Bureau of HCBS Systems & Data Reporting if they experience any billing questions.
NOTE: In special high risk circumstances, verbal consent may be given for the HCBS provider to begin services immediately to the Reported Adult. The PSU staff must first obtain verbal approval from the Supervisor and RM. A paper authorization should be completed the next business day.
3.00 Appendix 1 Services Units and Rates
Home and Community Based Services Manual
| SERVICE | PROCEDURE CODE | UNIT | LIMITS | UNIT RATE |
|---|---|---|---|---|
| State Plan Services | ||||
| Advanced Personal Care | T1019TF | 15 min. | $8.17 | |
| Advanced Personal Care – RCF/ALF | T1019U3 TF | 15 min. | $7.68 | |
| Authorized Nurse Visits | T1001 | 1 visit | 1 visit/day | $60.99 |
| Authorized Nurse Visits – RCF/ALF | T1001U3 | 1 visit | 1 visit/day | $57.18 |
| Basic Personal Care – Agency Model | T1019 | 15 min. | 387 units/mo | $8.14 |
| Basic Personal Care – RCF/ALF | T1019U3 | 15 min. | 412 units/mo | $7.66 |
| Personal Care Assistance – Consumer Directed Model | T1019U2 | 15 min. | 603 units/mo | $5.23 |
| Aged and Disabled Waiver Services | ||||
| Adult Day Care | S5100HC | 15 min. | 1-40 units (10hrs/day) 5 days per week | $3.32 |
| Homemaker | S5130 | 15 min. | $8.14 | |
| Chore | S5120 | 15 min. | $8.14 | |
| Home Delivered Meals | S5170 | 1 meal | 2/day | $6.71 |
| Respite - Basic | S5150 | 15 min. | $8.14 | |
| Respite - Advanced | S5150TF | 15 min. | $8.14 | |
| Independent Living Waiver Services (Central Office must approve services prior to authorization) | ||||
| Personal Care Assistance | T1019U6 | 15 min. | Unit | $4.63 |
| Case Management | T2024U6 | 1 unit/month | Unit | $38.17 |
| Financial Management Service | T2040U6 | 1 unit/month | Unit | $157.89 |
| Specialized Medical Equipment | T2029U6 | Actual cost | Unit | $100.00 |
| Specialized Medical Supplies | T2028U6 | Actual cost | Unit | $100.00 |
| Env. Accessibility Adaptations | S5165U6 | Actual cost | Unit | $100.00 |
| Adult Day Care Waiver | ||||
| Adult Day Care | S5100HB | 15 min. | 1-40 units (10 hrs/day) 5 days per week | $3.32 |
| Structured Family Caregiver Waiver | ||||
| Structured Family Caregiver | S5126HB | 1 day | 1 unit/day | $103.80 |
3.00 Appendix 2 HCBS Cost Maximums
Home and Community Based Services Manual
Average Statewide Monthly Cost for Care in a Nursing Facility
| Effective Date | 100% | 60% |
|---|---|---|
| July 1, 2025 | $5,262.08 | $3,157.25 |
Monthly Cost of Home and Community Based Services
| Services | 100% | 60% | Monthly Unit Maximum |
|---|---|---|---|
| State Plan – Agency Model | |||
| Advanced Personal Care | X | ||
| Basic Personal Care | X | 387 | |
| Authorized Nurse Visits | 26 units within 6 months | ||
| Advanced Personal Care in an RCF/ALF | X | ||
| Basic Personal Care in an RCF/ALF | X | 412 | |
| Authorized Nurse Visits in an RCF/ALF | 26 units within 6 months | ||
| Adult Day Care Waiver | X | 920 | |
| Aged and Disabled Waiver | |||
| Adult Day Care | X | 920 | |
| Chore | |||
| Homemaker | |||
| Home Delivered Meals | 62 | ||
| In-Home Respite Care | |||
| Structured Family Caregiver Waiver | X | 31 | |
| State Plan - Consumer Directed Services | |||
| Personal Care Assistance | X | 603 | |
| Independent Living Waiver | |||
| Personal Care Assistance | |||
| Financial Management Service | 1 unit/month | ||
| Case Management | 1 unit/month | ||
| Specialized Medical Equipment | Actual cost | ||
| Specialized Medical Supplies | Actual cost | ||
| Environmental Accessibility Adaptations | Actual cost |
3.55 Appendix 2 Waiting List Notice for Ilw Services
Home and Community Based Services Manual
Participants who meet all required eligibility criteria to participate in the Independent Living Waiver (ILW) are placed on the ILW Waiting List when no slots are available for enrollment. The Waiting List Notice for Independent Living Waiver Services (HCBS-12w) provides the participant and/or their authorized representative (e.g. guardian, or someone with a signed Authorization for Disclosure of Consumer Medical/Health Information that is in effect) with written notification of the participant’s number on the ILW Waiting List, along with appeal rights related to their number.
INSTRUCTIONS
Enter the date the letter is completed.
Enter the participant’s name and address.
- For participants that have a guardian, enter the guardian’s contact information.
Enter the participant’s number on the ILW Waiting List.
Enter the date of the participant’s most recent assessment in the two locations indicated.
Enter the name and signature of DSDS staff completing the form, along with the office address and telephone number.
DISTRIBUTION
The original HCBS-12w shall be mailed to the participant and/or their authorized representative. A copy shall be uploaded to the participant’s electronic case record.
A copy shall also be included in the exhibit packet sent to the Department of Social Services (DSS), Division of Legal Services (DLS) when a hearing is requested.
4.00 Home and Community Based Services Process Introduction
Home and Community Based Services Manual
Introduction
The Department of Health and Senior Services (DHSS), Division of Senior and Disability Services (DSDS), has the oversight responsibility for the provision of Home and Community Based Services (HCBS), (i.e., (re)assessment, person-centered care planning, and care plan maintenance). HCBS is designed to support and meet the unmet needs of seniors and individuals with disabilities who meet Nursing Facility Level of Care (NFLOC), by providing necessary assistance to remain in their homes.
Purpose
The primary goal of HCBS is to enable a current or potential participant to remain in the least restrictive environment.
Process
DSDS staff, or its designee, shall create, through the HCBS process, a person-centered care plan (PCCP) that is designed around the participant’s current level of supports and unmet needs, taking into consideration the participant’s health and safety needs. Unmet needs are those routine tasks which are allowable by the HCBS program but cannot be reasonably met by the members of the participant’s household or other support systems. The participant’s right to self-determination and state/ federal regulation shall guide the PCCP process.
The management of HCBS processes is controlled through an electronic case system. The intake, (re)assessment, PCCP authorization, and care plan maintenance activities are all completed in the participant's electronic case record. The electronic case system provides HCBS partners ‘real-time’ access to the participant’s PCCP information, which facilitates improved communication among agencies involved in service delivery.
The following policies shall guide DSDS or its designee through the HCBS process.
| Policy | Policy Number |
|---|---|
| Intake Process | 4.05 [Needs Link] |
| Explanation of Level of Care Determination Process | 4.10 [Needs Link] |
| Assessment Process | 4.15 [Needs Link] |
| Person Centered Care Planning and Maintenance Process | 4.20 [Needs Link] |
| Provider Reassessment Process | 4.25 [Needs Link] |
| Case Notes Documentation | 4.30 [Needs Link] |
| Service Coordination | 4.35 [Needs Link] |
| Department of Mental Health (DMH) Service Coordination | 4.35.1 [Needs Link] |
| Healthy Children and Youth (HCY) Service Coordination | 4.35.2 [Needs Link] |
| HCBS and PACE Coordination | 4.35.3 [Needs link] |
| Brain Injury Waiver Coordination | 4.35.4 [Needs Link] |
| Case Closure. | 4.40 [Needs Link] |
| Person Centered Care Planning Collateral Contacts | 4.00 Appendix 1 [Needs Link] |
| Participant Choice Statement and Instructions | 4.00 Appendix 2 Form [Needs Link] and Instructions [Needs Link] |
| Adult Day Care Participant Rights and Responsibilities | 4.00 Appendix 2c [Needs Link] |
| Agency Model Participant Rights and Responsibilities | 4.00 Appendix 2d [Needs Link] |
| CDS Participant Rights and Responsibilities | 4.00 Appendix 2e [Needs Link] |
| RCF/ALF Personal Care Participant Rights and Responsibilities | 4.00 Appendix 2f [Needs Link] |
| Structured Family Caregiver Waiver Rights and Responsibilities. | 4.00 Appendix 2g [Needs link] |
| In-Home Services Worksheet (HCBS-3a) and Instructions | 4.00 Appendix 3 Form and Instructions [Needs Link] |
| CDS Worksheet (HCBS-3c) and Instructions | 4.00 Appendix 4 Form and Instructions [Needs Link] |
| Physician Notification of Care Plan (HCBS-11) and Instructions | 4.00 Appendix 5 Form [Needs Link] and Instructions [Needs Link] |
| Department of Mental Health Customer Information Management, Outcomes and Reporting (CIMOR) | 4.00 Appendix 6 [Needs link] |
| Department of Mental Health Division of Developmental Disabilities Contact Information | 4.00 Appendix 7 [Needs Link] |
| SLUMS Examination and Instructions | 4.00 Appendix 8 Form and Instructions [Needs Link] |
| HCBS Community Options Information | 4.00 Appendix 9 [Needs Link] |
| Self-Direction Assessment Questions | 4.00 Appendix 10 Form and Instructions [Needs Link] |
| Participant Contact Letter | 4.00 Appendix 11 Form [Needs Link] and Instructions [Needs Link] |
| Participant Communication – Reason for Contact | 4.00 Appendix 12 [Needs Link] |
| Healthcare Professional Inquiry | 4.00 Appendix 13 Form [Needs Link] and Instructions [Needs Link] |
| Healthcare Information Request | 4.00 Appendix 15 Form [Needs Link] and Instruction [Needs Link] |
| Structured Family Caregiving Waiver Diagnosis Verification Form | 4.00 Appendix 16 Form [Needs Link] and Instruction [Needs Link] |
4.05 Intake Process
Home and Community Based Services Manual
Introduction
The Division of Senior and Disability Services (DSDS) is the initial point of contact for Home and CommunityBased Services (HCBS). DSDS operates a Customer Service Contact Center within the Bureau of HCBS Intake and PCCP, where initial referrals are received and processed. Potential participants must meet the Nursing Facility Level of Care (LOC) to be considered for HCBS.
Purpose
The Bureau of HCBS Intake and PCCP receive referrals from potential participants, HCBS providers and professional community partners. The bureau determines if a potential participant is appropriate for an initial assessment in their home.
Process
HCBS referrals shall be submitted utilizing the Online HCBS Referral Form. In instances where referrals cannot be submitted online, referrals can be submitted by completing the HCBS Referral Form and emailing to HCBSCallCenterReferrals@health.mo.gov.
Upon receipt of a completed referral for HCBS, DSDS shall determine if the potential participant is eligible for HCBS and is appropriate for an initial assessment by:
- Obtaining the potential participant’s Departmental Client Number (DCN) and either the date of birth or last name to access information in the participant’s electronic case record
- Verify whether the potential participant has the appropriate Medicaid type and age eligibility from the “Participant” screen in the electronic case record.
Note: Special intake requirements exist for Show-Me Home [NEEDS LINK].
Processing Limits
Managed Care Health Plans
Individuals enrolled in certain Managed Care Health Plans are not eligible to receive HCBS or certain HCBS authorized by DSDS. If a referral is received for an individual enrolled in a Managed Care Health Plan where requested services cannot be authorized, DSDS shall refer the individual to the Managed Care Health Plan contact information provided in the electronic case record.
SPENDDOWN
Referrals will not be processed if spenddown liability is not met at time of referral. Individuals who appear eligible for Home and Community Based (HCB) Medicaid and potentially eligible for an Aged and Disabled Waiver service will be referred to the Department of Social Services (DSS) Family Support Division (FSD).
FSD will determine HCB eligibility and initiate the HCBS referral if appropriate.
A referral will not be accepted for individuals who are not Medicaid or age-eligible on the date of the request.
MILLER TRUST
In addition, an IM-54A referral from the Family Support Division (FSD) indicating a Qualified Income Trust (QIT) [NEEDS LINK] or “Miller Trust” is being processed through FSD shall be accepted for those spenddown recipients who do not have Medicaid benefits in effect but are potentially eligible for an ADW service. IM-54A referrals from FSD indicating a SLMB-2 and/or a Division of Assets shall also be accepted and processed.
Referral Process
HCBS Intake will only process appropriate referrals. Incomplete referrals are considered inappropriate and will not be processed. They will be dispositioned as inappropriate. The applicable action will be chosen, and the referral will be closed.
Upon determination that the potential participant is an appropriate referral for HCBS The information gathered and/or verified at the time of intake is as follows:
- If the Participant applied for HCBS in the last ninety (90) days
- Participant’s name
- Participant’s DCN
- Participant’s DOB
- Participant’s physical address
- Participant’s mailing address
- Participant’s primary phone number
- Alternate phone number
- Other responsible person information (name, relationship, phone numbers, address)
- Communication needs
- Is the participant currently in the hospital? If so, the hospital name/address/contact person/phone number?
- Marital status
- Living arrangement
- Other household members receiving HCBS
- Primary medical conditions related to the participant’s need for HCBS
- Unmet needs of person being referred (tasks)
- Reason for referral
- Safety concerns
- Referrer’s information (name, relation, contacting information)
Note: The military status question needs to be asked per SB 120 – Section 42.051 RSMo. When a potential participant answers “yes” to this question, DSDS staff shall provide them the MO ATQ Resource Page either electronically or by mail.
The participant’s electronic case record shall be reviewed, completed, and updated with the required information on the HCBS Referral Form. Information regarding any safety concerns shall be addressed in the “Safety Concerns” section within the electronic case record. Information in the participant's electronic record shall be changed or updated at any time during the life of a case when DSDS or its designee becomes aware of the change or update. Other responsible person information shall be included when applicable.
Note: A case shall be added on the same day it is determined that the referral is appropriate for HCBS processing. A case shall remain open as long as there is an authorization for HCBS.
4.10 Explanation of Level of Care Determination
Home and Community Based Services Manual
Introduction
Individuals seeking Home and Community Based Services (HCBS) must meet nursing facility Level of Care (LOC). This measures the same eligibility criteria required for entry into a nursing facility as outlined in 19 CSR 30-81. LOC is determined during (re)assessments completed by Division of Senior and Disability Services (DSDS) staff or their designee.
Purpose
DSDS utilizes the InterRAI HC tool to conduct assessments. Based on the information gathered, algorithms within the electronic case record system determine the LOC score in individual categories. With an assessed LOC score of 18 points or higher, an individual is determined to be qualified for LOC and eligible for HCBS. If the individual does not meet LOC, they are determined to be ineligible and appropriate adverse action [NEEDS LINK] steps should be taken.
Categories
Cognition
- Determine if the participant has an issue in one or more of the following areas:
- Cognitive skills for daily decision making and ability to complete task in a sequence
- Memory or recall ability (short-term, procedural, situational memory)
- Disorganized thinking/awareness – mental function varies over the course of the day
- Ability to understand others or to be understood
| 0 pts | 3 pts | 6 pts | 9 pts | 18 pts |
|---|---|---|---|---|
| No issues with cognition and No issues with memory, mental function, or ability to be understood/ understand others | Displays difficulty making decisions in new situations or occasionally requires supervision in decision making and Has issues with memory, mental function, or ability to be understood/ understand others | Displays consistent unsafe/poor decision making or requires total supervision and Has issues with memory mental function, or ability to be understood/ understand others | Rarely or never has the capability to make decisions or Displays consistent unsafe/poor decision making or requires total supervision and Rarely or never understood/able to understand others | Trigger: Comatose state |
Eating
- Determine the amount of assistance the participant needs with eating and drinking. Includes intake of nourishment by other means (e.g. tube feeding or TPN).
- Determine if the participant requires a physician ordered therapeutic diet.
| 0 pts | 3 pts | 6 pts | 9 pts | 18 pts |
|---|---|---|---|---|
| No assistance needed and No physician ordered diet | Physician ordered therapeutic diet or Set up, supervision, or limited assistance needed with eating | Moderate assistance needed with eating, i.e. participant performs more than 50% of the task independently | Maximum assistance needed with eating, i.e. participant requires caregiver to perform more than 50% for assistance | Trigger: Total dependence on others |
Behavioral
- Determine if the participant:
- Receives monitoring for a mental condition
- Exhibits one of the following mood or behavior symptoms – wandering, physical abuse, socially inappropriate or disruptive behavior, inappropriate public sexual behavior or public disrobing; resists care
- Exhibits one of the following psychiatric conditions –abnormal thoughts, delusions, hallucinations
| 0 pts | 3 pts | 6 pts | 9 pts | 18 pts |
|---|---|---|---|---|
| Stable mental condition and No mood or behavior symptoms observed and No reported psychiatric conditions | Stable mental condition monitored by a physician or licensed mental health professional at least monthly or Behavior symptoms exhibited in past, but not currently present or Psychiatric conditions exhibited in past, but not recently present | Unstable mental condition monitored by a physician or licensed mental health professional at least monthly or Behavior symptoms are currently exhibited or Psychiatric conditions are recently exhibited | Unstable mental health condition monitored by a physician or licensed mental health professional at least monthly and Behavior symptoms are currently exhibited or Psychiatric conditions are currently exhibited | --- |
Toileting
- Determine the amount of assistance the participant needs with toileting. Toileting includes using the toilet (bedpan, urinal, commode), changing incontinent episodes, managing catheters/ostomies, and adjusting clothing.
- Determine the amount of assistance the participant needs with transferring on/off the toilet.
| 0 pts | 3 pts | 6 pts | 9 pts | 18 pts |
|---|---|---|---|---|
| No assistance needed or Only set up or supervision needed | Limited or moderate assistance needed, i.e. participant performs more than 50% of task independently | Maximum assistance needed, i.e. participant needs 2 or more helpers or more than 50% of caregiver weightbearing assistance | Total dependence on others | --- |
Bathing
Determine the amount of assistance the participant needs with bathing. Bathing includes taking a full body bath/shower and the transferring in and out of the bath/shower.
| 0 pts | 3 pts | 6 pts | 9 pts | 18 pts |
|---|---|---|---|---|
| No assistance needed or Only set up or supervision needed | Limited or moderate assistance needed, i.e. participant performs more than 50% of task independently | Maximum assistance, i.e. participant needs 2 or more helpers or more than 50% of caregiver weightbearing assistance or Total dependence on others | --- | --- |
Treatments
- Determine if the participant requires any of the following treatments:
- Catheter/Ostomy care
- Alternate modes of nutrition (tube feeding, TPN)
- Suctioning
- Ventilator/respirator
- Wound care (skin must be broken)
| 0 pts | 3 pts | 6 pts | 9 pts | 18 pts |
|---|---|---|---|---|
| None of the above treatments needed | --- | One or more of the above treatments are needed | --- | --- |
Dressing and Grooming
- Determine the amount of assistance the participant needs with:
- Personal Hygiene
- Dressing Upper Body
- Dressing Lower Body
| 0 pts | 3 pts | 6 pts | 9 pts | 18 pts |
|---|---|---|---|---|
| No assistance needed or Only set up or supervision needed | Limited or moderate assistance needed, i.e. participant performs more than 50% of task independently | Maximum assistance, i.e. participant needs 2 or more helpers or more than 50% of caregiver weightbearing assistance or Total dependence on others | --- | --- |
Rehabilitation
- Determine if the participant has the following medically ordered therapeutic services:
- Physical therapy
- Occupational therapy
- Speech-language pathology and audiology services
- Cardiac rehabilitation
| 0 pts | 3 pts | 6 pts | 9 pts | 18 pts |
|---|---|---|---|---|
| None of the above therapies ordered | Any of the above therapies ordered, 1 time per week | Any of the above therapies ordered 2- 3 times per week | Any of the above therapies ordered 4 or more times per week | --- |
Meal Prep
- Determine the amount of assistance the participant needs to prepare a meal. This includes planning, assembling ingredients, cooking, and setting out the food and utensils
| 0 pts | 3 pts | 6 pts | 9 pts | 18 pts |
|---|---|---|---|---|
| No assistance needed or Only set up or supervision needed | Limited or moderate assistance needed, i.e. participant performs more than 50% of task | Maximum assistance, i.e. caregiver performs more than 50% of task or Total dependence on others | --- | --- |
Medication Management
- Determine the amount of assistance the participant needs to safely manage their medications. Assistance may be needed due to a physical or mental disability.
| 0 pts | 3 pts | 6 pts | 9 pts | 18 pts |
|---|---|---|---|---|
| No assistance needed | Setup help needed or Supervision needed or Limited or moderate assistance needed, i.e. participant performs more than 50% of task | Maximum assistance needed, i.e. caregiver performs more than 50% of task or Total dependence on others | --- | --- |
Mobility
- Determine the participant’s primary mode of locomotion
- Determine the amount of assistance the participant needs
- Locomotion – how moves in the home, between locations on the same floor (walking or wheeling). If wheeling, how much assistance is needed once in the chair?
- Bed Mobility – transition from lying to sitting, turning, etc. while in bed
| 0 pts | 3 pts | 6 pts | 9 pts | 18 pts |
|---|---|---|---|---|
| No assistance needed or Only set up or supervision need | Limited or moderate assistance needed, i.e. participant performs more than 50% of task independently | Maximum assistance needed for locomotion or bed mobility, i.e. participant needs 2 or more helpers or more than 50% of caregiver weight-bearing assistance or Total dependence for bed mobility | --- | Trigger: Participant is bedbound or Total dependence on others for locomotion |
Safety
- Preliminary safety LOC score
- Determine if the individual exhibits any of the following risk factors:
- Vision Impairment
- Falling
- Balance – moving to standing position, turning to face the opposite direction, dizziness, or unsteady gait.
- After determination of preliminary score, history of institutionalization in the last 5 years and age will be considered to determine final score.
- Institutionalization – long term care facility, RCF/ALF, mental health residence, psychiatric hospital, settings for persons with intellectual disabilities
- Age – 75 years and over
| 0 pts | 3 pts | 6 pts | 9 pts | 18 pts |
|---|---|---|---|---|
| No difficulty or some difficulty with vision and No falls in last 90 days and No recent problems with balance | Severe difficulty with vision (sees only lights and shapes) or Has fallen in last 90 days or Has current problems with balance or Preliminary score of 0 and Age or Institutionalization | No vision or Has fallen in last 90 days and Has current problems with balance or Preliminary score of 0 and Age and Institutionalization or Preliminary score of 3 and Age or Institutionalization | Preliminary score of 6 and Institutionalization | Trigger: Preliminary score of 6 and Age Preliminary score of 3 and Age and Institutionalization |
4.15 Assessment Process
Home and Community Based Services Manual
Introduction
The Home and Community Based Services (HCBS) assessment process determines the current level of independent support and unmet needs necessary to enable the potential or current participant to remain in the least restrictive environment.
Purpose
The purpose of the assessment shall: • Establish eligibility or continued eligibility for HCBS • Ensure adequacy in the development of the Person-Centered Care Plan (PCCP) • Offer the appropriate services available • Identify and facilitate referrals outside of the HCBS program • Inform the participant of qualified HCBS providers in the participant’s area • Coordinate HCBS with the selected HCBS provider to ensure delivery of services
Legal Representative/Confidentiality
For potential or current participants who have a legal representative (e.g., guardian, or someone with a Durable Power of Attorney (DPOA) in effect), it is required the legal guardian be informed of the assessment, sign necessary documents (e.g., Participant Choice Statement) and approve the authorization of services. In addition, if there is a signed Authorization for Disclosure of Consumer/Medical Health Information in effect, the person listed shall be informed. Additional information may be needed to complete the assessment. Care should be taken to ensure the confidentiality of the potential or current participant is not compromised. When assistance from a third party is necessary to complete the assessment process, this information shall be thoroughly documented in case record of the participant’s electronic case record.
InterRAI HC Assessment
The InterRAI HC guides comprehensive care and service planning in community-based settings. It focuses on the person’s functioning and quality of life by assessing needs, strengths, and preferences. Completion of the InterRAI HC shall be done at initial referral of services and at each annual reassessment. Based on the information gathered from the completed assessment, algorithms within the electronic case record system determine the participant’s nursing facility level of care for eligibility purposes. Additional guidance for facilitating an accurate and uniform assessment with the InterRAI HC is available in the InterRAI HC manual.
Scheduling An Assessment/Reassessment
Initial Assessment
Upon receipt of a request for an initial referral for HCBS, the Division of Senior and Disability (DSDS) staff shall schedule and complete a face-to-face visit with the potential participant for an initial assessment. The scheduling and completion of all initial assessments must be completed within fifteen (15) business days of the date the referral was received.
To schedule an initial assessment, DSDS staff shall:
- Make a minimum of one (1) attempt by phone to contact the participant and/or legal guardian
- Leave a message and include their contact information, and the date the initial referral will be closed if attempts to contact are unsuccessful
- The closing date of the referral shall be at least ten (10) calendar days from the day the message was left.
NOTE: If the closing date is on a State Holiday or weekend, the next business day shall be considered the date to close the referral (e.g., if the 10th calendar day ends on Saturday, the next business day is Monday).
If a message cannot be left, DSDS staff shall:
- Send the Participant Contact Letter, outlining a response date
- The response date shall be at least ten (10) calendar days from the day the letter is sent.
DSDS staff shall close the case if no response is received by the date provided in the letter. The participant must initiate a new referral through the initial referral process.
The HCBS provider and/or the referring entity shall be notified of DSDS staff's attempts to contact the potential participant and informed of the closing date of the referral if no contact has been made. This provides an opportunity for the provider to assist with locating the potential participant.
If the participant and/or legal guardian contacts DSDS within the ten (10) calendar days, an assessment shall be scheduled. However, if the participant fails to attend the scheduled appointment as agreed upon, the HCBS referral will be closed on the same day. DSDS staff will send the Participant Contact Letter with the “Initial Missed Appointment” reason for closing. The participant must initiate a new referral if there is still a need for services.
Reassessment
All participants authorized for HCBS shall have a reassessment completed within 365 days from the last level of care determination. DSDS staff shall attempt to schedule a face-to-face reassessment; however, in certain instances, a reassessment may be performed by telephone.
To schedule a reassessment, DSDS staff shall:
- Make a minimum of one (1) attempt to contact the participant and/or legal guardian by phone
- Leave a message and include their contact information along with a response date if attempts are unsuccessful
- The response date shall be at least ten (10) calendar days from the day the message was left.
- An adverse action shall be sent if there is no response by the date outlined in the phone message. The participant and/or legal guardian have at least 10 calendar days to respond to the adverse action. If they fail to respond, the care plan and case shall be closed.
NOTE: If the 10th calendar day is a weekend or holiday, the next business day shall be considered the response date (e.g., if the 10th calendar day ends on Saturday, the next business day is Monday).
- If a message cannot be left, DSDS staff shall send an adverse action. The adverse action shall include the reason for contact.
- The participant and/or legal guardian have at least ten (10) calendar days to respond from the day it was sent. If no response, the case shall be closed.
NOTE: The current care plan shall only be reauthorized if the closing date on the adverse action exceeds the end of the current authorization date.
If the participant and/or legal guardian contacts DSDS before the closing date on either of the above adverse actions, an assessment shall be scheduled. However, if the participant fails to attend the scheduled appointment as agreed upon, DSDS will initiate an adverse action. The participant and/or legal guardian must contact DSDS within ten (10) calendar days of the adverse action to reschedule the assessment.
If the assessment is rescheduled and the participant fails to attend the second appointment, DSDS will close the case based on the closing date of the original adverse action. No other contact attempts are needed. The participant must initiate a new referral if there is still a need for services.
NOTE: DSDS staff shall contact the HCBS provider to ensure the provider is aware of the attempt to contact the participant and assist in locating them.
Participant Contact Letter
The Participant Contact Letter shall include at a minimum, the following information:
- DSDS staff's inability to contact the participant to schedule an HCBS face-to-face (re)assessment visit
- The date the participant and/or legal guardian is to respond by
- The legal reference
- A DSDS staff contact number
The ten (10) calendar days shall begin the first business day after the Participant Contact Letter is mailed. If the 10th calendar day ends on a weekend or State Holiday, the next business day shall be considered the 10th day (e.g., if the 10th calendar day ends on Saturday, the next business day is Monday).
Assessment/Reassessment Process
The (re)assessment process provides a basis in establishing a PCCP and the decisions regarding HCBS authorization. A complete thorough assessment to include information and related documentation obtained during the assessment process will establish an appropriate PCCP.
Initial Assessments
Upon receipt, all initial referrals shall be prioritized by the immediacy of the need for an initial assessment and HCBS. The following are examples of high priority referrals:
- Immediate discharge from a hospital or nursing facility
- Significant breakdown of current support system
- Catastrophic event
- Adult Protective Services request to assist with the participant’s safety and well-being
- Family Support Division referrals requesting Home and Community Based Medicaid (HCB) Medicaid, Qualified Income Trust (QIT) and Division of Assets
The assessment and all PCCP activities, including completion of the following, shall be completed as soon as possible, but not to exceed fifteen (15) business days from the receipt of the referral.
- InterRAI HC
- Participant Choice Statement
- Privacy Policies Acknowledgement Form
- Development and completion of the PCCP
If the potential participant does not meet the necessary level of care for HCBS, DSDS staff shall initiate an adverse action. The case shall be closed with the appropriate action and date upon completion of the adverse action process.
Reassessments
A participant shall have a reassessment completed by DSDS staff or its designee to establish continued eligibility for services. The end date, which reflects the last full month within 365 days from the previous level of care determination, will be indicated as the due date for the reassessment. (The month the current care plan authorization expires.)
DSDS staff shall verify the participant’s Medicaid eligibility prior to a reassessment. If the participant is a Medicaid spenddown recipient, spenddown must be met at least once within the last three (3) months to remain eligible for HCBS. DSDS staff shall verify with the Family Support Division (FSD) if the participant has pending expenditures waiting to be entered before closing the case. DSDS staff shall thoroughly document contacts with FSD and any attempts for additional information in the electronic case record.
If the participant is no longer Medicaid eligible, DSDS staff or its designee shall follow the Adverse Action policy.
Individuals enrolled in certain Managed Care Health Plans are not eligible to receive HCBS authorized by DSDS staff. If HCBS cannot be authorized for the participant, DSDS staff shall send a Notice of Closure to the individual and include their Managed Care Health Plan information on it.
The InterRAI HC shall be reviewed by DSDS staff or its designee.
- The reassessment shall reflect any change from the previous assessment.
- All information discussed during the reassessment interview shall be thoroughly documented.
- During the reassessment, DSDS staff, or its designee, shall determine the participant’s satisfaction with the HCBS they receive. DSDS staff or its designee shall follow the Provider Complaint protocol regarding any provider complaints.
DSDS staff or its designee shall develop a new PCCP to ensure the continuity of HCBS. All required documents shall be reviewed and completed at each reassessment including the Participant Choice Statement.
COOP Priority
Risk indicators will display on the participant screen of the participant’s electronic case record. This indicator is determined at the (re)assessment. These indicators are intended to assist the HCBS provider in prioritizing service delivery in instances such as temporary staffing shortages, natural or other disasters, and acts of terrorism.
Document the level of priority by evaluating circumstances (e.g., support system, confusion, and noncompliance) on the assessment tool. Risk indicator of one (1) shall be used when the lack of HCBS would pose a serious threat to the health, safety, and welfare of the participant. Discretion shall be used in assigning high risk. A fragile, unreliable or insufficient support system must be documented in the electronic case record justifying high risk status.
Goals
During the (re)assessment process, DSDS staff shall work with the participant to identify a personal goal. DSDS staff shall ensure the PCCP supports the goal when possible. Any barriers that may prevent the goal from being achieved shall be documented.
An appropriate goal shall reflect what the participant hopes to achieve through HCBS. DSDS staff shall encourage the participant to express a goal in their own words, which may reflect:
- To remain in their home
- To be able to walk again
A goal shall not be a statement of fact, such as:
- They don’t feel well
- They enjoy the meals they receive
Goals may come from the participant or legal representative. In the rare circumstance when a participant cannot verbalize a goal, a primary caregiver may provide the goal for the participant. Thorough case record documentation would be required in these instances. Case record documentation shall include:
- The participant is unable to express a goal
- Who the goal was provided by (the legal guardian or primary unpaid caregiver)
- Name and relationship of the person providing the goal
Backup Plan
DSDS staff shall identify, in collaboration with the participant and/or legal guardian, details of a backup plan to be used in the event of an emergency, and when events such as weather or illness prevent service delivery by the HCBS provider(s). If the aide or attendant is not available, the participant and/or legal guardian shall provide a support system to ensure needs are met and continuation of services. Available assistance may vary, but all availability should be considered.
The backup plan shall identify a specific individual(s) available to assist when needed and may consist of the following:
- Family, friends, a neighbor, collateral contacts, etc.
A brief, detailed summary of the support shall be provided and documented in the participant’s electronic case record to include:
- The name, phone number and relationship of the individual providing the support
- The specific tasks to be provided
- The frequency of each task being provided (e.g., all meals prepared Monday, Wednesday and Friday, bathing on Tuesday and Thursday)
NOTE: If multiple supports are identified, DSDS staff shall ensure all contact information, specific tasks, and the frequency of each task are documented specifically for those providing the support. 911 should only be used in rare instances and as the last option for participants with no other alternatives or support system (i.e. family, neighbor, friend, etc.). If 911 is the only alternative for an emergency contact, case record documentation shall thoroughly explain there are absolutely no other options available.
Provider Selection
DSDS staff shall allow fifteen (15) calendar days following the initial assessment for the participant and/or legal guardian to select an HCBS provider. If an HCBS provider is not selected by the end of the fifteen (15) calendar days, DSDS staff shall refer to the Adverse Action policy and initiate an adverse action. DSDS staff shall close the case if a response is not received within ten (10) calendar days from the date the adverse action was sent.
If within ninety (90) calendar days of the adverse action a participant and/or legal guardian notifies DSDS staff that a provider has been selected, a new assessment does not need to be completed. The DSDS staff who completed the initial assessment shall open the case and authorize HCBS using the initial assessment. If no HCBS provider is selected within the ninety (90) calendar days of the adverse action, the case remains closed. If an HCBS provider is selected after ninety (90) calendar days, a new assessment shall be completed.
NOTE: ‘Assessment—State Designee’ is only used if no HCBS provider is available to serve the participant.
For initial assessments, DSDS staff or its designee shall contact the referring HCBS provider when the participant has chosen another provider for authorization of HCBS. DSDS staff or its designee shall inform the referring HCBS provider the authorization was processed per the request of the participant and did not result in authorization to the referring provider.
As part of the reassessment process DSDS staff or its designee shall ensure an HCBS provider is selected. If a participant has a circumstance that requires a selection of a different provider, DSDS staff shall refer to the Person Centered Care Planning and Maintenance policy.
Physician Notification Of Care Plan
Per 13 CSR 70-91.010, the participant’s primary care physician shall be informed of, and have the opportunity to be involved with the development of the PCCP.
DSDS staff shall notify the participant’s physician of the initial PCCP for HCBS via the Physician Notification of Care Plan (HCBS-11) within three (3) business days of the date of approval.
- The associated copy of the PCCP shall be attached to the Physician Notification of Care Plan for forwarding to the physician.
- This notification is required only at initial authorizations of all HCBS, regardless of the service authorization.
- The Physician Notification of Care Plan informs the physician of the availability of electronically monitoring their patient’s PCCP.
- Physicians may contact DSDS staff or their designee to discuss the PCCP and make recommendations. The PCCP shall comply with the recommendations or requests of the physician, unless sufficient justification is documented to the contrary. Any modification that adversely impacts the participant shall require notification as outlined in the Adverse Action policy.
- Any decision not to comply with physician recommendations or requests (i.e., statutory or regulatory violation, etc.) shall be reviewed and approved by the DSDS supervisor and documented in the participant’s electronic case record. Notification to the physician shall be made, in writing, as to why the physician’s recommendation or request is not being followed. All documentation shall be maintained within the electronic case record.
- The completed Physician Notification of Care Plan shall be scanned and attached to the participant’s electronic case record.
Case Record Documentation
All documentation, contacts and actions made regarding the (re)assessment and the development of the PCCP shall be electronically recorded in the participant’s electronic case record. This provides a summary and justification of the participant’s circumstances and provides a record of the interaction between the participant, collateral contacts and HCBS providers. The Case Record Documentation Policy and the Case Record Documentation Quick Guide shall be utilized to ensure all appropriate documentation is completed for all case actions.
NOTE: HCBS provider reassessors shall include their email address at the conclusion of each case note entered.
Finalization
HCBS (re)assessments, corresponding documentation and information shall be entered into the electronic case record. DSDS staff shall ensure the following:
- The authorization of units and cost of the care plan does not exceed the cost maximum
- Documentation justifies the PCCP
- Goals and backup plans are identified and appropriate
- An HCBS provider has been selected
All HCBS participants shall receive a copy of the completed and signed Participant Choice Statement. The completed Participant Choice Statement shall be attached to the participant’s electronic case record.
HCBS providers shall be instructed to provide the participant with a copy of the PCCP detailing the authorization of their HCBS via the electronic case record. DSDS staff shall send the PCCP upon the participant's request.
4.20 Person Centered Care Planning and Maintenance
Home and Community Based Services Manual
Introduction
The development of a person centered care plan (PCCP) is the result of a thorough review of the participant’s needs. PCCPs are individualized in accordance with the unmet needs of the participant and outline what services are necessary to keep the participant living independently in their home. HCBS authorized within the PCCP shall be mutually identified as necessary by the participant and the Department of Health and Senior Services (DHSS), Division of Senior and Disability Services (DSDS) or its designee. The PCCP process assesses the health and safety factors of the participant and outlines the participant’s personal goals in order to remain in their least restrictive environment.
Purpose
The PCCP translates identified participant specific needs into a plan for action. The identification of functioning problems, current resources (formal and informal), unmet needs, and related documentation shall serve as the foundation for developing the PCCP. The HCBS authorized under the PCCP shall strengthen and enhance the current support system of the participant.
The following basic principles shall be used as a guide for PCCP development:
- A comprehensive, thorough review of the participant’s current abilities shall determine the needs of the participant
- The participant and anyone asked by the participant, may be involved in the PCCP development process
- Planning shall involve both formal and informal supports
- The PCCP shall reflect cost awareness
Note: For a participant who has a legal representative (e.g., guardian, or someone with a Durable Power of Attorney (DPOA) in effect), it is required the legal guardian be notified and given the option to assist with the development of the PCCP. If a guardian has been identified, DSDS staff, or its designee shall obtain copies of the guardianship paperwork and attach them to the electronic case record.
Person Centered Care Plan Development
Process
A PCCP shall be developed with and agreed upon by the participant and/or legal guardian during the development process and authorization of HCBS.
Authorized HCBS shall not replace or duplicate existing formal or informal support systems without adequate documentation that such support will no longer be available to the participant.
The following shall be determined:
- If there are any support systems currently in place that will not be continued, and the reason why
- The tasks requiring the authorization of HCBS or referral to another entity
Authorizing certain HCBS when the participant lives with others who are able to perform those services or tasks is not appropriate, as explained below:
- Tasks such as cleaning shared areas, (areas used by other household members of the residence), shall not be authorized.
- Tasks that are a primary benefit to a household unit or when members of the participant’s household may reasonably be expected to share or do for one another shall not be authorized (unless such tasks are above and beyond typical activities household members may reasonably provide for one another).
Note: Assistance with meal preparation based on preference (e.g. eating at different times or prefer different foods) shall not be authorized for participants who live with others and have the availability of shared meals.
Thorough documentation shall support the reasons why other household members or current support systems cannot complete necessary tasks. Services authorized shall only be those required to meet the participant's needs.
As part of the PCCP development, the following shall be taken into consideration:
- The aide’s ability to perform multiple tasks within the same timeframe
- Size of the participant’s living area
- Assistance provided by others in the household
- Assistance provided by other formal and informal supports
- Access to transportation, including the availability of MO HealthNet Non-Emergency Medical Transportation (NEMT)
- Availability of laundry facilities
- Any other factors that may influence the type and amount of services required to meet the participant’s needs
In all instances, DSDS staff or its designee shall authorize HCBS necessary to meet the participant’s identified unmet needs within the appropriate services guidelines as described in the HCBS Policy, Chapter 3 [NEEDS LINK]. All service authorizations must be supported by thorough documentation within the electronic case record and must be reasonable and necessary according to the participant's condition and functional capacity.
A referring entity can make suggestions as a collateral contact during the development of the PCCP. However, DSDS staff or its designee must primarily consult with the participant and/or legal guardian to determine unmet needs and arrange the services necessary.
Collateral Contacts
Additional information may be needed to assist in the PCCP development and coordinate care for the participant. Independent collateral contacts shall not compromise the rights and confidentiality of the participant. When considering collateral information during the design of the PCCP, sufficient documentation shall explain any discrepancies in the expressed wishes of the participant. Collateral contacts should be an individual(s) familiar with the needs of the participant.
Unless prevented by circumstances, a discussion shall be conducted with the participant and/or legal guardian during the PCCP process, indicating what information will be obtained and sources contacted. The appropriate privacy policies in HCBS Policy, Chapter 9 [NEEDS LINK], shall be reviewed with the participant and/or authorized representative.
Resources which may assist in PCCP development include:
- Medical sources: Information regarding the current medical condition, prior authorizations, history, and limitations may be obtained through the participant’s electronic case record, physicians, hospitals, clinics, and home health agencies.
- Relatives, neighbors, and friends: These individuals may be able to provide additional observations and information regarding the participant when identified as a part of the informal support system.
- Other Social Agencies: Information may be available through local community agencies providing support or services to the participant.
- Agencies: Services may be accessed through various state agencies and funding sources designed to care for participants with specific medical conditions. Participants in need of such services shall be referred, and care will be coordinated in an effort to maximize state and federal resources. Information shall be obtained to determine and coordinate services currently authorized by:
- Department of Mental Health
- Department of Social Services
- Other Divisions within DHSS
- Home Health
- Hospice
DSDS staff or its designee shall complete all related PCCP activities including entry of the service authorizations for HCBS as soon as possible.
Backup Plan
As part of the PCCP maintenance process, DSDS staff shall determine if the backup plan is still appropriate. If necessary, DSDS staff shall work with the participant to ensure the backup plan is updated and current information is provided.
The backup plan shall be provided in the event of an emergency and when the HCBS provider is unable to deliver services due to temporary staffing shortages, natural or other disasters, and acts of terrorism. A backup plan may include more than one individual. The following shall be included for each individual listed as part of the plan:
- Name
- Relationship to the participant (e.g., family, friend, neighbor, etc.)
- Contact information (phone number)
- A brief summary of the assistance the individual will provide in the event HCBS are unable to be delivered.
Note: 911 should only be used in rare instances and as the last option for participants with no other alternatives or support system (i.e. family, neighbor, friend, etc.). If 911 is the only alternative for an emergency contact, case note documentation shall thoroughly explain there are absolutely no other options available.
COOP Priority
A COOP priority risk indicator will display on the participant screen of the participant’s electronic case record. This indicator can be updated at any time during the authorization period. These indicators are intended to assist the HCBS provider in prioritizing service delivery in instances such as temporary staffing shortages, natural or other disasters, and acts of terrorism.
Document the level of priority by evaluating circumstances (i.e., support system, confusion, and noncompliance) in the electronic case record. Risk indicator of one (1) shall be used when the lack of HCBS would pose a serious threat to the health, safety, and welfare of the participant. Discretion shall be used in assigning high priority. A fragile, unreliable or insufficient support system must be documented in the electronic case record, justifying high priority status.
Authorization
Specific services may have associated tasks. Suggested tasks that are mutually identified and agreed upon shall be selected. Suggested times and frequencies are provided for these tasks as a standard baseline. Task frequencies that are significantly different from the suggested time and frequency shall be documented within the participant’s electronic case record.
When developing a PCCP the following shall be taken into consideration:
- Personal Care (PC) shall be included in the overall cost of care for the participant as referenced in the HCBS Cost Maximums [NEEDS LINK] policy.
- PC services shall not exceed 60% of the cost maximum
- The combination of agency model PC and CDS shall not exceed 60% of the cost maximum.
- The cost of authorized nurse visits is not included in the 60% monthly maximum cost for basic personal care.
- The 60% cost maximum can be exceeded by the cost of APC and RN visits, but only up to the full monthly cost of 100%.
Note: When the PCCP includes an authorization for RN services, the cost of one RN visit shall be excluded from the calculation of a PCCP’s cost. These costs will not display in the total calculated cost maximum in the participant’s electronic case record.
- When the combination of PC, other State Plan services, and an HCBS Waiver (e.g., Aged and Disabled Waiver (ADW) or Independent Living Waiver (ILW)) exceeds 100% of the monthly cost maximum, approval is required from the Bureau of Federal Programs (BFP).
- The appropriate supervisor for DSDS staff shall review all PCCP requests over the 100% cost cap to ensure the participant’s unmet needs require the amount of service requested.
- If documentation supports the request, the case shall be forwarded to BFP for consideration and approval prior to authorization over 100% of the cost cap.
- Pending the approval from BFP to exceed the cost maximum, PC services in combination with other State Plan or ADW or ILW services can be authorized up to 100% of the cost maximum.
- When a PCCP includes Adult Day Care authorized through the ADW or the Adult Day Care Waiver (ADCW), the total cost of care cannot exceed 100% of the cost maximum.
Note: Pursuant to federal guidelines, a participant can only be enrolled in one HCBS waiver at a time, regardless of which department administers the waiver program.
Provider Selection
Choosing an HCBS provider is the right and responsibility of the participant and/or legal guardian. DSDS staff or its designee shall explain that selecting an HCBS provider is part of the PCCP process. Upon request, a list of all qualified HCBS providers in their geographic location shall be provided to assist in the selection process. Participants shall contact potential HCBS providers to discuss specific company practices, such as policies, hours, etc.
DSDS staff or its designee shall coordinate all service authorizations with the selected HCBS provider to ensure they are able to accept the new care plan. This may involve multiple contacts to ensure the provider’s capacity to deliver HCBS. The HCBS provider may review the participant’s electronic case record prior to accepting the participant. All contacts made with or on behalf of the participant shall be thoroughly documented in the electronic case record.
Active HCBS participants will have ten (10) business days to select another HCBS provider whenever a twenty-one (21) day notice has been issued from their current provider or Missouri Medicaid Audit and Compliance (MMAC) notifies DSDS that a provider’s contract will be closing. In areas where it is known that HCBS providers are experiencing staff shortages, the participant and/or legal guardian shall be asked to note a backup HCBS provider in the event the first choice is not able to accept a new case.
If the participant and/or legal guardian does not select a new HCBS provider that can accept the PCCP the following may occur:
- DSDS staff shall initiate an adverse action, referring to the Adverse Action [NEEDS LINK] policy
- DSDS staff shall allow ten (10) calendar days from the date of the adverse action for the participant and/or legal guardian to choose an HCBS provider that is able to accept the PCCP
- If a new HCBS provider is not chosen within ten (10) calendar days, DSDS staff shall close the relevant service type(s) and/or case.
If the participant and/or legal guardian contacts DSDS staff within ninety (90) calendar days from the date of the adverse action with a new HCBS provider that can accept the PCCP:
- DSDS staff who initiated the adverse action will open the case and enter the selected HCBS provider if an assessment was completed ninety (90) calendar days prior to the date of the adverse action.
Note: DSDS staff should refer the participant to the Bureau of HCBS Intake and PCCP Customer Service Contact Center to initiate a new referral for services if the participant and/or legal guardian contacts DSDS after ninety (90) days of the adverse action.
After exhausting all qualified HCBS providers in the geographic location, if an HCBS provider is still not available, the participant shall be moved into State Designee Status. DSDS staff shall refer to the Adverse Action [NEEDS LINK] policy.
Person Centered Care Plan Completion
Upon completion of the selection of all requested services, DSDS staff, or its designee shall review and complete the PCCP with the participant. All information on the applicable Rights and Responsibilities form(s) shall be discussed with the participant and/or legal guardian.
HCBS providers shall be instructed to access the PCCP via the participant’s electronic case record and will receive an alert regarding a PCCP authorization. This will remain in the ‘My Agencies Participant's” queue. When a change has been made to the care plan, an alert will display in the provider's queue to accept or reject the care plan changes and start date.
All HCBS participants shall receive a copy of the PCCP detailing the authorization of their HCBS. HCBS providers shall provide a copy of the PCCP to the participant. DSDS staff shall send the PCCP upon participant request.
Note: Pursuant to Section 191.656, RSMo HCBS providers serving an individual with HIV or AIDS may only disclose the health status of the individual to employees providing direct health care services to the individual only after the provider has determined the employee has a reasonable need to know. Such disclosure should be done in strictest confidentiality and prohibit further disclosure.
Person Centered Care Plan Maintenance
DSDS staff or its designee shall conduct all PCCP maintenance activities within the electronic case record. A participant’s PCCP shall be modified to address unmet needs resulting from changes in the participant’s health, supports, safety and abilities.
- Increasing or decreasing services/tasks
- Adding or deleting services/tasks
- Changing HCBS providers
- HCBS case closure
DSDS staff or its designee may receive a request for a PCCP change through several different sources, including, but not limited to:
- The participant and/or legal guardian
- The HCBS provider
- Formal or informal support
- A community resource (e.g., senior center, hospital, etc.)
- Participant’s physician
- MMAC
Administrative oversight of HCBS includes timely action and closing of cases with an expired PCCP. However, extenuating circumstances may preclude closing a case on a timely basis. These may include, but are not limited to:
- Participant is deceased and DSDS staff did not receive notification
- Participant has requested a hearing due to an adverse action
- Participant is waiting for a hearing decision
- DSDS staff is waiting for the return of physician or other collateral information.
When such circumstances delay the timely closing of cases with an expired PCCP, DSDS staff or its designee shall make the appropriate documentation in the participant’s electronic case record with follow-up as necessary until the closing action is completed.
As with any maintenance activity, the basic principles of the PCCP process shall be followed:
- The participant and/or legal guardian shall be consulted in all instances when a change to the PCCP has been requested. DSDS staff or its designee shall make additional contacts, as necessary, to verify status changes that warrant the requested modification to the PCCP.
- DSDS staff or its designee shall coordinate with the participant’s HCBS provider on all changes to the PCCP.
- If a new service type is added to the PCCP, a copy of the appropriate Rights and Responsibilities form shall be provided to the participant.
- When changes are made to a PCCP for a participant authorized for services through the Department of Mental Health (DMH), a copy of the new PCCP shall be forwarded to the Division of Developmental Disabilities (DD) support coordinator.
- All maintenance activities that adversely affect the participant’s PCCP shall be subject to the Adverse Action [NEEDS LINK] process.
Person Centered Care Plan Change Request
In instances of a PCCP change request:
- DSDS staff shall make one (1) attempt to contact the participant and/or legal guardian at each number listed on the request.
- If a voicemail can be left, DSDS staff shall leave a detailed message, including the purpose of the call and the date on which the participant must return the call to proceed with the request. DSDS staff shall provide the participant and/or legal guardian ten (10) calendar days to respond.
- If a voicemail cannot be left, DSDS staff shall send a Participant Contact Letter.
- All contacts shall be thoroughly documented in the participant’s electronic case record.
Note: The ten (10) calendar days shall begin the first calendar day after the Participant Contact Letter is mailed. If the 10th calendar day ends on a State Holiday or weekend, the next business day shall be considered the 10th day (e.g., if the 10th calendar day ends on Saturday the next business day is Monday).
Adverse actions are not required if the reductions or closing requests are agreed upon through a discussion between DSDS staff and the participant and/or legal guardian. In instances where a participant and/or legal guardian requested a reduction or closure of services, DSDS staff shall verify the identity of the participant and/or legal guardian and document in the electronic case record. Actions of this nature may be taken immediately.
PCCP changes resulting in a decrease only are to be authorized with an effective date on the first day of the month following the date of change. If an adverse action has been initiated, the change will take affect the first day of the next month following the expiration of the adverse action.
When a PCCP change includes an increase, even if a particular task(s) was decreased or removed, the effective date is based on participant need and provider availability. Therefore, effective dates for PCCP changes with both an increase and a decrease may occur anytime during the month.
All contacts shall be thoroughly documented in the participant’s electronic case record, referring to Case Notes Documentation [NEEDS LINK].
4.25 Provider Reassessment Process
Home and Community Based Services Manual
Introduction
In order to continue to improve efficiency and operations in the reassessment and care planning process for Home and Community Based Services (HCBS), HCBS providers may enroll as Medicaid Type 27 providers to gather the information necessary for the Division of Senior and Disability Services (DSDS) to determine the continued eligibility for HCBS as authorized by DSDS. Enrollment in the HCBS provider reassessment program is voluntary. This policy outlines the reassessment process for HCBS providers approved to complete reassessments for DSDS. Enrolled HCBS providers shall ensure the qualified reassessors [NEEDS LINK] have completed the required DSDS sponsored training prior to completion of any reimbursable reassessment. HCBS provider assessors are expected to follow policy and procedures outlined in the DSDS sponsored training [NEEDS LINK], HCBS policy, memorandums and any additional HCBS guidance. The Provider Reassessment Information [NEEDS LINK] page contains additional information.
Purpose
The purpose of the reassessment is to:
- Establish continued eligibility for HCBS (i.e. Medicaid, Nursing Facility Level of Care (LOC) and continued unmet needs)
- Ensure the adequacy of the Person Centered Care Plan (PCCP)
- Assess new unmet needs that may require additional HCBS authorization
- Complete all necessary documentation and required forms
- Determine the participant’s satisfaction with the current HCBS provider
All participants authorized for HCBS shall have a reassessment completed within 365 days from the last LOC determination. HCBS providers enrolled to perform reassessments shall perform face-to-face visits to complete the reassessment with the participant, utilizing the InterRAI HC.
HCBS providers shall not bill for any reassessment that was not assigned unless communicated and approved by DSDS. Additional information regarding reassessment reimbursement rates and claim filing is included on the Provider Reassessment Information [NEEDS LINK] page.
Confidentiality
HCBS providers involved in the reassessment process gather personal and confidential information regarding HCBS participants to determine the continued eligibility and need for HCBS. HCBS providers shall keep all protected health information (PHI) confidential and shall only use PHI to perform functions, activities or services related to the delivery of HCBS. All PHI must be exchanged securely. When communicating with DSDS by email, HCBS providers shall utilize the Proofpoint Email Encryption [NEEDS LINK] software available through DSDS.
Policy Fundamentals
HCBS providers enrolled as a reassessment providers shall ensure their reassessors have, in addition to this policy, a thorough working knowledge of all applicable HCBS policies [NEEDS LINK] to include but not limited to:
- Eligibility components
- Medicaid
- Nursing Facility Level of Care (LOC)
- All HCBS available for authorization
- State Plan (Agency)
- State Plan Residential Care Facility (RCF)/Assisted Living Facility (ALF)
- State Plan (Consumer Directed Services (CDS)
- Adult Day Care Waiver (ADCW)
- Aged and Disabled Waiver (ADW)
- Independent Living Waiver (ILW)
- Structured Family Caregiving Waiver (SFCW)
- Brain Injury Waiver (BIW)
- Understanding of the PCCP process
- Case Record Documentation
- Safety and Special Accommodations
- Identification and mandated reporting of potential abuse, neglect and/or exploitation
- Participant’s electronic case record functionality
- Updating demographics:
- Address, county and phone number(s)
- Primary Language
- Marital Status/Living Arrangement
- Physician Information added as a contact
- Adding a reassessment
- Completion of the InterRAI HC
- Enter the requested PCCP
- Adding Case Notes
- Adding Attachments
- Manage Household
- Select if participant resides with others
- Updating demographics:
Reassessment Preparation
Standardized criteria are applied to determine the assignment of monthly reassessments. Assigned Reassessments will be accessed using the electronic case record system and HCBS providers shall be granted access to obtain their reassessments. Only those assigned to the HCBS provider by DSDS are to be completed. HCBS providers shall review their assigned reassessments monthly to identify changes.
If a provider has been assigned a reassessment and has experienced a PCCP update leading to a provider change or multiple providers, the HCBS provider may still complete the reassessment if the participant agrees. HCBS providers will be reimbursed for the completed reassessment as long as it has been assigned to them.
If the HCBS provider chooses not to complete an assigned reassessment, they must immediately notify the DSDS Provider Reassessment Review Team by selecting the action ‘unable to complete’ and reason ‘unable to complete the assessment’ in the month in which they receive their assigned reassessment and/or as soon as the decision is made not to complete it.
HCBS providers shall check the Medicaid Eligibility (ME) Code [NEEDS LINK] in the participant’s electronic case record to ensure the participantis eligible for a reassessment and reauthorization of services. When the HCBS provider reassessor identifies a potential Medicaid eligibility problem, the HCBS provider reassessor shall not complete the reassessment. The action ‘unable to complete’ and the reason ‘inactive Medicaid’ shall be selected.
- Individuals enrolled in a Managed Care Health Plan ME code other than E2 (e.g. 05) are not eligible to receive HCBS authorized by DSDS.
- If the participant is a Medicaid spenddown recipient, spenddown must be met at least once within the last three (3) months to remain eligible for HCBS.
The DSDS Provider Reassessor Review Team (PRR) must always be notified immediately of any identified circumstances that prevent the completion of assigned reassessments.
Case History
After the assigned reassessments have been reviewed and Medicaid eligibility has been established, HCBS providers shall review the participant’s case history. HCBS providers shall determine if there were changes to the previous authorization period that would need to be addressed and documented during the reassessment visit, e.g. changes in mental status that would impact the ability to self-direct for CDS participants. This review includes the following:
- InterRAI HC
- Current PCCP and Utilization History
- Case Notes
- Demographics and Living Arrangement
- Attachments
- The need for interpreter services
- Interpreter services are provided by DSDS free of charge. If Limited English Proficiency (LEP) is utilized, the LEP form located on the Provider Reassessment Information/Quick Guides and Resources [NEEDS LINK] shall be completed and submitted to the PRR team at Providerreassessmentreview@health.mo.gov.
Note: The case record shall be reviewed for any care plan change requests that are pending. The HCBS provider reassessor shall discuss the requests with the participant and make the necessary updates to the care plan.
When the provider reassessor will not have a portable computer device or internet connectivity in the participant’s home, they shall take copies of the participant’s most recent (re)assessment and the current care plan to review and update during the face-to-face visit. These materials can be printed from the electronic case record.
The reassessment dates entered shall reflect the date of the actual face-to-face visit. If the reassessment is not completed on the same day, the date the reassessment isfully completed shall be entered in Section T of the InterRAI HC. Additional instructions for portions of the InterRAI HC can be found below.
Section A: Goal [BROKEN LINK] – During the reassessment process, the HCBS provider reassessor shall work with the participant to review and update their goal for HCBS and ensure the PCCP works toward supporting the goal when possible. Any barriers that may prevent the goal from being achieved shall be documented.
An appropriate goal shall reflect what the participant hopes to achieve. The HCBS provider shall encourage the participant to express a goal in their own words, which may reflect:
- I want to be living on my own and retain my independence.
- I would like to ensure I have consistent help available to help with my day to day needs. A goal shall not be a statement of fact such as:
- I want to continue to receive services.
- I don’t know, or I’m really not sure.
Goals may come from the participant or legal representative. In the rare circumstance when a participant cannot verbalize a goal, a primary unpaid caregiver may provide the goal for the participant. Thorough case note documentation would be required in these rare instances. Case note documentation shall include:
- The participant is unable to express a goal
- Who the goal was provided by (the legal guardian or primary unpaid caregiver)
- Name and relationship of the person providing the goal
Section S: Backup Plan [NEEDS LINK] - The HCBS provider reassessor shall review and ask the participant and/or legal guardian for details of their backup plan to be used when events such as weather or sickness prevent service delivery by their HCBS provider(s). If the aide or attendant is not available, the participant and/or legal guardian shall provide a support system to ensure needs are met and continuation of services. Available assistance may vary, but all availability should be considered.
The backup plan shall identify a specific individual(s) available to assist when needed and may consist of the following:
- Family, friends, a neighbor, collateral contacts, etc.
A brief detailed summary of the support shall be provided and documented in the participant’s electronic case record and include:
- The name, phone number and relationship of the individual providing the support
- The specific task(s) to be provided
- The frequency of each task being provided (e.g., all meals prepared Monday, Wednesday and Friday, bathing Tuesday and Thursday)
Note: If multiple supports are identified, HCBS provider reassessors shall ensure all contact information, specific tasks, and the frequency of each task is documented specifically for each individual providing the support.
911 should only be used in rare instances as the last option for participants with no other alternatives or support system (i.e. family, neighbor, friend, etc.). If 911 is the only alternative for an emergency contact, case note documentation shall thoroughly explain there are absolutely no other options identified.
Section T: Assessment Information (Signature) – The signature area in Section T of the InterRAI shall include the provider reassessors signature.
The provider reassessor shall determine if there is a newly appointed legal guardian. If a newly appointed legal guardian has been identified, the HCBS provider reassessor shall update the information in the participant’s electronic case record. The HCBS provider reassessor shall attempt to obtain copies of the guardianship paperwork and attach them in the participant’s electronic case record. When these attempts are unsuccessful, the HCBS provider reassessor shall document this in case notes.
Person Centered Care Plan Development
An essential component of a quality reassessment process is the development of a PCCP. All PCCPs developed by the HCBS provider reassessor are completed in a ‘requested’ status and require review and approval by DSDS. Therefore, HCBS provider reassessors shall ensure that all requested PCCPs are:
- Supported by a thorough, well documented reassessment, and associated case notes that identify functioning problems, current resources (formal and informal), and unmet needs
- Developed with the participant and/or authorized representative to address identified unmet needs while being supportive of the right to self-determination
- Developed within the guidelines of HCBS programmatic policies
- Built on the participant's unmet needs without duplicating current formal and informal supports
During the annual reassessment the HCBS provider reassessor shall determine the participant’s satisfaction with the HCBS they receive and document the participant’s satisfaction in case notes.
Collateral Contacts
When additional information is needed to assist in PCCP development and coordinate care for the participant, collateral contacts (an individual familiar with the needs of the participant) shall be made by the HCBS provider reassessor. These contacts shall not compromise the rights and confidentiality of the participant. Possible resources to assist in the PCCP development may include formal and/or informal supports:
- Medical sources (Formal): Information regarding the current medical condition, history, and limitations may be obtained through the electronic case record system under the Claims tab
- Family members, neighbors, and friends (Informal): These individuals may be able to provide additional observations and information regarding the participant
- Social and/or State Agencies: Information may be available through local community agencies providing support or services to the participant
Service/Tasks Guidelines
The PCCP identifies the services and tasks based on the participant’s needs. The HCBS authorized under the PCCP shall provide reinforcement and enhancement to the current support system of the participant
Authorized HCBS shall not replace or duplicate existing formal or informal support. It is not appropriate to recommend certain HCBS when the participant lives with other person(s) who are able to perform those services or tasks. The following shall be taken into consideration when developing a PCCP:
- The aide’s or attendant’s ability to perform multiple tasks within the same timeframe
- Size of the participant’s living area
- Assistance provided by others in the household
- Space/Tasks shared with others residing in the household
- Assistance provided by other formal and informal supports
- Meal preparation
- Cleaning
- Availability of laundry facilities
Note: Assistance with meal preparation based on preference (e.g. eating at different times or prefer different foods) shall not be authorized for participants that live with others and have the availability of shared meals. Thorough documentation shall support the reasons why other household members or current support systems cannot complete necessary tasks.
When authorizing CDS Essential Transportation, there must be an identified need for personal care assistance even if that need is met by supports other than CDS. Personal care does not need to be performed while Essential Transportation is being conducted.
CDS Transportation does not include transporting to medical appointments when those appointments are covered under the MO HealthNet Non-Emergency Medical Transportation (NEMT) program. To determine if NEMT covers the medical appointment and to determine availability, contact the NEMT provider at 1-866- 269-5927. For more information regarding NEMT, visit the Department of Social Services webpage.
The In-Home Services Worksheet/Instructions and/or CDS Worksheet/Instructions may be used as a tool to temporarily develop the PCCP. The worksheets assist in the development of a more uniform and consistent approach when determining the appropriate amount of services necessary to meet a participant's unmet needs. The worksheets are designed to provide information identifying suggested times and frequencies to be considered with the care needs of the participant in mind.
Note: HCBS provider reassessors shall utilize the CDS Worksheet and/or In-Home Services Worksheet to include justifications of tasks when completing an Independent Living Waiver (ILW) reassessment. The completed worksheet(s) shall be placed in the participant's electronic case record for review by the DSDS Provider Reassessor Review Team
Upon completion of the PCCP development, the HCBS provider shall enter and submit the PCCP in the participant’s electronic case record. The pending PA shall include accurate provider selection. Instructions are located in the electronic case record user guide.
COOP Priority
A COOP priority risk indicator must be determined during the reassessment process and entered in the participant’s electronic case record. This indicator is intended to assist the HCBS provider in prioritizing service delivery in instances such as temporary staffing shortages, natural or other disasters, and acts of terrorism. To determine the level of risk, the HCBS provider reassessor shall evaluate the participant’s circumstances (i.e., support system, cognitive ability, and noncompliance) and the importance of service delivery during any staffing shortage.
The risk indicator of one (1) shall be used when the lack of HCBS would pose a serious threat to the health, safety, and welfare of the participant. Discretion shall be used in assigning the risk. A fragile, unreliable or insufficient support system must be documented in case notes justifying risk status.
Forms
Forms are to be completed per HCBS policies and specific programmatic requirements. Should the participant have a legal guardian, it is necessary to obtain the legal guardian’s signature on official forms/documents. It may also be necessary to obtain signatures from authorized representatives (Medical Durable Power of Attorney, etc.). In addition to the reassessor, forms shall only be signed by the participant, legal guardian, or authorized representative.
The provider reassessor shall have two (2) copies of each form and obtain the appropriate signatures on both copies. The provider reassessor shall keep one copy of the signed form and the additional copy shall be provided to the participant, legal guardian, or authorized representative. If a participant is unable to understand the information in the forms presented and does not have a legal guardian or authorized representative, a case note shall be made stating why a signature could not be obtained.
- The Participant Choice Statement [BROKEN LINK] must be reviewed and completed at each reassessment and attached in the participant’s electronic case record.
- The Participant Rights and Responsibilities shall also be reviewed at each reassessment. However, the forms are not required to be attached to the participant’s electronic case record. Some participants may require more than one type of Rights and Responsibilities.
- Adult Day Care Participant Rights and Responsibilities [NEEDS LINK]
- Agency Participant Rights and Responsibilities
- CDS Participant Rights and Responsibilities
- RCF/ALF Personal Care Participant Rights and Responsibilities
- Structured Family Caregiver Waiver Rights and Responsibilities
Additional forms may be required dependent on the situations specific to the participant. The forms shall be attached in the participant’s electronic case record upon completion of the reassessment. Such forms may include, but are not limited to:
- St. Louis University Mental Status (SLUMS) (Instructions) [NEEDS LINK]
- Self-Direction Assessment Questions Instructions [NEEDS LINK]
Case Notes Documentation
The participant’s electronic case record must contain all documentation involving the participant. All contacts made and actions regarding a participant’s HCBS shall be electronically recorded. Case notes summarize the participant’s circumstances, justify the actions taken and provide a record of the interaction between the participant, collateral contacts and HCBS providers. The Case Record Documentation Policy [NEEDS LINK] and the Case Record Documentation Quick Guide [NEEDS LINK] should be utilized to ensure all appropriate documentation is completed for all case actions.
To facilitate effective communication provider reassessors shall include in their case note signature and their email address associated with the agency, or an agency email address that would be best for the provider reassessor to be contacted. Personal email addresses should not be used. Case notes shall not be entered or signed by any other individuals employed with the provider.
Identification of Adverse Action
Any action that adversely affects the request for, or amount of, authorized HCBS shall be communicated to DSDS and documented thoroughly in case notes. HCBS provider reassessors shall be aware of the following actions that would adversely affect HCBS:
- Reduction of HCBS
- Closing of an HCBS
- No documented need
- LOC not met
- Inability to self-direct
- Entering a facility
- Non-compliant
- Program eligibility
- Threatening behavior
- Unable to locate the participant
- HCBS provider reassessors shall educate the participant of the potential adverse action and provide DSDS with the necessary information and documentation when a change to the participant's HCBS adversely affects the PCCP. DSDS requires the following information to determine if an adverse action is to be initiated.
- Case notes
- Documentation shall provide a clear explanation of a needed adverse action.
- Document the conversation was held with the participant and if they agree or disagree with the changes being made to the care plan.
- Forms (when applicable)
- St. Louis University Mental Status (SLUMS)
- Self-Direction Assessment Questions
Upon review of the information submitted, DSDS will contact HCBS providers for additional information if necessary.
Finalization and Submission
HCBS reassessments and corresponding documentation shall be entered into the participant’s electronic case record within five (5) business days of the reassessment. All reassessments not submitted by the last calendar day of the month on which the reassessment is due will automatically be electronically returned to the DSDS PRR Team. Weekends, holidays, and/or office closures do not affect the due date.
HCBS Provider Review and Submission
Prior to submitting a reassessment, the HCBS provider reassessor shall review and ensure all documentation and information is present in the participant’s electronic case record. Provider reassessors shall ensure:
- All necessary forms are attached
- Selection of appropriate tasks
- Appropriate HCBS provider is selected
- Case note documentation is clear and accurate
- The reassessment and PCCP are entered correctly and in pending status
- Collateral contacts are entered and updated in the participant's electronic case record
Upon verifying the appropriate documentation and information has been entered, choose the ‘Submit Care Plan for Review’ action to notify the PRR Team.
DSDS Review and Remediation
The DSDS PRR Team will review each reassessment and the PCCP, ensuring all information is complete and accurate, and that all requirements are met. The review will also consist of the following:
- The authorization of units and cost of the PCCP
- Documentation justifies the pending PCCP
- Provider selection
Reassessments found to be inadequate and/or incomplete by the DSDS Provider Reassessor Review Team includes:
- Insufficient documentation and/or information
- DSDS PRR Team has not been notified of an entry of a reassessment by the last calendar day of the month prior to when the reassessment is due
- DSDS PRR Team has not been notified of the inability to complete a reassessment by the last calendar day of the month prior to when the reassessment is due
When the DSDS PRR Team determines the reassessment, PCCP and/or documentation are inadequate, the HCBS provider will be contacted for remediation. To ensure sufficient time for review and approval of the reassessment, the HCBS provider shall have three (3) business days to complete the remediation and notify the DSDS PRR Team of its completion. If the HCBS provider reassessor is not available to complete the necessary remediation, the provider agency must ensure completion by the required timeframe.
Approval of the PCCP
The HCBS provider shall check the participant’s electronic case record to access information related to each participant’s reassessment and PCCP approval status. The HCBS provider should notify the DSDS PRR Team through encrypted email of any questions or concerns regarding a reassessment or PCCP at ProviderReassessmentReview@health.mo.gov.
4.30 Case Record Documentation
Home and Community Based Services Manual
Introduction
All contacts made and actions taken regarding a participant’s Home and Community Based Services (HCBS) shall be recorded in the electronic case record. The electronic case record is the participant’s official case record and must contain all documentation involving the participant.
Purpose
Division of Senior and Disability Services (DSDS) staff, HCBS, and other providers and stakeholders have access to the case notes in the participant’s electronic case record. The transparency of the electronic case record allows for information to be shared among all HCBS bureaus, HCBS providers and physicians involved in coordinating and maintaining the participant’s services. Case notes are also reviewed by all parties involved in any administrative hearing.
Case Note Guidelines
The participant’s electronic case record shall only be used to document HCBS situations specific to the participant. Information unrelated to the participant, such as system issues, work order assignment, and tracking, shall not be recorded in the electronic case record.
Case notes documentation shall provide the link between information gathered through:
- Screening and assessment,
- Development of a Person Centered Care Plan (PCCP), and
- Any subsequent action taken by DSDS staff, providers, or collateral party not contained elsewhere in the participant’s electronic case record.
The following documentation principles shall guide all case note entries:
- Accuracy
- Accurate documentation of the information received effectively communicates to the reader the participant’s care needs and associated service delivery.
- Clarity
- Clarity can best be achieved using plain language. Simple words and sentences are preferable to jargon, bureaucratic language, slang words and excessive wordiness.
- Concise
- Concise case notes are easier to read, save time, and improve the quality of the documentation.
- Avoid vague or general terms, such as some, sometimes, often, many, several, etc. Instead, use phrases such as, “three times a week”.
- Facts
- Facts shall document who, what, when, where, why and how as it relates to the participant and any associated PCCP.
- Avoid using judgmental phrasing.
- Cite any professional conclusions or comments regarding the participant with a fair background and context.
- Avoid the use of “feel” and “think”. Instead, use “observe” and “conclude”. o Avoid diagnosing a participant who has not been established by a medical or psychological professional. Instead, record the facts of what was observed.
Case Note Entry
Every contact and attempt to contact made regarding a participant and their receipt of HCBS shall be documented. The contact documentation shall include:
- Note Type
- Date of the contact
- The ‘contact date’ entered shall reflect the actual date the contact was made regarding the participant. Multiple contacts on the same day may be entered within the same case note; however, there shall be a clear distinction for each contact (e.g., separate paragraphs). Contacts with differing dates must be documented in separate case note entries.
- Identification and contact information of the contact person
- Summary of the discussion
- Identification of the type of contact (e.g. face-to-face contact, phone contact, email correspondence, etc.) for each case note entry
At the conclusion of a case note, the electronic case record will auto-populate the following for DSDS staff:
- First name
- Last name
- Title
NOTE: HCBS provider reassessors shall include their email address at the conclusion of each case note entered.
Throughout the assessment process, DSDS staff entering the case note have the ability to edit and delete the case note until the final action is taken on the case and saved.
Case Action Guidance
The following guidance provides a documentation framework for the various HCBS Case Actions. HCBS is person-centered; therefore:
- Each participant and associated case documentation is unique.
- Only applicable aspects of the guidelines below shall be documented
- Information not included in the case action guidance below that is pertinent to the participant’s case record shall be included in the documentation.
- More than one set of guidelines outlined in the case action guidance may need to be used during a contact.
- PCCP maintenance applies to multiple documentation instances provided in the case action guidance. Refer to the Person Centered Care Planning subsection below on PCCP change requests and processing PCCP guidance when appropriate.
NOTE: Case notes shall be entered at the time of contact unless specific completion timeframes are stated below.
Case Actions
Referral Intake
Referrals may be received via phone, email, or online. All referrals are entered into the Online HCBS Referral Form to document the details of the referral request. Additional documentation outside of the information included in the referral form includes:
- Date received
- Notation that the referral form was uploaded to the documents section of the case record
- Online submission number (if submitted online)
Documentation for an inappropriate referral includes:
- Date received
- Reason it was inappropriate
- Online submission number (if applicable)
NOTE: Inappropriate referral documentation is only entered if the participant has a historical case record. A new case record shall not be opened only to enter an inappropriate referral.
Person Centered Care Plan Change Request Intake
PCCP Change Requests may be received via phone, email, or online. All requests are entered into the Online PCCP Request Form to document the details of the PCCP change request. Additional documentation outside of the information included in the request form includes:
- Date received
- Key details of change(s) being requested
- Provider changes should include the details of the new requested provider
- Notation that the request form was uploaded to the documents section of the case record
- Online submission number (if submitted online)
Documentation for an inappropriate/no longer needed request includes:
- Date received
- Reason it was inappropriate or no longer needed
- Online submission number (if applicable)
Assessment
Documentation for an initial assessment and reassessment includes, but is not limited to, the following:
- Who was present and who responded to the assessment questions
- If there is a guardianship relationship, ensure appropriate documentation has been uploaded to the participant’s electronic case record.
- Condition of the home and any needed referrals to address identified issues
- Participant’s living arrangements
- If other persons in the home are authorized for HCBS, document how services are to be coordinated to avoid duplication of tasks.
- If other adults are living in the household, identify shared spaces and the other adults’ abilities/responsibilities.
- If the participant is currently in a hospital, skilled nursing facility, or rehabilitation facility, include name of facility, the reason for stay and date of discharge.
- Formal (e.g. Home Health/Hospice) and/or informal supports providing assistance and how the requested HCBS will be integrated with the supports
- How the participant’s health condition(s) necessitate the need for the HCBS requested by the participant
- Elaboration on the coding of vague assessment questions (e.g. Physician ordered diet type)
- Risks and needs identified outside of HCBS supports, along with any resources provided to assist, shall be thoroughly documented
- Denials, reductions, and closings information (e.g., LOC, unmet need, or Medicaid ineligibility). See section below.
- Any difficulties the participant has with signing the required forms and the associated accommodations made
- Any paperwork sent to the participant (if applicable) o At initial assessment, document the forwarding of the Physician Notification.
- PCCP documentation (see section below)
Case note documentation related to an assessment may require multiple contacts and entries. Each action during the assessment process shall be entered as soon as possible, but no later than five (5) business days following the assessment.
Person Centered Care Planning
The following outlines general PCCP documentation guidelines that may be applied during an (re)assessment or a PCCP change request:
- Document any discrepancies between the coding of the assessment and the tasks on the PCCP (e.g. if a participant is coded as needing bathing assistance due to safety risks but refuses assistance due to modesty concerns).
- Provide explanation when task frequency exceeds or deviates significantly from the suggested times and frequencies.
- Provide specifics related to denials, reductions, closings information. See section below.
- Provide the reason for underutilization when the PCCP remains the same or are increased despite recent underutilization.
- Provide explanation of vague PCCP tasks (e.g. treatments, clean/maintain equipment, other nursing task, transfer device assistance.)
- Document referrals or information provided to the participant to assist with risks or needs that could not be addressed in the PCCP.
- Document the participant’s provider choice and/or satisfaction.
- At initial assessment, document the participant’s preferred provider.
- At reassessment/PCCP change request, document the participant’s satisfaction with the current provider(s) or document the preferred provider when a change is requested.
- Contact with the provider(s) regarding the PCCP (re)authorization. Include PCCP specifics reviewed, effective date of the change(s), provider staff name and phone contact number/email address.
- Any paperwork sent to the participant (if applicable)
PCCP change specific documentation includes, but is not limited to the following:
- Identity of PCCP change requestor
- If not the participant, document name, relationship to the participant and phone contact number.
- If there is a guardianship relationship, ensure appropriate documentation has been uploaded to the participant’s electronic case record.
- Change(s) being requested, e.g. increase or decrease of service, new service type, or provider change.
- The contributing factors to the change(s) being requested.
- New health condition or change in status of an existing health condition.
- Change in living arrangement.
- Reason for requesting a new provider when related to future PCCP needs
- Any formal (e.g. Home Health, Hospice, etc.) and/or informal supports providing assistance and how the requested HCBS change will be integrated with the supports
- Provider change request information, including provider name and contact information (if applicable)
- Any paperwork sent to the participant (if applicable)
NOTE: HCBS provider complaint information shall not be documented within the case record, but staff shall indicate an appropriate referral was made.
CDS Ability to Self-Direct
CDS ability to self-direct documentation includes, but is not limited to the following:
- Participant’s ability to participate in the assessment and communicate their needs during the PCCP process
- Concerns with the ability to self-direct, which may include:
- Participant deferring to others present during assessment for answers.
- Participant displays confusion regarding PCCP needs and completion.
- Participant not understanding how to use the Electronic Visit Verification (EVV) system or concerned with learning the process if they are new to CDS.
- Any other observations that led to cognitive or memory coding on the assessment.
- Documents obtained and/or contacts made that validate a participant’s inability to self-direct.
- Summarization of the results of the St. Louis University Mental Status (SLUMS) Exam and Self-Direction Assessment Questionnaire.
- If applicable, identify if another individual responds to the Self-Direction Assessment Questionnaire on behalf of the participant
- Information given regarding the availability of other services when the participant is determined unable to self-direct
Provider Reassessments Review
Provider reassessment review documentation includes, but is not limited to:
- Confirmation the provider reassessment was reviewed
- Denials, Reductions, Closings information (e.g. LOC, unmet need, or Medicaid ineligibility)
- Follow-up contact(s) with the provider and/or participant
- Necessary when information is incomplete
- Approved PCCP
- Notification provided to the provider (including provider staff name and phone contact information) and participant.
- Paperwork sent to the participant (if requested)
Show-Me Home
Show-Me Home (SMH) Money Follows the Person (MFP) documentation shall include, but not limited to:
- When the initial referral was received and from whom
- Document the current situation
- Name of facility
- Reason for stay
- Date of admission
- Date of discharge (if known)
- Name and phone contact information for facility discharge planner (if applicable)
- SMH eligibility
- Document whether the participant meets all criteria for participation in the SMH, and if applicable, documentation that the Show-Me Home Approval Notice[NEEDS LINK?] has been uploaded to the participant’s electronic case record and a copy of the Show-Me Home Approval Notice has been sent to the contractor of the region where the participant will reside.
- The participant’s proposed living arrangements if able to transition to the community, including other household members and shared spaces.
- If there is a guardianship relationship, ensure appropriate documentation has been uploaded to the participant’s electronic case record.
- Completion of the Show-Me Home Referral Assessment for participants who do not need HCBS.
Case note documentation shall be entered as soon as possible, but no later than ten (10) business days after the contact was made or information received.
Denials/Reductions/Closings
Documentation shall include, but not limited to the following:
- Reasons the service/task/request was denied, reduced, or closed
- Such action must be supported by the citation contained on the Adverse Action Notice.
- Level of Care (LOC)
- Describe InterRAI HC responses and other observations in relation to each of the categories in LOC.
- Ability to Self-Direct
- Describe the inability to self-direct, referencing information gathered during the completion of the InterRAI HC, SLUMS, Self-Direction Assessment Questions and related contacts.
- Service Reduction
- Document the reasons why the service/task is being reduced.
- Contact and discussion regarding adverse action
- Document contact and discussion with the participant and/or authorized representative, including whether the participant agreed with the action.
- Notice of Closure
- Document the participant’s understanding that an Adverse Action Notice or Notice of Closure will be mailed and their right to appeal, if applicable.
- Date the Adverse Action Notice or Notice of Closure is mailed.
- Changes to PCCP
- Document any changes made to the PCCP including contacts to the participant and the appropriate provider.
Adverse Actions/Hearing Requests/Hearing Proceedings
Documentation shall include, but not limited to:
- Hearing Request
- Document how the hearing request was received from the participant (through mail, telephone, or in person).
- Additional information
- Document follow-up with participant for any additional pertinent information that would affect the adverse action.
- Review Time Frames
- Document if the request was received within the appropriate time frame.
- Participant Contact
- Document the discussion with the participant regarding the appeal process, including whether the participant wants to maintain level of services, if applicable.
- Hearing Application
- Document the date the Application for a State Hearing is forwarded to the DSDS Supervisor and supervisory review of the Application for a State Hearing.
- Hearing Documents
- Document the description of the information and documents, and the date sent to the Division of Legal Services (DLS) and the participant.
- Date of receipt of Notice of Administrative Hearing
- Date of receipt of the Final Decision and Order
Case note documentation shall be entered as soon as possible, but no later than ten (10) business days after the contact was made or information received.
Documentation of Concerns and Special Circumstances
Protective Services
Protective service investigations and interventions are documented in the DSDS Adult Protective Services (APS) case management system and shall not be documented in the participant’s electronic case record.
When a contact indicates a potential protective service situation, DSDS staff or designee shall make the mandated hotline report and enter a note in the participant’s electronic case record stating an ‘Appropriate referral was made’.
Safety Concerns
Pertinent information regarding the participant and/or household to ensure continuity of care and alert DSDS staff and HCBS providers of special circumstances shall be documented in the ‘Safety Concerns’ field on the participant’s main screen in the electronic case record.
- ‘Safety Concern’ includes situations that pose a safety risk (e.g., drug use, weapons, etc.) to individuals entering and working with a participant in their home.
- Include the date of the case note(s) referencing the concerns.
- Further details surrounding the potential safety risk may be documented in case notes if needed.
Address Notes
If needed, enter the directions to the participant’s residence in the ‘Address Notes’ field on the participant’s main screen in the electronic case record.
Interpreter Services
If a participant requires an interpreter, they should be encouraged to use DSDS provided interpreter services. The offering of interpreter services shall always be documented along with the participant’s decision to use or refuse them. If the participant refuses DSDS provided interpreter services and chooses an adult family member or friend as the interpreter, this preference must also be recorded. Documentation shall be entered in the ‘Accommodations’ field on the participant’s main screen in the electronic case record.
Other Special Circumstances
The electronic case record provides additional fields to select that are specific to the special circumstances below. These fields are located on the participant’s main screen in the electronic case record, and only limited DSDS staff can make the selection. Additional documentation may be included in the case record as applicable.
- Notification the participant is Consumer Directed Services (CDS) Restricted
- Notification of SMH participation
- Notification of a (Department of Mental Health) DMH waiver
- Notification of dual waivers
- This will only occur in very rare situations as Medicaid participants are not permitted to be in more than one (1) waiver at a time.
- Shared households shall be documented
- Bureau of Federal Programs (BFP) notification of approval to exceed cost maximum
- Provides notice the participant has been approved to exceed the cost maximum through an Aged and Disabled Waiver (ADW) service.
- Other necessary information in each individual participant’s record to facilitate the PCCP development
NOTE: All requests to exceed the cost maximum shall be sent to BFP for approval. If a PCCP is over the cost maximum and no documentation is provided, BFP shall be contacted to determine if approval was granted. The ‘Cost Cap Pre-Approved’ in the participant's electronic case record shall be selected when approval is granted.
Contact Tab
The following shall be entered in the electronic case record using the ‘Contacts’ tab:
- List the name and contact information (phone number) of the primary family or friend caregiver(s). Include any relevant information in the ‘Contact Notes’ box regarding availability and caregiving role. (This is not the assigned caregiver of a provider agency.)
- Add name and contact information (phone number) for providers outside of HCBS (e.g., home health, hospice, therapy services, specialty care, mental health, etc).
- List the name and contact information (phone number) for key individuals involved in the care planning process and include any additional relevant information in the “Contact Notes”.
- List the name and contact information (phone number) of the participant’s primary care physician (PCP).
4.35 Service Coordination
Home and Community Based Services Manual
Participants may already be receiving or be eligible to receive services through various federal, state and community-based programs and/or agencies. Staff shall ensure coordination of each participant’s personcentered care plan with other services the participant is receiving. Participants not currently receiving, but potentially eligible for such services shall be referred as appropriate, and the care plan coordinated in an effort to maximize state and federal resources.
The following policies provide a guide in determining potential eligibility for services and the process for care plan coordination.
| Department of Mental Health | 4.35.1 |
| Healthy Children and Youth Service Coordination | 4.35.2 |
4.35.1 Department of Mental Health Service Coordination
Home and Community Based Services Manual
Introduction
The Missouri Department of Mental Health (DMH) has various community-oriented or Home and Community Based Services (HCBS) available through the Division of Behavioral Health (DBH) and the Division of Developmental Disabilities (DD).
Purpose
Coordination of HCBS provided by the Department of Health and Senior Services (DHSS), Division of Senior and Disability Services (DSDS) is necessary with DBH and DD so that services best meet the needs of the individuals served.
The Division of Behavioral Health (DBH)
The Division of Behavioral Health (DBH), manages programs and services to assist individuals with their mental illnesses and/or substance use. DBH works to assure prevention, evaluation, treatment, and rehabilitation. Available DBH services include:
- Outpatient Community-Based Services
- Targeted Case Management
- Day Treatment/Partial Hospitalization
- Residential Services
- Inpatient (Hospitalization) Respite
- Treatment Family Home Program
- Community Psychiatric Rehabilitation (CPRP)
These services are accessed through regional service areas, with each service area responsible for specific counties of the state. Community Mental Health Centers and/or their affiliates are responsible for providing these services. These agencies determine a person's eligibility and arrange for the provision of services.
Coordination of Services with the Division of Behavioral Health
When it is necessary to coordinate DSDS authorized HCBS or refer participants for DBH services, a Community Mental Health Center can be contacted.
Participants who meet the guidelines for DSDS authorized HCBS can receive HCBS while also receiving services through DBH. The exception would be when a participant resides in a skilled institutional setting. Those participants cannot receive HCBS services.
Division of Developmental Disabilities (DD)
Division of Developmental Disabilities (DD) serves a population that has developmental disabilities such as intellectual disabilities, cerebral palsy, head injuries, autism, epilepsy, and certain learning disabilities with the goal to improve lives through supports and services that foster self-determination. DD operates four Home and Community Based waivers.
The Community Support Waiver is for persons who have a place to live in the community, usually with family. However, the family is unable to provide all the services and supports the person requires, which may include 24-hour care or supervision, seven days a week. The services provided in this waiver include; day habilitation, in home respite, personal assistant, prevocational services, supported employment, support broker, Applied Behavior Analysis (ABA), assistive technology, career planning, community integration and transition, community specialist, counseling, crisis intervention, environmental accessibility adaptations, individualized skill development, job development, occupational, physical, and speech therapy, out of home respite, person centered strategies consultation, specialized medical equipment and supplies, and transportation. This waiver has an individual cost limit of $28,000 per year.
The Comprehensive Waiver requires individuals to have needs that cannot be met by the Community Support Waiver. The services available through this waiver are the same as those available through the Community Support Waiver; however, this is the only DD waiver that provides residential services. This waiver does not have an individual cost limit on the amount of service an individual may receive annually through the waiver.
Missouri Children with Developmental Disabilities Waiver (MOCDD)
The MOCDD Waiver provides services until the individual's 18th birthday. The services provided in this waiver include; personal assistant, respite care, transportation, environmental accessibility adaptations, specialized medical equipment and supplies, support broker, day habilitation community specialist, crisis intervention and ABA services.
The Partnership for Hope Waiver (PFH)
The Partnership for Hope Waiver (PFH) serves adults and children. Eligibility requirements for participants include active Medicaid status, met eligibility criteria for DD services, the participants’ needs must be able to be met with current community support system and waiver services not to exceed an annual cost of $12,362, the participant must meet intermediate care facility for individuals with intellectual disabilities (ICF/ID) Level of Care, participant must reside in a participating county, and participant must meet crisis or priority criteria. The services provided in this waiver include personal assistant, temporary residential, transportation, environmental accessibility adaptations, specialized medical equipment and supplies, support broker, ABA services, community integration and transition, physical, occupational, and speech therapy, individual skill development, dental, assistive technology, and day habilitation.
Coordination of Services with the Division of Developmental Disabilities
It is a federal requirement that Medicaid State Plan services be expended prior to accessing a comparable service within a HCBS Waiver program. Medicaid State Plan Services authorized by DSDS include Basic Personal Care, Advanced Personal Care, Authorized Nurse Visits, and Consumer Directed Services (CDS.)
Personal assistant services available in the DMH waivers are considered comparable to State Plan Personal Care services authorized by DSDS. Therefore, when a DD support coordinator has determined that personal assistant services are needed, they must contact DSDS to ensure that State Plan Personal Care, as authorized by DSDS, is exhausted before the authorization of personal assistant services in a DD waiver. A participant can receive personal care services from DSDS and personal assistant services from DD. A DD support coordinator may also determine if a participant is in need of other services authorized by DSDS.
Division of Developmental Disabilities Responsibilities
Upon determination that a DD participant needs services authorized by DSDS, the DD support coordinator shall:
- Inform the participant of this requirement
- Initiate a referral to DSDS
Note: As outlined in both the Basic Personal Care – Agency Model and the Personal Care Consumer Directed Model, encouragement (prompting and cueing) and instruction of participants in self-care may be a component of a task; however, encouragement and instruction do not constitute a task in and of themselves. Therefore, if a DD participant only requires prompting and cueing to perform a personal care task independently, a referral to DSDS is not appropriate and should not be made.
Division of Senior and Disability Services Responsibilities
DSDS shall process the referral to determine eligibility.
- When eligibility has been met, DSDS staff shall contact the DD support coordinator prior to the initial assessment visit to discuss the participant’s unmet needs. Additionally, DSDS staff shall consult the DD support coordinator regarding the Special Considerations when applicable.
- DSDS staff shall complete the assessment with the participant to determine Level of Care (LOC) eligibility. If LOC is met, DSDS staff shall develop a proposed Person Centered Care Plan (PCCP) in the electronic case record or with the In-Home Services Worksheet (HCBS-3a) and/or Consumer-Directed Services Worksheet (HCBS-3c) identifying all service options available. If using the worksheets, they shall be uploaded to the electronic case record once completed and shared with the DD support coordinator.
- If it is determined upon completion of the assessment that the participant is not eligible for services, DSDS staff shall thoroughly document all contacts, follow the adverse action [NEEDS LINK] process and close the case in the participant’s electronic case record. A copy of the adverse action shall be sent to the DD support coordinator.
- If the participant chooses not to participate in an assessment for State Plan Personal Care, DSDS staff shall advise the participant that the cost maximum for State Plan Personal Care will be deducted from the DD Waiver Individualized Support Plan (ISP). This may encourage the individual to participate. DSDS staff shall notify the DD support coordinator if they still choose not to participate. All contacts shall be thoroughly documented, and the case will be closed in the participant’s electronic case record.
- If the participant accepts State Plan Personal Care, DSDS staff shall finalize the PCCP in the electronic case record. A copy of the PCCP shall be forwarded to the DD support coordinator, who utilizes the care plan to develop the ISP for DD services.
- If the participant chooses not to accept State Plan Personal Care, DSDS shall advise them that a copy of the proposed PCCP will be forwarded to the DD support coordinator, and the cost of the proposed PCCP may be deducted from the DD Waiver ISP. No Adverse Action Notice is required.
Note: When changes are made to the PCCP, at reassessment or through care plan maintenance, DSDS staff shall provide a copy of the new PCCP to the DD support coordinator.
Special Considerations with the Division of Developmental Disabilities
Self-Direction
Participants may only be enrolled in one self-direction program at a time. For participants who qualify for State Plan CDS, DSDS staff shall coordinate with the DD support coordinator to inform the participant they may only be enrolled in one self-direction program at a time. The DD support coordinator will assist in educating the participant about their self-directed service options through DD programs so the participant can make an informed decision.
Note: Participants qualifying for both self-directed programs who choose to receive self-directed services through DD must utilize State Plan-Agency model services prior to the authorization of DD waiver services. If the participant chooses not to accept State Plan-Agency model services, this information shall be documented in Case Notes and provided to the DD support coordinator. No Adverse Action Notice shall be sent to the participant in these circumstances.
Restrictions
Participants authorized for the following services through DD are not eligible to receive State Plan Personal Care services through DSDS.
- Shared Living (also known as Host Home or Companion Home)
- Residential Habilitation
- Individualized Supportive Living (ISL)
Note: View the Licensed/Certified Provider Directory to confirm the type of facility placement.
To determine if a potential participant is authorized for one of the residential habilitation services listed above, DSDS shall either:
- Utilize DMH’s Customer Information, Management, Outcomes and Reporting (CIMOR) system to determine if the participant is authorized for the above services. Authorization is reflected by a procedure code:
- S5136 (Shared Living)
- T2016 (ISLs or Residential Habilitation).
- Utilize the Claims tab – Residential Habilitation services will be identified as ‘Habil res waiver per diem’ with the associated procedure code listed above.
- Contact the appropriate DD regional support coordinator to verify the authorization.
Division of Senior and Disability Waiver Services
As outlined in the Home and Community Based Services Introduction policy, DSDS has oversight responsibility of Home and Community Based Waivers under the authority in §1915(c) of the Social Security Act.
- Aged and Disabled Waiver
- Adult Day Care Waiver
- Brain Injury Waiver
- Independent Living Waiver
- Structured Family Caregiving Waiver
HCBS waivers allow state agencies the flexibility to develop specialized services for a targeted group of people. State agencies can design each waiver program and select the mix of services that best meets the needs of the population they wish to serve. However, Medicaid participants can only receive services through one Medicaid HCBS waiver at a time, regardless of the state agency administering the waiver.
During the course of any HCBS process, DSDS staff shall make the necessary contacts to validate information that indicates the participant may be receiving services through another waiver. If it is determined the participant is receiving services through another waiver, DSDS shall coordinate with the participant and the DD support coordinator to determine which waiver service best meets the participant’s needs.. Refer to the DHSS and DMH waiver resources for a comprehensive list of these waiver services. Adverse Action processes shall be followed when a participant selects participation in a DD waiver over an HCBS waiver.
4.35.2 Healthy Children and Youth Service Coordination
Home and Community Based Services Manual
Introduction
The Healthy Children and Youth (HCY) Program provides service coordination and authorization for medically necessary services for MO HealthNet recipients with special health care needs from birth to age twenty-one (21).
Purpose
The Bureau of Special Health Care Needs (BSHCN) [NEEDS LINK], the Bureau of Home and Community Based Services Field Operations and the Department of Mental Health (DMH) [NEEDS LINK] collaborate to provide a smooth transition for HCY participants who are moving to MO HealthNet adult coverage at the age of twenty-one (21) and will no longer qualify for HCY services. All three offer services for participants twenty-one (21) years of age and older.
Process
HCY Service Coordinators (SC) will begin discussing transition options with the participant/responsible party at least one year prior to the participant’s twenty-first (21st) birthday. HCY SCs will also offer to schedule interagency transition meetings for participants aging out of HCY who are eligible for the Medically Fragile Adult Waiver (MFAW) [NEEDS LINK]. These transition discussions allow participants and families to learn about all agencies and the programs offered. The Transition for Aging Out of HCY resource guide provides information on available programs.
Participants receiving only Advanced Personal Care Assistance/Personal Care Assistance (APCA/PCA) who are not eligible for MFAW will be referred to available DSDS and DMH programs. DSDS and DMH will coordinate a joint transition meeting for those participants without SHCN representation.
SHCN maintains a list of participants who will age out of HCY. This list will be sent to the available DHSS/DSDS and DMH/DD program's designated contacts biannually to make them aware of upcoming HCY transitions. The following information is included on the list:
- Participant
- DCN
- Date of Birth
- Age
- SHCN Program Enrollment
- Anticipated HCY Closure
- HCY Authorized Services
- HCY Service Coordinator (SC)
- HCY Region
- County Residence
- Indicator of whether the participant has an active DMH waiver
New HCY enrollments that will reach the age of twenty-one (21) within twelve (12) months of their initial enrollment and need a multiagency transition meeting will be sent to the designated contacts at time of enrollment. Discussions on transitioning are as follows:
- Twelve (12) months prior to the participant’s twenty-first (21st) birthday
- HCY SC will discuss transition information and multi-agency options with the participant/responsible party.
- Six (6) months prior to the participant’s twenty-first (21st) birthday
- HCY SC will schedule an interagency transition meeting to occur three (3) months prior to the participant’s twenty-first (21st) birthday. This will include participants who would benefit from receiving additional information regarding options offered through available DSDS and DMH programs to make the most informed decision regarding their future services.
Note: SHCN will not schedule or participate in transition meetings for participants who receive only APCA/PCA services and are not eligible for MFAW. The HCY SC will notify the DSDS and DMH program contacts of these referrals. The families will be informed that DSDSS and DMH will contact them to schedule a transition meeting to provide information about options available through each agency.
The transition meeting will be conducted with the participant/responsible party, HCY SC (as applicable), and DSDS and DMH contacts (preferably at a face-to-face home visit). This meeting allows the participant/responsible party to discuss options with all representatives, address their questions, and make an informed decision regarding their future service options.
4.35.3 HCBS and PACE Coordination
Home and Community Based Services Manual
Introduction
The Program of All-Inclusive Care for the Elderly (PACE) is a Medicare and Medicaid program that helps people meet their health care needs in the community instead of going to a nursing or other care facility.
Purpose
PACE provides comprehensive health care services to eligible individuals. PACE covers all Medicaid covered services as well as additional services necessary to improve and maintain health, which includes:
- Adult Day Care (including physician, nursing, and therapy services)
- Home care
- Meals
- Medical specialty services
- Physician and nursing services
- Prescription drugs
- Transportation to the PACE center and medical appointments
Eligibility
The eligibility for PACE includes the following:
- Must be 55 years of age or older,
- Live in a designated PACE service area,
- Require nursing facility level of care, and
- Be able to live safely in the community with PACE supports.
Enrollment determination for PACE can be made by contacting the PACE organization.
Note: A participant enrolled in the PACE program is not eligible for any service authorized through the Home and Community Based Services (HCBS) program.
PACE Enrollment Process
As part of the PACE enrollment process the MO HealthNet Division (MHD) will:
- Verify if there is an active authorization for HCBS.
- Notify the PACE organization of an authorization for HCBS.
The PACE organization will inform the participant that all HCBS authorizations will close upon enrollment into the PACE program. If the participant chooses to continue with enrollment, the PACE organization will assist the participant in submitting a letter to the Division of Senior and Disability Services (DSDS) requesting HCBS closure due to enrolling in the PACE program and include the effective date. The Person Centered Care Plan (PCCP) team will process the request the day before the effective date of PACE enrollment.
PACE Disenrollment/HCBS Referral Process
The process for a PACE participant to voluntarily disenroll from the PACE program to access HCBS is as follows:
- The PACE organization will submit an HCBS referral, utilizing a referral form specific for PACE.
- The referral shall be submitted at least 30 business days before the tentative PACE disenrollment date.
- DSDS will process PACE coordinated referrals outside of the electronic case record.
- DSDS will complete the initial assessment, develop a proposed PCCP worksheet ( In-Home Service Worksheet and/or CDS Worksheet), and coordinate with the selected HCBS provider.
Note: The tentative effective date for HCBS services must be the first day of the following month, as PACE services can only end on the last day of the month.
DSDS will send notification to MHD.PACE@dss.mo.gov and obtain confirmation on the date the PACE participant will be disenrolled from the program. DSDS will not be able to enter actions or authorizations into the electronic case record until the PACE lock-in has ended. PACE coordinated referrals will be handled as standard priority, as PACE services can be accessed up to the date HCBS is authorized.
PACE Complaint Process
The Division of Senior and Disability Services (DSDS) shall direct any grievances or complaints about PACE services to the PACE organization to file a complaint. An official PACE grievance policy specific to each PACE organization must be followed. Participants will be informed of the official grievance policy in their participant enrollment agreement. MHD must allow the PACE organization an opportunity to address all grievances before MHD can take action. Additional grievance guidance is located in the Code of Federal Regulations for PACE.
If the participant refuses to contact the PACE organization to file a complaint, DSDS shall send a detailed summary of the reported concerns to MHD.PACE@dss.mo.gov.
4.35.4 Brain Injury Waiver Service Coordination
Home and Community Based Services Manual
Introduction
The Brain Injury Waiver (BIW) is a Home and Community Based Services (HCBS) waiver offered through the Division of Senior and Disability Services (DSDS). BIW aims to promote and support an individual to reach their highest degree of independence after a traumatic brain injury (TBI).
Purpose
The service is designed to be person centered, outcome oriented and relies on community inclusion. It provides a variety of services which includes home modifications, assistive technology, and therapy services.
Eligibility
All BIW participants must meet the following eligibility criteria:
- Be between the ages of 21 to 65
- Once a participant reaches the age of 65, the participant shall be disenrolled from the BIW. The participant shall be offered eligible services provided through the Division of Senior and Disability Services.
- Be in active Medicaid status
- Participants who are eligible for Medicaid on a spenddown basis may be authorized to receive the BIW during periods when they meet their spenddown liability.
- A participant is responsible for the cost of services received during periods of time when they have not met their spenddown liability.
- Participants who receive Medicaid due to eligibility for Blind Pension (BP) may not be authorized for the BIW.
- Authorization of the BIW does not meet the requirements for an individual to be eligible for Home and Community Based (HCB) Medicaid.
- Have an appropriate Medicaid Eligibility (ME) code
- Meet Nursing Facility Level of Care (LOC)
- Have medical documentation of a Traumatic Brain Injury
Restrictions and Limitations
Initial and continued enrollment in BIW is subject to the following:
- BIW services may not exceed $32,000 a year per participant.
- May not be enrolled in any other waiver programs (ILW, SFCW, ADW).
- The BIW year runs from October 1st of each year through September 30th of the following year.
Note: If a participant leaves the BIW during a waiver year for any reason, the slot is still considered occupied for the period of the waiver authorization.
Process
An initial assessment is completed within 15 business days of receipt of referral. An individual is required to meet nursing home level of care to qualify for the BIW. Once nursing home level of care is met, the appropriate services and needs of the participant are determined through the Service Coordination Assessment (SCA). A reassessment is then conducted at least twice a year to determine if the participant’s needs have changed.
Brain Injury Waiver Services
Physical Therapy
Physical Therapy (PT) treats physical motor dysfunction through various routes. The service includes evaluation, plan development, direct therapy, and consultation/training of caretakers and others who work with the individual. Therapies available to adults under the state plan are for rehabilitation needs only.
Occupational Therapy
Occupational therapy (OT) assists individuals to learn or regain skills of daily living. OT requires a prescription by a physician and evaluation by a certified Occupational Therapist or Certified Occupational Therapy Assistant under the supervision of an Occupational Therapist. The service includes:
- Evaluation
- Plan development
- Direct therapy
- Consultation
- Training of caretakers and others who work with the participant.
Speech Therapy
Speech Therapy is for individuals who have speech, language, or hearing impairments. The need for services must be identified in the care plan and prescribed by a physician. Services must be provided by a licensed speech language therapist. Speech Therapy provides treatment for:
- Delayed speech
- Stuttering
- Spastic speech
- Aphasic disorders
- Hearing disabilities that require specialized auditory training, lip reading, signing, or use of a hearing aid.
Note: The services may also include consultation provided to families, other caretakers, and habilitation service providers.
Home Modifications
These are modifications to the home required by the participant’s plan of care, which are necessary to ensure the health, welfare, and safety of the individual; or which enable the individual to function with greater independence in the community; and without which, the recipient would require institutionalization. Such adaptations may include the installation of ramps, widening of doorways, modifications of bathroom facilities, or installation of specialized electric and plumbing systems which are necessary to accommodate a medical need.
Note: There is a $5,000 annual cost limit per participant. This is part of the $32,000 annual cost maximum for the participant.
Personal Care
Personal care (PC) services are intended to meet personal requirements that enable the participant to remain in his/her home and maintain a functional capacity by fulfilling needs that cannot be met by other resources. PC services are authorized when the participant requires hands on assistance in one or more of the following categories that exceeds typical level of care for an individual of that age: dressing, grooming, bed mobility, toileting, bathing, eating, ambulating, transferring, and/or housekeeping. PC services only occur in the home of the participant.
Note: Consumer Directed Services (CDS) is not an option under BIW and state plan services must be utilized first.
Applied Behavioral Analysis
Applied Behavioral Analysis may be provided to assist a person in learning new behaviors directly related to existing challenges. Services may also be provided to increase/reduce existing behaviors or to omit behaviors under environmental conditions. The service shall include monitoring of data from continuous assessments of the individual’s skills in the following areas:
- Learning
- Communication
- Social competence
- Self-care
Assistive Technology
Assistive Technology (AT) is assistive, adaptive, and rehabilitative devices for people with disabilities and the elderly. They can be used by individuals with disabilities to perform functions that might otherwise be difficult or impossible and protect the health and welfare of the participant.
Note: There is a $5,000 annual cost limit per participant. This is part of the $32,000 annual cost maximum for the participant.
Cognitive Rehabilitation Therapy
Cognitive Rehabilitation Therapy (CRT) therapy includes goal-oriented counseling to maximize strengths and reduce behavior problems and/or functional deficits which interfere with a participant’s personal, familial, vocational, or community adjustment. CRT can be provided to the participant and families when the participant is present. This service is not available to adults when State Plan psychology services are appropriate to meet the individual’s needs.
Neuropsychological Evaluation
Neuropsychological Evaluation and Consultation consists of the administration and interpretation of a standardized battery of neuropsychological tests to provide information about a participant’s cognitive strengths and weaknesses following a TBI. It includes consultation with the participant, guardian, family, or other significant key persons designated by the participant and BIW staff for information gathering and/or interpretation of results.
Coordination Process
Referrers Responsibility
- Confirm all eligibility requirements are met
- Submit referral to the following:
- Waivers.LTSS@health.mo.gov
- Phone: (573) 751-6246 or Toll-free: (800) 451-0669
When submitting a referral, the following information is required:
- Name of participant (full, legal name)
- DOB (must be between the ages of 21-64)
- Responsible Party:
- Is the referral their own responsible party?
- Do they have a legal guardian?
- Do they have a DPOA-HC? If so, who is that person and what is their contact information?
- Contact information to include current home/mailing address, phone number, email contact, etc.
- What services does the referral source believe would benefit the referred?
BIW Support Coordinators (SC) responsibility
- Process the referral to determine eligibility.
- Ensure there is a slot available for the participant, as there are a limited number available.
- If slot is not available, participant will be added to wait list.
- Complete the assessment and discuss service options with the participant.
- Authorize appropriate services with approval of state waiver manager.
- Conduct monthly phone calls and bi-annual home visits to ensure services are still active and appropriate for participants.
- Participate in care planning/treatment team meetings with participants and stakeholders. May include treatment planning, waiver updates, concerns.
4.40 Case Closure
Home and Community Based Services Manual
A component of Home and Community Based Services (HCBS) case record compliance, when closing a case, is to ensure that documentation accurately reflects actions taken when notifying HCBS providers of case closures.
Reasons for closure includes:
- Participant is deceased (include date);
- Participant does not meet Nursing Facility Level of Care;
- Participant does not meet program eligibility criteria;
- Falsified records (CDS);
- Participant is ineligible for MO HealthNet Benefits;
- Participant has entered a Long Term Care Facility (include date);
- Participant has moved out of the State of Missouri;
- No documented need for services;
- Non-compliance with Person Centered Care Plan (PCCP)
- Unable to locate the participant
- Participant is not receiving services or is refusing services
- Participant’s spenddown has not been met
- Participant voluntarily withdraws
When it is necessary to close a participant’s HCBS authorization, the Division of Senior and Disability Services (DSDS) shall notify the participant’s HCBS providers that the participant’s case is closed and the effective date services will no longer be reimbursed. Providers to be notified could include:
- Agency model and Consumer Directed Services (CDS) providers;
- Area Agency on Aging for participants receiving Home-Delivered Meals; and
- Adult Day Care facilities providing authorized services.
All contacts regarding case closure shall be documented in the electronic case record and shall include the HCBS provider name and the name and telephone number of the person contacted.
When case closure is due to an Adverse Action, DSDS shall follow the procedures outlined in the Adverse Action Policy [NEEDS LINK].
4.00 Appendix 1 Person Centered Care Planning Collateral Contacts
Home and Community Based Services Manual
1. The Missouri Department of Health and Senior Services (DHSS), Bureau of Special Health Care Needs makes varied Home and Community Based Services (HCBS) available for individuals with special health care needs who have or are at increased risk for a disease, defect or medical condition that may hinder the achievement of normal physical growth and development and who also require health and related services of a type or amount beyond that required by individuals generally. For more information, contact the Bureau of Special Health Care Needs at 573-751-6246 or (toll-free) 800-451-0669 or review the website at https://health.mo.gov/seniors/shcn/[NEEDS LINK].
The Bureau of Special Health Care Needs oversees three HCBS programs.
- Healthy Children and Youth Program (HCY)
The (HCY) program provides service coordination and authorization for medically necessary services for MO HealthNet recipients with special health care needs from birth to age 21. Service coordination includes assessment through home visits and links to services and resources that enable participants to remain safely in their homes with their families. Authorized services may include in-home personal care, in-home nursing care, and skilled-nursing visits. For more information on the HCY program, review the website at http://www.health.mo.gov/living/families/shcn/hcy.php.[NEEDS LINK] - Medically Fragile Adult Waiver (MFAW)
The MFAW provides service coordination and authorization for medically necessary services to MO HealthNet recipients with serious and complex medical needs who have reached the age of 21 and are no longer eligible to receive these services through the HCY program. The Waiver provides a cost effective alternative to placement in an intermediate care facility (ICF). Authorized services may include in-home personal care, in-home nursing care, skilled nursing visits, supplies and equipment. For more information on the MFAW, review the website at http://www.health.mo.gov/living/families/shcn/pdw.php[NEEDS LINK]. - Adult Brain Injury Program (ABI)
The ABI program assists Missouri residents, ages 21 to 65, living with a traumatic brain injury (TBI). Through service coordination, the program links participants to resources to enable each person to obtain goals of independent living, community participation, and employment. Participants who meet financial eligibility requirements may also receive rehabilitative services to help them achieve identified goals. Rehabilitative services include counseling, vocational training, employment supports and home and community based support training. For more information on the ABI program, review the website at http://www.health.mo.gov/living/families/shcn/abi.php.[NEEDS LINK]
2. The Missouri Department of Health and Senior Services (DHSS), Bureau of HIV, STD, and Hepatitis offers case management and HCBS for individuals with the Human Immunodeficiency Virus (HIV) virus that causes Acquired Immune Deficiency Syndrome (AIDS). For more information, contact the Bureau of HIV, STD, and Hepatitis at 573-751-6439 or (toll-free) 866-628-9891 or review the website at http://health.mo.gov/living/healthcondiseases/communicable/hivaids/casemgmt.php[NEEDS LINK].
- Personal Care
Services available through the State Plan Personal Care Program include personal care (assistance with activities of daily living such as bathing, grooming, dressing and medically related household tasks), advanced personal care (assistance with activities of daily living when such assistance requires devices and procedures related to altered body functions), and authorized nurse visits (maintenance or preventive services provided for stable chronic conditions). - AIDS Waiver Program
Services include waiver personal care, Private Duty Nursing, (needing nursing RN/LPN care in an amount greater than 3 hours per day), Waiver Attendant Care (hands-on supportive and healthrelated care including nursing care), and supplies (under-pads, diapers and gloves).
3. Home care is health care or supportive care provided in an individual’s home by healthcare professionals. Home care is primarily provided by Home Healthcare and Hospice agencies.
- Home Healthcare
Home healthcare provides skilled nursing care, physical and occupational therapy, speech-language therapy, and medical social services in the comfort of home. Home healthcare is prescribed by an individual’s physician and is provided by a variety of healthcare professionals. For more information, call toll-free (800) MEDICARE (800-633-4227) or review the website at https://www.medicare.gov/coverage/home-health-services.html - Hospice
Hospice is a special way of caring for people who are terminally ill, and for their families. This care includes physical care and counseling. Hospice care is given by a public agency or private company approved by Medicare. It is for all age groups, including children, adults, and the elderly during their final stages of life. The goal of hospice is to care for individuals and their family and to help individuals make the most of the last months of life by giving comfort and relief from pain. For more information, review the following website https://www.missourihospice.org/.
4. Area Agencies on Aging (AAA) serve Missouri seniors with a wide variety of programs designed to assist seniors with legal, financial, and health care needs. The Senior Legal Help line, disease prevention, home delivered and congregate meal programs are just a few examples of the services the AAAs have available.
There are 10 AAAs in Missouri, each serving a different geographic area; for more information on a local AAA in a specific area review the MA4 website at http://www.ma4web.org/find-your-local-agency.
4.00 Appendix 2 Participant Choice Statement Instructions
Home and Community Based Services Manual
The Participant Choice Statement shall be completed at each initial and subsequent (re)assessment used to determine eligibility for Home and Community Based Services (HCBS). Upon completion of the assessment and authorization of HCBS, the Participant Choice Statement shall be uploaded to the participant’s electronic case record. The Participant Choice Statement provides documentation of the participant’s involvement in the selection of services and providers, and development of the Person Centered Care Plan (PCCP), as well as education regarding available community services and supports and reporting abuse, neglect, or exploitation. It is also used to assess the continued compliance with the HCBS Final Rule [NEEDS LINK] based upon participant feedback.
Instructions
Participant Name: Enter the participant’s name.
DCN: Enter the participant’s Departmental Client Number (DCN).
County Name: Enter the participant’s county of residence.
The Division of Senior and Disability Services (DSDS) shall utilize the guidance below to explain each item detailed in the Participant Choice Statement. Self-explanatory items are not included.
#1 Explain and offer all services the participant is in need of and eligible to receive.
#2 Explain that the participant may choose from any provider in their area. Offer a list of providers if the participant is unsure which to select.
#6 Review the applicable Rights and Responsibilities document(s) with the participant. Reiterate by signing the Participant Choice Statement, the participant is agreeing to the Rights and Responsibilities.
- There are five (5) different Rights and Responsibilities forms. Staff shall review and leave the participant with the appropriate Rights and Responsibilities form(s) based upon the participant’s proposed or authorized PCCP.
#7 Notify the participant that a copy of DHSS’ Notice of Privacy Practices [BROKEN LINK] is available and will be provided to them upon request. They can request a copy of the privacy practices at their annual assessment or by contacting the Person Centered Care Planning (PCCP) team.
#8 Explain abuse, neglect, and exploitation as defined below and provide the information to report an incident.
Abuse: The infliction of physical, sexual, or emotional injury or harm, including financial exploitation by any person, firm, or corporation and bullying (192.2400, RSMo).
Neglect: The failure to provide services to an eligible adult by any person, firm or corporation with a legal or contractual duty to do so, when such failure presents either an imminent danger to the health, safety, or welfare of the client or a substantial probability that death or serious physical harm would result (192.2400, RSMo).
Exploitation: The Crime of Financial Exploitation involves allegations that a person (whether a family member, joint tenant, caregiver/attendant, or someone who has assumed fiduciary responsibility) has knowingly by deception, intimidation, undue influence, or force obtained control over an eligible adult’s property with the intent to permanently deprive the eligible adult benefit or possession of his or her property as directed in 570.145, RSMo.
Other Critical Incident: A negligent event that led to an emergency visit or hospitalization.
#9 Discuss all identified risks and needs. Explain the services and referral options available to meet their unmet needs or risks. It is the participant’s choice whether to proceed with the presented options or decline the option to address a specific risk(s) or need(s).
#10 In order to meet Centers of Medicare and Medicaid Services (CMS) standards, this section shall be used to assess continued compliance with the HCBS Final Rule [NEEDS LINK] based upon participant feedback. DSDS staff or their designee shall pay particular attention to participants in an Adult Day Care setting or a provider owned or controlled setting. If a participant indicates to DSDS staff, or their designee, concerns regarding the participant’s setting, the staff should utilize the HCBS Final Rule Participant Survey to prompt further discussion. If necessary, DSDS staff, or their designee, shall forward all settings concerns to the Bureau of Federal Programs (BFP). Additional information regarding the HCBS Final Rule transition plan [NEEDS LINK] is available.
Assessor Signature and Date: The individual completing the assessment shall sign and date the Participant Choice Statement reflecting when the assessment was completed.
Assessor Name (Printed): Print the name of the Assessor.
Employed By: Enter the name of the Assessor’s employer.
Participant Signature and Date: Obtain the participant’s/responsible person’s signature and date. When the participant is unable to sign the form, DSDS staff or their designee shall document this information in the case notes section of the participant’s electronic case record or on the Participant Choice Statement itself. In the event of a refusal, the participant should be informed the services may not be authorized without consent and the case should be closed. Documentation of this should be included in the case notes.
Distribution: A copy shall be provided to the participant. A copy shall be uploaded and maintained in the participant’s electronic case record. If the participant does not meet eligibility and is therefore, not authorized for HCBS, it is not necessary to obtain a signature from the participant or upload the form.
4.00 Appendix 2d Agency Model Rights and Responsibilities
Home and Community Based Services Manual
YOU ARE EXPECTED TO
- Explain how the tasks authorized on the person-centered care plan (PCCP) are to be completed
- Provide supplies needed to complete tasks
- Allow General Health Evaluations (GHE’s) to be completed as scheduled and required by state law
- Utilize Electronic Visit Verification (EVV) as required by State and Federal Law
- Let your provider know when you will not be home or available to receive care
- Let your provider know if you have problems with how services are delivered
- Agree to participate in a comprehensive face-to-face (re)assessment with Division of Senior and Disability Services (DSDS) or its designee
- Accept or select an aide without regard to race, color, national origin, sex, age, religion, political beliefs, or disability
- Act in a respectful, courteous manner
YOU MAY NOT
- Physically, verbally, or sexually abuse or threaten harm toward the provider or DSDS staff, nor should you permit other individuals in your household to do so. This may result in your services being terminated
- Expect services to be provided not authorized on your care plan
- Expect services to be provided for your pets, friends, or visitors
- Allow services to be provided in your home when you are not home
- Offer provider or DSDS staff gifts or tips
- Engage in activities that would be considered fraud of the program; for example, the misuse of the EVV system
FOR YOUR SAFETY, DO NOT
- Ask your aide for advice
- Leave valuables, cash, or checkbook in plain sight
YOU HAVE THE RIGHT TO
- Appeal decisions regarding your PCCP, including the denial, reduction, or termination of services
- You must appeal within ninety (90) calendar days of the date of the decision.
- You must request a hearing within ten (10) calendar days of the date of the notice if you wish to continue receiving services pending the hearing decision.
- If the DSDS’ decision is affirmed, you may be held responsible for the cost of any services received while the appeal is pending.
- Receive services without regard to race, color, national origin, sex, age, religion, political beliefs, or disability
PROVIDER STAFF ARE EXPECTED TO
- Act in a professional manner
- Ensure that you receive care only from those who are registered and screened by the Family Care Safety Registry (FCSR [NEEDS LINK])
- Be on time for scheduled visits
- Notify you if they are unable to deliver services
- Arrange a make-up visit satisfactory to you
PROVIDER STAFF MAY NOT
- Accept food, drink (except water), gifts or tips
- Give you (or anyone in your household) a ride
RESOURCES
- To find a primary care physician
- Mental health or substance abuse
4.00 Appendix 2e Consumer Directed Services Rights and Responsibilities
Home and Community Based Services Manual
YOU ARE EXPECTED TO
- Select and hire your attendant
- Train your attendant to perform the tasks authorized on the person-centered care plan (PCCP)
- Explain how tasks authorized on the PCCP are to be completed
- Provide supplies needed to complete tasks
- Supervise the work performed by your attendant and ensure the attendant is able to meet your personal needs
- Terminate your attendant
- Let your caregiver know when you will not be home to receive care
- Let your caregiver know if you have problems with how services are delivered
- Agree to participate in a comprehensive face-to-face (re)assessment with the Division of Senior and Disability Services (DSDS)or its designee
- Select a caregiver without regard to race, color, national origin, sex, age, religion, political beliefs, or disability
YOU ARE RESPONSIBLE FOR
- Following up with your CDS provider regarding assignment of Employer Identification Number (EIN) and Missouri Tax ID and maintain for your records. The provider will need these to pay employee taxes on your behalf.
- Ensuring that completed work is approved and the number of units delivered does not exceed what is authorized on your PCCP
- Utilizing Electronic Visit Verification (EVV) as required by State and Federal law
FOR YOUR SAFETY, DO NOT
- Ask your aide for advice
- Leave valuables, cash, or checkbook in plain sight
YOU MAY NOT
- Physically, verbally, or sexually abuse or threaten harm toward provider or DSDS staff, nor should you permit other individuals in your household to do so. This may result in your services being terminated
- Expect services to be provided not authorized on your care plan
- Expect services to be provided for your pets, friends, or visitors
- Allow services to be provided in your home when you are not home
- Engage in activities that would be considered fraud of the program; for example, the misuse of the EVV system
- Hire a legally responsible relative (i.e., spouse or guardian)
- Be a consumer of the CDS program if employed as a CDS personal care attendant
YOU HAVE THE RIGHT TO
- Appeal decisions regarding your PCCP, including the denial, reduction, or termination of services o You must appeal within ninety (90) calendar days of the date of the decision.
- You must request a hearing within ten (10) calendar days of the date of the notice if you wish to continue receiving services pending the hearing decision.
- If DSDS’ decision is affirmed, you may be held responsible for the cost of any services received while the appeal is pending.
- Receive services without regard to race, color, national origin, sex, age, religion, political beliefs, or disability
RESOURCES
- To find a primary care physician
- Mental health or substance abuse
4.00 Appendix 2f Residential Care Facilities/assisted Living Facilities Rights and Responsibilities
Home and Community Based Services Manual
YOU ARE EXPECTED TO
- Accept provider staff without regard to race, color, national origin, sex, age, religion, political beliefs, or disability
- Agree to participate in a comprehensive face-to-face (re)assessment with the Division of Senior and Disability Services (DSDS) or its designee
- Let your provider know if you have problems with how services are delivered
- Act in a respectful, courteous manner
YOU MAY NOT
- Engage in activities that would be considered fraud of the program; for example, document time for services that have not been provided
- Physically, verbally, or sexually abuse or threaten harm towards the provider or DSDS staff
FOR YOUR SAFETY, DO NOT
- Ask your provider staff for advice
- Leave valuables, cash, or checkbook in plain sight
YOU HAVE THE RIGHT TO
- Appeal decisions regarding your person-centered care plan, including the denial, reduction, or termination of services
- You must appeal within ninety (90) calendar days of the date of the decision.
- You must request a hearing within ten (10) calendar days of the date of the notice if you wish to continue receiving services pending the hearing decision.
- If the DSDS’ decision is affirmed, you may be held responsible for the cost of any services received while the appeal is pending.
- Receive services without regard to race, color, national origin, sex, age, religion, political beliefs, or disability
RESOURCES
- To find a primary care physician
- Mental health or substance abuse
4.00 Appendix 2g Structured Family Caregiving Waiver Rights and Responsibilities
Home and Community Based Services Manual
You Are Expected To
- Reside with the primary caregiver, either in your home or the primary caregiver’s home
- Work with the provider to identify tasks that can be met through services
- Let your provider know when you are in need of a substitute caregiver
- Let your provider know when you are not available for a visit
- Let your provider know if you have problems with your care delivery
- Accept or select a caregiver without regard to race, color, national origin, sex, age, religion, political beliefs, or disability
- Agree to participate in a comprehensive face to face (re)assessment with Division of Senior and Disability Services (DSDS) or its designee
You May Not
- Be enrolled in any other Home and Community Based Services (HCBS) or waiver service, regardless of the state agency that administers the waiver
- Have a primary caregiver who maintains outside employment
- Physically, verbally, or sexually abuse or threaten harm toward the provider or DSDS staff, nor should you permit other individuals in your household to do so. This may result in your services being terminated
- Engage in activities that would be considered fraud of the program
For Your Safety, Do Not
- Leave valuables, cash, or checkbook in plain sight
You Have The Right To
- Appeal decisions regarding your person-centered care plan, including the denial, reduction, or termination of services
- You must appeal within ninety (90) calendar days of the date of the decision.
- You must request a hearing within ten (10) calendar days of the date of the notice if you wish to continue receiving services pending the hearing decision.
- If the Division of Senior and Disability Services’ decision is affirmed, you may be held responsible for the cost of any services received while the appeal is pending.
- Receive services without regard to race, color, national origin, sex, age, religion, political beliefs, or disability
Provider Staff Are Expected To
- Act in a professional manner
- Ensure that you receive care only from those who are registered and screened by the Family Care Safety Registry (FCSR [NEEDS LINK])
- Be on time for scheduled visits
- Notify you if they are unable to deliver services
Provider Staff May Not
- Accept gifts or tips
- Provide care to your pets, friends, or visitors
Resources
- To find a primary care physician
- Mental health or substance abuse
4.00 Appendix 3 In-Home Services Worksheet
Home and Community Based Services Manual
The In-Home Services Worksheet (HCBS-3a) shall be used when the Division of Senior and Disability Services (DSDS) staff or its designee cannot access the participant’s electronic case record or when necessary to support the development of a Person Centered Care Plan (PCCP). It contributes to a more consistent approach when determining the appropriate amount of services necessary to meet a participant's unmet needs. Suggested times and frequencies have been developed with the care needs of an average or typical participant in mind.
The HCBS-3a is an Excel document. When filling out the form electronically, there are auto-calculations built within the body of the document. In addition, there are certain restricted fields that do not allow data entry. Those fields can be identified by the shaded cells. To navigate the form efficiently, it is suggested to use the tab key to go from field to field.
Number of Copies
When necessary, one copy of the HCBS-3a shall be made
Instructions
The HCBS-3a shall be completed for all other Home and Community Based Services (HCBS) authorizations when DSDS or its designee cannot access the electronic case record. The form should only be uploaded in the participant's electronic case record when used for ILW authorization.
Participant Information
NAME: Enter the participant’s name
DCN: Enter the participant’s Departmental Client Number (DCN)
CDS: Check if the participant currently receives, or is being authorized for, Personal Care Assistance (Consumer-Directed Model) (CDS) in addition to other HCBS
PROVIDER NAME: Enter the name of the participant’s chosen provider
PROVIDER PHONE: Enter the chosen provider’s phone number
Calculations
Each of the services included are task-oriented and generally authorized on an ongoing basis.
#MIN/DAY: Enter the estimated minutes required to complete the task per day
#UNITS/DAY: No entry (With the Exception of Home Delivered Meals)
#DAY/WK: Enter the number of days per week
MAX DAYS/MONTH: No entry
#MIN/WK: No entry
UNITS/WK: No entry
TOTAL UNITS CALCULATION: (Excludes nurse visits)
TOTAL COST: No entry
Description Of Needs
Enter any comments regarding care planning needs to be used as a reference upon return to the office. Completion of this column is only mandatory for Independent Living Waiver (ILW) requests, and the information should provide a clear explanation of why each task is being requested and why the amount of time requested is appropriate.
Services
Personal Care
- RCF/ALF
- Check the box when the participant is a resident of an RCF/ALF
- Enter time and frequency for all suggested task
- Check the hen Medically Related Household tasks are checked, and indicate which tasks are to be completed in the Homemaker section.
Homemaker
- Check the RCF/ALF box when the participant is a resident of either entity
- Check the Medically Related Household tasks box when the Homemaker tasks are to be provided under the Personal Care authorization
Advanced Personal Care
- Check the RCF/ALF box if the participant is a resident of either entity
- When entering only one task, the task needs to be in 15-minute increments.
- Two (2) nurse visits are required in the first month of authorization to assist in developing the PCCP and to sufficiently train the APC aide. A care plan with ongoing nurse visits will not require the additional nurse visit for the first full month of the PCCP.
Authorized Nurse Visits
The following shall be completed for authorized nurse visits:
- Check the RCF/ALF box when the participant is a resident of either entity
- Check the appropriate boxes for the necessary tasks to be completed during the nurse visit
- Enter the number of visits per month in the total units box.
- When the nurse visit occurs on a less than weekly basis, do not enter days per week; enter days per month.
- General Health Evaluation
- This task should only be checked for the semi-annual nurse visits
- Other
- This task should be used when DSDS or its designee request the provider nurse to make a home visit for ‘other’ non-routine nurse tasks. Those tasks, such as venipuncture, physician ordered injections, etc. must be prior approved and authorized by DSDS or its designee.
Respite Care
- Check the box for the appropriate type of Respite (Basic or Advanced)
- Enter the number of minutes per day and days per week the service will be provided
Home Delivered Meals
- Enter the units per day and the number of days per week the meals are received
Chore Services
- Enter the number of minutes per day and the number of days per week
Adult Day Care
- Adult Day Care (ADC) (ages 63 and older) and Adult Day Care Waiver (ADCW) (ages 18-62)
- Enter the number of minutes per day and the number of days per week. A number in multiples of 15, which cannot exceed 10 hours per day. The maximum number of days per week cannot exceed five (5).
Comments
- Enter any comments regarding nursing services, including adding the specific months for the General Health Evaluation.
- Enter any comments or necessary information
DSDS Staff Signature and Date
- DSDS staff shall sign and date the HCBS-3a the day the worksheet is completed.
Emergency Contact/Phone
- Enter the participant’s emergency contact name and phone number
4.00 Appendix 4 Worksheet for Consumer Directed Services
Home and Community Based Services Manual
The Consumer-Directed Services (CDS) Worksheet (HCBS-3c) shall be used when the Division of Senior and Disability Services (DSDS) staff or its designee cannot access the participant’s electronic case record or when necessary to support the development of a Person Centered Care Plan (PCCP) and authorization of the Independent Living Waiver (ILW). It contributes to a more consistent approach when determining the appropriate amount of services necessary to meet a participant's unmet needs. Suggested times and frequencies have been developed with the care needs of an average or typical participant in mind.
The HCBS-3c is an Excel document. When filling out the form electronically, there are auto-calculations built within the body of the document. In addition, there are certain restricted fields which do not allow data entry. Those fields can be identified by the shaded cells. In order to navigate the form efficiently, it is suggested to use the tab key to go from field to field.
Instructions
The HCBS-3c shall be completed on all CDS service authorizations when DSDS or its designee cannot access the electronic case record system.
Participant Information
PARTICIPANT NAME: Enter the participant’s name
DCN: Enter the participant’s Departmental Client Number (DCN)
IHS: Check if the participant currently receives, or is being authorized for, other HCBS in addition to CDS
PROVIDER NAME: Enter the name of the participant’s chosen provider
PROVIDER PHONE: Enter the chosen provider’s phone number.
PERSONAL CARE ASSISTANCE: Check the type(s) of program in which the participant is enrolled (i.e., State Plan or ILW). Once units are calculated, enter the monthly units after the type of assistance.
START DATE: Enter the earliest date CDS can begin.
Calculations
SUGGESTED TIME: No Entry
SUGGESTED FREQUENCY: No Entry
#MIN/DAY: Enter the estimated amount of time required to complete each task per day
#UNITS/DAY: No entry
#DAYS/WEEK: Enter the number of days per week
TOTAL UNITS/DAY: No Entry
MAX DAYS/MONTH: No Entry
UNITS/WEEK: No Entry
TOTAL UNITS/MO: No Entry
Description of Needs
Enter any comments regarding care planning needs to be used as a reference upon return to the office. Completion of this column is only mandatory for Independent Living Waiver (ILW) requests and the information should provide clear explanation of why each task is being requested and why the amount of time requested is appropriate.
INDEPENDENT LIVING WAIVER (ILW) SERVICES: Indicate if ILW services (i.e., case management, financial management services, specialized medical equipment/supplies, and environmental accessibility adaptations) are being requested.
- Any participant who requires more units per month of State Plan Personal Care than allowed within the established cost maximums, must be considered for the ILW to meet that need. Approval for ILW services must be obtained from the Bureau of Federal Programs (BFP) prior to authorization.
Comments
- Enter any comments or necessary information here
ASSESSOR SIGNATURE AND DATE
- The individual completing the document shall sign and date the HCBS-3c on the date the worksheet is completed.
EMERGENCY CONTACT/PHONE
- Enter the participant’s emergency contact name and phone number.
4.00 Appendix 5 Physician Notification of Care Plan
Home and Community Based Services Manual
The Physician Notification of Care Plan (HCBS-11) is necessary to provide the participant’s Primary Care Physician (PCP) an opportunity for input on the development of a Person-Centered Care Plan (PCCP) for their patient. The HCBS-11 shall be mailed within three (3) business days of the initial approval of the PCCP for all recipients of Home and Community Based Services (HCBS) authorized by the DHSS, Division of Senior and Disability Services (DSDS), or its designee.
Instructions
TO: Enter the physician’s name and mailing address.
RE: Enter the participant’s name.
DCN: Enter the participant’s Departmental Client Number (DCN).
DATE: Enter the date the form is completed.
ASSESSOR SIGNATURE: The individual completing the form shall sign the document.
ASSESSOR NAME: The individual completing the form shall print their name.
TELEPHONE: Enter the telephone number of the assessor.
MAILING ADDRESS: Enter the mailing address of the assessor.
FAX NUMBER: Enter the fax number of the assessor.
PHYSICIAN SECTION: It is not required for this form and/or the PCCP to be returned by the PCP. However, the PCP may choose to enter comments in the Physician Comment section and return it to the assessor. If returned, staff shall review information provided, complete any necessary follow up action, and upload the returned form into the electronic case record.
Distribution
The form shall be sent to the PCP, along with a copy of the associated PCCP, and be uploaded to the electronic case record.
4.00 Appendix 6 Department of Mental Health Customer Management, Outcomes, and Reporting (CIMOR)
Home and Community Based Services Manual
The Department of Mental Health (DMH) uses the computer application, ‘Customer Information Management, Outcomes, and Reporting’ (CIMOR) for individuals served by DMH, which provides an array of information regarding DMH consumers. As the Division of Senior and Disability Services (DSDS) and DMH have shared participants, CIMOR can be utilized as a tool to assist in the authorization of services, to improve the continuity of care, and reduce the duplication of services (DMH Service Coordination [NEEDS LINK]).
Note: DSDS staff can apply for access to this system upon employment. The complete ‘DHSS Training Guide to CIMOR’ is available through supervisory channels. The following information provides a quick reference to determine if an individual is enrolled in a DMH Waiver, receiving Self-Directed services though DMH, or residing in a residential setting.
Log in to the CIMOR site at https://cimor.dmh.mo.gov/CIMORLogin.aspx?ReturnUrl=%2f
On the ‘Home Screen’ two links will display (on the left side of the screen). -- ‘Consumer’ and ‘Reports.’ Either link provides information to assist in the coordination of HCBS.
Consumer link (To determine DMH Waiver enrollment)
- Select ‘Consumer’ and complete the following fields:
- ID Type: This is a dropdown field, select ‘Medicaid DCN’;
- ID Number: Enter the participant’s Departmental Client Number (DCN); click on the enter key or search button.
- If CIMOR finds a match, click on the ‘Select’ hyperlink next to the DMH consumer’s name.
- In the links to the left, expand the ‘Demographics’ button.
- Click on ‘Identifiers’ button. This screen lists unique identifiers about the consumer e.g., Social Security Number, DCN, etc. Additionally this screen will display any DMH Waivers the waivers that consumer is currently or has been enrolled. Review the ‘From’ and ‘To’ dates to determine if the consumer is still enrolled in the waiver.
Reports link (To determine DMH Waiver enrollment and/or service authorization including self-direction and residential placement)
- Select the ‘Reports’ link
- Report Category: From the drop downfield, select ‘DHSS’ and click on the enter key or search button.
- Click on ‘View’ next to DMH Services.
- Enter DCN: Enter the DCN of the DMH customer.
- Enter Start Date to filter the report - mm/dd/yy.
- Enter End Date to filter the report - mm/dd/yy.
- Select ‘View.’
When the report displays review the following fields:
- ‘Waiver Type’ field displays the DMH Waiver name if the DMH consumer is currently enrolled in a DMH Waiver.
- ‘Residential’ field displays a ‘Y’/yes or ‘N’/no to indicate if the DMH consumer has been placed in a community residential setting.
- Service lines listed can be reviewed to determine the specific DMH services authorized during the selected search parameters.
- The ‘Service Category’ field indicates if services authorized are self-directed.
- ‘Procedure Code/W Mod’ displays for each service line (see below).
- ‘Procedure Description’ displays the service types authorized for the time period in question.
Review to determine if any of the following are authorized; - Personal Assistant, Individual Self-Directed: T1019 U2;
- Personal Assistant, Medical/Behav., Self-Directed: T1019 TG.
- Group Home: T2016 HQ
- Residential Habilitation / Individualized Support Living: T2016
- Shared Living: S5136
4.00 Appendix 7 Department of Mental Health, Division of Developmental Disabilities Contact Information
Home and Community Based Services Manual
Central Missouri Regional Office (CMRO) includes the following counties: Adair, Benton, Boone, Callaway, Carroll, Chariton, Cole, Cooper, Howard, Moniteau, Morgan, Pettis, Randolph, and Saline.
CMRO
1500 Vandiver Drive, Suite 100
Columbia, MO 65202
Phone: (573) 441-6278 Fax: (573) 884-4294
Satellite Offices
Kirksville Office
1702 E. LaHarpe St.
Kirksville, MO 63501
Phone: (660) 785-2500 Fax: (660) 785-2520
Rolla Office
105 Fairgrounds Road
PO Box 1098 (Use both addresses)
Rolla, MO 65402
Phone: (573) 368-2200 Fax: (573) 368-2206
Sikeston Regional Office (SRO) includes the following counties: Bollinger, Butler, Cape Girardeau, Carter, Dunklin, Howell, Madison, Mississippi, New Madrid, Oregon, Pemiscot, Perry, Reynolds, Ripley, Scott, Shannon, Ste. Genevieve, Stoddard, and Wayne.
SRO
112 Plaza Drive
PO Box 966
Sikeston, MO 63801
Phone: (573) 472-5300 Fax: (573) 472-5308
Satellite Office
Poplar Bluff
2351 Kanell Blvd
Poplar Bluff, MO 63901
Phone: (573) 840-9300 Fax: (573) 840-9311
St. Louis County Regional Office includes the following counties: St Louis County
St. Louis County
9900 Page Avenue
Suite 106
St. Louis, MO 63132
Phone: (314) 587-4800 Fax: (314)8777-5606
St. Louis Regional Tri-County Office (SLRTCO) includes the following counties: Audrain, Jefferson County, Lincoln Marion, Monroe, Montgomery, Pikes Ralls, St. Charles County, and Warren.
SLRTCO
111 N. 7th Street, 6th Floor Wainwright Bldg
St. Louis, MO 63101
Phone: (314) 244-8800 Fax: (314) 244-8804
Satellite Office
Hannibal Office
805 Clinic Road
Hannibal, MO 63401
Phone: (573) 248-2400 Fax: (573) 248-2408
Kansas City Regional Office (KRO) includes the following counties: Andrew, Atchison, Bates, Buchanan, Caldwell, Cass, Clay, Clinton, Davies, Dekalb, Gentry, Harrison, Holt, Nodaway, Jackson, Johnson, Lafayette, Platte, Ray, and Worth.
KRO
821 East Admiral Blvd.
P.O. Box 412557
Kansas City, MO 64106
Phone: (816) 889-3400 Toll-free: (800) 454-2331 Fax: (816) 889-3325
Satellite Office
Albany Office
809 N. 13th Street
Albany, MO 64402
Phone: (660) 726-5246 Fax: (660) 726-5612
Springfield Regional Office (SPRO) includes the following counties: Barry, Barton, Cedar, Christian, Dade, Dallas, Douglas, Greene, Henry, Hickory, Jasper, Laclede, Lawrence, McDonald, Newton, Ozark, Polk, St. Clair, Stone, Taney, Vernon, Webster, and Wright.
SPRO
1515 East Pythian, PO Box 5030
Springfield, MO 65801-5030
Phone: (417) 895-7400 Toll-free: 1-888-549-6635 Fax: 417-895-7412
Satellite Office
Joplin Office
3600 E. Newman Road
Joplin, MO 64802
Phone: (417) 629-3020 Fax: (417) 629-3026
4.00 Appendix 8 Slums
Home and Community Based Services Manual
A screening tool for dementia developed by Saint Louis University (SLU) geriatricians demonstrates effectiveness in detecting mild cognitive decline. The screening tool, titled St. Louis University Mental Status (SLUMS) exam, shall be utilized by the Department of Health and Senior Services (DHSS), Division of Senior and Disability Services (DSDS), or its designee, when there is a concern about a current or potential participant’s ability to self-direct their own care as required by the Personal Care Assistance ConsumerDirected (CDS) Model.
Researchers found that the screening tool developed by SLU detects early cognitive problems, specifically mild neurocognitive disorder (MNCD), missed by other screening tools. As with any screening tool, the SLUMS indicates to clinicians when they should pursue further testing in diagnosing cognitive decline or dementia.
Further evaluation of mental capacity must be pursued. This may include collateral contacts with mental health professionals or physicians to request additional information regarding the participant’s mental capacity. It may also include a review of prior abuse/neglect history and information contained in the HCBS case file. The SLUMS exam cannot be used exclusively to deny CDS services or transition coordination services available through Show-Me Home (SMH) a Money Follows the Person program.
Number of Copies
At least one copy shall be completed when necessary.
Instructions for Completion
Name: Enter the respondent’s name.
Age: Enter the respondent’s age.
Date of Examination: Enter the date when exam is completed.
Is Participant (respondent) Alert: Instead of only answering “yes” or “no”, indicate the level of alertness. Alert indicates that the individual is fully awake and able to focus. Other descriptors include, but are not limited to: drowsy, confused, distractible, inattentive, and preoccupied.
Level of Education: Enter the respondent’s last completed grade level. If the respondent has completed college, indicate the degree obtained.
Questions
Allow the respondent enough time to answer all questions. As space allows, note the answer given next to the question. The bold number in parentheses indicates the value of each question.
1-3. Self-explanatory.
- Ask the respondent to repeat each of the five objects to make sure the respondent heard and understood what was said.
- Obtain the answer to the first part of the question before moving on to part two. Do not prompt or give hints but do give ample time to answer. The answer to part one is $23. The answer to part two is $77.
- Using a second hand on a watch or clock, ask the respondent to name as many animals as possible in one minute.
- Self-explanatory.
- State each number by its individual name. 87 is pronounced eight, seven; 649 is pronounced six, four, nine; 8537 is pronounced eight, five, three, seven.
- Use the larger clock face of the SLUMS exam as necessary to assist those with visual impairments. When scoring, give full credit for either all 12 numbers or all 12 ticks. If the respondent puts only 4 ticks on the circle, prompt them once to put numbers next to those ticks (12, 3, 6, and 9) for full credit. When scoring the correct time, make sure the hour hand is shorter than the minute hand, and that the minute hand points at the 10 and the hour hand points at the 11.
NOTE: The time on this clock should be 10 minutes to eleven. - Self-explanatory
- Read question #11 as written; provide ample time to answer each question. Do not give hints. The answer of Chicago as the state gets no credit but the assessor may prompt the respondent once by repeating the question. The answers from left to right are Jill, a stockbroker, when her children were teenagers, and Illinois.
Scoring
Place the respondent’s score on each question in the column to the left of the question and total down.
| High Scchool Education | Less than High School Education | |
|---|---|---|
| 27-30 | Normal | 25-30 |
| 21-26 | MNCD* | 20-24 |
| 1-20 | Dementia | 1-19 |
| *Mild Neurocognitive Disorder | ||
Distribution
The SLUMS form shall be scanned into the respondent's electronic case record.
4.00 Appendix 9 Community Options Information
Home and Community Based Services Manual
As a result of your interest in home and community based services, this information is being provided to assist you in locating additional resources that may help you maintain an independent lifestyle. There are many different kinds of services that individuals may be able to get when they need help with day-to-day activities. Services may be available in the person’s own home, or a residential care, an assisted living or a long term care facility. Some services may be covered by your health or long term care insurance. You should contact your insurance company or agent with any questions. Missouri Medicaid for the aged, blind and disabled provides medical care for persons who meet specific eligibility requirements. If you wish to make application for Medicaid benefits contact your nearest Family Support Division Office or visit https://mydss.mo.gov/healthcare.
Other agencies that can assist you in locating resources specific to your needs include:
- Area Agencies on Aging (AAA) offices located throughout the state can provide information and assistance services about the many resources available to older persons and their caregivers. To locate an AAA that serves your area, contact the Department of Health and Senior Services at 573/526-4542 or visit https://www.ma4web.org/.
- Centers for Independent Living (CIL) provide a variety of services to persons with disabilities to increase their independence and opportunities to participate in day-to-day life within their community. Services provided include: information and referral, peer support, skills training and advocacy. To locate the CIL that serves your area, visit http://www.mosilc.org/mo-centers-db/ or contact the Division of Vocational Rehabilitation at 573/751-3251 or toll-free at (877) 222-8963.
- 2-1-1 By dialing 2-1-1 callers can talk with a trained professional 24-hours a day, 7 days a week who can access a database of information specific to the request and area of the state. Dialing 2-1-1 is a fast, free and confidential way to get help. If you are calling from a cell phone, you can reach the 2-1- 1 call center by dialing (800) 427-4626.
Other informational links:
http://health.mo.gov/seniors/seniorservices/ [NEEDS LINK]
4.00 Appendix 10 Instructions for Self-Direction Assessment Questions
Home and Community Based Services Manual
The Self-Direction Assessment Questions shall be used to help staff and/or their designee to determine the current or potential participant’s ability to self-direct their Consumer-Directed Services (CDS).
The Self-Direction Assessment Questions shall not be used exclusively to deny CDS services. If there are further questions about the participant’s ability to self-direct their own care, staff shall complete further evaluation using the Saint Louis University Mental Status (SLUMS) exam, Healthcare Professional Inquiry, and/or collateral contacts.
Number of Copies
At least one copy shall be completed when necessary.
Instructions for Completion
Name: Enter the participant’s name
DCN: Enter the participant’s Departmental Client Number (DCN)
Date: Enter the date questionnaire is completed
Questions
Questions should be posed to the participant. If another individual responds on behalf of the current or potential participant, this must be documented in the Case Notes. Allow the participant enough time to answer all questions. As space allows, note the answer given next to the question. Further clarification can be given to the participant to ensure understanding of the question, particularly if the participant has never received CDS. Staff should use sound judgment if the participant is unable to appropriately answer questions to determine if further action should be taken by staff to determine the participant’s ability to self-direct their own care. If the participant has difficulty answering questions #1 and #2, the participant is able to use whatever materials they may have available to them to locate the answer (i.e. calendar, cell phone, etc.). Questions #14 through #17 shall only be asked if the participant is currently authorized for CDS or has been a CDS participant in the past.
Distribution
The Self-Direction Assessment Questions shall be uploaded to the participant’s electronic case record.
4.00 Appendix 11 Contact Form Instruction
Home and Community Based Services Manual
The Contact Form provides the current or potential participant and/or their authorized representative, (e.g., guardian, or someone with a signed Authorization for Disclosure of Consumer Medical/Health Information that is in effect) with written notification of the Division of Senior and Disabilities (DSDS) attempts to reach the participant and/or their authorized representative by phone or in person.
Instructions
Enter the current or potential participant’s name, DCN, address, and last known phone number, including an extension number as appropriate.
• For current or potential participants that have an authorized representative, enter the authorized representative’s contact information.
Enter the appropriate “Communication: Reason for Contact” from Appendix 12.
• It may be appropriate in certain cases to enter more than one category from Appendix 12.
DSDS staff completing the form shall enter their name, email address, office phone number, including an extension number as appropriate and mailing address.
Enter the date the notice is mailed.
Distribution
Upon completion, the original Contact Form shall be mailed to the current or potential participant and/or their authorized representative. A copy is also maintained in the participant’s electronic case record.
4.00 Appendix 12 Communication: Reason for Contact
Home and Community Based Services Manual
PROVIDER CHOICE/CHANGE
Provider List Mailed – After Intake
This letter is in regard to the Home and Community Based Services (HCBS) initial referral completed on (date). HCBS participants are required to select a provider agency as part of the initial assessment process.
Please refer to the enclosed provider list. It is recommended you speak with your preferred agency/agencies to confirm they are accepting new clients and have availability in your area. Once you have selected a provider, please have the provider information available at the time of your assessment.
Please note: the Customer Service Center is closed on all state and federal holidays.
Provider List Mailed – Change of Provider Request
The Division of Senior and Disability Services (DSDS) has attached a Home and Community Based Services (HCBS) Provider List(s) per your request or due to a request made on your behalf.
If you are in need of a provider change, please select a provider, contact the provider and confirm that the provider can accept your care plan. Once you have confirmation that the selected provider will accept your care plan with a tentative start date, please contact HCBS Intake's Customer Service Center at 866-835-3505 (Monday-Friday, 8:30am-3:00pm) to make a provider change request. Please note: the Customer Service Center is closed on all state and federal holidays.
Provider Choice - After Initial Assessment
This letter is in regard to the Home and Community Based Services (HCBS) assessment completed on (date). You have met the qualifications for HCBS, but I am awaiting your choice of provider to begin your services. Please refer to the provider list (received during the assessment) (enclosed) or (mailed to you on (date)). Contact our office by (date) at the number below with your choice of provider. If our office does not hear from you by this date, the referral will be closed without any services being authorized.
Change In Provider - Provider No Longer Available to Provide Services
This letter is to inform you that (name of provider) will no longer be providing your Home and Community Based Services (HCBS) through the Department of Health and Senior Services (DHSS), effective (date). Therefore, you will need to select a new provider. I have enclosed a copy of a provider list for your convenience. Please contact our office by (date) at the number below with your choice of provider. A lapse in service or closure of your case may result if our office does not hear from you by this date.
Change In Provider – Provider Acquisitions
This letter is being sent to you by the Missouri Department of Health and Senior Services (DHSS), Division of Senior and Disability Services (DSDS) in regard to your Home and Community Based Services (HCBS). DSDS.
Change In Provider – Provider Acquisitions
This letter is being sent to you by the Missouri Department of Health and Senior Services (DHSS), Division of Senior and Disability Services (DSDS) in regard to your Home and Community Based Services (HCBS). DSDS was informed that (name of previous provider) transferred ownership to (name of new provider). As a result, your care plan has been updated effective (date) to maintain your current services and supports.
You have the right to choose any HCBS provider for your care plan. If you would like to change HCBS providers, please select a new provider and confirm they can accept your care plan. Once selected, contact our Customer Service Center by calling 866-835-3505, Monday through Friday, from 8:30 a.m. - 3:00 p.m. Please note: the Customer Service Center is closed on all state and federal holidays. You may also request changes to your care plan online by going to https://health.mo.gov/seniors/ [NEEDS LINK] and clicking on the Online Person Centered Care Planning (PCCP) Request icon. Please contact our Customer Service Center if you need to request a current list of approved HCBS providers for your area.
CARE PLAN CHANGE/SERVICES OR TASKS
Care Plan Change
This letter is in regard to (your request) or ((provider name) request) for a care plan change for your Home and Community Based Services (HCBS). An attempt to reach you by phone has been unsuccessful. Please contact our office by calling the number below to discuss this care plan change request no later than (date). If our office does not hear from you by this date, it will be assumed your current care plan is satisfactory and it will remain unchanged.
Care Plan Reduction/Closure – Provider Requested
This letter is to inform you that (name of provider) has requested a care plan change for your Home and Community Based Services. According to our records, a service is not being used at the amount currently authorized. An attempt to reach you by phone has been unsuccessful. Please contact our office by calling the number below to discuss this care plan change request no later than (date). If our office does not hear from you by this date, it will be assumed the service is no longer needed and an adverse action will be sent.
Care plan changes (Subsequent to an EDL Investigation)
This letter is in regards to recommendations made by the Office of Special Investigations (OSI) for changes to occur with your care plan for your Home and Community Based Services (HCBS). An attempt to reach you by phone has been unsuccessful. Please contact our office by calling the number below to discuss your care plan no later than (date). If our office does not hear from you by this date, The Division of Senior and Disability Services (DSDS) will take appropriate action to determine your continued eligibility (i.e., restricting Consumer Directed Services (CDS), authorizing other HCBS, and/or issuing an adverse action).
Provider Change - Participant Requested
This letter is in regard to your request to change providers for your Home and Community Based Services. An attempt to reach you by phone has been unsuccessful. Please contact our office by calling the number below to discuss this care plan change request no later than (date). If our office does not hear from you by this date, it will be assumed this provider change is no longer necessary and your service provider will remain unchanged.
ATTEMPT TO CONTACT
Initial Assessment
This letter is in regard to a Home and Community Based Services (HCBS) referral through the Department of Health and Senior Services (DHSS). A face-to-face assessment must be completed to determine your eligibility for services. An attempt to reach you by phone has been unsuccessful. Please contact our office no later than (date) at the number below to discuss your options. If our office does not hear from you by this date, the referral will be closed without any services being authorized.
Initial Assessment – Missed Appointment
This letter is in regard to your scheduled assessment for Home and Community Based Services (HCBS) through the Department of Health and Senior Services (DHSS). A face-to-face assessment was scheduled with you for (date). You were not present for your scheduled assessment. As a result, your referral for HCBS has been closed. If you are still in need of services, a new referral can be made through the Online HCBS Referral Form or by contacting DSDS at 1-866-835-3505.
Reassessment
This letter is in regard to your current Home and Community Based Services (HCBS) with (provider name) through the Department of Health and Senior Services (DHSS). For services to continue, an assessment of your needs is required annually. (The Department of Health and Senior Services) or (provider name) has attempted to reach you by phone but have been unsuccessful.
It is important for you to contact our office at the number below no later than (date) to schedule your annual assessment. If our office does not hear from you by this date, your services and case will be closed. An adverse action has been sent with this participant contact form to inform you of your appeal rights.
Participant Choice Statement
This letter is in regard to your Home and Community Based Services (HCBS) through the Department of Health and Senior Services (DHSS). A current Participant Choice Statement (PCS) is a requirement for your case file. Please complete the Participant Choice Statement you received and return it to the address listed below. Failure to complete and return this form will result in the closure of your HCBS.
Home and Community Based Options Letter [Needs Link]
This letter is in regard to your interest in resources in your community. Please find enclosed a list of community options that may assist you in locating additional resources.
Authorized Representative Contact Letter
This letter is in regard to the participant’s Home and Community Based Services (HCBS) through the Department of Health and Senior Services. Enclosed you will find a copy of the participant’s Person Centered Care Plan. Additional forms must be signed and current in the participant’s case record to ensure accurate service planning and delivery. Failure to complete and return these documents could result in the closure of the participant’s HCBS.
Please complete the following documents and return to the address listed below.
- DHSS Notice of Privacy Policies and a Privacy Policies Acknowledgement Form
- Participant Choice Statement Form
4.00 Appendix 13 Healthcare Proffessional Inquiry
Home and Community Based Services Manual
When further information is needed to determine a participant’s ability to self-direct their Consumer-Directed Services, the Healthcare Professional Inquiry form shall be sent to a participant’s healthcare professional, such as a Physician, Registered Nurse, Nurse Practitioner, and Physician Assistant. After the assessor has administered the St. Louis University Mental Status (SLUMS) examination and the Self-Direction Assessment questions and there continues to be concerns with the participant’s ability to self-direct, the assessor shall send the Healthcare Professional Inquiry form.
The assessor shall contact the healthcare professional to obtain the appropriate fax number and inform them Division of Senior and Disability Services (DSDS) staff will be faxing this form to obtain the opinion of the healthcare professional.
NUMBER OF COPIES
One copy of the form shall be completed per healthcare professional.
INSTRUCTIONS
TO: Enter the healthcare professional’s name and mailing address.
PARTICIPANT NAME: Enter the participant’s name.
DCN: Enter the participant’s Departmental Client Number (DCN).
DATE OF BIRTH: Enter the participant’s date of birth.
CHECKBOX SECTION: The healthcare professional shall answer the question about the participant’s ability to self-direct by marking YES or NO.
• If the answer is NO, the healthcare professional is encouraged to provide an explanation of the reason in the space provided.
NAME: The healthcare professional completing the form shall print their name.
DATE: The healthcare professional completing the form shall enter the date they signed the form.
SIGNATURE: The healthcare professional completing the form shall sign their name.
ASSESSOR COMMENTS: This space shall be utilized by the assessor to relay other applicable information to the healthcare professional from the assessor when necessary.
ASSESSOR SIGNATURE: The assessor completing the form shall sign their name.
ASSESSOR NAME: The assessor completing the form shall print their name.
TELEPHONE: Enter the telephone number of the assessor.
DATE FAXED: Enter the date the assessor faxed the form to the healthcare professional.
MAILING ADDRESS: Enter the mailing address of the assessor.
FAX NUMBER: Enter the fax number of the assessor.
A copy of the Healthcare Professional Inquiry form shall be scanned into the participant’s electronic case record.
4.00 Appendix 15 Healthcare Information Request Form
Home and Community Based Services Manual
The Healthcare Information Request Form may be utilized by the Division of Senior and Disability (DSDS) during the interRAI assessment process to verify participant self-reporting information with the physician. For reassessments completed by providers, the form may be completed by the Provider Review Team.
The completed form will be sent to all physicians whom the participant sees regularly. A provider nurse or other staff who has applicable information may also complete the form.
As best practice and when time allows, DSDS staff may call the physician’s office and notify them that the form will be faxed, emailed or mailed and explain the reason for the request. If the form is not returned by the case due date, DSDS staff shall proceed with processing utilizing the information gathered during the original assessment.
When the form is returned, DSDS staff shall update the assessment as needed with the information provided by the physician to determine if there is a change in LOC.
NUMBER OF COPIES
One copy of the form will be sent per physician or healthcare professional contacted.
INSTRUCTIONS
TO: Enter the physician’s name and address.
PATIENT’S NAME: Enter the participant’s name.
DOB: Enter the participant’s date of birth.
DCN: Enter the participant’s Departmental Client Number (DCN).
LEVEL OF CARE CATEGORIES: Enter the self-reported information and needs provided by the participant or responsible party in each of the LOC categories. LOC categories that have already been validated by other means may be left blank prior to sending to the physician. For example, the assessor witnesses the participant’s difficulty moving to a standing position, inability to climb stairs or unsteady gait. If there is no other need to confirm with the physician or healthcare professional regarding the participant's mobility, the category can be left blank.
PHYSICIAN RESPONSE: The physician or healthcare professional indicates YES or NO on the information provided by DSDS staff
DSDS STAFF COMMENTS: DSDS staff may use this section to provide additional information to the physician.
PHYSICIAN COMMENTS: The physician or healthcare professional may use this section to further explain the YES or NO answer in the LOC categories.
PHYSICIAN or HEALTHCARE PROFESSIONAL SIGNATURE and DATE: The individual responding to the form shall sign and date the document.
STAFF SIGNATURE: The individual completing the form shall sign the document.
STAFF NAME: The individual completing the form shall print their name.
DATE: Enter the date the form is completed.
ADDRESS: Enter the business mailing address of the DSDS staff.
FAX NUMBER: Enter the fax number of the DSDS staff.
DISTRIBUTION
The completed and returned form(s) shall be uploaded to the participant’s electronic case record.
4.00 Appendix 16 Structured Family Caregiving Waiver Diagnosis Verification Form
Home and Community Based Services Manual
When further information is needed to verify a participant has a diagnosis of either Alzheimer’s or a dementia related disorder, the Structured Family Caregiving Waiver (SFCW) Diagnosis Verification Form shall be sent to a participant’s healthcare professional, such as a Physician, Nurse Practitioner, or Physician Assistant. After the Division of Senior and Disability Services (DSDS) staff have confirmed the participant’s diagnosis cannot be determined by using a diagnosis provided in the electronic case management system by the participant’s healthcare professional, or the inability to confirm diagnosis by the healthcare professional by telephone, the DSDS staff shall send the SFCW Diagnosis Verification Form.
The DSDS staff shall contact the healthcare professional’s office to obtain the appropriate email or fax number and inform them DSDS staff will be sending this form to obtain the opinion of the healthcare professional.
NUMBER OF COPIES
One copy of the form shall be completed per healthcare professional.
INSTRUCTIONS
NAME: Enter the name of the healthcare professional this form is being sent to.
ADDRESS: Enter the healthcare professional’s street address.
ADDRESS (SUITE, BOX): Enter the suite or PO Box for the healthcare professional.
CITY: Enter the city where the healthcare professional’s office is located.
STATE: Enter the state where the healthcare professional’s office is located.
ZIP CODE: Enter the zip code where the healthcare professional’s office is located.
EMAIL ADDRESS: Enter the email address of the healthcare professional.
PHONE NUMBER: Enter the telephone number of the healthcare professional.
FAX NUMBER: Enter the fax number of the healthcare professional.
PARTICIPANT NAME: Enter the participant’s name.
DATE OF BIRTH: Enter the participant’s date of birth.
DCN: Enter the participant’s Departmental Client Number (DCN).
CHECKBOX SECTION: The healthcare professional shall answer the question about the participant’s diagnosis being either Alzheimer’s or a related dementia disorder by marking YES or NO.
- If the answer is YES, the healthcare professional is encouraged to provide an explanation of the reason in the space provided.
DIAGNOSIS: The healthcare professional completing the form shall enter the participant’s diagnosis.
ICD-10 CODE: The healthcare professional completing the form shall enter the participant’s ICD-10 code.
HEALTHCARE PROFESSIONAL NAME (PRINT): The healthcare professional completing the form shall print their name.
HEALTHCARE PROFESSIONAL SIGNATURE: The healthcare professional completing the form shall sign their name.
DATE: The healthcare professional completing the form shall enter the date they signed the form.
DSDS STAFF NAME (PRINT): The DSDS staff completing the form shall print their name.
DSDS STAFF SIGNATURE: The DSDS staff completing the form shall sign their name.
DATE: Enter the date the DSDS staff sent the form to the healthcare professional.
EMAIL ADDRESS: Enter the email address of the DSDS staff.
FAX NUMBER: Enter the fax number of the DSDS staff.
PHONE NUMBER: Enter the telephone number of the DSDS staff.
A copy of the SFCW Diagnosis Verification Form shall be scanned into the participant’s electronic case record.
5.00 Adverse Actions
Home and Community Based Services Manual
Introduction
Home and Community Based Service (HCBS) participants and applicants are required to receive written notice from the Division of Senior and Disability (DSDS) staff when an action adversely affects certain HCBS referrals or currently authorized services. HCBS participants and applicants have the right to appeal an adverse action.
DSDS staff shall send an Adverse Action Notice to provide notice when an action:
- Denies initial request for HCBS
- Denies care plan change request
- Reduces the current authorization of HCBS
- Closure of partial/complete HCBS
A reduction, denial or closure of HCBS is not considered an adverse action when a HCBS participant or applicant is in agreement. DSDS staff shall thoroughly document agreements in the electronic case record.
Purpose
The purpose of this policy is to:
- Provide guidance to DSDS staff on how to process adverse actions
- Provide guidance on different adverse action situations
- Provide timeframes for sending adverse actions
- Provide timeframes for how long an HCBS participant or applicant can appeal
Process
Within three (3) business days of an identified need for an adverse action, DSDS staff shall mail an Adverse Action Notice explaining all the services affected and reason(s) for the adverse action, including the Legal References for the Adverse Action [NEEDS LINK] to be taken.
Anyone may make the initial request for a hearing on the participant’s behalf. However, the participant and/or their legal guardian must be contacted directly to confirm the request. If DSDS staff cannot reach the participant and/or legal guardian by the third attempt (Appeal and Hearing Process [NEEDS LINK]), the hearing request shall not be processed, and the adverse action will proceed as appropriate.
When the participant contacts DSDS staff verbally or in writing to request a hearing, DSDS staff shall complete the Application for State Hearing Form with information provided by the participant (Appeal and Hearing Process [NEEDS LINK]).
- If the participant requests paperwork be sent to an authorized representative for the hearing process, the participant and/or their legal representative must complete and return an Authorization for Disclosure of Consumer Medical/Health Information Form.
All forms and documents related to the adverse action process shall be uploaded to the participant’s electronic case record.
Pursuant to the Code of Federal Regulations (CFR), specifically 42 CFR 431.211 regarding advance notice of an adverse action, unless otherwise specified, any adverse action that results in a change to the case status or changes to a prior authorization shall require a ten (10) calendar day notification prior to the date of the change or closing.
- The ten (10) calendar day period begins the day after mailing the Adverse Action Notice and ends the morning of the eleventh (11) calendar day
When a participant contacts DSDS staff in response to an Adverse Action or Waiting List Notice for Independent Living Waiver (ILW) Services [NEEDS LINK], DSDS staff may need to make adjustments to the participant’s proposed care plan based on new information provided.
- A new Adverse Action may be required in situations including, but not limited to:
- When the proposed amount of current HCBS is increased, but not to the level requested by the participant
- If additional HCBS are denied
- If the proposed care plan is further decreased
In these cases, DSDS staff shall mail a Reversal of Adverse Action Form for the original action.
The participant has ninety (90) calendar days from the date the Adverse Action Notice is mailed to appeal the decision.
However, the participant must appeal within ten (10) calendar days of the date the Adverse Action Notice was mailed in order to continue receiving current services.
Note: If the appeal is ruled in favor of DSDS, the participant and/or the participant’s estate may be liable for the cost of HCBS delivered during the appeal process. DSDS staff shall notify the participant of possible liability.
The participant’s decision to continue or discontinue HCBS shall be communicated to the provider and thoroughly documented in case notes in the participant’s electronic case record.
Ineligible Due to MO Healthnet Benefits
Adverse action as a result of ineligibility for Medicaid benefits is subject to appeal initiated through the Department of Social Services (DSS), Family Support Division (FSD). This includes participants who become enrolled in a Medicaid managed care plan.
- In such cases, the participant shall be notified by completing the Notice of Closure for HCBS Form.
- The Notice of Closure for HCBS Form shall be mailed within one (1) business day of receipt of information of ineligibility.
- This action does not require a ten (10) calendar day waiting period.
Assessment Level of Care Ineligibility
An Adverse Action Notice shall be sent when a potential or current participant does not meet the minimum required LOC score for the provision of HCBS.
Note: An Adverse Action Notice shall be mailed, even if the individual is in agreement with the LOC ineligibility determination.
Exceptions to the Ten Day Notification
DSDS staff shall mail the Adverse Action Notice to the last known address in the following situations, without having to wait ten (10) calendar days before processing the action, when:
- The participant does not meet Level of Care (LOC) during an initial assessment
- The participant is admitted to an institution where HCBS may not be continued
- The participant has moved to another state and is no longer eligible to receive Medicaid benefits in Missouri
- The whereabouts of the participant is unknown (e.g., mail returned by the Post Office indicates no known forwarding address)
Note: An Adverse Action Notice does not need to be mailed to the last known address if factual notification of the participant’s death is received.
ILW Waiting List
Participants placed on the Independent Living Waiver (ILW) Waiting List [NEEDS LINK] have the right to appeal their placement on the list.
- These participants shall be notified by sending the Waiting List Notice for ILW Services [NEEDS LINK]. This action does not require a ten (10) calendar day waiting period
- The participant has ninety (90) calendar days from the date the Waiting List Notice for ILW Services is mailed to appeal
Participant Demonstrating Threatening or Abusive Behavior
When a participant, or a member of the participant’s household, demonstrates threatening and/or abusive behavior towards a provider or other DSDS staff, the provider may request to discontinue services. DSDS staff and supervisors shall consult with DSDS Management for approval to proceed with the adverse action. The case record shall be reviewed to ensure documentation supports the action taken to discontinue the service authorization, and the participant’s failure to comply with Participant Rights and Responsibilities.
Participants Not Requesting a Hearing
All affected HCBS shall be reduced or closed as appropriate. DSDS staff shall complete necessary actions for the reduction or discontinuation.
- DSDS staff shall notify the HCBS provider of the action taken
- DSDS staff shall document actions taken in the participant’s electronic case record
- No further action is necessary for participants placed on the ILW Waiting List
State Designee
The selection of State Designee shall be used when there is no HCBS provider available. The Prior Authorization shall only remain in State Designee status for ninety (90) days. State Designee is not to be selected if the participant and/or legal guardian fail to select an HCBS provider.
- If an HCBS provider does not become available within ninety (90) days, DSDS staff shall initiate an adverse action.
- The justification of “No Provider Selected or Available” shall be used.
- If there is no response from the participant and/or legal guardian within ten (10) calendar days of the date of the adverse action, DSDS staff shall end date the State Designee Prior Authorization and close the case.
- If within ninety (90) calendar days of mailing the adverse action, DSDS staff is notified by the participant and/or legal guardian that an HCBS provider has been selected, DSDS staff shall reopen the case and authorize HCBS.
Note: The case shall be reopened and HCBS authorized only if an assessment has been completed within ninety (90) calendar days of the adverse action being sent. An assessment is required if one has not been completed within 90 calendar days of the adverse action being sent.
5.00 Appendix 1 Legal References for Adverse Action
Home and Community Based Services Manual
Action Taken
- Your request for Medicaid Home and Community Based Services has been denied.
- Your Medicaid Home and Community Based Services are being closed.
- Your Medicaid Home and Community Based Services care plan has been reduced.
- Your request for a change in your Medicaid Home and Community Based Services care plan has been denied.
- Your request to participate in the Money Follows the Person Demonstration program has been denied.
Explanation / Authority
5.00 Appendix 3 Adverse Action Notice
Home and Community Based Services Manual
The Adverse Action Notice for Home and Community Based Services (HCBS-12) provides the current or potential participant and/or their authorized representative (e.g. guardian or someone with a signed Authorization for Disclosure of Consumer Medical/Health Information that is in effect) with written notification of denials (i.e. of an initial request, request for increase, or additional services), reductions, or closings of services. This notice shall be used for all adverse actions, except those due to loss of Medicaid benefits or a participant’s number on the Independent Living Waiver (ILW) Waiting List as outlined in the Adverse Action policy.
INSTRUCTIONS
The HCBS electronic case record system will generate the adverse action form, which will include the following:
- Participant Information
- Current or potential participant’s name
- DCN
- Address
- Phone number (Include an extension number if appropriate)
NOTE: For current or potential participants with a guardian, ensure the guardian’s contact information is included on the form. •
- Choose the appropriate “Action Taken” and any applicable “Explanation/Authority” from the Legal References for Adverse Action
- It may be appropriate to select more than one category from the “Explanation/Authority” section in certain cases.
- Certain categories for Consumer-Directed Services contain a list of reasons for the adverse action.
- Date of Change
- The date shall be the day the change will take place
- This date shall be the eleventh (11th) day from the date the notice is mailed unless noted otherwise as outlined in the Adverse Action policy
- Hearing Request
- The date in both fields shall be when the participant must request a hearing to continue receiving HCBS at the current level.
- This date shall be the tenth (10th) day from the date the notice is mailed as outlined in the Adverse Action policy.
- DSDS Staff Information
- DSDS staff’s name
- Signature
- Phone number (Including an extension number as appropriate and mailing address)
- The date the notice is mailed
DISTRIBUTION
Upon completion, the original HCBS-12 shall be mailed to the current or potential participant and/or their authorized representative. A copy is also maintained in the participant’s electronic case record. When a hearing is requested for Medicaid funded services, a copy of the HCBS-12 shall be included in the exhibit packet sent to the Department of Social Services (DSS), Division of Legal Services (DLS).
5.00 Appendix 4 Adverse Action Notice
Home and Community Based Services Manual
The Adverse Action Notice for Home and Community Based Services (HCBS-12) provides the current or potential participant and/or their authorized representative (e.g. guardian or someone with a signed Authorization for Disclosure of Consumer Medical/Health Information that is in effect) with written notification of denials (i.e. of an initial request, request for increase, or additional services), reductions, or closings of services. This notice shall be used for all adverse actions, except those due to loss of Medicaid benefits or a participant’s number on the Independent Living Waiver (ILW) Waiting List as outlined in the Adverse Action policy.
INSTRUCTIONS
The HCBS electronic case record system will generate the adverse action form, which will include the following:
- Participant Information
- Current or potential participant’s name
- DCN
- Address
- Phone number (Include an extension number if appropriate)
NOTE: For current or potential participants with a guardian, ensure the guardian’s contact information is included on the form.
- Choose the appropriate “Action Taken” and any applicable “Explanation/Authority” from the Legal References for Adverse Action
- It may be appropriate to select more than one category from the “Explanation/Authority” section in certain cases.
- Certain categories for Consumer-Directed Services contain a list of reasons for the adverse action.
- Date of Change
- The date shall be the day the change will take place
- This date shall be the eleventh (11th) day from the date the notice is mailed unless noted otherwise as outlined in the Adverse Action policy
- Hearing Request
- The date in both fields shall be when the participant must request a hearing to continue receiving HCBS at the current level.
- This date shall be the tenth (10th) day from the date the notice is mailed as outlined in the Adverse Action policy.
- DSDS Staff Information
- DSDS staff’s name
- Signature
- Phone number (Including an extension number as appropriate and mailing address)
- The date the notice is mailed
DISTRIBUTION
Upon completion, the original HCBS-12 shall be mailed to the current or potential participant and/or their authorized representative. A copy is also maintained in the participant’s electronic case record. When a hearing is requested for Medicaid funded services, a copy of the HCBS-12 shall be included in the exhibit packet sent to the Department of Social Services (DSS), Division of Legal Services (DLS).
5.00 Appendix 4 Application for the State Hearing
Home and Community Based Services Manual
The Application for State Hearing for Home and Community Based Services allows the current or potential participant and/or their authorized representative (e.g. guardian or someone with a signed Authorization for Disclosure of Consumer Medical/Health Information Form that is in effect) an opportunity to appeal an adverse action taken in regard to denials (i.e., of an initial request of HCBS, request for increase or additional services), reductions, or closings of services.
This application shall be used to confirm a request for an official hearing for all Home and Community Based Services (HCBS) authorized by the Department of Health and Senior Services (DHSS), Division of Senior and Disability Services (DSDS).
The Application for a State Hearing for HCBS shall be completed by DSDS using information provided by the participant.
NOTE: The Application for a State Hearing for HCBS may be completed by the participant upon request
INSTRUCTIONS
DSDS staff shall enter the following information in the appropriate fields:
- Applicant Information
- Applicant’s Name
- DCN
- County
- Address
- Phone number (include extension if appropriate)
- Name of applicant requesting the hearing
- Reason for the hearing request
- Authorized Representative Information, when applicable
- Name
- Phone number (include extension if appropriate)
- Address
NOTE: The participant may name anyone as their authorized representative; however, the Authorization for Disclosure of Consumer Medical/Health Information Form shall be completed prior to the release of protected health information (PHI)
- Indicate whether the participant requested to continue receiving services at the current level. If selection is not made, services shall remain authorized
- This does not apply to participants appealing their number on the Independent Living Waiver (ILW) Waiting List
- Applicant’s signature and date, when completed by the participant
- Indicate in the signature field if the request is made via phone
- Indicate if the hearing request is based on a denial, discontinuance, or reduction
- This does not apply to participants appealing their number on the ILW Waiting List
- Date the hearing was requested
- Reason for the planned action or decision, including the legal reference for the decision
- This shall be the same reason and legal reference as stated on the Adverse Action Notice
- The reason stated on the Waiting List Notice for ILW Services Form regarding the participant’s number on the ILW Waiting List, which includes the legal reference
- List service(s) being adversely affected
- DSDS Staff Information
- Name
- Phone number (include extension when appropriate)
- Address
- DSDS staff shall forward the form to their immediate supervisor for review within three (3) business days.
- Division of Legal Services Information (completed by DLS)
- Date received by DLS
- Assigned DLS Hearings Officer
SUPERVISOR RESPONSIBILITIES
- Review the request and confirm validity within three (3) business days
- Sign the form
- Submit this form along with the Adverse Action form and the Agency Witness List to the DSDS HCBS Hearings Representative
NOTE: Supervisor may, at their discretion, request additional collateral contacts be made to further verify validity. This additional contact should not exceed three (3) additional business days.
HCBS HEARINGS REPRESENTATIVE RESPONSIBILITIES
- Submit the exhibits packet to the Regional Administrative Hearings Office
- Enter the date sent to DLS
- Send the exhibit packet ten (10) business days prior to the hearing to the Participant, DSDS staff and supervisor
NOTE: The Exhibits packet may be delayed if additional information is required.
DISTRIBUTION
- A copy shall be mailed to the participant and/or their authorized representative, when necessary
- A copy is maintained in the participant’s electronic case record
5.00 Appendix 5 Reversal of Adverse Action Notice
Home and Community Based Services Manual
The Reversal of Adverse Action Notice form for Home and Community Based Services (HCBS) shall be utilized to notify current or potential participants and/or authorized representatives (e.g., guardian, or someone with a signed Authorization for Disclosure of Consumer Medical/Health Information that is in effect) that the Department of Health and Senior Services (DHSS), Division of Senior and Disability Services (DSDS) has reversed its previous decision regarding an adverse action. The Department of Social Services (DSS), Division of Legal Services (DLS), and the DSDS HCBS Hearings Representative shall also be notified of the reversal when necessary.
INSTRUCTIONS
DSDS staff shall enter the following information in the appropriate fields:
- Current or potential participant Information
- Name
- DCN
- Date notice is being mailed
- Address
- Phone number (include extension when appropriate)
NOTE: When the current or potential participant has a guardian, the guardian's information shall be entered in this section.
- Check the appropriate box or boxes regarding the original adverse action.
- Check the box in the last section ONLY when reversing an adverse action that has been submitted to DLS
- Enter the address of the appropriate Regional Administrative Office.
- DSDS staff information
- Signature and
- Printed name
- Phone number (include extension when appropriate)
- Address
DISTRIBUTION
- The original form shall be mailed to the participant and/or their authorized representative.
- A copy is maintained in the participant’s electronic case record.
NOTE: If a hearing request has already been forwarded to DLS, a copy of the Reversal of Adverse Action Notice shall be mailed to the appropriate DLS Regional Office and DSDS HCBS Hearings Representative.
5.00 Appendix 6 Notice of Closure
Home and Community Based Services Manual
The Notice of Closure form for Home and Community Based Services (HCBS) provides current participants and/or their authorized representative (i.e., guardian, or someone with a signed Authorization for Disclosure of Consumer Medical/Health Information that is in effect) with written notification of the closing of currently authorized services. This notice shall only be used for HCBS closed by the Department of Health and Senior Services (DHSS), Division of Senior and Disability Services (DSDS), due to the participant’s loss of Medicaid benefits covering the authorization of HCBS or when participants are enrolled in a Managed Care Health Plan.
DSDS shall mail this notice no later than the date the action is taken.
If the participant wants to request an appeal, they must contact the Department of Social Services (DSS), Family Support Division (FSD).
INSTRUCTIONS
DSDS staff shall enter the following information in the appropriate fields:
- Participant information
- Name
- DCN
- Address
- Phone (include extension when appropriate)
NOTE: When the participant has a guardian, the guardian’s information shall be entered in this section.
- Select the appropriate checkbox.
- Check the first box when services must close based upon FSD’s determination that the participant is not eligible for Medicaid benefits or the participant’s Medicaid Eligibility (ME) [NEEDS LINK] code does not include DSDS HCBS benefits.
- Check the second box when the participant has been enrolled in Managed Care and choose the appropriate drop-down selections based on the participant’s Managed Care Organization.
- Enter the date the change will take place. This is the date of mailing
- DSDS staff information
- Signature
- Printed Name
- Address
- Date
- Phone (include extension when appropriate)
DISTRIBUTION
- The original shall be mailed to the participant and/or their authorized representative
- A copy is maintained in the participant’s electronic case record
6.00 Appeal and Hearing Process
Home and Community Based Services Manual
INTRODUCTION
Upon receipt of a verbal or written request to appeal an Adverse Action for a denial, reduction, or closure of Home and Community Based Services (HCBS), the Department of Health and Senior Services (DHSS), Division of Senior and Disability Services (DSDS) staff shall initiate the appeal process.
PROCESS
Anyone may make the initial request for a hearing on the participant’s behalf. However, the participant/guardian must be contacted directly to confirm the request. All contacts and attempts to contact must be documented in case notes.
- When the request is made by someone other than the participant/guardian, DSDS staff shall begin attempts to contact the participant/guardian within one (1) business day of receipt of a hearing request.
- DSDS staff shall make a minimum of three (3) attempts on at least three (3) separate business days to contact the participant/guardian
- If unable to reach the participant/guardian by the third attempt, the request for hearing shall not be processed and the adverse action shall proceed as appropriate
When contact is made with the current or potential participant/guardian, DSDS staff shall:
- Discuss any additional information that would affect the reason for the adverse action
- Ensure the participant/guardian wishes to continue the appeal process
- When the appeal has been filed within ten (10) calendar days, notify the participant/guardian that HCBS will continue at the current level unless the participant/guardian chooses not to continue receiving services at that level
NOTE: If the appeal is ruled in favor of DSDS, the participant/guardian and/or the participant’s estate may be liable for the cost of HCBS delivered during the appeal process. The participant/guardian shall be notified of the possible liability.
- Notify the participant/guardian that the proposed action will be implemented on the 11th day, if the participant/guardian does not appeal within ten (10) calendar days from the date the Adverse Action Notice was mailed
- Notify the participant/guardian whose initial request for HCBS was denied by DSDS that they have ninety (90) calendar days from the date the Adverse Action Notice is mailed to appeal the decision, but they do not have the right to receive HCBS pending the hearing decision
- Notify participant/guardian placed on the Independent Living Waiver (ILW) Waiting List that they have ninety (90) calendar days from the date the Waiting List Notice for ILW Services is mailed to appeal their number on the list
- Advise the participant/guardian that a supervisory review will be conducted prior to forwarding the hearing request to the Department of Social Services (DSS), Division of Legal Services (DLS)
- Advise the participant/guardian that DSS/DLS determines the date of the hearing and DSS/DLS will notify the participant/guardian of that date, along with any other instructions needed
- Advise the participant/guardian copies of pertinent supporting documentation will be mailed to them
- If the participant/guardian wants to designate an authorized representative to receive mailed documents, the Authorization for Disclosure of Consumer Medical/Health Information shall be mailed to the participant/guardian for completion
DSDS staff shall complete the Application for State Hearing form using information provided by the participant/guardian.
DSDS staff shall notify their immediate supervisor that a hearing has been requested and the case record is ready for review in the participant’s electronic case record.
NOTE: If a participant’s care plan is adjusted at any point during the hearing process, a new Adverse Action Notice may be required.
If the participant/guardian indicates at any point prior to the hearing that they have obtained legal counsel, staff shall inform their supervisor and the DSDS Hearings Representative. The DSDS Hearings Representative shall submit the case to the Office of General Council (OGC) database as an Attorney General (AG) referral, include the date of the hearing, and indicate the date DSDS staff was contacted by the participant/guardian’s attorney or the date the participant/guardian informed DSDS staff they have legal counsel, whichever happens first.
- If DSDS staff is not contacted by the participant/guardian’s attorney by the date of the hearing, the hearing will continue without legal counsel for both DSDS staff and the participant/guardian.
- If DSDS staff discovers the participant/guardian has an attorney present for the hearing without previous notice, DSDS staff will ask for a continuance and follow the process outlined later in this policy under DSDS Responsibilities.
SUPERVISOR REVIEW
The DSDS supervisor shall review all hearing requests prior to submitting the request to the DSDS Hearings Representative. The DSDS supervisor shall review the participant’s case record and all supporting documentation within three (3) business days of the date of the request for hearing. Supervisory review shall be documented in the participant’s electronic case record.
The DSDS supervisor review shall ensure the following:
- Accuracy and validity of the case action
- Compliance with policy, statutes and regulations
- Appropriate judgment from DSDS staff
The DSDS supervisor may, at their discretion, request additional collateral contacts be made to further verify validity. This additional contact should not exceed three (3) additional business days. All contacts shall be documented in the participant’s electronic case record.
If the DSDS supervisor review determines the adverse action is inaccurate, the DSDS supervisor shall contact DSDS staff to discuss the case.
- Should the adverse action need to be withdrawn, DSDS staff shall notify the participant/guardian verbally, explaining the decision to reverse the proposed adverse action.
- Written notification shall be made by completing the Reversal of the Adverse Action Notice. HCBS shall be (re)authorized, increased, or continued as authorized.
- If services are not restored to the previous level, a new Adverse Action Notice shall be completed and the Application for State Hearing Form shall be revised to reflect the updated information.
- Upon completion of the case review, the DSDS supervisor shall review and sign the Application for State Hearing Form and ensure the legal reference included in the Application for a State Hearing Form matches the reference included in the Adverse Action Notice.
When a decision is made to move forward with the hearing, the DSDS supervisor shall ensure the Adverse Action Notice, Application for State Hearing, and Agency Witness List are completed and forwarded to the DSDS Hearings Representative. Once the documents have been reviewed by the DSDS Hearing Representative, they will be forwarded to the DLS. A copy of the Application for State Hearing will be sent to the participant/guardian, or any authorized representative(s). A copy of the Application for State Hearing will be uploaded to the participant’s electronic case record.
HEARING EXIHIBITS
Information used in making the determination for adverse action shall be provided to the participant/guardian and presented as evidence at the hearing. The DSDS Hearings Representative shall complete and forward a Cover Letter for Hearing Request listing all exhibits to the appropriate DLS office with case documentation. Each document shall be marked with the appropriate exhibit number.
All packets shall include the following:
- Adverse Action Notice or Waiting List Notice for ILW Services, as appropriate
- Application for a State Hearing Form
- Case Notes pertinent to the adverse action
Additional information used to make the determination could include, but is not limited to:
- HCBS Care Plan and Participant Choice Statement
- HCBS Assessment (InterRAI HC), to include the LOC score
- In-Home Services Worksheet
- Consumer-Directed Services Worksheet
- Printed Prior Authorization – Care Plan; Letter from the Department of Health & Human Services (DHHS), Centers for Medicare & Medicaid Services (CMS) regarding the reduction of any State Plan services (i.e.,Basic Personal Care, Advanced Personal Care, or Authorized Nurse Visits) for individuals residing in a Residential Care Facility (RCF) or Assisted Living Facility (ALF)
- Any other supporting documentation (e.g., General Health Evaluation and Level of Care Recommendation from a provider nurse, letter from a physician, etc.) used to make the determination for the adverse action.
Additional documentation shall be required when the participant’s ability to self-direct his/her own care with regard to the Consumer Directed Services/Independent Living Waiver (CDS/ILW) program is questioned. Documentation shall include:
- All documentation in Case Notes within the participant’s electronic case record as to why a potential participant does not have the capacity to direct his/her own care or can no longer fulfill the program responsibilities as a current CDS/ILW participant
- Any additional information to support this determination, such as:
- The SLUMS exam
- The Self-Direction Assessment Questions
- Documentation from the participant’s physician
- Psychological evaluation
Additional documentation shall also be required when a decision regarding services was made based on information received from the Office of Special Investigation (OSI). For hearings alleging CDS/ILW participant fraud, the following guidelines shall be followed:
- The DSDS Hearings Representative shall notify the OSI investigator of the appeal, obtain their contact information and availability and DLS will notify them of the hearing date
- OSI staff shall work with the DSDS Hearings Representative by redacting the investigative case file and providing it to the DSDS Hearings Representative for the hearing packet
- OSI staff shall testify for DSDS regarding their findings in the investigation
SCHEDULING A HEARING
Upon receipt of the hearing request, DLS will register the request and schedule the hearing.
- A Notice of State Hearing will be sent by DLS to the participant/guardian, any authorized representative, participant’s attorney, if applicable, DHSS/Office of General Counsel (OGC), and DSDS staff listed on the Agency Witness List. The Notice of State Hearing includes the time and place of the hearing and information regarding procedures for rescheduling.
- If DSDS staff will not be present at the FSD office for the hearing and the participant plans to appear in person, the DSDS Hearings Representative shall contact the appropriate FSD office to ensure FSD staff are available to assist the participant in gaining access to the room and connecting to the hearing conference call.
- DSDS staff shall not contact a DLS Hearings Officer directly. If DSDS staff have questions concerning hearing logistics or scheduling, contact the DSDS Hearings Representative. The DSDS Hearings Representative shall coordinate with support staff at the appropriate DLS Regional Office for clarification.
PARTICIPANT/GUARDIAN AND/OR AUTHORIZED REPRESENTATIVE RIGHTS
Pursuant to the Code of Federal Regulations (CFR), specifically 42 CFR 431.242, the participant/guardian must be given an opportunity to do the following:
- Examine, before the date of the hearing and during the hearing, all documents to be used by DSDS at the hearing. In addition, upon request, they have the right to examine the entire content of their case record
- Exhibits are mailed to the participant ten (10) business days prior to the scheduled hearing. If there is a delay due to the need of additional information, the DSDS Hearings Representative will coordinate with the participant and DLS.
- Bring witnesses to the hearing
- Establish all pertinent facts and circumstances
- Present an argument without undue interference
- Question or refute any testimony or evidence, including the opportunity to confront and cross-examine any adverse witness
The participant/guardian may withdraw the appeal request at any time prior to the hearing. This request must be received in writing and shall be forwarded to the DSDS Hearings Representative. If this occurs and a hearing request has already been forwarded to DLS, the withdrawal request shall be forwarded to the DSDS Hearings Representative. A copy shall also be uploaded to the participant’s electronic case record.
DSDS RESPONSIBILITIES
DSDS staff attending the hearing shall ensure they understand the process and review the documentation to be presented. They may also request assistance from the DSDS Hearing Representative if needed. The DSDS Hearing Representative can help them understand both the process and the documentation.
- When provider staff have completed the assessment and recommended the care plan, DSDS staff are responsible for presenting testimony to defend the case action taken based on that information.
- DSDS shall request that provider staff with pertinent knowledge of the participant’s circumstances attend the hearing.
- Staff must be prepared to address how that information impacted the decision.
When DSDS is informed an attorney (or other staff from an attorney’s office) is representing the participant/guardian for their appeal, the DSDS Hearings Representative shall:
- Notify DHSS/OGC immediately at 573/751-6005 for appropriate action
- On the day of the hearing, if it is discovered that the participant/guardian is represented by an attorney or other staff from an attorney’s office, request a continuance of the hearing to secure legal representation.
- Document the information in the participant’s electronic case record
When there is a care plan change that impacts the adverse action after the hearing request information has been sent to DLS, a copy of the Reversal of Adverse Action Notice must be forwarded to the DSDS Hearings Representative.
- If the participant/guardian is in agreement with the revised care plan and no longer wishes to appeal the original decision, DSDS staff shall inform the participant/guardian they must notify DLS in writing.
- If the participant/guardian is not in agreement with the revised care plan, copies of the new Adverse Action Notice or Waiting List Notice for ILW Services, and Application for State Hearing form must be forwarded to DLS.
HEARING PROTOCOL
The burden of proof lies with the party seeking the change in status quo. DSDS has the burden of proof where there is a proposed change that adversely affects the participant’s current care plan. When a request for has been denied, the participant/guardian has the burden of proof.
During the hearing, DSDS staff and the DSDS Hearings Representative shall testify to qualify themselves and their position, establish the case, and state other facts relevant to the proceeding. The DSDS Hearings Representative is also responsible for presenting evidence (exhibits) to support the decision.
HEARING DECISION ISSUANCE
The DLS Hearing Officer will issue a Decision and Order containing the Introduction and Appearances, Findings of Fact, Conclusions of Law, Decision, and Order.
- The law provides additional appeal rights for the participant/guardian if they are still aggrieved.
- Instructions for these appeal rights are outlined in the Decision and Order and can be initiated by the participant/guardian through DLS.
HEARING DECISION RECEIPT
Once the Decision and Order is received, DSDS staff shall take appropriate action, as outlined below.
When DSDS action is affirmed:
- All affected HCB services the participant received during the hearing process shall be reduced or closed as appropriate
- DSDS staff shall notify the provider of the action taken
- The hearing decision receipt date, or the date action is entered into the participant’s electronic case record, shall be the date of the change
- When the hearing involves participant fraud or falsification and DSDS is affirmed, only the supervisor or higher shall check the CDS Restricted Checkbox in the participant’s electronic case record to prevent the participant from receiving CDS
- Document CDS restriction in case notes.
- The participant/guardian shall be informed of agency-option HCBS available to the participant and complete necessary care planning or close the case, as appropriate.
- The participant’s number on the ILW Waiting List shall remain the same
If DSDS action is reversed:
- The HCB services shall continue, be increased, be reassessed, or be immediately authorized as required by the Decision and Order
- Participant’s number on the ILW Waiting List shall be reevaluated and adjusted, as necessary
- DSDS staff shall notify the HCBS provider of the action taken
- The effective date shall be the date the adverse action was taken
When the Hearing Officer includes in the Decision and Order a statement that DSDS must complete another assessment, the assessment shall be completed within fifteen (15) business days of receipt of the Decision and Order.
The Decision and Order shall be retained in the participant’s electronic case record.
6.00 Appendix 1 Department of Social Services, Division of Legal Services Regional Offices
Home and Community Based Services Manual
REGIONAL ADMINISTRATIVE HEARINGS OFFICES | ||
|---|---|---|
Jefferson City PO Box 1527 Jefferson City, MO 65102 573-751-0335 573-751-0334 (Fax) DLS.JCIMHRG@dss.mo.gov | Kansas City 8800 E. 63rd Street # 520-B Raytown, MO 64133 816-325-5918 816-325-5908 (Fax) DLS.KCIMHRG@dss.mo.gov | St. Louis 8501 Lucas & Hunt Road Suite 110 St. Louis, MO 63136 314-877-2173 (Fax) DLS.STLIMHRG@dss.mo.gov |
01-Adair 004-Audrain 010-Boone 012-Butler 014-Callaway 015-Camden 016-Cape Girardeau 018-Carter 023-Clark 026-Cole 027-Cooper 028-Crawford 033-Dent 035-Dunklin 037-Gasconade 045-Howard 046-Howell 047-Iron 052-Knox 053-Laclede 056-Lewis 061-Macon 063-Maries 064-Marion 066-Miller 067-Mississippi 068-Moniteau 069-Monroe 070-Montgomery 071-Morgan 072-New Madrid 075-Oregon 076-Osage 077-Ozark 078-Pemiscot 081-Phelps 082-Pike 085-Pulaski 087-Ralls 088-Randolph 090-Reynolds 091-Ripley 098-Schuyler 099-Scotland 100-Scott 101-Shannon 102-Shelby 103-Stoddard 107-Texas 111-Wayne 114-Wright | 002-Andrew 003-Atchison 005-Barry 006-Barton 007-Bates 008-Benton 011-Buchanan 013-Caldwell 017-Caroll 019-Cass 020-Cedar 021-Chariton 022-Christian 024-Clay 025-Clinton 029-Dade 030-Dallas 031-Davies 032-Dekalb 034-Douglas 038-Gentry 039-Greene 040-Grundy 041-Harrison 042-Henry 043-Hickory 044-Holt 048-Jackson 049-Jasper 051-Johnson 054-Lafayette 055-Lawrence 058-Linn 059-Livingston 060-McDonald 065-Mercer 073-Newton 074-Nodaway 080-Pettis 083-Platte 084-Polk 086-Putnam 089-Ray 093-St. Clair 097-Saline 104-Stone 105-Sullivan 106-Taney 108-Vernon 112-Webster 113-Worth | 009-Bollinger 036-Franklin 050-Jefferson 057-Lincoln 062-Madison 079-Perry 092-St. Charles 094-St. Francois 095-Ste. Genevieve 096-St. Louis County 109-Warren 110-Washington 115-St. Louis City |
6.00 Appendix 2 Home and Community Based Services Witness Information
Home and Community Based Services Manual
Preparing the Case
In any hearing, the decision will be based on the evidence presented. The Department of Health and Senior Services (DHSS), Division of Senior and Disability Services (DSDS) must prepare the case by selecting the documents from the case record and the necessary references from the Home and Community Based Services Manual, Code of State Regulation (CSR), Code of Federal Regulation (CFR), or State Statute as evidence to develop the case.
For a telephone hearing conducted by the Department of Social Services (DSS), Division of Legal Services (DLS), the DSDS HCBS Hearings Representative will provide DLS with the contact numbers for all agency witnesses prior to the hearing.
Hearings are held at the affected participant’s local Family Support Division’s (FSD) Resource Center. In instances where DSDS does not go to the FSD Resource Center where the participant resides, or other state office where the administrative hearing is scheduled, DSDS shall ensure the FSD Resource Center is aware of the pending hearing and that a connection to the hearing via telephone conference call is available for the participant.
Qualifying Statement
Hearing testimony should lay a proper foundation that includes qualifying DSDS staff, qualifying the case record documents as a business record, establishing relevance to the issue, explaining state policy, and authenticating exhibits. Therefore, at each hearing, DSDS must qualify themselves as a witness and the case record documents as part of a business record. It is necessary to establish that entries are made in the case record in the regular course of business. In order to qualify themselves at the start of their testimony, DSDS shall recite the information contained in the Qualifying Witness Statement [NEEDS LINK].
Evidence/Exhibits
To establish the case, the DSDS HCBS Hearings Representative shall present evidence necessary to sustain the adverse action. The DSDS HCBS Hearings Representative shall testify and introduce various forms and documents as evidence for the record so that the case is presented in chronological order. The specific evidence needed from the case record will include documents and case notes available to support the decision of DSDS. It should be established that the exhibit is relevant by a brief statement about what the document contains and how it pertains to the decision made. In addition, when copies are presented, it must be established through testimony that it is authentic, Authentication of Exhibits [NEEDS LINK]. Additional DSDS staff or agency witnesses may be present to provide testimony on their interactions with the participant.
Rebuttal Testimony
After testimony by the current or potential participant and/or witnesses, the hearing officer should provide DSDS an opportunity to make rebuttal testimony. If the hearings officer does not offer this opportunity, DSDS may make this request, if necessary. During rebuttal testimony, DSDS shall offer additional testimony regarding the facts presented by the current or potential participant and/or his/her witnesses.
DSDS may request to examine exhibits that the current or potential participant or his/her witnesses enter as evidence.
A non-attorney cannot perform actions that are normally done by an attorney who is acting in a representative capacity. Therefore, DSDS employees must act as a witness rather than as a representative and cannot:
- Cross examine;
- Conduct direct examination; or
- Object.
6.00 Appendix 3 Qualifying Witness Statement
Home and Community Based Services Manual
At each hearing, the Department of Health and Senior Services (DHSS), Division of Senior and Disability Services (DSDS) staff must qualify themselves as a witness and qualify the case record documents as part of a business record. In order to satisfy this requirement, DSDS shall use the following qualifying statement prior to giving testimony.
Qualifying Statement for DSDS HCBS Hearings Representative
My name is ______ .
I am employed by _____ and my current position is ____ . I have been employed since ____ (timeframe).
I am the custodian of the DSDS case record for (name of current or potential participant). Information contained in the case documents will be used during testimony.
It is the policy of DSDS during the regular course of business for employees to document in the electronic record when the current or potential participant or any other collateral contact is made and/or information is received.
In addition, it is also DSDS’ policy for continued maintenance of a case record on all service participants and case documents for all service applicants. All entries in the case record for (name of current or potential participant) are in the usual form and were completed in the normal course of business.
Qualifying Statement for additional DSDS staff
My name is _________ .
I am employed by and have been engaged in assessment and level of care determination, development and maintenance of current or potential participant’s person centered care plans.
My current position is a/an________. I have been employed by _____ for ______ (timeframe).
For each exhibit introduced during testimony:
All documents or forms from the case record used to support the decision for the case action shall be authenticated using the following guideline:
During testimony, to authenticate a document as an exhibit, DSDS shall:
- Identify the name of the exhibit
- Explain the purpose of the exhibit;
- State if the form is an authentic copy of information contained in the case record;
- Proceed with the explanation that reveals the contents of the document; and
- Request that the DLS Hearing Officer enter the exhibit as evidence.
Specific to the InterRAI HC, the witness shall also attest to, as necessary, the following information:
The InterRAI HC is an internationally utilized assessment tool developed for use in assessing the health status needs of frail elderly and adults with disabilities living in the community. This instrument incorporates the level of care score requirements in the Missouri Code of State Regulations, specifically, 19 CSR 30-81.030 and is a ‘point in time’ assessment of the participant’s functional abilities. Although level of care is determined by algorithms behind the scenes, the algorithms in the InterRAI HC are based upon the participant’s answers to specific questions in regard to the CSR’s twelve (12) level of care categories.
I will be giving testimony on ______’s (name of the current or potential participant) responses to these questions, as well as observations made of _____’s (name of current or potential participant) ability to perform certain tasks. This assessment was completed on _____ (date).
6.00, Appendix 8 Agency Witness List
Home and Community Based Services Manual
The Agency Witness List shall be utilized by Division of Senior and Disability Services (DSDS) staff to identify agency witness contact information and availability for purposes of scheduling a Home and Community Based Services (HCBS) administrative hearing.
INSTRUCTIONS
Enter witness information, including name, phone, and alternative phone (where applicable), e-mail, and availability.
- For availability, enter dates and times during which the witness is available to attend the hearing. These dates should cover at least the next thirty (30) business days from date this form is completed.
DISTRIBUTION
Upon completion, the Agency Witness List shall be included with the Adverse Action Notice (HCBS-12) and the completed Application for State Hearing (HCBS-12a) forwarded to the participant/guardian, DSDS HCBS Hearing Representative and the Department of Social Services, Division of Legal Services.
7.00 Show-Me Home
Home and Community Based Services Manual
Introduction
Show-Me Home (SMH) is a Money Follows the Person (MFP) program that supports adults with disabilities and older adults in Missouri to transition from an institutional setting to specified community settings. SMH was awarded by the Centers for Medicare and Medicaid Services (CMS) to the Department of Social Services (DSS) in January 2007 and implemented in collaboration with the Department of Health and Senior Services (DHSS), Division of Senior and Disability Services (DSDS).
Eligibility Criteria
All SMH participants must meet the following criteria:
- Currently reside in a Skilled Nursing Facility (SNF) for at least the last sixty (60) consecutive days
- Consecutive days shall include any hospitalizations, home visits, and short-term rehabilitation services covered by Medicare, etc., as long as the participant is not discharged from the facility.
- Residential Care Facilities (RCF) and Assisted Living Facilities (ALF) do not meet the SNF eligibility criteria for participation in the SMH program.
- Currently receive MO HealthNet benefits in the SNF prior to transition
- The Medicaid benefits must be in effect on the day of discharge from the SNF.
- Eligible for Medicaid benefits after the transition to the community
- Move to qualified housing in which the health and welfare of the potential participant can be assured. Qualified housing includes the following:
- A home owned or leased by the potential participant or the potential participant's family member.
- An apartment with an individual lease, with lockable entry and exit points, which includes living, sleeping, bathing, and cooking areas over which the potential participant or the potential participant’s family have domain and control.
- A community-based residence in which no more than four unrelated individuals reside
- Agree to the terms set forth in the SMH Participation Agreement.
In addition to the eligibility criteria specified above, the health and welfare of the potential participant cannot be compromised as a result of the transition to a community setting.
Referrals
The SMH Database tracks all SMH referrals and must be updated throughout the transition process, as instructed by the SMH Project Director. Direct referrals for SMH can be made through any of the following ways:
- DSDS HCBS Intake
- The appropriate DSDS staff
- One of the DSDS SMH contractors
- The Long-Term Care Ombudsman Program (LTCOP)
Referrals may also be generated as a result of the Section Q Long Term Care Minimum Data Set (MDS) questionnaire.
- SNF staff enter MDS referrals into the SMH Database, which are then routed to the appropriate SMH contractor for the potential participant’s county of residence.
- The SMH contractor makes a face-to-face contact with the resident for Options Counseling, updates the SMH Database, then forwards the referral to the appropriate DSDS staff for follow-up and a decision on eligibility for SMH services.
In addition, MDS Q+ Index potential referrals are generated by algorithms within the MDS system and transferred to the SMH Database for review by SMH contractors according to the terms of the contract.
Procedures
Upon receipt of a referral, DSDS staff shall conduct an assessment with potential participants, utilizing the InterRAI HC for individuals appropriate for HCBS. When HCBS is not appropriate, DSDS staff shall use the SMH HCBS Referral/Assessment form to determine eligibility for other SMH services and ensure it is uploaded into the participant’s electronic case record.
The assessment shall be conducted within ten (10) business days from receipt of the referral notification and the following shall apply:
- If the potential participant has a legal guardian or invoked Durable Power of Attorney (DPOA), DSDS staff shall make arrangements to include the guardian or invoked DPOA in the assessment process.
- Documentation shall be included in the participant’s electronic case record to reflect if the guardian or invoked DPOA chose to participate in the assessment process.
- A Nursing Facility Level of Care (NF LOC) score is not required for participation in SMH. However, an NF LOC score is required if HCBS needs are identified and will be authorized.
DSDS staff is responsible for determining that all eligibility criteria are met and shall:
- Discuss the contents of the SMH Participation Agreement with the potential participant to ensure they are aware of the requirements for participation in SMH
- Obtain the participant’s signature on the agreement to indicate the participant wishes to proceed
- Open a case in the electronic case record system
- Upload the signed agreement to the participant’s electronic case record
- Notify SMH DSDS oversight staff of the new enrollment
- Potential participants who do not meet eligibility criteria for participation in SMH during the initial assessment visit shall not complete the SMH Participation Agreement
DSDS staff shall send an Adverse Action Notice to participants not eligible for enrollment. SMH appeals and hearings shall follow the Adverse Action and Appeal and Hearing [NEEDS LINK] process outlined in the HCBS Manual.
Note: Only DSDS staff may deny enrollment in SMH. If a referral is first received by a SMH contractor and preliminary screening indicates the individual will not be eligible for participation in SMH, the contractor must complete the Referral Notification and submit it to DSDS staff for review and a final decision.
- If DSDS staff identifies a need for additional screening, the contractor will be notified to complete Options Counseling or other necessary action.
- DSDS staff shall complete the Adverse Action Notice when necessary and process any Appeal and Hearing [NEEDS LINK] as outlined in the HCBS Manual.
Once the SMH Participation Agreement has been signed, the participant will begin working with a Transition Coordinator (TC), from the SMH contractor that provides services in their area. This applies to all participants, even those who will not need HCBS following transition. The TC shall assist the participant in determining their needs, finding appropriate housing, requesting any necessary SMH services funding, and verifying the safety and accessibility of potential housing.
The TC shall discuss and provide participants with resource information regarding the SMH program, community resources, and adult protective services. Appropriate brochures can be requested from SMH DSDS oversight staff.
The TC shall complete a Transition Plan (Plan) for each SMH participant in consultation and agreement with the participant and/or family members, participant’s legal representative, SNF discharge planner, and DSDS staff. The Plan must address each of the areas included on the form, with particular attention to the participant’s backup strategy for emergencies.
- The Health, Safety, and Welfare Assessment is an optional tool for use in documenting additional critical needs that may need to be addressed for a successful transition.
The Plan must be fully completed and signed by the participant and TC before it can be approved by DSDS staff. Once approved, DSDS staff shall upload a copy of the completed Plan to the participant’s electronic case record.
Special Considerations
Many factors can affect the participant’s ability to complete a transition to the community. Housing needs, health issues, or other concerns may prevent a potential participant from being able to transition immediately following the referral. The participant and TC shall notify DSDS staff when the applicant is prepared to return to the community.
If the potential participant returns to the community within a year of the initial SMH assessment, another face-to-face assessment is not required. DSDS staff shall make a telephone contact to update the information obtained during the original face-to-face assessment to ensure the participant’s care needs can still be met.
When the participant is ready to move to the community setting and is eligible for HCBS, DSDS staff shall complete the participant’s Person Centered Care Plan (PCCP) in the electronic case record. Development of the PCCP is based on the participant’s anticipated needs. SMH participants may be eligible for all HCBS authorized by DSDS, excluding RCF/ALF Personal Care. If the participant chooses Consumer-Directed Services (CDS), they must be able to self-direct their care and meet all other criteria for CDS participation.
DSDS staff may need to adjust the PCCP after the participant’s move to reflect actual needs. SMH participants are eligible for SMH demonstration services funding based on individual needs to assist with initial transition costs. The SMH demonstration services funding is available throughout the first 365 days of the move and is designed to assist with expenses related to establishing a home in the community. Any tangible items purchased with this funding become the property of the SMH participant, whether the participant remains in the community or not. The funds can be utilized for various items, including the following:
- Rent deposits
- Utility deposits
- Cleaning supplies
- Toiletries
- Furniture
- Household items
- Groceries
- Vehicle modifications
- Durable medical equipment
The TC must request reimbursement for SMH demonstration services funding. Requests are submitted to SMH DSDS oversight staff for review before reimbursement will be authorized. The TC will be notified of the payment decision upon completion of the review.
The TC shall use the following guidance when considering purchasing an item using SMH demonstration services funding:
- Items needed to facilitate the move back to the community
- Items needed to maintain a community residence
Participation
Participation in the SMH program requires a series of three (3) Quality of Life surveys. These surveys are administered by contracted surveyors. The first survey is to be completed while the individual is residing in the SNF. The second survey is completed at the conclusion of the first year in the community, and the third at the conclusion of the second year in the community.
- SMH Project Director’s staff will schedule the initial survey upon receipt of the signed Participation Agreement from DSDS staff.
- A potential participant who is not surveyed before leaving the facility may be disqualified from participation in SMH. If DSDS staff becomes aware of a potential participant transitioning to the community that has not completed the survey, a request for the survey shall be made by notifying the SMH Project Director’s staff.
- Tracking the participant and scheduling surveys beyond the first year are not the responsibility of DHSS.
- SMH participants may refuse to participate in the Quality of Life surveys; any such refusal shall be documented in the SMH Database and the HCBS electronic case record.
Participation in the SMH program is limited to 365 days of community residence (one year) following the participant’s actual transition back to the community. Hospital and SNF days are not counted toward this time period.
The TC is required to make at least monthly contact with the participant throughout the year. Extensive tracking of SMH participants is required by CMS; therefore, the TC shall obtain as much information as possible during the monthly contacts.
Any information or incident that is critical to the health and welfare of the participant shall be documented in the SMH Database and the participant’s electronic case record. The TC shall notify DSDS staff when documentation has been added to a participant’s electronic case record. Examples include, but are not limited to:
- Hospitalization or re-institutionalization (including the reason)
- Critical incidents which could harm the participant such as abuse, neglect or exploitation
- Emergency situations that could endanger the health and welfare of a participant and may lead to a critical incident if not addressed. Situations could include:
- lack of transportation to a medical appointment
- life support equipment repair or replacement needed
- critical health issues
- direct service/support workers not showing up
- ambulance calls/ER visits, injuries/accidents
- Involvement with the criminal justice system
When there is an inpatient admission to a SNF for more than thirty (30) days, the participant shall be disenrolled from SMH. However, the participant can be re-enrolled for SMH services without re-establishing the sixty (60) day SNF residency requirement if they are able to return to their community residence. Any inpatient days would not be counted toward the 365 days allowable during the first year.
In some cases, the SMH participant’s circumstances may change to the extent that continued participation in the program is not appropriate. In that event, DSDS staff shall gather documentation outlining the reasons that the disenrollment of the participant is being recommended. Those reasons may include, but are not limited to, the following:
- The participant has transitioned to the community, and it is determined that the health and welfare of the participant can no longer be assured in a community setting
- The participant is no longer Medicaid eligible
- The participant has moved to a non-qualified living arrangement
Documentation shall describe the issues and behaviors which resulted in this recommendation, as well as collateral contacts with other persons and agencies involved in the participant’s plan.
After review of all information, DSDS staff will document the decision in the participant’s electronic case record. If the SMH participant is disenrolled or denied services, DSDS staff shall send an Adverse Action Notice to the participant. The SMH participant has the right to appeal the decision, following the Adverse Actions and Appeal and Hearing [NEEDS LINK] processes outlined in the HCBS Manual. DSDS staff shall also notify SMH DSDS oversight staff and the SMH Project Director when a participant is no longer enrolled for SMH.
Prior enrollment as a SMH participant does not disqualify a person from re-enrollment if they return to a community setting. DSDS staff shall review previous circumstances to determine the likelihood of a successful transition and obtain approval from DSDS Supervisor and the SMH Project Director prior to reenrolling the participant. All SMH criteria must be met in order to re-enroll.
7.00 Appendix 1 Show Me Home Services Specialist
Home and Community Based Services Manual
Region 1 – includes the following counties: Barry, Barton, Bates, Cedar, Christian, Dade, Dallas, Douglas, Greene, Henry, Hickory, Howell, Jasper, Lawrence, McDonald, Newton, Oregon, Ozark, Polk, St. Clair, Shannon, Stone, Taney, Texas, Vernon, Webster, and Wright.
Gabriel Adkins
Phone: 417/895-5789
Region 2 – includes the following counties: Bollinger, Butler, Cape Girardeau, Carter, Dent, Dunklin, Iron, Jefferson, Madison, Mississippi, New Madrid, Pemiscot, Perry, Reynolds, Ripley, St. Francois, Ste. Genevieve, Scott, Stoddard, Washington, and Wayne.
Laurie Bell
Phone: 573/290-5150
Region 3 – includes St. Louis County and City of St. Louis.
Nan Downing
Phone: 314/340-7495
Region 4 – includes the following counties: Andrew, Atchison, Benton, Buchanan, Caldwell, Carroll, Cass, Chariton, Clay, Clinton, Daviess, DeKalb, Gentry, Grundy, Harrison, Holt, Jackson, Johnson, Lafayette, Livingston, Mercer, Nodaway, Pettis, Platte, Ray, Saline, and Worth.
Steven Wright
Phone: 816/889-2724
Region 5 – includes the following counties: Adair, Audrain, Boone, Callaway, Camden, Clark, Cole, Cooper, Crawford, Franklin, Gasconade, Howard, Knox, Laclede, Lewis, Lincoln, Linn, Macon, Maries, Marion, Miller, Moniteau, Monroe, Montgomery, Morgan, Osage, Phelps, Pike, Pulaski, Putnam, Ralls, Randolph, St. Charles, Schuyler, Scotland, Shelby, Sullivan, and Warren.
Rachel Beyer
Phone: 660/372-6109
7.00 Appendix 6 SMH/MFP Approval Notice
Home and Community Based Services Manual
The Show-Me Home (SMH) / Money Follows the Person Demonstration (MFP) Approval Notice provides notification to the Transition Coordinator (TC) of the participant’s eligibility for SMH enrollment. The notice includes information necessary for the TC to continue transition planning and ensure the participant’s health, safety and welfare needs are addressed appropriately.
INSTRUCTIONS
This form is completed by the SMH Services Specialist [NEEDS LINK]
- Enter participant’s name and DCN
- Enter date the notice is completed
- Enter date participant’s eligibility for MO HealthNet benefits will be reviewed
- Enter participant’s reported income
- Enter location and type of housing preferred by participant, along with any other details known
- Enter any details regarding substance abuse history
- Enter criminal history information that could impact transition
- Provide details regarding any challenges to the participant’s ability to transition to a community setting, including emergency plans, financial issues, housing, etc.
- Enter financial concerns that may need to be addressed, including living expenses, etc.
- Enter any community supports needed by the participant
- Enter participant’s health conditions and issues
- Enter details regarding need and eligibility for Home and Community Based Services (HCBS)
- Indicate whether facility staff supports participant’s ability to transition, along with any details available
- Include any miscellaneous details that may be appropriate for transition planning
- Enter the SMH Services Specialist's name, phone number and e-mail address
DISTRIBUTION
The SMH/MFP Approval Notice shall be forwarded to the TC, along with a copy of the completed Participation Agreement. A copy shall also be provided to SMH DSDS oversight staff and the SMH/RC’s supervisor. A copy shall be uploaded to the participant’s electronic case record.
7.00 Appendix 7 Ombudsman SMH/MFP Referral Instructions
Home and Community Based Services Manual
The Missouri Long-Term Care Ombudsman Program (LTCOP) recruits and trains volunteers that visit residents in all types of long-term care facilities. These volunteers may interact with residents in Skilled Nursing Facilities (SNF) that express a desire to return to the community. When that happens, the volunteer contacts the Regional Ombudsman Coordinator (ROC) and a Show-Me Home (SMH)/Money Follows the Person Demonstration (MFP) referral is made on the resident’s behalf.
Instructions
Completed by the ROC
- Name
- Email to SMH@health.mo.gov
- Date completed
Referral Section
Completed by the ROC
- Facility name, address, and telephone number
- Resident’s name, date of birth, SSN, and DCN
- Date resident entered the facility
- Resident’s health conditions and other information that could impact the ability to return to a community setting
- Additional pages may be attached if necessary.
Disposition Section
Completed by the Show Me Home (SMH) Services Specialist within 30 days of the date of referral
- Indicate if the resident is eligible
- Indicate date of enrollment for SMH services
- Indicate if the resident is not enrolled in SMH and check all applicable reasons
- Indicate if the participant is approved for MFP but does not meet level of care (LOC) to receive Home and Community Based Services (HCBS)
- Enter the SMH Service Specialist's name and telephone number
Comments
Comments may be entered by the ROC and/or the SMH Services Specialist as necessary. Information could include details on the resident’s community support network, needed resources, potential challenges to transition, etc. Additional pages may be attached if necessary.
Distribution
Upon completion by the ROC the following shall occur:
- The referral is faxed to SMH DSDS oversight staff
- SMH DSDS oversight staff forwards to the appropriate SMH Services Specialist
At disposition, the following shall occur:
- The SMH Services Specialist or DSDS staff shall fax a copy back to SMH DSDS oversight staff
- Ensure a copy is uploaded to the participant’s electronic case record when applicable
SMH DSDS oversight staff shall:
- Provide a copy of the completed form to State LTCOP staff
8.00 Abuse, Neglect and Exploitation
Home and Community Based Services Manual
The Missouri Department of Health and Senior Services (DHSS), Division of Senior and Disability Services (DSDS) has statutory authority (192.2415, RSMo) for investigating all allegations of Abuse, Neglect, and Exploitation (ANE) of eligible adults, age 60 and older or age 18-59 with a disability, with a protective service need. This includes eligible adults that are unable to protect his or her own interests or adequately perform or obtain services which are necessary to meet his or her essential human needs.
Mandated reporters are required by law (192.2475, 565.188, 208.912, and 198.070, RSMo) to report suspicions or allegations of ANE immediately to the DSDS Central Registry Unit (CRU) at 800-392-0210. Mandated reporters do not have to witness the ANE in order to make a report. Information gained from a secondary source may reveal ANE and those instances shall also be reported to CRU.
Mandated Reporting of Abuse/Neglect
The law requires mandated reporters to report any suspected abuse or neglect regarding eligible adults, age 60 and older or age 18-59 with a disability, residents of facilities, and Home and Community Based Services (HCBS) participants. A mandated reporter shall immediately report to CRU any situation in which he/she:
- Has reasonable cause to believe that an HCBS participant has been abused or neglected as a result of HCBS (192.2475, RSMo); or
- Has reasonable cause to suspect that a person sixty years of age or older has been subjected to abuse or neglect (565.188, RSMo); or
- Observes a person sixty years of age or older being subjected to conditions or circumstances which would reasonably result in abuse or neglect (565.188, RSMo); or
- Believes that a participant has been abused or neglected as a result of the delivery or failure to deliver Personal Care Assistance within the Consumer-Directed Model (CDS) (208.912, RSMo); or
- Believes that a resident of a facility has been abused or neglected (198.070, RSMo).
Reporter Immunity
Reporters (witnesses) who report (testify) in good faith or cooperate in the administrative or judicial proceedings arising from a report which alleges abuse, neglect, misappropriation of funds/property, or falsification of service delivery documents of HCBS shall be immune from criminal or civil liability for making a report or testifying.
CRU is the central point of intake for reports of ANE. CRU operates from 7 a.m. to midnight, 365 days a year. When calling CRU, DSDS or its designee, shall have available as much information regarding the situation occurring as possible. This includes, but is not limited to:
- The reported adult’s (RA) name, address, and phone number;
- The alleged perpetrator (AP) of the ANE and relationship to the RA, if any;
- Nature and extent of the RA’s condition;
- A description of the current situation and any information regarding the nature of the ANE;
- The date, time, and frequency of event(s);
- Any involved persons or witnesses to the event;
- Name, address, and phone number of any person responsible for the RA’s care; and
- The reporter’s name and daytime phone number.
I. Abuse
The infliction of physical, sexual, or emotional injury or harm including financial exploitation by any person, firm or corporation (192.2400, RSMo).
A. Physical abuse: The infliction of physical injury or harm by any person, firm or corporation in accordance with section 192.2400, RSMo. Physical injury or harm may include but is not limited to punching, kicking, striking, wounding, burning, choking, restraining, etc. Other examples include: mistreatment or maltreatment of the eligible adult in a brutal or inhumane manner; handling the eligible adult with more force than is reasonable or apparently necessary under the circumstances; physical contact with an eligible adult knowing it will be regarded as harmful; placing an eligible adult in apprehension of immediate physical injury. Actual observable injury is not required.
B. Sexual abuse: The infliction of sexual injury or harm by any person, firm or corporation in accordance with section 192.2400, RSMo. Sexual injury or harm is considered the result of any actions of a sexual nature inflicted upon an eligible adult by another person, when the eligible adult has not given or is incapable of giving consent. This may involve the use of forcible compulsion. Forcible compulsion means either the use of physical force that overcomes reasonable resistance or a threat, express or implied, that places a person in reasonable fear of death, serious physical injury or kidnapping. Sexual injury or harm includes rape or molestation and may include but is not limited to: punching, striking or wounding a person in the genitals or the breast, touching of another person with the genitals or any touching of the genitals or anus of another person, or the breast directly or through clothing for the purpose of arousing or gratifying sexual desire of any person, promoting/observing activities of the eligible adult for sexual purposes, failure to prevent inappropriate activity observed by a third person when it is known or believed that the eligible adult is at risk of harm or injury, etc.
C. Emotional abuse: The infliction of emotional injury or harm by any person, firm or corporation in accordance with section 192.2400, RSMo. Emotional injury or harm includes incidents that would cause emotional distress to a reasonable adult regardless of age or physical/mental impairment. Emotional injury or harm may result from acts of verbal abuse or the act of purposefully withholding or withdrawing affection from the eligible adult with the intent to provoke distress. Other examples include referring to an eligible adult in their presence with profanity or in a demeaning, undignified, or derogatory manner, etc.
II. Neglect
The failure to provide services to an eligible adult by any person, firm or corporation with a legal or contractual duty to do so, when such failure presents either an imminent danger to the health, safety, or welfare of the client or a substantial probability that death or serious physical harm would result (192.2400, RSMo).
A. Passive neglect: Careless conduct or a breach of a duty resulting in injury by the unintentional failure to fulfill a caregiving obligation or failure to provide based on ignorance.
B. Active neglect: Careless conduct or a breach of a duty resulting in injury by the intentional failure to fulfill caregiving needs (for example, the deliberate denial of food or medicine).
III. Financial Exploitation
The crime of Financial Exploitation involves allegations that a person (whether a family member, joint tenant, caregiver/attendant, or someone who has assumed fiduciary responsibility) has knowingly by deception, intimidation, undue influence, or force obtained control over an eligible adult’s property with the intent to permanently deprive the eligible adult benefit or possession of his or her property as directed in 570.145, RSMo.
IV. Misappropriation of Funds/Property of In-Home Services Participants or CDS Consumers:
Reports which allege an HCBS provider, its employee, or a personal care attendant is believed to have diverted personal property or funds from an HCBS participant for personal use (or the use of the provider) meet the statutory definition of Misappropriation of Funds/Property of in-home services participants or CDS consumers. Such investigations may result in a referral to the Employee Disqualification List (EDL) (APS Policy 1702.90[FILE NOT FOUND])
V. Falsification of Documents, Verifying Service Delivery:
Allegations of falsification of any documents verifying service delivery to an HCBS participant by any HCBS provider employee or personal care attendant are considered Class A misdemeanors as directed in 192.2480, RSMo, and may result in a referral to the EDL (APS Policy 1702.90[FILE NOT FOUND]).
VI. Misappropriation of Funds of Elderly or Disabled Nursing Facility Residents:
Reports which allege that a responsible party has misappropriated funds or failed to pay for care of an elderly person in a facility meet the statutory definition of misappropriation of funds of elderly nursing facility residents. Such breach of fiduciary duty is a criminal offense as defined in the statute:
"Misappropriation of funds of elderly or disabled nursing home residents, penalty:” 198.097(1), RSMo. Any person who assumes the responsibility of managing the financial affairs of an elderly or disabled person who is a resident of any facility licensed under this chapter shall be guilty of a Class E felony if such person misappropriates the funds and fails to pay for the facility care of the elderly person or disabled person.
Failure to remit funds of a Medicaid eligible facility resident to a licensed facility is also addressed under the Crime of Financial Exploitation 570.145 (7)(1), RSMo.
8.00 Appendix 1 Abuse, Neglect and Exploitation Indicators
Home and Community Based Services Manual
The following list contains typical indicators of abuse, neglect, and exploitation (ANE) for the reported adult (RA). This list, while not all inclusive, should serve as a guide for making a report of ANE.
ABUSE
- PHYSICAL INDICATORS:
- Unexplained bruises and welts
- Bruises in the shape of an object
- Unexplained fractures
- Unexplained burns
- Unexplained lacerations or abrasions
- Broken bones
- Injuries on the neck, bottom of feet or genitals
- SEXUAL INDICATORS:
- Sudden interest in sexual issues
- Questions regarding pregnancy
- Bruising on breasts or genital area
- Acting out inappropriately in a sexual manner
NEGLECT
- ENVIRONMENTAL:
- Excessive garbage in home
- Inadequate/exposed wiring
- Rodent or insect infestation
- Inadequate/unsafe structure such as holes in walls or ceiling of home
- Inadequate/ no food in home
- Inadequate/no utilities or shut-off notices for utilities
- Inadequate/no plumbing or running water
- PHYSICAL:
- Inadequate/lack of personal hygiene: not clean, has bad odor, hair matted or tangled
- Soiled clothing/bedding or same clothing all the time
- MEDICAL:
- Inadequate/lack of essentials: eyeglasses; hearing aid; teeth; walker; crutches; wheelchair; and/or other prosthetic devices.
- Excessive number of old medicine bottles with outdated prescriptions
- Inadequate/lack of medical care
- Malnourishment and/or dehydration
- Unhealed sores/untreated injuries
- Untreated infections/conditions
EXPLOITATION
- Eviction notices
- Disparity between income/assets and lifestyle
- Sudden or numerous changes to wills or powers of attorney
- Property or money missing
- Sudden change in banking practices
- Unexplained/unauthorized bank withdrawals
- Sudden lack of money or inability to purchase essentials
- Unpaid bills
BEHAVIORAL INDICATORS
- Destructive behaviors unusual to the reported adult
- Yells obscenities at others
- Assaults others
- Tears up belongings of others or themselves
- Threatens self-harm or suicide
- Refuses needed life-sustaining services (medical care)
- Inappropriately displays rage in public
- Steals without an apparent need for the things stolen
- New onset of depression or apathy
- Anger
- Withdrawal - stops talking to others, pulls away from usual social pursuits
8.00 Appendix 2 Abuse, Neglect and Exploitation Alleged Perpetrator Indicator List
Home and Community Based Services Manual
The following list, while not all inclusive, contains typical indicators of the alleged perpetrator’s (AP) behaviors or actions regarding abuse, neglect, and exploitation (ANE). This list, along with ANE Indicators list, should serve as a guide for making a report of ANE.
ABUSE
- Explanation of abuse not feasible
- Isolates reported adult (RA) from others
- Will not allow visitors
- Hides injuries which were not reported
- Past history of similar incidents
NEGLECT
- Explanation of neglect not feasible or not consistent with injury
- Does not provide needed personal or medical care
- Withholds food and/or medication
- Prolonged interval between treatment and injury
- Doctor hopping
- Inability to articulate care needs of RA
EXPLOITATION
- Implausible explanations about property/finances of the RA
- Financial problems/lack of money
- Transfers property and/or savings of individual
- Unexplained cash flow
- Evasiveness on payment of bills
- Excessive payment for care
- Unusual expenses with no visible means of income
BEHAVIOR INDICATORS
- Lack of physical, facial, or eye contact
- Hostile, secretive, or frustrated
- Shows little concern or blames RA
- Blaming someone or something else for problems
- Denial of problem
- Resentment toward RA
- Treats RA as a child
- Unrealistic expectations of RA
8.05 Participant Case Records
Home and Community Based Services Manual
The information in the Home and Community Based Services (HCBS) Web Tool is the participant’s official electronic record. DSDS staff shall document and upload information accurately and timely in order to ensure the participant’s record is up to date. HCBS participant’s records shall be maintained for seven (7) years.
The Department of Health and Senior Services (DHSS), Division of Senior and Disability Services (DSDS) may receive a request for a copy of the HCBS participant’s case record. A caserecord request shall be processed by the appropriate DSDS staff. DSDS staff shall document and upload information accurately and timely in order to ensure the participant’s case record is up to date. Any verbal request for the participant case record shall be documented in Case Notes in the participant’s electronic case record. Any written request shall be uploaded to the participant’s electronic case record, with corresponding notation in Case Notes. DSDS staff shall complete the case record request no later than thirty (30) business days from receipt of the request. Staff shall refer to Adult Protective Services Policy 1706.40[PAGE NOT FOUND] for guidance in processing requests received for hotline investigation records.
A participant and/or their legal representative, acting on behalf of the participant, may request the participant’s electronic case record either verbally or in writing using the Authorization for Disclosure of Consumer Medical Health Information Form. The Authorization for Disclosure should be uploaded to the participant’s electronic record when received. Any requestor, other than the participant or legal representative, must provide an Authorization for Disclosure of Consumer Medical Health Information Form signed by the participant or legal representative. The participant and/or legal representative can ask for the electronic case record be sent directly to them to provide to others.
Additionally, DSDS staff may receive requests for documentation of HCBS eligibility. A participant and/or their legal may request this information either verbally or in writing using the Authorization for Disclosure of Consumer Medical Health Information Form. The participant may request the records be sent directly to them or, if the records are to be sent to the participant’s legal representative, staff shall advise the legal representative to use this form. Any requestor other than the participant or legal representative must provide an Authorization for Disclosure of Consumer Medical Health Information Form signed by the participant and/or legal representative.
The participant’s information shall be entered into the Participant Level of Care (LOC) Eligibility Letter (see Policy 8.00 Appendix 8[PAGE NOT FOUND]) to respond to these types of requests. The Participant LOC Eligibility Letter shall only be completed in response to a request for documentation of eligibility. This letter is only to be utilized after the initial assessment or reassessment has been completed.
A subpoena for records may be received requesting a copy of the participant’s case record. For this type of request, prior to the release of the record, either 1) the participant or legal representative will need to authorize the disclosure through use of the Authorization for Disclosure of Consumer Medical Health Information or 2) the request must be reviewed by the Office of General Counsel (OGC) for validity.
Once it is determined that the participant’s case record is to be released, DSDS staff shall perform a thorough review of the record and redact any confidential information prior to release of the record.
Items to be redacted are as follows:
- Protected Health Information (PHI) regarding persons other than the HCBS participant.
- Social Security Number (SSN)/Departmental Client Number (DCN) of persons other than the requesting party.
- SSN/DCN of the participant may need to be redacted in situations where asubpoena has been received for a copy of the case record.
- Information received from third parties (e.g., DMH, hospital records, and physician records).
Requested documents may include but are not limited to the following:
- Prescreen
- All case notes
- InterRAI HC
- Saint Louis University Mental Status (SLUMS)
- Self-Direction Assessment Questions
- Participant Choice Statement
- Health Care Professional Inquiry
- Adverse Action Information
- HCBS Assessment Attestation
8.00 Appendix 4 General Health Evaluation & Level of Care Recommendation Instructions
Home and Community Based Services Manual
The Home and Community Based Services (HCBS) provider nurse shall complete the General Health Evaluation and Level of Care Recommendation (GHE) form for all agency model personal care participants during the semi-annual GHE nurse visits. The GHE form shall be uploaded to the participant’s electronic case record promptly after the date of completion, but no later than ten (10) working days after the nurse visit. The GHE form may also be completed for participants during their regular monthly nurse visits; however, uploading a copy to the participant’s electronic case record is unnecessary unless there has been a significant change in the participant’s condition.
The form shall be completed in its entirety for each semi-annual evaluation to best serve the participant's needs.
Instructions
A: Participant Information
The following information shall be entered in the appropriate fields:
- DATE: Enter the date the form is completed
- PARTICIPANT: Enter NAME, DCN, DATE OF BIRTH, ADDRESS, COUNTY, and PHONE NUMBER
B: Provider Nurse Information
The following information shall be entered in the appropriate fields:
- NAME OF PROVIDER NURSE: Enter the name of the nurse completing the evaluation
- PROVIDER: NAME and PHONE NUMBER
C: Reason for Nurse Visit
- Select all boxes that apply and explain when requested
Note: DSDS shall be notified via the online Person Centered Care Plan (PCCP) request form of any needed changes identified during the visit.
D: Health Care Information
The following information shall be entered in the appropriate fields.
- PRIMARY HEALTH CARE PROVIDERS: List all pertinent health providers currently treating the participant
- CURRENT DIAGNOSIS/CONCERNS
- RECENT HOSPITALIZATIONS, SURGERIES, OR PROCEDURES
- ANY ADDITIONAL HEALTH INFORMATION: List any upcoming surgeries, procedures, or additional health information relevant to the participant
E: Allergies and Vital Signs
The information shall be entered in the appropriate fields.
Note: A1C may not be available for all participants.
F: Cardiopulmonary Assessment
- Select the appropriate boxes and provide the additional information requested
G: Integumentary Assessment
- Select the appropriate box
- Concerns can be indicated on the available body diagram
H: Level of Care Determination
This section shall, at minimum, be completed during the semi-annual GHE and LOC Recommendation and at any time requested by DSDS staff or its designee.
- Evaluate and mark the box with the corresponding point value for each of the twelve (12) LOC categories
- Add a comment to each corresponding section for any additional information used to determine the point value assigned
I: Current Authorization Review
- Select the appropriate boxes and explain when requested
- Complete the Emergency Back-up Plan
- Select the appropriate risk box (see Policy 4.15 Risk Indicators section)
- Document directions to locate, safety concerns, or additional comments
J: Veteran History
- Select the appropriate boxes
Signatures
The form must be signed and dated by both the participant and the HCBS provider nurse. If an LPN completes the evaluation, the supervisory RN or physician must sign and date it in the appropriate fields.
8.00, Appendix 9 Person Centered Care Plan Form
Home and Community Based Services Manual
The Person Centered Care Plan (PCCP) form shall be utilized by Home and Community Based Services (HCBS) providers when requesting care plan changes for HCBS participants. It is not to be utilized to report abuse, neglect, or exploitation or disclose hotline information. Mandated Reporters are required to report these concerns to the Adult Abuse & Neglect Hotline via the Online Reporting System.
The form shall be completed in its entirety to best serve the needs of the participant. Information can be entered into the fillable areas.
INSTRUCTIONS
PARTICIPANT NAME: Enter the participant’s last name and first name
DCN: Enter the participant’s Departmental Client Number (DCN)
DOB: Enter the participant’s full date of birth.
PHONE NUMBER: Enter the participant’s current phone number with the area code
ALTERNATIVE PHONE NUMBER: Enter the participant’s alternative phone number with the area code, if applicable
PARTICIPANT EMAIL: Enter the participant’s e-mail address, if applicable
PHYSICAL ADDRESS: Enter the participant’s full address where they currently reside
MAILING ADDRESS: Enter the participant’s complete mailing address if different from the physical address
CARE PLAN CHANGE REQUEST
Utilize the dropdown for the following:
- Select the task or waivered service that is being requested in each area
Utilize the columns to the right of the task to select the following actions:
- Request to add, increase, decrease, or remove the task or waiver
- If more than two actions are requested, add the information in the “Details of Requests/Additional Information” section.
CLOSING REQUESTED
This section should only be used when the participant’s HCBS authorization and case need to be closed. In this circumstance, select “Yes”.
Utilize the dropdown to select the following:
- Reason the participant’s authorization for HCBS needs to be closed
- All participants who voluntarily request all HCBS authorizations be closed must contact DSDS to confirm.
- Enter the anticipated closing date
NOTE: If a case closing is a request for any other reason besides the reason listed in the dropdowns, utilize the “Other Reason” field to provide an explanation.
21-DAY NOTICE
This section should only be used by Agency Model (IHS) providers when a participant has been given a formal 21 Day Notice.
- In this circumstance, select “YES”
- Upload a copy of the 21 Day Notice to the Documents tab in the participant’s electronic case record
- Enter the participant’s last day of service, as noted on the 21 Day Notice
PROVIDER CHANGE
This section should be used to communicate instances where a participant needs or requests a new HCBS provider.
- In this circumstance, select “YES”
- Indicate if the request is to switch from one program to another
Select the reason for the provider change request based on guidance below:
- Participant Choice: Select when the participant requests a new provider
- Provider Choice: Select when the provider is unable/unwilling to continue providing services
- Unable To Self-Direct: Select when there are concerns that the participant is unable to direct their own care
- Moved Out of Service Area: Select when the participant moved out of the provider’s coverage area
Enter the proposed new provider’s name, if applicable.
Enter the proposed new provider’s phone number, if applicable.
Indicate if the new provider is willing and able to accept the participant as a client.
- Provide the tentative start date for the proposed new provider.
- All provider changes require DSDS approval. Services with the proposed provider may not start until authorized by DSDS.
Indicate if the participant needs a provider list to select a new provider.
- DSDS will utilize the participant’s e-mail address to send the provider list, if applicable.
- If the participant does not have an e-mail address, DSDS will mail the participant a provider list.
DETAILS OF REQUEST/ADDITIONAL INFORMATION
Add any additional information pertinent to the request being submitted.
REQUESTOR INFORMATION
The following shall be entered:
- Name
- Affiliation
- Phone Number
- E-mail of the person submitting the request
OTHER RESPONSIBLE PARTY/LEGAL GUARDIAN CONTACT INFORMATION
The following shall be entered:
- Name, Phone
- Number
- Alternate Phone Number
- Mailing Address
- E-mail of the guardian or other responsible party of the participant
9.00 Confidentiality Requirements
Home and Community Based Services Manual
During the normal course of business, the Department of Health and Senior Services (DHSS), Division of Senior and Disability Services (DSDS) gathers extensive personal and confidential information regarding individuals that have a need for Home and Community Based Services (HCBS). All such information shall be held in confidence and shall only be disclosed when there is a need to know (e.g. arranging for service delivery) and/or an appropriate authorization by the participant is in place.
DSDS is also required to comply with the provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) as amended by the Health Information Technology for Economic and Clinical Health Act (HITECH) (PL-111-5) (collectively, and hereinafter, HIPAA) and maintain the confidentiality of all HCBS participants. All DSDS employees shall ensure they are familiar with DHSS Administrative Policies related to HIPAA and general confidentiality issues, including the following:
- Chapter 11 – Rules of Personal Conduct and Responsibility, specifically
- Policy 11.6[SITE CAN'T BE REACHED] Code of Conduct – Confidential Information; and
- Policy 11.6A[SITE CAN'T BE REACHED] Confidentiality Agreement;
- Chapter 19[SITE CAN'T BE REACHED], HIPAA – in its entirety, and;
- Chapter 22[SITE CAN'T BE REACHED], Information Technology, in its entirety.
During all phases of the HCBS assessment process, DSDS shall hold all protected health information (PHI) as confidential and shall only use PHI to perform functions, activities, or services related to the provision of HCBS. DSDS shall implement administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity and availability of PHI that is created, received, maintained, or transmitted on behalf of the HCBS participant.
All HCBS participants, during the face-to-face visit for initial assessment, shall be given a copy of the DHSS Notice of Privacy Practices(Notice). DSDS shall explain this Notice to the participant and have the participant sign the Privacy Policies Acknowledgement (PPA) form stating the Notice was received. If the participant has a guardian, the guardian must sign the PPA form.
PHI will be made available only to the guardian, when applicable, and to any person the participant designates as an ‘authorized representative.’ In order to designate an authorized representative, permission must be given by the participant. This permission may be given verbally in the presence of the person to be designated, or in writing by completing and signing the Authorization for Disclosure of Consumer Medical/Health Information (Authorization) form.
- Any time hard copies are released to someone other than the participant or the guardian, a fullycompleted Authorization must be in place prior to the release of information.
Once an authorized representative has been designated, DSDS will be able to release pertinent information in the participant’s person centered care plan (PCCP) until the Authorization expires or is rescinded.
Note: If a participant’s case is closed and later reopened for HCBS, the participant must be provided with a current copy of the Notice and sign a new PPA form.
9.00 Appendix 5 Acknowledgement Form Instructions
Home and Community Based Services Manual
The Privacy Policies Acknowledgement (PPA) form documents a Home and Community Based Services (HCBS) participant’s receipt of the Department of Health and Senior Services’ (DHSS) Notice of Privacy Practices [BROKEN LINK]. This acknowledgment is required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) as amended by the Health Information Technology for Economic and Clinical Health Act (HITECH) (PL-111-5) (collectively, and hereinafter, HIPAA). The Notice explains how DHSS may use and/or disclose the participant’s medical information. It shall be given to all participants at the initial face-to-face assessment.
Instructions
The following shall be entered:
- Participant’s first name, middle initial, and last name
- Participant's birth month, day, and year
- Social Security Number only if the individual does not have an assigned Departmental Client Number (DCN)
- Participant’s DCN
The person receiving the Notice shall print their first name, middle initial and last name.
- This will be the participant, their legal guardian, or any individual named in a Durable Power of Attorney for Health Care (DPOA-HC) that has been invoked.
Obtain the signature of the person whose name is printed on the form and who is receiving it, and include the date.
- Participants who cannot sign may mark with an “X.”
- If the person who signs the PPA form is the guardian or DPOA-HC, a copy of the document granting legal authority to act on behalf of the participant must be uploaded into the participant’s electronic case record.
- The only time a parent may sign is if the participant is a minor child.
Check the appropriate box to describe the relationship between the participant and the person who signed the PPA form.
- If the participant refuses to sign the form, DSDS staff shall check the box “client refused to sign form.”
The following shall be completed by DSDS staff:
- Name and address of the bureau or program that provided the Notice to the participant.
- If DSDS is present when the PPA form is completed, they shall sign and print their name and enter the date
Distribution
The original form shall be uploaded into the participant’s electronic case record. Upon request, a copy shall be given to the participant.
Note: If a participant’s case is closed and later reopened for services, the participant must be provided with a current copy of the Notice and sign a new PPA form.
9.00 Appendix 6, Authorization For Disclosure Of Consumer Medical/Health Information
Home and Community Based Services Manual
Overview
The Authorization for Disclosure of Consumer Medical/Health Information (Authorization) is a statewide form implemented by multiple state agencies, including the Department of Health and Senior Services (DHSS), in response to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) as amended by the Health Information Technology for Economic and Clinical Health Act (HITECH) (PL-111-5) (collectively, and hereinafter, HIPAA). This form serves as written documentation to obtain and/or release protected health information (PHI) as required by HIPAA. PHI is defined as any individually identifiable health information which would include:
- Participant case record information
- Demographic information (name, address, date of birth, etc.)
- Physical and mental health information contained in the case
This form provides maximum protection for the participant’s privacy and serves as a legal means of documenting the participant’s permission for information sharing. Use of this form also documents what information is released and the purpose of the disclosure. This form shall be completed any time PHI will be released in hard copy form to a person or entity other than the participant, guardian, or other legal representative. It may also be used to document permission to share information verbally, when necessary as outlined in the Confidentiality Requirements[NEEDS LINK] policy.
The authorization becomes effective on the date of signature and expires one year from that date unless it is revoked by the participant prior to that time.
Instructions
This form shall be typed or clearly written in ink prior to being signed by the participant.
- No blank or partially completed forms are to be signed by the participant.
- DSDS staff completing the form shall review all the information contained in the document with the participant
Enter the information on the form as outlined below:
- Enter the name of the person authorizing the release of the participant's medical/health information
- This may be the participant, a legal guardian, or an individual named as a durable power of attorney for health care (DPOA-HC) that has been invoked.
- If the authorizing individual is not the participant, a copy of the document granting legal authority to act on behalf of the participant must be attached.
- If the person is deceased, the document granting legal authority would be papers appointing a personal representative.
- Check the appropriate field to indicate the entity providing medical/health information about the participant
- When using the ‘Other’ field, enter the name of the specific entity.
- Enter the participant’s full legal name, Departmental Client Number (DCN), and date of birth
- Enter the Social Security Number only if the participant does not have an assigned DCN
- This may be the participant, a legal guardian, or an individual named as a durable power of attorney for health care (DPOA-HC) that has been invoked.
Purpose of Disclosure
The following shall be completed:
- List the specific dates of services included in the requested records
- The phrase “any and all” is not specific and shall not be used.
- Check the appropriate box to indicate the entity that will receive the information
- When using the ‘Other’ box, enter the name of the specific entity and complete the address information.
- Check all applicable purposes for the disclosure.
- If the boxes provided are not applicable, mark “other” and write in the purpose.
- Check all applicable information to be disclosed
- When the requested information is not listed, mark other and provide a description of the specific information.
Review of Information with Participant
The information obtained shall be reviewed with the participant.
- Obtain the participant’s signature (when there is no legal guardian or DPOA-HC) and enter the date signed
- Obtain the witness's signature and enter the date signed
- Obtain the signature of legal guardian, DPOA-HC, or other legal representative, when applicable
- This signature should match the name of the person authorizing the disclosure.
Authorization to Disclose Substance Abuse Treatment
When the form is completed to request disclosure of substance abuse treatment information, the participant must also review, sign and date this section.
Revocation
This section shall be completed if the participant or the individual with legal authority to act as a representative for the participant wishes to revoke the authorization. The participant or representative must send the form to the department, facility, agency, or entity indicated at the beginning of the form.
- Enter the date of revocation
- Enter the participant’s name
- Obtain signature of the participant or their legal representative, as appropriate
Distribution
- One copy shall be provided to the participant/representative
- A copy shall be sent to the agency disclosing/releasing the information
- A copy shall be uploaded into the participant’s electronic case record
Agency Model Personal Care (In-Home Services)
Home and Community Based Services Manual
Agency Model Personal Care (In-Home Services)
Assisted Living Facility/Residential Care Facility Personal Care
Home and Community Based Services Manual
Consumer Directed Services/Transportation (Essential Transportation)
Home and Community Based Services Manual
Consumer Directed Services/Transportation (Essential Transportation)
Overview
Home and Community Based Services Manual
The purpose of this document is to clarify policy and apply it situationally. This is not intended to create new policy. The contents are subject to change based on revisions to statutes, regulations or Centers for Medicare and Medicaid Services (CMS) requirements. Each question and answer is phrased and categorized based on how it was presented to the Division of Senior and Disability Services (DSDS) and may be applicable to other sections as well.
Structured Family Caregiving Waiver (SFCW)
Home and Community Based Services Manual
Structured Family Caregiving Waiver (SFCW)
Task Chart
Home and Community Based Services Manual
| Task | *Basic Personal Care | *Advanced Personal Care | Nursing Level of Care Tasks |
|---|---|---|---|
| Manual Assistance with self-administration of non-injectable medications | Physical assistance only-Opening medicine planner or bottles and guiding/steadying participant’s hand for oral medication and inhalants, oxygen and equipment – adding distilled water, changing tubing and cleaning equipment/ filter | Prompting participant, opening lockbox and guiding/steadying participant’s hand for ear and eye drops, steady hand for pin-prick blood sugar monitor/PT INR and read levels | Filling the medicine planner/ administration of injectable medications, filling insulin syringes, administering blood sugar check or PT INR check finger prick tests |
| Catheter Hygiene | N/A | Emptying and changing the bag, cleaning (soap and water around catheter site) for indwelling or suprapubic catheters, removal/replacement of external (condom/Texas, etc.) catheters only | Catheter change of indwelling or suprapubic catheters. |
| Bowel Program | N/A | Enemas (prepackaged), sphincter stimulation, suppository administration for participants w/o contraindicating rectal or intestinal condition, Malone Antegrade Continence Enema (MACE) for well healed stomas | Administration of all other enemas, removal of fecal matter digitally |
| Central Line Care | N/A | N/A | Flushing lines, dressings, blood draws |
| Ostomy Care-tracheostomies, gastrostomies and colostomies | N/A | Changing bags and/or wafer, and soap and water hygiene around a well healed ostomy site | Insertion of treatments or medications |
| Medicated lotion/ointment application | Application of nonprescription topical ointments or lotions | Application of prescription lotions, ointments and powders and/or dry aseptic dressings to unbroken skin (Stage I only) | Application of aseptic dressings to Stage II and above |
| Application of compression dressings/stockings | Application of Class I stockings/dressings | Lymphedema wraps and sleeves, and Class II dressings/stockings placement and removal of physician ordered orthotics. | Compression dressings/stockings higher than a Class II |
| Mobility/Transfer assistance | Assist with transfer/ ambulation when participant able to bear most of their own weight, gait belt for mobility assistance | Use of assistive devices for transfer (participant able to bear little to no weight), including mechanical/Hoyer, sit-to-stand, slide board, sling, Barton chair, trapeze, gait belts and pivot discs | N/A |
| Passive Range of Motion (PROM) | N/A | With physicians order, flexion of joint within normal range | N/A |
| Bathing | Assist with bathing including shampooing of hair | N/A | N/A |
| Toileting / Continence | Assist in transporting to/from restroom, changing of bed linens | N/A | N/A |
| Dietary | Assist with meal prep/ clean up, and eating/ feeding, including participants requiring softened, pureed, liquid, or prep with a thickening agent for their diet | N/A | Tube feeding |
| Dressing / Grooming | Assistance in dressing/ undressing, combing hair, nail care, oral hygiene/ denture care, shaving, application of Class I compression stockings | N/A | Nail care for participants who are diabetic, prescribed anticoagulants, diagnosed with peripheral vascular disease or with a compromised immune system |
| Medically Related Household Tasks: Homemaker Services | Cleaning kitchen, bath, living areas, changing linens, laundry (home/off site), iron/mend, washing windows and blinds, trash, shopping/errands, essential correspondence | N/A | N/A |
*CDS may complete all Basic Personal Care and Advanced Personal Care tasks