Medically Complex Children and Youth Guidebook

Foreword

Medically Complex Children and Youth Guidebook

The purpose of the Guidebook is to provide practical written guidance for any staff member who implements the Medically Complex Children and Youth (MCCY) Program, a program that serves medically eligible children with special health care and their families. The Bureau of Special Health Care Needs (SHCN) has been providing Administrative Case Management for the MCCY Program since 1989.

The MCCY Program provides service coordination and authorization for medically necessary in-home services for MO HealthNet recipients with special health care needs from birth to age 21. Special Health Care Needs Nurse Service Coordinators monitor services through assessments, regular home visits, medical records, and care plan review.

In an effort to provide condensed practical guidance, sections of the Guidebook merely provide a brief overview of content areas that have established written detailed information used for training and reference. The program recognizes supporting materials are dynamic and undergo changes often. All additional detailed materials referenced throughout the Guidebook will be maintained on the SHCN intranet. SHCN staff members are encouraged to reference the SHCN intranet for current information and discuss individual training needs with their supervisor.

The guidance provided has been developed and structured in a manner which will enhance the success of the MCCY Program. The MCCY Program framework assists in meeting the program philosophy and meets state and federal requirements of the MCCY Program and the Vision and Mission of the Missouri Department of Health and Senior Services (DHSS).

DHSS Vision: Healthy Missourians for Life.
DHSS Mission: To be the leader in promoting, protecting and partnering for health.

The MCCY Program is funded by multiple sources including Medicaid, Missouri state general revenue, and the federal Maternal and Child Health Bureau. The statutes and rules governing the MCCY Program are Sections 208.895.1 (referral timelines, provider guidelines), 208.906.1 (Personal Care (PC)), 208.912.1 (abuse and neglect), 208.915.1 (misappropriation of funds), 208.921.1 (denial of eligibility),1-208.924.1 (discontinuation of services), RSMo and 13 CSR 70-90.010 (Home Health), 13 CSR 70-91.010 (PC), and 19 CSR 70-95.010 (Private Duty Nursing (PDN)).

Federal Healthy Children and Youth Program

Medically Complex Children and Youth Guidebook

The MO HealthNet Division of the Missouri Department of Social Services (DSS), administers the Missouri Medicaid Program, commonly known as MO HeathNet. DSS, along with the U.S. Department of Health and Human Services, Center for Medicare and Medicaid Services (CMS), promulgates rules and regulations used in the administration of this program.

Nationally known as Early Periodic Screening, Diagnosis and Treatment (EPSDT), the federal HCY Program is a comprehensive, primary, and preventive health care program for MO HealthNet eligible children and youth under the age of 21 years. For further information on EPSDT refer to the State of Missouri MO HealthNet Manuals.

Components of the HCY Program include:

Routine preventative and medical screening
Lead Risk assessment
Immunizations
Authorization of HCY Case Management
Assessment and authorization of medically necessary in-home services

Every applicant under age 21 (or his or her responsible party) is informed of the federal HCY Program by the Family Support Division at the initial application for assistance. The participant is reminded of the federal HCY Program at each annual redetermination review.

The goal of the federal HCY Program is to have a health care home (medical home) for each participant; that is, to have a primary care provider who manages a coordinated, comprehensive, continuous health care program to address the participant’s health needs. The medical home should follow the screening periodicity schedule, perform interperiodic screens when medically necessary, and coordinate the participant’s specialty needs.

SHCN has a cooperative agreement with the DSS, MO HealthNet Division, to provide service coordination for fee-for-service MO HealthNet eligible participants enrolled in the HCY Program who require in-home services. SHCN HCY Service Coordinators (SCs) perform the following activities:

Authorization of HCY Case Management, delivered by a MO HealthNet case management provider (typically a Local Public Health Agency)*.
Assessment and authorization of medically necessary in-home services delivered by MO HealthNet providers, such as:
- Home Health Services
- Authorized Registered Nurse Visits
- Personal Care Services
- Advanced Personal Care Services
- Private Duty Nursing

Program Philosophy

Medically Complex Children and Youth Guidebook

The HCY Program respects the dignity of each individual and their family, and partners with participants and families to achieve coordinated, ongoing, comprehensive care within a medical home which will provide for successful transitions into adulthood.

Early identification and integration of resources will enable the best possible health outcomes with the greatest degree of independence within the community.

Core Values

The Program is guided by the following core values:

• Person-centered,

• Outcome oriented,

• Community inclusion,

• Participant, parent(s) and/or responsible party(ies) involvement in ongoing planning,

• Participant, parent(s) and/or responsible party(ies) responsibility for achieving independence, and

• Collaborative relationships in all areas.

Special Health Care Needs Mission

To develop, promote, and support community-based systems that enable the best possible health and greatest degree of independence for Missourians with special health care needs.

Vision

All Missourians with special health care needs will have equal access to comprehensive quality health services, enabling them to achieve their highest level of functioning.

Description of Individuals with Special Health Care Needs

Individuals with special health care needs are those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by individuals generally.*

*Adapted from the Maternal and Child Health Bureau (MCHB) of the Department of Health and Human Services, Health Resources and Services Administration (HRSA).

Program Description

Medically Complex Children and Youth Guidebook

The HCY Program provides service coordination and authorization for medically necessary in-home services for qualifying MO HealthNet participants 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 individuals to remain safely in their homes. Authorized services may include personal care, nursing care, and skilled nursing visits.

Services will be authorized when there is a medical need for a constant level of care exceeding the family’s ability to independently care for the child at home on a long-term basis. These services do not take the place of the parent(s)/responsible party(ies). Major commitments on the part of the child’s family and community are necessary to meet the child’s extraordinary needs and to ensure the child can be maintained safely in the home. The intention of the program is to support not replace the parent(s)/responsible party(ies).

Eligibility

To be eligible for HCY Program services, the participant must:

Be a Missouri resident
Be birth to age 21 years
Be enrolled in fee-for-service MO HealthNet
Need medically necessary in-home services

Service Coordination

SHCN Nurse Service Coordinators (SC) monitor services through assessments, regular home visits, medical records, and care plan review.

Service coordination includes:

Evaluation and assessment of needs
Identifying and accessing service providers
Service plan development and implementation
Coordination of services through resource identification and referral
Family support
Assisting in establishing a medical home
Transition planning
Prior authorization of medically necessary services, including:
- Private Duty Nursing (PDN)
- Personal Care Aide (PCA)
- Advanced Personal Care Aide (APCA)
- Authorized Registered Nurse visits (ARN)
- Skilled Nursing Visits (SNV)
- Administrative Case Management (ACM)

Service Coordination Role and Process

Medically Complex Children and Youth Guidebook

Special Health Care Needs (SHCN) Service Coordinators (SC) provide HCY case management activities for fee-for-service participants. These activities/responsibilities include, but are not limited to, the following:

Gather medical and insurance information to determine eligibility for the HCY Program.
Talk with the participant, parent(s) and/or responsible party(ies) about their current medical treatment.
Complete a comprehensive assessment of needs for the participant, parent(s) and/or responsible party(ies) including but not limited to identifying needs/goals and making referrals to meet those needs/goals, as appropriate.
Develop a service plan by identifying the goals of the participant, parent(s) and/or responsible party(ies) and determine the services, funding sources, and outcomes needed in order to reach these goals.
Complete necessary paperwork to obtain services and document the information in the SHCN Information System as per policy/procedure.
Evaluate if referrals are needed to resources to other programs or agencies outside of SHCN, and assist in accessing these services such as therapies, child care, counseling, medical equipment and supplies, financial assistance, and transportation. (Note: SCs are not permitted to transport participant, parent(s) and/or responsible party(ies)).
Assist the participant, parent(s) and/or responsible party(ies) in accessing a medical home as needed or desired.
Organize and participate in team conferences with the participant, parent(s) and/or responsible party(ies).
When made aware of participant hospitalization, discuss hospital discharge planning with the participant, parent(s) and/or responsible party(ies). Document their concerns, expected outcomes and priorities and collaborate with hospital case managers, discharge staff and provider agency(ies) to coordinate necessary supportive services.
Review the plan of care with the participant, parent(s) and/or responsible party(ies) for ongoing needs, make changes as necessary, and discuss participant, parent(s) and/or responsible party(ies) satisfaction and compliance with services.
Monitor the participant’s receipt of authorized HCY services, evaluate any identified barriers to receiving services and collaborate with the participant and/or responsible party(ies) to address barriers, including assessment of eligibility for additional services and/or resources and the need for referral(s).
Routinely discuss transition planning with the participant, parent(s) and/or responsible party(ies) and document their concerns, expected outcomes and priorities. Participate in discussions with the Regional Coordinator (RC) and Program Manager (PM) as well as other agency representatives to design an achievable plan that supports the participant, parent(s) and/or responsible party(ies) to achieve the best possible outcomes consistent with the situation.
Adjust supports and services based on changing needs of program participants.

Service Coordination Process

Service coordination is a culturally competent, collaborative, proactive, and comprehensive health care process designed to help each participant, parent(s) and/or responsible party(ies) achieve the best possible health and greatest degree of independence.

The primary mechanisms of Service coordination are:

Individualized Assessment
Planning
Implementation
Monitoring
Assist with Barrier Removal
Transitioning

Referral and Initial Enrollment

Medically Complex Children and Youth Guidebook

Referrals may be accepted from many sources. Examples of these sources may include health care providers, families, other state and/or local government agencies, schools, and advocacy organizations. Pertinent information is gathered at the time a referral is received utilizing the approved HCY referral form.

When a referral for HCY services is received, participant information, including the referral source, should be entered into the SHCN Information System. The participant is then enrolled in service coordination status. The date for enrollment in service coordination is the date the referral was received.

Determining HCY eligibility is a multi-step process that begins upon receipt of a referral and is based on the criteria listed below.

The participant must:

Be a Missouri resident,
Be birth to age 21,
Be enrolled in fee-for-service MO HealthNet, and
Need medically necessary in-home services.

Once the above criterion has been met, the SC will contact the participant, parent(s) and/or responsible party(ies) to gather additional information. The SC will arrange a home visit (as indicated) if the needs of the participant/family may be met through services authorized by the HCY Program. The initial contact and home visit will occur within 15 business days of the receipt of the referral for PCA and/or APCA services and within 10 business days of the receipt of the referral for PDN. If it is not possible to make a visit within these time frames due to participant/family circumstances, the reason for the delay and the plan for scheduling a visit will be documented in the SHCN Information System.

Medical Necessity

Medically Complex Children and Youth Guidebook

Determining Medical Necessity

The HCY SC authorizes in-home services based on medical necessity. There are several factors used to ensure the criteria for medical necessity are met, including but not limited to:

Services are clinically appropriate, in terms of type, frequency, extent, site, duration and are considered effective for the participant’s illness, injury or disease;
Services are authorized at an appropriate level of service that supports the safety, health, and well-being of the participant but does not replace the parent(s) and/or responsible party(ies) as the main caregiver(s);
Services are authorized on a case-by-case basis based on credible evidence using the applicable assessment tools that apply to the actual direct care and treatment of the participant;
Services are delivered/performed in accordance with the identified medical treatment needs but do not include interventions in which prompting, cueing, and/or redirection of either a verbal or physical nature is necessary to ensure the safety, health, and well-being of the participant; and
Services are not for the convenience of the participant, parent(s) and/or responsible party(ies).

The SC will determine medical necessity and eligibility for HCY services by using the Personal Care/Advanced Personal Care Assessment Tool for Personal Care Services and/or the Private Duty Nursing Assessment Tool for Private Duty Nursing. In addition to these standard tools, the SC may also review other sources of information to obtain sufficient understanding of the participant’s care, specific medical needs, and interventions, which may include:

Physician's orders, plans of care, and/or medical reports,
Provider progress notes and reports,
A previous SHCN record,
Documentation of verbal reports from the hospital discharge planners, service provider(s), Department of Mental Health Case Managers; and/or Family Support Division Case Workers, and
Parent(s) and/or responsible party(ies) strengths and challenges that may affect the ability to provide care.

Confidentiality

Medically Complex Children and Youth Guidebook

All information about the participant/family (verbal, electronic, or in written form) is confidential. The DHSS Notice of Privacy Policies is provided to the participant, parent(s), and/or responsible party(ies) upon enrollment and annually thereafter. The Acknowledgement form is required to be signed by the participant, parent(s), and/or responsible party(ies) upon enrollment and annually thereafter to document receipt of the privacy policy.

All access to health/medical information should be requested, released, or viewed using a written and signed Health Insurance Portability and Accountability (HIPAA) document considered by DHSS to be compliant with current regulatory guidance. The SHCN current compliance document is the DHSS Authorization for Disclosure of Consumer Medical/Health Information form.

Obtaining from or Releasing Information to Non-Participants and/or Parent(s)/Responsible Party(ies)

In order to request and/or share records of participants, a current original signed DHSS Authorization for Disclosure of Consumer Medical/Health Information form must be obtained and kept in the hard file. These forms may be completed at the annual home visit but are not required if Protected Heath Information (PHI) is not being sought or shared.

Releasing Participant Records to Participants, Parent(s), and/or Responsible Party(ies)

Requests for participant records from the participant, parent(s), and/or responsible party(ies), must be submitted in writing and given to the RC. The RC then notifies the PM, Associate Bureau Chief, and Bureau Chief of this request. The PM will coordinate the release of information with the RC and SC.

Mandatory Reporting

Medically Complex Children and Youth Guidebook

Abuse and neglect occurs when a person(s) responsible for the care of a child, person over the age of 60 or person with a disability, either deliberately or by extraordinary inattentiveness, permits the individual in his/her care to experience avoidable suffering and/or fails to provide one or more of the components deemed essential for developing a person’s physical, intellectual, and emotional capacities.

SHCN staff are mandatory reporters and must report suspected abuse/neglect, whether or not it involves an enrolled participant with HCY. SHCN staff receiving reports from other sources, including MO HealthNet Division (MHD) provider agencies, (i.e., third party allegations) are required to report the allegations (third party hotline). SHCN staff must remind the MHD provider agency of their mandated responsibility to call the appropriate hotline and report the incident. The determination as to whether the event is investigated is the responsibility of the protective service agency.

Concerns to report may include, but are not limited to:

Suspected neglect,
Any non-accidental physical injury or injury is at variance with the history given,
Suspected sexual abuse,
Suspected emotional abuse,
Non-organic failure to thrive,
Suspected financial exploitation, and
Use of restraint, seclusion, or any restrictive intervention.

How to Report

The following procedure shall be carried out to report suspected abuse/neglect:

For suspected abuse/neglect of individuals ages 0 thru 17 years, call the Children’s Division at (800) 392-3738 or report on-line.
For suspected abuse or neglect of a person with a disability 18 years of age or older or a person 60 years of age or older, staff will call the Division of Senior and Disability Services at (800) 392-0210 or report on-line.

Notification

The RC must be notified within 24 hours of the concern being identified.
A Confidential Event Report (CER) shall be completed and submitted to the RC within 24 hours of the concern being identified.

Documentation

Documentation of a hotline call requires two separate Progress Note entries as follows:

The first progress note entry documents the entire incident (without mention of making a hotline call). The appropriate ‘Contact Type’ selection will indicate how the SC learned of the event.
The second progress note entry documents the action of making the hotline call. The ‘Contact Type’ selection is always ‘Other’. The body of the progress note will only state ‘A hotline call was made.’ No additional statement is to be entered. This note entry will follow the first progress note in date/time sequence.

Good Faith Effort

Medically Complex Children and Youth Guidebook

On initial PCA, APC or PDN referrals to BSHCN a good faith effort will be made to reach each participant/responsible party within 10 business days from the date of first contact.

A good faith effort consists of three (3) documented attempts to reach the participant/ responsible party. Attempts consist of at least two phone calls and a letter asking the participant/responsible party to contact BSHCN to set up a home visit. The Service Coordinator must attempt to reach the participant by both letter and electronic mail if an email address is available.

Active participants or new referrals who do not respond to multiple attempts to schedule appointments, to obtain signatures on required BSHCN paperwork, or who do not comply with program guidelines may be discontinued at the discretion of the Service Coordinator.

All contacts and attempted contacts should be documented in the BSHCN Information Systems.

Comprehensive Assessment

Medically Complex Children and Youth Guidebook

Assessment is a continuous activity that begins when the referral/application is received and continues throughout the service coordination process.

The assessment information is obtained through the use of the Service Coordination Assessment (SCA). The assessment must be conducted during a face-to-face home visit with the participant and/or responsible party initially, annually, and when warranted due to changing participant circumstances. The initial SCA will be conducted at the home visit that will occur within 15 business days of the receipt of the referral for PCA and/or APCA services and within 10 business days of the receipt of the referral for PDN.

Example: If the initial SCA is conducted on any day in April 2016 then the annual SCA should be conducted no later than April 30, 2017.

Information obtained during the SCA visit will be used in the development of the service plan. The SC will contact the participant, parent(s) and/or responsible party(ies) to schedule a face-to-face home visit to complete the SCA and service plan. During the home visit, the SC will:

Conduct an interview (using the SCA) with the participant, parent(s), and/or responsible party(ies) to obtain assessment information,
Identify services the participant is currently receiving,
Explain the applicable MO HealthNet services that may be authorized through the HCY Program,
Complete all forms related to the type of service the participant requires;
Have participant, parent(s) and/or responsible party(ies) sign any required forms;
Determine if additional services are needed,
Provide information about other resources that may be helpful to the participant, parent(s) and/or responsible party(ies), including contact names, addresses, and telephone numbers, and
Assist family in locating a provider agency
- Provide in-home service agency list with location and telephone numbers.

Required Forms

Designated SHCN staff will enter the following documents into the SHCN Information System.

CC-1 Form
- Signature and date are required when enrolling in PCA, APC or PDN.
Notice of Privacy/Privacy Policies Acknowledgement Form
Rights and Responsibilities/Acknowledgement Form (must be read aloud during SCA visit)
Expectations for In-Home Services (must be read aloud during SCA visit)
Authorization for Disclosure of Consumer Medical/Health Information

Emergency Response and Priority Levels

Medically Complex Children and Youth Guidebook

The SC will offer assistance to all participants, parent(s), and/or responsible party(ies) to establish an Emergency Response Plan.

Emergency management and response materials should be given to each participant, parent(s), and/or responsible party(ies). The SC will offer assistance with the completion of an emergency management plan. The plan will be reviewed with the participant, parent(s), and/or responsible party(ies) annually and documented in the Safety section of the SCA.

When an emergency such as a natural disaster or terrorism event occurs, the SC may be directed to contact participant, parent(s), and/or responsible party(ies) whose care may have been compromised as soon as possible after the event to assess for unmet needs. The phone contact will be documented in the SHCN Information System.

Each service coordination or paid service enrolled participant shall have a priority level assignment. Based on professional judgment, the SC will assign a priority level for each participant with a corresponding entry on the Enrollment screen in the SCHN Information System. Priority levels are reviewed and updated annually due to changing circumstances. Priority levels will be documented in the Safety section of the SCA. SC’s may assign a higher priority level than the definitions indicate; this requires justification in the progress note and/or SCA. The definition for each level is:

Level 1

MFAW (All)
Electronic Dependent (vent, 1x daily use of electronic device, i.e., vent, suction,
nebulizer, Chest Physio Therapy [CPT] vests)
PDN (20-24 hours any given day of the week)

Level 2

PDN (Not included priority #1)
Electronic Dependent (Less than daily)

Level 3

PCA (participants that do not meet Level 1 or Level 2 criteria)

Level 4

All other HCY Categories (ST SNV, LT SNV)
CYSHCN (Enrolled in service coordination or paid services)
ABI (Enrolled in service coordination or paid services)
HCY (Enrolled in service coordination)

Documentation and Reports

Medically Complex Children and Youth Guidebook

Documentation is essential in assessing the effectiveness of service coordination activities. All contacts with or about the participant should be documented in the SHCN Information System (MOHSAIC) as soon as possible, but no longer than 10 business days after the date of the contact. This applies to all types of contact including phone calls, attempted phone calls, home visits, transition planning, making a referral or completing an assessment, etc. All documentation in the SHCN Information System is considered to be a legal record.

The seven basic components of documentation are:

Contains a full and clear description of the contact,
Factual, no opinions,
Contains only relevant information,
Objective,
Concise but thorough,
Describe the steps that have been taken, and
Detail future steps/plans.

Reporting Complaints, Concerns, Unusual Events

The “Confidential Event Report” (CER) is completed by the person first aware of the event. If appropriate, the person aware of the event may take steps and/or make recommendations toward resolving the issue. The report is to be forwarded to the RC within the initial 24 hours after the concern has been identified for review. The RC will then route the CER to PM, Associate Bureau Chief, Bureau Chief, and designated program staff.

RCs will keep the original electronic copy of the CER form completed by the SC. The SCs shall not keep any copies (electronic or written) of the CER submissions. RCs will facilitate updates and follow up to the CER if additional information is received.

Documentation of Hotline Calls

Documentation of a hotline call requires two separate Progress Note entries as follows:

The first progress note entry documents the entire incident (without mention of making a hotline call). The appropriate ‘Contact Type’ selection will indicate how the SC learned of the event.
The second progress note entry documents the action of making the hotline call. The ‘Contact Type’ selection is always ‘Other’. The body of the progress note will only state ‘A hotline call was made.’ No additional statement is to be entered. This note entry will follow the first progress note in date/time sequence.

Death Notification

When notified of the death of a participant, the SC shall complete and submit a Death Notification form to the RC within 24 hours of notification of the participant’s death. The RC will review the report and forward it to the PM and other designated staff.

Monthly Information and Education Contact Reports

Activities such as public information, referrals, education, etc. are also a public health function. This is required to ensure that public contact of all types is included in reports to federal and other funders. This information helps to ensure the continuity of program provision. Therefore, SHCN staff are required to track and count the number of people not enrolled in an SHCN program, which they provided with information, education, or referred to another program. Multiple contacts with the same individual should count as one contact. When in doubt include the contact.

The number of these contacts is entered on a Monthly Information and Education Contact Report Form and is then submitted to the designated person. A report covering the previous month is due in Central Office on the fifteenth of the following month. For example the report covering contacts made in March would be due by April 15^th.

Personal Care Services

Medically Complex Children and Youth Guidebook

Personal Care (PC) is a medically related service designed to meet the maintenance needs of a participant with a chronic, stable condition delivered in the participant’s home. The possible range of services that may be authorized include basic PC Aide (PCA), Advanced Personal Care (APC) Aide, and Authorized Registered Nurse (ARN) Visits. The ARN is used to train and evaluate the APC Aide. The authorized services are certified by a physician as the medically oriented tasks that are necessary to meet a participant’s physical needs. PC Aide services are intended to meet personal, physical requirements, as opposed to general housekeeping 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. Definitions to determine the appropriate level of services are as follows:

PC Aide services must include the performance of direct hands-on assistance and cannot consist solely of oversight or supervision. PC Aide services are authorized when the participant requires 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. (NOTE: HCY PC Aides are not allowed to perform any skilled nursing tasks. These may include, but are not limited to, medication administration, g-tube feedings, suctioning, and any other doctor ordered treatments.) PC Aide services occur only in the home or residence of the participant.
APC Aide services are authorized to provide assistance with activities of daily living when such assistance requires devices and procedures related to altered body functions. Examples include: routine personal care for persons with ostomies and/or external, indwelling, and suprapubic catheters; use of a lift or other device for transfers; provide passive range of motion; apply non-sterile dressings to superficial skin breaks or abrasions; apply medicated lotions or ointments, and dry, non-sterile dressing to unbroken skin; administer prescribed bowel program; and/or manually assist with oral medications.
ARN home visit is required when APC Aide services are authorized for the participant. The ARN visit is used to train and evaluate the APC Aide.

If the participant is receiving APC Aide services and PDN through the same provider agency, the PDN may provide this service. If there are no PDN services authorized through the same agency as APC Aide services then one monthly ARN visit is authorized.

The parent/responsible party is the primary caregiver and the PC Aide is not to take the place of the parent/responsible party. It is not permissible for the parent(s)/responsible party(ies) to be away from the home with the expectation the PC Aide provider agency shall accept total responsibility for the participant. The parent(s)/responsible party(ies) must designate an individual to provide direct care and for medical care decisions in the extended absence of the parent(s)/responsible party(ies). This designated individual shall not be an employee of the provider agency nor a SHCN employee.

PC Aide Assessment Tools

The PC Aide/APC Aide Assessment tool and the SCA will be completed by the SC to assist in determining medical necessity and the appropriate level of service. In addition to these standard tools, the SC may review other sources of information to obtain sufficient understanding of the participant’s care, specific medical needs, and interventions. This may include:

Physician's orders, plans of care, and/or medical reports,
Provider progress notes and reports,
A previous SHCN record,
Documentation of verbal reports from the hospital discharge planners, service provider, Department of Mental Health Case Managers, and/or Children’s Division Case Workers, and
Parent(s) and/or responsible party(ies) strengths and challenges that may affect the ability to provide care.

The SC will evaluate the family's ability to provide the participant's care by gathering other information such as:

The family structure,
Number of caregivers available,
Routine absences of caregiver(s),
Number, age, and health status of other household members,
Mental and physical health of caregiver(s),
Requirement of teaching the caregiver(s), and/or
Willingness of the caregiver(s) to participate in the participant’s care.

PC Aide Assessment Process

Assessment is a continuous activity that begins when the referral/application is received and continues throughout the time the participant receives services. The SC must complete the SCA and all required forms (including, but not limited to, the PC Aide/APC Aide Assessment tool) during a face-to-face home visit with the participant, parent(s), and/or responsible party(ies) within 15 business days of the receipt of the referral. The SCA must be completed initially, annually, and when warranted due to changing participant circumstances.

Information obtained during the SCA visit will be used in the development of the service plan. During the home visit, the SC will:

Conduct an interview (using the SCA) with the participant, parent(s), and/or responsible party(ies) to obtain assessment information,
Identify services that the participant is currently receiving,
Explain the applicable MO HealthNet services that may be authorized through the HCY Program,
Complete all forms related to the type of service the participant requires,
Have participant, parent(s), and/or responsible party(ies) party sign any form requiring signatures,
Determine if additional external supportive services are needed,
Provide information about other resources that may be helpful to the participant, parent(s), and/or responsible party(ies), including contact names, addresses, and telephone numbers, and
Assist family in locating a provider agency
- Provide in-home service agency list with location and telephone numbers.

When the SCA and the home visit have been completed, the SC will:

Enter the SCA information into the SHCN Information System
Document the home visit using the appropriate template and contact type in the SHCN Information System

Required forms for Personal Care Services

SCA (Annually)
PC Aide/APC Aide Assessment tool (Every six months)
CC-1 (Annually)
DHSS Notice of Privacy and Privacy Policies Acknowledgement (Annually)
Authorization for Disclosure of Consumer Medical/Health Information (As necessary)
Rights and Responsibilities (Annually)
Prior Authorization Request form (PA) (Every six months)
Confirmation of Verbal Authorization (Initially and with changes to authorization)
Expectations For In-Home Services (Annually)

Provider Selection

The SC will provide the participant, parent(s) and/or responsible party(ies) with a regional provider list that includes current agency contact information.

The participant, parent(s), and/or responsible party(ies) will select a provider agency within 30 days of receipt of the provider list.
If the participant, parent(s), and/or responsible party(ies) has not chosen a provider agency in 30 days, the SC will contact the family to offer assistance with provider selection. If assistance is requested, the SC will inquire with provider agencies regarding staffing availability. Results will be communicated to the participant, parent(s), and/or responsible party(ies) for provider selection.
If the participant, parent(s), and/or responsible party(ies) has not selected a provider agency in 90 days of receipt of the provider list, SHCN will close the case and send a closure letter.

Service Authorization

Plan of Care

The provider agency is responsible for obtaining a Plan of Care and the Physician’s Certification of Need with the physician’s signature. The provider agency may choose to do a 485 in lieu of the Plan of Care and Physician Certification of Need. The Plan of Care specifies the type, frequency (number of 15 minute units per day or per week), and duration (how many weeks or months) of services to be provided as well as the specific PC Aide and/or APC Aide tasks to be completed. The provider agency is responsible for submitting the Plan of Care, a signed Physician’s Certification of Need, and an accurately completed Prior Authorization Request (PA) form to SHCN. The Plan of Care and Physician Certification of Need are to be reviewed and re-established by the physician at least every six months and include the following elements:

Changes to frequency or type of services authorized during a certification period must be authorized by the physician by way of verbal or written order,
All pertinent diagnoses must be included on the Physician’s Certification of Need, and
Frequency and duration of services including the type of professional to provide the authorized services.

Upon receipt of this documentation from the agency, the SC and the Facilitator will review for accuracy and appropriate content. The SC or the Facilitator shall complete the Service Plan section in the SHCN Information System. Upon completion, the SC will sign and date the PA indicating approval. PC Aide/APC Aide/ARN services may not be authorized for longer than a six month period. At the initiation for PC Aide services for a participant (for new referrals and provider changes), the SC will authorize an additional ARN Visit for recertification in the sixth month of the initial authorization period. This is only for the first authorization period. After that time, two visits per year, Procedure Code T1001TDEP R.N. Evaluation Visit for PC Aide services through HCY, are sufficient to meet the requirements. The Facilitator sends the original PA form to the Department of Social Services, MO HealthNet Division Fiscal Agent for data entry and a copy of the PA is kept in the participant’s file.

Required Contacts and Home Visits

Initial Home Visit

The SC completes a SCA during the initial home visit with the participant, parent(s), and/or responsible party(ies) within 15 business days of the date of the referral. The RC or the HCY PM may grant exceptions to this requirement.

Annual and Routine Home Visits

The SC completes a SCA annually during a home visit with the participant, parent(s), and/or responsible party(ies). Home visits are required every six months and the participant must be seen. It is expected that the participant, parent(s), and/or responsible party(ies) participate in all home visits except in extenuating circumstances with the RC approval. The SC will document home visits in the SHCN Information System using the appropriate home visit template.

Place of Service

PC Aide/APC Aide services are only to be provided in the home or residence of the participant, parent(s)/responsible party(ies) or other caregiver. The PC Aide/APC Aide may not drive the participant or provide care for the participant in the aide’s home.

Two or more participants in the same residence

When two or more participants residing in the same residence require PC Aide/APC Aide services and their personal care needs can be met by one staff person during the same timeframe, the total units authorized for each participant shall be based on each individual’s needs and may not exceed the actual amount of time (in 15 minute units) the PCA is in the home. The SC will authorize only the medically necessary units of service required.

When PC Aide/APC Aide services are approved for two participants at the same time, the SC will complete a new VC for each participant and send to the provider agency.

Example:

Four hours/day of PC Aide/APC Aide to be shared with other sibling in home (do not specifically name other sibling).

In instances when there is a large variance in the medically necessary care of the participants, the SC must consult with the RC and HCY PM to discuss the appropriate services to authorize for each participant.

Authorization of PRN Hours

Inclusion of PRN hours when authorizing PCA/APC services is uncommon and should only be considered in extenuating circumstances or when multiple providers are in the home.

PCA PRN solely for multiple agencies to cover missed shifts requires RC approval through VC review
- SC will submit the VC with the requested PCA authorization to the RC, including an outline that the PRN hours are authorized to allow flexibility when there is coverage by multiple agencies
- In this instance, a portion of the authorized hours are designated as PRN that can be used by multiple agencies serving the same participant and the total authorized PCA hours should not be exceeded
Any PCA PRN authorizations outside of multiple agencies in the home with shared PRN requires approval through a PM Change Request

Discontinuation of PCA Services

Participant records are closed by the SC for various reasons. In all instances, good faith efforts must be made and documented in the SHCN Information System to show effective service coordination, and when appropriate, successful transition from HCY services. Reasons for closure may include:

The applicant/participant demonstrates an unwillingness to cooperate with HCY requirements,
Participant does not meet eligibility criteria,
Request of the participant, parent(s), and/or responsible party(ies),
Unable to locate after good faith efforts,
The participant has become institutionalized or a Ward of the Court with guardianship assigned to the Department of Mental Health or the Division of Youth Services, or
The participant reaches the age of 21 and is no longer eligible for HCY services.

Once the determination has been made to close services, the SC will complete and send a closure letter indicating the reason for closure along with the closure date, allowing 10 business days for response prior to closure. This action will also be documented in the SHCN Information System. Exceptions to the 10 business day closure rule include the following:

Over age – day before 21^st birthday.
Moved out of state – date of move if known; otherwise use the date that staff became aware of move.
Deceased - date of death if known; otherwise use the date staff became aware of the death.

Discontinuation of the delivery of PC Aide/APC Aide Services by Provider Agencies

Providers must give notification to the participant, parent(s), and/or responsible party(ies) and SHCN prior to the discontinuation of services. The PC Aide/APC Aide service provider notifies the participant, parent(s), and/or responsible party(ies) in writing of the decision to discharge a participant and provides a minimum of 21 day notice prior to the discontinuation of services for reasons that include, but are not limited to, the following:

The participant, parent(s), and/or responsible party(ies) are non-compliant to the agreed upon Plan of Care,
The provider is no longer able to meet the service needs of the participant, and/or
The participant, parent(s), and/or responsible party(ies) requests a change.

The PC Aide/APC Aide provider agency shall advise SHCN within 72 hours of the

participant, parent(s), and/or responsible party(ies) notification of planned discontinuation of PC Aide/APC Aide services. The SC shall assist the participant, parent(s), and/or responsible party(ies) in making appropriate arrangements to locate and transfer care (if possible and necessary) to a new provider agency. The provider agency shall notify SHCN within 72 hours of closure of a case due to the following circumstances:

Death of the participant
Participant’s admission to a health care facility
Participant is no longer in need of care

Exceptions for Special Circumstances

Acute or Intense Needs: When the participant, parent(s), and/or responsible party(ies) requests a notable increase in personal care PC Aide or combined PC Aide with APC Aide due to an acute or intense need, the SC confers with the RC who may include the HCY PM if necessary.

In addition, for any combination of service authorization (PC Aide, APC Aide, PDN) exceeding 16 hours/day or 112 hours/week, the SC must complete a PM Change Request form to submit to the RC to facilitate a peer review. Once the peer review is completed, the RC makes their recommendation and then forwards the request to the PM for review and approval/denial. These requests must be completed each time a new authorization period is to begin.
PC Aide/APC Aide and Short Term Skilled Nursing Combination: Participants receiving PC Aide/APC Aide services may, in rare instances, require additional intermittent Skilled Nurse Visits (SNV). It is possible for a participant to receive PC Aide/APC Aide services as well as SNV for a specific procedure such as intravenous medications)). When the nurse providing the SNV is in the home, the PC Aide/APC Aide must not be on the clock during the duration of the SNV to avoid duplication of services but may remain in the home during this time and resume providing care once the nurse providing SNV leaves.

Exclusions

The PC Aide/APC Aide employed by the agency who actually delivers the personal care service must not be a family member. A family member is defined as a parent; sibling; child by blood, adoption, or marriage; spouse; grandparent; or grandchild.
PC Aide/APC Aide services are not authorized for a participant receiving inpatient hospital services or residing in a skilled nursing facility, intermediate care facility, or any other institutional setting or health care facility.

Private Duty Nursing

Medically Complex Children and Youth Guidebook

Private Duty Nursing

Private Duty Nursing (PDN) is the provision of individual and continuous care (in contrast to part-time or intermittent care) provided by a licensed nurse acting within the scope of the Missouri Nurse Practice Act, according to an individualized Plan of Care approved by a physician. Per MO HealthNet Division guidelines and the Missouri Code of State Regulations, Healthy Children and Youth (HCY) participants may receive PDN services "when there is a medical need for a constant level of care, exceeding the family's ability to independently care for the participant at home on a long-term basis without the assistance of at least a four (4) hour shift of home nursing care" for each date of service. A Registered Nurse (RN) or Licensed Practical Nurse (LPN) may deliver these medically necessary nursing services. Services provided in periods of three hours or less shall be considered an intermittent Home Health Skilled Nursing visit. (Please refer to Skilled Nursing Visit section)

The parent(s) and/or responsible party(ies) is the primary caregiver and the PDN is not to take the place of the parent and/or responsible party, with the understanding that the presence of a responsible party(ies) does not obviate the medical necessity of PDN services. It is not permissible for the parent(s) and/or responsible party(ies) to be away from the home for extended periods of time with the expectation the PDN provider agency shall accept total responsibility for the participant, as the intent of the program is to support, not replace, the parent(s)/responsible party(ies). The parent(s) and/or responsible party(ies) must designate an individual to provide direct care and make medical care decisions in the extended absence of the parent(s) and/or responsible party(ies). This designated individual shall not be an employee of the provider agency nor a SHCN employee.

PDN Assessment Tools

The PDN Assessment tool and the SCA will be completed by the SC to assist the SC in determining medical eligibility and the level of service authorization that is appropriate to meet the needs of the participant. In addition to these standard tools, the SC may review other sources of information to obtain sufficient understanding of the participant’s care, specific medical needs, and interventions, which may include:

Physician's orders, plans of care, and/or medical reports,
Provider progress notes and reports,
A previous SHCN medical record,
Documentation of verbal reports from the hospital discharge planners, service provider, Department of Mental Health Case Managers; and/or Family Support Division Case Workers, and
Evaluation of parent(s) and/or responsible party(ies) strengths and challenges that may affect the ability to provide care for the participant, including a backup caregiver plan in the event that nursing staff is unavailable, by gathering information such as:
- Family structure,
- Number of caregivers available,
- Routine absences of caregiver(s),
- Number, age, and health status of other household members,
- Mental and physical health of caregiver(s),
- Requirement of teaching the caregiver(s), and/ or
- Willingness of the caregiver(s) to participate in the participant’s care.

The following situations represent examples that would indicate a necessity for PDN:

Unusual support to sustain vital functions (e.g. oxygen, respiratory support, inhalation therapy, postural drainage),
Frequent "nursing" monitoring as the result of surgical or medical procedures such as tracheotomies, ileostomies, colostomies or gastrostomies,
Continuous maintenance attention because of medical conditions (e.g. frequent suctioning, gastrostomy feedings, etc.), and/or
Monitoring of vital functions because of threatening episodic events (e.g. seizures, requiring intervention, apnea, arrhythmias).

PDN Assessment and Service Planning Process

Assessment and service planning are continuous activities that begins when the referral/application is received and continues throughout the time the participant receives services. The SC must complete the SCA and all required forms (including, but not limited to, the PDN Acceptance form and PDN Assessment tool) during a face-to-face home visit with the participant, parent(s), and/or responsible party(ies) within 10 business days of the receipt of the referral. The SCA must be completed initially, annually, and when warranted due to changing participant circumstances.

Information obtained during the SCA and routine home visits will be used in the development of the service plan. During the home visit, the SC will:

Conduct an interview (using the SCA and home visit template) with the participant, parent(s), and/or responsible party(ies) to obtain assessment information,
Identify services that the participant is currently receiving,
Review the MO HealthNet Authorization vs. Utilization report
Explain the applicable MO HealthNet services that may be authorized through the HCY Program,
- Evaluate the participant/responsible party(ies) backup plan for when PDN services are unavailable,
- Assess the eligibility for authorization or referral for other available
  MO HealthNet services, such as personal care (understanding that PCA services cannot replace PDN services), home health services, medical equipment and supplies.
Document all reasonably foreseeable barriers to the participant’s receipt of authorized PDN hours and all steps that will be taken by SCs, parent(s) and/or responsible party(ies) to address barriers to the participant’s receipt of all authorized PDN hours,
Complete all forms related to the type of service the participant requires,
Have participant, parent(s), and/or responsible party(ies) sign any form requiring signatures,
Determine if additional external supportive services are needed and offer to assist families in connecting to these resources,
Provide information about other resources and make referrals for services that may be helpful to the participant, parent(s), and/or responsible party(ies), including contact names, addresses, and telephone numbers, as outlined in the home visit template and
Assist family in locating a provider agency(ies), as outlined below in ‘Provider Selection’

When the SCA and the home visit have been completed, the SC will:

Enter the SCA into the SHCN Information System
Document the home visit using the appropriate template and contact type in the SHCN Information System

Based on the data gathered above and in discussion with the participant, parent(s), and/or responsible party(ies), the SC determines the frequency, amount, and duration of services needed to support the medical needs of the participant. If services are deemed necessary, the SC will prior authorize a minimum of a continuous four hour shift of private duty nursing care per day. It is the policy of MO HealthNet and SHCN that 448 units (112 hours) per week is the maximum amount of private duty nursing services that may be authorized. Exceptions to the policy can be made on a short term basis not to exceed three consecutive weeks or with the notification of the SHCN RC and approval of the HCY PM when there is documentation to support this need.

If the authorized PDN exceeds 112 hours/week, the SC must complete a PM Change Request to be reapproved annually with each SCA.

PDN services are authorized as a total number of units per month, based on weekly hours, which are determined by the assessed medical needs of the participant. The participant/responsible party(ies) may schedule services through the provider to meet their needs/schedule throughout the week. The participant/responsible party(ies) must be encouraged to stay within the monthly authorized units. Monthly service authorizations will be based on a maximum of 112 hours per week unless otherwise authorized by the BSHCN, as indicated above. Requested increases in authorizations due to misutilization of the authorized monthly units will not be approved by BSHCN. Participants/responsible party(ies) will need to contact their Service Coordinator to notify them of any status changes that would necessitate a requested change in authorized monthly units.

Required Forms for Private Duty Nursing

SCA (Annually)
Private Duty Nursing Assessment tool (Every three months)
CC-1 (Annually)
DHSS Notice of Privacy and Privacy Policies Acknowledgement (Annually)
Authorization for Disclosure of Consumer Medical/Health Information (As Necessary)
Rights and Responsibilities (Annually)
Prior Authorization Request form (PA) (Every six months)
Confirmation of Verbal Authorization (Initially, annually and with changes to authorization)
Expectations For In-Home Services (Annually)
PDN Acceptance form (Annually)

Provider Selection

The SC will provide the participant, parent(s), and/or responsible party(ies) with a regional provider list that includes current agency contact information.

The participant, parent(s), and/or responsible party(ies) will select a provider agency within 30 days of receipt of the provider list.
When initially providing the list, the SC will offer to assist the participant/responsible party(ies) with connecting with provider agencies in their region, if such assistance is needed.
If the participant, parent(s), and/or responsible party(ies) has not chosen a provider agency in 30 days, the SC will contact the family to offer further assistance with provider selection. If assistance is requested, the SC will inquire with provider agencies regarding staffing availability.
- Offer for SHCN staff to send an email blast to provider agencies in the participant’s region
- Communicate the response(s) from provider agency(ies) to the participant, parent(s), and/or responsible party(ies) for provider selection
The participant, parent(s), and/or responsible party(ies) is considered to have selected a provider agency when they inform the SC of the name of the agency with whom they are working to secure a PDN and set a schedule for PDN services. The provider agency’s inability to staff or fully staff a participant’s required PDN services shall not be considered a failure to select a provider agency.
If the participant, parent(s), and/or responsible party(ies) has not selected a provider agency in 90 days of receipt of the provider list, ongoing good faith efforts are not being made by the participant and/or responsible party(ies), and sustained efforts have been made by the SC to assist the participant with selecting a provider agency, SHCN will close the case and send a closure letter.

Service Authorization

Once a provider agency is chosen by the participant, parent(s), and/or responsible party(ies), the SC contacts the provider agency to discuss the service authorization. A HCY Confirmation of Verbal Service Authorization (VC) is sent to the provider agency to be signed and returned to SHCN. This form is filed in the participant’s record. The paid service enrollment date is the date that in-home services are authorized to begin. The enrollment screen is updated to reflect the change in status from ‘service coordination’ to ‘paid service’. An updated VC will be sent with any change in service authorization.

Plan of Care

The provider agency is responsible for developing a Plan of Care and obtaining the physician’s signature. The Plan of Care specifies the type, frequency (number of 15 minute units per day or per week), and duration (how many weeks or months) of services to be provided. The Plan of Care must also include the specific skilled nursing procedures to be completed. The provider agency is responsible for submitting the Plan of Care to SHCN that must be signed by a physician or the provider agency registered nurse indicating receipt of a verbal order from the physician. The Plan of Care needs to include the following elements:

Reviewed and re-established by the physician at least every 60 days,
Changes to frequency or type of services authorized during a certification period must be authorized by the physician by way of verbal or written order,
All pertinent diagnoses, including mental status, types of services, supply list, frequency of services, prognosis, medications and treatments, safety measures to protect against injury, and discharge plans (where applicable),
Frequency and duration of services including the type of professional to provide the authorized services, and
Address short term as well as long term nature of the care required.

Upon receipt of this documentation from the agency, the Facilitator and SC will review for accuracy and appropriate content. The Facilitator shall complete the PA form for the authorized services. Upon completion, the SC will sign and date the PA form indicating approval. PDN services may not be authorized for longer than a six month period. The Facilitator emails the original PA form to the DSS, MO HealthNet Division Fiscal Agent for data entry and a copy of the PA form is kept in the participant’s record.

Required Contacts and Home Visits

Initial Home Visit

The SC completes a SCA during the initial home visit with the participant, parent(s), and/or responsible party(ies) within 10 business days of the date of the referral. The RC or the HCY PM may grant exceptions to this requirement.

Annual and Routine Home Visits

The SC completes a SCA annually during a home visit with the participant, parent(s), and/or responsible party(ies). Home visits are required quarterly and the participant must be seen. It is expected that the participant, parent(s), and/or responsible party(ies) participate in all home visits except in extenuating circumstances. The SC will document home visits in the SHCN Information System using the home visit template.

Ongoing Identification of Barriers and Assistance with Barrier Removal

At each home visit, the SC should assess and identify any barriers to obtaining PDN services and assist the participant/responsible party(ies) in removing identified barriers, as necessary. Removing barriers may require assessments for other services and/or referrals to other agencies or community resources who might aid in the removal of the identified barrier(s).

The SC should complete the following steps to assist with barrier identification/removal:

Review monthly reports comparing the PDN services received and authorized and discuss the participant’s needs in light of any gap in service delivery,
Assess any potential barriers to receipt of authorized PDN hours,
Provide assistance to families, as necessary, in removing identified barriers consistent with that family’s circumstances and,
Review progress toward the removal of any barriers previously identified.

Place of Service

PDN services may be provided in the following settings:

Home of the participant, parent(s)/responsible party(ies) or other caretaker
Licensed Prescribed Pediatric Extended Care (PPEC) facility (see PPEC Policy)
Outside the home during the hours when their normal life activities take them outside the home setting
- Service delivery outside the home requires the consent of the participant, parent(s) and/or responsible party(ies)
- The PDN may not drive the participant
- It is not permissible for PDN to be authorized solely for activities outside the home
- Normal life activities in the local community include those types of activities that do not require time away from the home overnight, which include but are not limited to the following:
  - Attending medical appointments, going shopping, attending religious services, going to a restaurant, going to family functions, and going to a movie or a sporting event.
  - No additional hours of PDN services may be authorized for the exclusive use outside the home.
Authorization of PDN services for overnight travel is required on an individual basis per trip.
- The SC completes a VC, specifying the approved range of dates for travel, to authorize PDN services to provide medically necessary care for the participant.
- The provider must ensure that the PDN staff has appropriate licensure for the states in which they will provide the PDN services.
- Payment will be for the PDN services only and not include travel expenses.
- No additional hours of PDN services may be authorized for the overnight travel authorization.

Discontinuation of PDN Services

Participant records are closed by the SC for various reasons. In all instances, good faith efforts must be made by the SC, as outlined in the ‘Good Faith Effort’ policy and documented in the SHCN Information System to show effective service coordination, including efforts to identify and address barriers regarding the ability of the participant and/or responsible party(ies) to meet ongoing HCY Program requirements, and when appropriate, successful transition from HCY services. Reasons for closure may include:

The participant, parent(s), and/or responsible party(ies) demonstrates an unwillingness to cooperate with HCY requirements.
Participant does not meet eligibility criteria.
Parent(s), and/or responsible party(ies) request closure of HCY services.
Unable to locate after good faith efforts.
Participant becomes institutionalized, a Ward of the Court with guardianship assigned to the Department of Mental Health or the Division of Youth Services or can no longer be maintained in the home utilizing HCY benefits.
The participant reaches the age of 21 and is no longer eligible for HCY services.

Once the determination has been made to close services, the SC will request a closure letter to be sent indicating the reason for closure along with the closure date, allowing 10 calendar days for response prior to closure. This action will also be documented in the SHCN Information System. Exceptions to the 10 calendar day closure rule include the following:

Over age – day before 21^st birthday;
Moved out of state – date of move if known; otherwise use the date that staff became aware of move;
Deceased – date of death if known; otherwise use the date staff became aware of the death.

Discontinuation of the delivery of PDN Services by Provider Agencies

Providers must give notification to the participant, parent(s), and/or responsible party(ies) and SHCN prior to the discontinuation of PDN services. The PDN service provider notifies the participant, parent(s), and/or responsible party(ies) in writing of the decision to discharge a participant and provides a minimum of 21 days’ notice prior to the discontinuation of services for reasons that include, but are not limited to, the following:

The participant, parent(s), and/or responsible party(ies)are non-compliant with the agreed upon Plan of Care,
The provider is no longer able to meet the service needs of the participant, and/or
The participant, parent(s), and/or responsible party(ies) requests a change.

The PDN provider agency shall advise the SHCN within 72 hours of the

participant, parent(s), and/or responsible party(ies) notification of planned discontinuation of PDN services. The SHCN SC shall assist the participant, parent(s), and/or responsible party(ies) in making appropriate arrangements to locate and transfer care (if possible and necessary) to a new PDN provider agency. The PDN provider shall notify the SHCN within 72 hours of closure of a case due to the following circumstances:

Death of the participant,
Participant’s admission to a health care facility, and/or
Participant is no longer in need of care.

Exceptions for Special Circumstances

Authorization Prior to Face-To-Face Assessment: For instances when it is not possible to complete the PDN Acceptance form and PDN Assessment tool prior to service authorization, the SC may use verbal or written information about the participant's diagnosis, condition, nursing interventions, and caregiver availability/support in determining the medical necessity of this service. Authorizations made without completion of the PDN Assessment and PDN Acceptance form shall not exceed 10 working days and require notification to the RC. If there is a need for an extension beyond the 10 working days, the SC must obtain approval from the RC and the HCY PM.
Acute or Intense Needs: If the SC determines that the need for PDN exceeds 112 hours/week, the SC may authorize the appropriate level of services, not to exceed three consecutive weeks. The SC must notify the RC of this exception at the time of the authorization. The SC must notify the RC and obtain approval from the HCY PM for authorizations exceeding 112 hours/week for longer than three consecutive weeks.
In addition, for any authorization exceeding 112 hours/week, the SC must complete a PM Change Request form to submit to the RC for peer review. Once the peer review is completed, the RC forwards the request to the HCY PM for review and approval/denial. This form is also required for any requests for an exception to authorize services for a participant who scores less than 50 points on the PDN Assessment form. These requests must be completed each time a new authorization period is to begin.
Hospice: When a participant is placed on hospice care in the home, PDN services may still be authorized as indicated by medical necessity and must meet the four hour block minimum standard. When the hospice nurse is in the home, the HCY PDN must not be on the clock during the duration of the hospice nurse visit to avoid duplication of services but may remain in the home during this time and resume providing care once the hospice nurse leaves. The services provided by the hospice nurse are considered to be part of the continuous four hour requirement and do not constitute a break in service.
PDN and Short Term Skilled Nursing Combination: Participants receiving PDN services may, in rare instances, require additional intermittent skilled nursing visits (SNV). It is possible for a participant to receive PDN services as well as SNV (for a specific procedure such as intravenous medications). When the nurse providing the SNV is in the home, the PDN must not be on the clock during the duration of the SNV to avoid duplication of services but may remain in the home during this time and resume providing care once the nurse providing SNV leaves. The SNV services are considered to be part of the continuous four hour requirement and do not constitute a break in service.
Private Duty Nursing In School and In Home: PDN may be authorized by SHCN in the private school setting if determined medically necessary by the SC. In the public school setting, SHCN does not authorize PDN services, including school sponsored transportation and Early Childhood Programs; these PDN services are authorized and funded by the public school system utilizing expanded school based services.
- The following circumstances may constitute the authorization of a four hour block of HCY PDN services:
  - In home PDN services are provided immediately before and/or immediately after school, and
  - Participant requires and receives continuous nursing services while in route to and from the school as well as during school hours
    Example: A participant needs two hours of PDN before school and nursing is authorized during school. The SC may authorize PDN before school only if a nurse accompanies the participant en route to school and provides continuous nursing care to meet the minimum four hour requirement. However, if there is a block of time inside the four hours (such as a school bus ride) that the participant does not have nursing care, the requirement for a four hour block of continuous nursing is not met and PDN cannot be authorized.
PPEC and In-Home PDN: SHCN may authorize PPEC services in conjunction with in-home PDN. If the participant is authorized for PPEC services, the requirement of a four hour continuous block of skilled nursing needs for PDN is met. PDN can then be authorized in the home before and/or after PPEC attendance and can be provided in less than a four hour block.

Exclusions

PDN services are not authorized for a participant receiving inpatient hospital services or residing in a skilled nursing facility, intermediate care facility, or any other institutional setting or health care facility.

Flexibility in Utilization of Authorized PDN

Service Coordinator (SC) will work with participant(s), parent(s) and/or responsible party(ies) so the authorization allows maximum flexibility relating to when approved hours are scheduled. The participant(s) and parent(s)/responsible party(ies) availability including, but not limited to, work/sleep schedule, health needs, other family members, and other household responsibilities will be taken into consideration when authorizing PDN. The SC may consider the need for authorizing PRN (as needed) hours to be used to allow additional flexibility.

PRN hours may be authorized for circumstances including, but not limited to:

Allowing additional time for nurses to accompany the participant/family to healthcare appointments,
Multiple participants receiving services in the home,
- Assess the shared authorization to ensure the skilled needs of each participant are being met by the overall authorization
- Consider the utilization of PRN hours for circumstances in which one participant is not in the home, such as medical appointments or hospitalization
The parent/responsible party to work additional hours,
To allow flexibility when there is coverage by multiple agencies
- In this instance, a portion of the authorized hours are designated as PRN that can be used by multiple agencies serving the same participant

When assessing the participant’s authorization needs, the SC will collect information to determine the best way to write the authorization to meet the family’s needs and to provide optimum flexibility in utilization of services. The authorization is continually reevaluated to determine when changes are needed. The following steps are taken to develop the individualized authorization:

Ask the family to identify the participant’s skilled needs and their need for paid support services.
Assess the participant’s needs, including times throughout the day in which skilled care is needed.
Assess the availability of any and all potential caregivers to provide care, including but not limited to; family members, friends, and other paid support services. Collaborate with the family to develop the authorization that fits the needs of both the participant’s skilled care needs and families need for paid support services, as permitted by MO HealthNet guidelines.
The provider and family will develop a schedule for paid support services in the home.

Provider Selection and Multiple Providers in the Home

Provider Selection

The Service Coordinator (SC) will provide the participant, parent(s), and/or responsible party(ies) with a regional provider list that includes current agency contact information. The SC will inform the family they may choose multiple agencies, this will be noted on the Provider List given to the participant, parent(s), and/or responsible party(ies).

The participant, parent(s), and/or responsible party(ies)will select a provider agency or agencies within 30 days of receipt of the provider list.
If the participant, parent(s), and/or responsible party(ies) has not chosen a provider agency or agencies in 30 days, the SC will contact the family to offer assistance with provider selection. If assistance is requested, the SC will inquire with provider agencies regarding staffing availability. Results will be communicated to the participant, parent(s), and/or responsible party(ies) for provider selection.
If the participant, parent(s), and/or responsible party(ies) has not selected a provider agency or agencies in 90 days of receipt of the provider list, SHCN will close the case and send a closure letter. Participant will not be closed if actively pursuing services.

Role of the HCY Service Coordinator

Develop a service plan by identifying the goals of the participant, parent(s) and/or responsible party(ies) and determine the services, funding sources, and outcomes needed in order to reach these goals.
Complete necessary paperwork to obtain services and document the information in the SHCN Information System as per policy/procedure.
Coordinate the plans of care for multiple agencies.
Adjust supports and services of multiple providers based on changing needs of program participants.
Multiple providers cooperate with each other to provide services to meet the needs of the participant. When multiple providers are utilized, it is expected that the providers, family, and SC will work together to coordinate the service utilization.

Multiple PDN Providers

There are times when one PDN agency is unable to staff all the PDN services authorized for a participant. A participant may utilize multiple PDN provider agencies to provide the authorized units of PDN services. Services must be prior authorized for each provider agency. A specific number of hours is authorized for each provider agency based on the anticipated services each agency will provide. The authorized hours can be adjusted and/or moved to another agency in the event an agency is not able to staff their authorized hours but another agency is able to staff the hours. Contact the appropriate Regional Office for SHCN to adjust the authorization. SHCN should be contacted within 72 hours if an unforeseen situation arises which results in a need to adjust the authorization.

Multiple Agency Selection

The SC will educate the family on the process of having two or more agencies in the home. The SC, participant, parent(s), and/or responsible party(ies) will work together to coordinate how selected agencies can be best utilized to meet the needs of the participant based on family preference, caregiver availability, and staffing availability.
The SC will discuss staffing with the participant, parent(s), and/or responsible party(ies) during each quarterly visit and as needed
The SC should consider the need for authorizing PRN (as needed) hours to be used for the agencies to cover for one another.
SC should outline the following information on the authorizations:
- There are multiple agencies in the home
- Services should be coordinated accordingly between agencies
- PRN hours are authorized to be used to cover missed shifts
- The total authorized hours should not be exceeded
- Two or more nurses cannot be in the home providing services at the same time

Example Authorization

Agency 1 – PDN: 937 UNITS/MONTH FOR MONTHS WITH 30 DAYS & 966 UNITS/MONTH FOR MONTHS WITH 31 DAYS (BASED ON PDN: 50 HOURS/WEEK, PLUS 20 HOURS/MONTH PRN TO BE USED TO COVER MISSED SHIFTS BY SECOND AGENCY IN THE HOME, AS SCHEDULED BY THE PARTICIPANT/FAMILY). THE TOTAL AUTHORIZATION PROVIDED BETWEEN THE TWO AGENCIES SHOULD NOT EXCEED 112 HOURS/WEEK AND TWO OR MORE NURSES CANNOT BE IN THE HOME PROVIDING SERVICES AT THE SAME TIME.

Agency 2 – PDN: 1,143 UNITS/MONTH FOR MONTHS WITH 30 DAYS & 1,178 UNITS/MONTH FOR MONTHS WITH 31 DAYS (BASED ON PDN: 62 HOURS/WEEK, PLUS 20 HOURS/MONTH PRN TO BE USED TO COVER MISSED SHIFTS BY SECOND AGENCY IN THE HOME, AS SCHEDULED BY THE PARTICIPANT/FAMILY). THE TOTAL AUTHORIZATION PROVIDED BETWEEN THE TWO AGENCIES SHOULD NOT EXCEED 112 HOURS/WEEK AND TWO OR MORE NURSES CANNOT BE IN THE HOME PROVIDING SERVICES AT THE SAME TIME.

Staffing Support Services

When a participant, parent(s), and/or responsible party(ies) reaches out for assistance the Service Coordinator (SC) will:

Respond to any request for assistance from the participant, parent(s), and/or responsible party(ies) by telephone or email within 3 business days.
Determine what action is needed to resolve the issue.
Communicate with participant/parent(s), responsible party(ies) all efforts taken to resolve the issue.
Follow the procedure for reporting the issue up the chain of command for staffing issues.
Follow-up with participant, parent(s), responsible party(ies) to make them aware of the resolution.
Document all communication and all steps taken to remediate in the SHCN Information System

Participant/Family Contact

Initial – SC will reach out to the participant, parent(s), responsible party(ies) to identify needs and offer current regional provider list with agency contact information and make sure the family is aware they may select more than one provider, this will also be noted on the provider list.

Follow-up – SC will reach out to the participant, parent(s), responsible party(ies) and take the following actions, including, but not limited to:

Offer another current provider list,
Offer to reach out to providers through email and/or by phone,
Communicate with Regional Coordinator (RC) as needed.

Issues with staffing (including missed shifts or inability to locate staff) are not escalated outside of the Regional Office. Follow-up may be expedited dependent upon the participant/family circumstances, including, but not limited to a pending hospital discharge or crisis situation. A crisis situation is defined as the inability to obtain/lack of PDN services resulting in a high risk of placement in a healthcare facility; sudden or unexpected prolonged loss of PDN services or the inability to discharge from a healthcare facility due to being unable to obtain PDN services. By way of explanation, the term crisis is not to be interpreted as a word indicating there is a medical emergency requiring Emergency Medical Services.

SC – When the SC becomes aware of staffing issue. Actions will include but not be limited to:

Identify the need.
Provide the participant, parent(s), and/or responsible party(ies) with an up-to-date regional provider list and inform the family they may choose multiple agencies. This will be noted on the provider list given to the participant, parent(s), and/or responsible party(ies).
Offer to reach out to providers through email blast and/or by phone and follow-up with additional phone calls and/or emails.
Notify RC of issue as needed.

RC – Notified of staffing issue by SC. Actions will include but not be limited to:

Work with SC, participant, parent(s), and/or responsible party(ies), and/or provider to resolve staffing issue.
RC or Designee will send email blast to providers and follows-up with phone calls and emails.

Two or More Participants in the Same Residence

When two or more participants reside in the same residence who require PDN and their skilled needs can be met by one nurse, the total units authorized must be divided between the participants receiving services and may not exceed the actual amount of time (in 15 minute units) the nurse is in the home. The Service Coordinator (SC) will authorize only the medically necessary units of service required.

An assessment is completed for each participant to determine their individual skilled needs and whether or not one nurse can safely and adequately meet the care needs of both participants at the same time.
The authorization for each participant is individualized, the authorizations for each participant may not be equal.
Authorization of PRN (as needed) hours may be considered to ensure adequate nursing is available for circumstances when one participant is not in the home, such as medical appointments or hospitalization
In instances when there is a large variance in the medically necessary care of the participants, the SC must consult with the Regional Coordinator (RC) and HCY Program Manager as soon as practicable to discuss the appropriate services to authorize for each participant, based on their individual skilled needs.

If one participant is out of the home due to hospitalization or other reason, the family should notify the SC as soon as possible. The participant remaining in the home will only receive their authorized PDN services until the SC is contacted so the authorization can be evaluated.

When PDN services are approved for multiple participants in the same home, the SC will complete a new Confirmation of Verbal Service Authorization form for each participant. The SC will give the provider agency notification that the authorization will be for one nurse to provide services to multiple children.

Example Authorization

Assessed Service Needs – 8 hours/night Sunday through Thursday for each child.

Participant A – PDN 4 hours/night Sunday through Thursday.

Participant B – PDN 4 hours/night Sunday through Thursday.

Services Provided – 8 hours/night Sunday through Thursday split between siblings (4 hours/sibling).

If one participant is out of the home, the participant remaining in the home will receive 8 hours/night Sunday through Thursday.

Prescribed Pediatric Extended Care

Prescribed Pediatric Extended Care (PPEC) is the provision of a multidisciplinary service, including skilled nursing, personal care and speech, physical and occupational therapy. PPEC facilities operate, at a maximum, 12 hours/day Monday-Friday. Per MO HealthNet Division guidelines, Healthy Children and Youth (HCY) participants may receive PPEC services in a licensed PPEC facility when they meet PDN eligibility, are under the age of six (6) and PPEC services are ordered by a physician. PPEC services are delivered in either half day (4 hours or less) or full day (more than 4 hours) increments through a MO HealthNet (MHN) enrolled provider. However, PPEC is only authorized as a full day per diem rate by HCY staff. If half days are served by the PPEC provider agency, they are required to bill MHN accordingly. Please refer to the PDN Policy and MHN PDN Manual for PDN eligibility requirements and the Prior Authorization (PA) Policy for PPEC PA requirements.

PPEC Assessment, Required Contacts and Home Visits

SCs initially determine PDN eligibility using the assessment tools outlined in the PDN Policy. If a HCY participant is eligible for PDN and meets PPEC age requirements, they are subsequently eligible for PPEC services if they are prescribed by a physician. It is the responsibility of the PPEC provider to work in conjunction with the participant’s physician to obtain PPEC orders. Ongoing assessment, required forms, contacts and home visits will also be completed according to the PDN Policy. When a participant is receiving services in a PPEC facility, it is highly encouraged to complete at least 1-2 of the required visits per year in the PPEC setting.

Provider Selection and PPEC Enrollment

The SC will provide the parent(s) and/or responsible party(ies) with a regional provider list that includes current PPEC agency contact information. PPEC providers are responsible for maintaining a waitlist, working with the parent(s) and/or responsible party(ies) to determine a start date for PPEC enrollment and set a schedule for planned PPEC attendance. The parent(s) and/or responsible party(ies) are responsible for informing the SC when a PPEC provider is selected. The PPEC provider is responsible for notifying SHCN of the intended services start date.

Service Authorization

Once a provider agency is chosen by the parent(s) and/or responsible party(ies), the SC will contact the provider agency to discuss the service authorization. A HCY Confirmation of Verbal Service Authorization (VC) will be sent to the provider agency to be signed and returned to SHCN. This form will be filed in the participant’s record. An updated VC will be sent with any change in service authorization.

PPEC services will be authorized as a full day per diem rate, regardless of the hours per day listed on the POC, and are based on the number of weekdays (Monday – Friday) per month. If half days are served by the PPEC provider agency, they are required to bill MHN accordingly. Please see the below PPEC authorization example and Prior Authorization (PA) Policy for PPEC PA requirements.

Example PPEC Authorization

PPEC: As scheduled by the responsible party(ies) and provider within facility hours of operation Monday – Friday

When authorizing PPEC in conjunction with PDN, the hours of PPEC attendance should be factored into the overall HCY authorization. All participants receiving PPEC services should be authorized for 40 hours/month of PRN hours, to be used specifically on days when the participant is unable to attend PPEC. Those 40 hours/month PRN will be in addition to PDN authorized outside of the PPEC setting. If a participant typically receives all authorized PDN services in a PPEC setting, they should be approved for 40 hours/month of PRN hours only to be used when unable to attend PPEC. If changes need to be made to the PDN and/or PPEC authorization(s), the parent(s) and/or responsible party(ies) should contact the SC to request the changes.

Example Authorizations

Example 1: HCY participant who is authorized for 112 hours/week of PDN and chooses to typically receive 50 hours/week in a PPEC facility.

Total Approved PDN Authorization: 112 hours/week
Total PDN Hours Typically Served in a PPEC: 50 hours/week
PDN: 62 hours/week plus 40 hours/month PRN only to be used when unable to attend PPEC
PPEC: Days/month (based on number of weekdays in each month)

Example 2: HCY participant who is authorized for 80 hours/week of PDN and chooses to typically receive 25 hours/week in a PPEC facility.

Total Approved PDN Authorization: 80 hours/week
Total PDN Hours Typically Served in a PPEC: 25 hours/week
PDN: 55 hours/week plus 40 hours/month PRN only to be used when unable to attend PPEC
PPEC: Days/month (based on number of weekdays in each month)

Example 3: HCY participant who is authorized for 50 hours/week of PDN and chooses to typically receive 50 hours/week in a PPEC facility.

Total Approved PDN Authorization: 50 hours/week
Total PDN Hours Typically Served in a PPEC: 50 hours/week
PDN: 40 hours/month PRN only to be used when unable to attend PPEC
PPEC: Days/month (based on number of weekdays in each month)

Plan of Care

The provider agency is responsible for developing a Plan of Care and the physician’s signature. The Plan of Care specifies the type, frequency (number of days per month), and duration (how many weeks or months) of services to be provided. The Plan of Care is a comprehensive plan approved by a physician to direct PPEC staff members in care and treatment of eligible children that contains nutrition orders, medication orders, treatment orders, equipment orders, and interventions for developmental goals. The provider agency is responsible for submitting the Plan of Care to SHCN that must be signed by a physician or the provider agency registered nurse indicating receipt of a verbal order from the physician. The Plan of Care shall be reviewed and re-established by the physician at least every 60 days or as frequently as medically necessary. Changes to frequency or type of services authorized during a certification period must be authorized by the physician by way of verbal or written order.

The Plan of Care must include the following elements:

Identification of all allowed practitioners involved in the care of the child,
A medication list that includes the medication name, dose, frequency, and route of administration,
The medical equipment and emergency equipment necessary to care for the child,
The diet, nutrition, and developmental requirements for the child,
The frequency of treatment for skilled nursing, speech, physical, and occupational therapy; and
Treatments required by the child.

Upon receipt of this documentation from the agency, the Facilitator and SC will review for accuracy and appropriate content. The Facilitator shall complete the PA form for the authorized services. Upon completion, the SC will review, sign and date the PA form indicating approval. PPEC services may not be authorized for longer than a six (6) month period. The Facilitator will email the original PA form to the DSS, MO HealthNet Division Fiscal Agent for data entry and a copy of the PA form will be kept in the participant’s record.

Discontinuation of PPEC Services

SCs should notify PPEC providers of the discontinuation of PPEC services with a HCY Confirmation of Verbal Service Authorization (VC) for reasons that include, but are not limited to, the following:

The participant is deemed ineligible for PDN services,
The participant’s HCY case is closed, and/or
The parent(s) and/or responsible party(ies) request to discontinue PPEC services

If the provider agency initiates PPEC closure, they must give notification to the parent(s) and/or responsible party(ies) and SHCN prior to the discontinuation of PDN services. The PPEC service provider shall notify the parent(s) and/or responsible party(ies) in writing of the decision to discharge a participant and must provide a minimum of 21 days’ notice prior to the discontinuation of services for reasons that include, but are not limited to, the following:

The participant, parent(s), and/or responsible party(ies) are non-compliant with the agreed upon Plan of Care, and/or
The provider is no longer able to meet the service needs of the participant

The PPEC provider shall notify the SHCN within 72 hours of PPEC discontinuation due to the following circumstances:

Death of the participant,
Participant reaches the age of six (6) and is no longer eligible for PPEC services,
Participant’s admission to a health care facility,
Participant is no longer in need of care, and/or
Parent(s) and/or responsible party(ies)request to discontinue PPEC services

The SHCN SC shall assist the parent(s) and/or responsible party(ies) in making appropriate arrangements to locate and transfer care (if possible and necessary) to a new PPEC facility and/or PDN provider agency(ies).

Home Health Services

Medically Complex Children and Youth Guidebook

Home health services provide primarily medically-oriented treatment to individuals with an acute illness, or an exacerbation of a chronic or long-term illness, which can be therapeutically managed at home. The care follows a written plan of treatment established and periodically reviewed by a physician. The types of home health services authorized by SHCN are Home Health Aide, Short Term Skilled Nursing Visits, and Long Term Skilled Nursing Visits and are described below.

Home Health Aide

Home health aide services are covered home health services when the participant meets the home health qualifying criteria and there is a prescribed specific need for simple skills and personal care services in helping the participant with the activities of daily living (ADLs). Home health aide activities include performing simple procedures as an extension of therapy services, personal care, and household services essential to health care at home, assisting with medications that are ordinarily self-administered and do not require the skills of a licensed nurse. Home health aide services are frequently authorized in conjunction with skilled nursing and/or physical, occupational, or speech therapy services.

The services of the aide must be reasonable and necessary to maintain the participant at home and there must be no other person available who could and would perform the services.

The assignment of a home health aide to a participant must be made in accordance with a written plan of treatment established by a physician who indicates the participant’s need for personal care services. The reason for the visits by the home health aide must be to provide hands-on personal care of the participant or services that are needed to maintain the participant’s health or to facilitate treatment of the participant’s illness or injury.

A unit of service for home health aide service is a visit. A visit is a personal contact for a period of time not to exceed three hours delivered in the participant’s place of residence.

Short-Term Skilled Nursing

Skilled nursing care is a covered home health service provided that all the following conditions are met:

The services are ordered by and included in the Plan of Care established by the physician for the participant.
The services are required on an intermittent basis.
The services are performed by or under the direct supervision of a licensed nurse (RN or LPN) to assure the safety of the participant and to achieve the medically desired result.
The services are reasonable and necessary to the treatment of an illness or injury.

These services include assessing, teaching, planning, interviewing, and evaluating participant or family needs and their responses to nursing care, as well as provision of nursing care to persons in their own homes. The SC may not authorize skilled nursing visits solely for the purpose of an initial evaluation or as a supervisory visit for other staff.

A skilled nursing visit is defined as lasting from 15 minutes to three hours in length. Skilled nursing visits may be allowed twice daily when documentation clearly substantiates that the service is reasonable and necessary for the active treatment of an illness or injury and that the need for such service is short-term. Twice a day visits are not normally paid for more than seven consecutive days.

Plan of Care

Skilled nursing services are prescribed by a physician and provided in accordance with a Plan of Care, which clearly documents the need for services and is reviewed by the physician at least every 60 days.

Providers must use the CMS-485 or forms developed by the agency that contain all fields and information on standardized forms for MO HealthNet participants. The orders on the Plan of Care must indicate the type of services to be provided to the participant, the professional who will provide the services, the nature of the individual services, and the frequency of the services.

Example: SN 7/w x 1/wk; 3/wk x 4/wk; 2/wk x 3/wk, (skilled nursing visits 7 times per week for 1 week; 3 times per week for 4 weeks, and 2 times per week for 3 weeks) for skilled observation and evaluation of the surgical site, for teaching sterile dressing changes, and to perform sterile dressing changes.

Plans of care may not exceed a one-visit variance in the frequency of the ordered care. “PRN’ may be used if the number of visits is specified and the order does not exceed a one-visit variance in the frequency of the ordered care. (e.g., PRN 2-3 times per week.)

Prior Authorization of Short-Term Skilled Nursing Visits

The SC will receive a referral from a Home Health Agency requesting prior authorization of a specific number of skilled nursing visits. Indicators the SC shall consider for the prior authorization of skilled nursing visits may include, but are not limited to:

Teaching specific medical care such as injecting medications, dressing changes, self-catheterization, or ostomy care
Performing specific procedures such as catheter changes, wound care
Colostomy assessment, ostomy care, tracheostomy care
Infusion of intravenous medications or total parenteral nutrition

When requesting home health services, the provider must clearly document the medical needs of the participant and provide enough information to support the amount, frequency, and duration of services called for in the Plan of Care. If the request is not accompanied by a Plan of Care which has been approved by a physician, the request should state the name of the physician ordering the home health service. If inadequate information is provided, the SC shall contact the home health agency or the physician, or both, to request necessary documentation. The SC must have enough information about the participant to make a decision to either approve or deny the service request, or they may approve at a reduced level, frequency or duration.

The SC will approve or deny the request. If the request is approved, the SC will follow up with a VC to confirm the prior authorization. If the request is denied, the SC will communicate with the Home Health agency by contacting them via telephone to advise of the decision.

Required Contacts

SHCN will mail the following forms to the participant, parent(s) and/or responsible party(ies):

SNV Referral Letter
DHSS Notice of Privacy and Privacy Policies Acknowledgement Forms
Rights and Responsibilities Form and Acknowledgement Form

The SC does not complete home visits with short-term skilled nursing participants.

Place of Service

Home Health Services, including short-term skilled nurse visits, can be provided in the participant’s place of residence or where the participant is engaging in normal life activities.

Prior Authorization Request Form

The Home Health agency is responsible to submit a written prior authorization form and physician approved Plan of Care with each authorization request. The agency may request reauthorization of services near the end of each authorization period. Each request must include a summary of services, a progress report, and a current Plan of Care approved by a physician.

Skilled nursing visits may be authorized for up to a six month time frame. One line on the PA may include more than one month of service. The requested authorization should always end with the last day of a month.

Prior Authorizations for skilled nursing visits involving Synagis Injections may be written for up to a seven month time frame. The first six months should be written on one line and the seventh month on the next line.

If no documentation has been received from the provider within 90 days of the start date, the Facilitator/SC must make good faith efforts to contact the provider to obtain the required documentation prior to closing the referral.

Failure to Thrive

Failure to thrive may be chronic or acute; it is the acute condition due to malnutrition for which skilled nursing treatment in the home is reimbursed under MO HealthNet. A participant diagnosed with failure to thrive is eligible for eight weeks of nursing service if there is documentation of deficient weight relative to the participant’s height. The number of visits may not exceed 12 visits over the eight-week period. A standardized growth chart must be maintained in the participant’s chart and dates of observation must be recorded.

When a failure to thrive condition remains unimproved after eight weeks of nursing intervention, it is likely that either the condition itself is organic in nature and requires more intensive treatment than can be given by the home health nurse, or the situation in the home is neglectful, requiring intervention by appropriate authorities. If neglect is suspected, the home health nurse is legally required to report to the Family Support Division, Children’s Division.

No Protective Service Component

Home health does not cover medical social services and therefore does not reimburse services directed solely at resolving social or emotional problems that have been identified as an impediment to the effective treatment of the participant’s medical condition or the maintenance of the participant’s health. In cases in which these problems have been identified, other intervening agencies and professionals must be identified.

Long Term Skilled Nursing

Skilled nursing visit authorizations that are extended beyond six consecutive months are considered ‘long-term’. (Authorizations solely for Synagis injections are not included.)

The SC will monitor skilled nursing authorizations that are nearing six months in duration. Upon receipt of a referral/reauthorization request from a home health agency indicating continuation of short-term skilled nursing visits that extend continuous skilled nursing care beyond six months the SC will:

Authorize skilled nursing visits, as appropriate, per the short-term skilled nursing guidelines.
Contact the participant, parent(s) and/or responsible party(ies) within 15 business days of the receipt of the referral/reauthorization request to schedule a home visit.
Conduct a home visit during the seventh month of service to complete an assessment and the required forms to continue long-term skilled nursing authorization.

Required Contacts and Home Visits

Initial Home Visit

The SC completes a SCA during the initial home visit with the participant, parent(s) and/or responsible party(ies) within 15 business days of the date of the referral. The RC or the HCY PM may grant exceptions to this requirement.

Annual and Routine Home Visits

The SC completes a SCA annually during a home visit with the participant, parent(s) and/or responsible party(ies). Home visits are required every six months and the participant must be seen. It is expected that the participant, parent(s) and/or responsible party(ies) participate in all home visits except in extenuating circumstances with the RC approval. The SC will document home visits in the SHCN Information System using the appropriate home visit template.

Required forms for Long-Term Skilled Nursing Services

Service Coordination Assessment (SCA) (Annually)
Personal Care/Advanced Personal Care Assessment tool (Every six months)
CC-1 (Annually)
DHSS Notice of Privacy and Privacy Policies Acknowledgement (Annually)
Authorization for Disclosure of Consumer Medical/Health Information (As Necessary)
Rights and Responsibilities (Annually)
Prior Authorization Form (PA) (Every six months)
Confirmation of Verbal Authorization (Initially and with changes to authorization)
Expectations For In-Home Services (Annually)

Exceptions for Special Circumstances

Authorization In Excess of Two SNVs per day: More than two SNVs may be authorized in a 24 hour period only after it is determined that Private Duty Nursing (PDN) services are not appropriate. Supporting documentation is required in the SHCN Information System. Prior to granting authorization, the SC must obtain approval from the RC and the HCY PM.

HCY Case Management

Medically Complex Children and Youth Guidebook

This section references the HCY Case Management service that is requested and delivered by a MO HealthNet Case Management provider such as a local public health agency, doctor, or community based clinic. The role of the HCY SC is to authorize these services and process prior authorizations as appropriate.

HCY Case Management is an activity under which responsibility for locating, coordinating, and monitoring a group of necessary services for a participant rests with a designated person or organization in order to promote the effective and efficient access to necessary comprehensive health services. HCY Case Management seeks to promote the good health of participants and includes referral to various agencies for other needed services, such as Women, Infant and Children (WIC). It centers on the process of collecting information on the health needs of the participant, making and following up on referrals as needed, maintaining a health history, and activating the examination/diagnosis/treatment ‘loop’.

HCY Case Management may be used to reach out beyond the bounds of the MO HealthNet Program to coordinate access to a broad range of services, regardless of the source of funding for the services to which access is gained. The services to which access is gained must be found by the MO HealthNet Program to be medically necessary for the participant. HCY Case Management services are intended to assist MO HealthNet eligible individuals in gaining access to needed medical, social, educational, and other services. However, MO HealthNet cannot pay for social, educational, and other services that are not medical in nature even though HCY Case Management which assists the individual in accessing these services is covered.

Case Management Authorization

To provide and bill for HCY Case Management, a provider must be approved and enrolled as a Case Management provider with MO HealthNet.

Prior Authorization requests must be initiated by the provider who will be performing the HCY Case Management services. The provider must submit a Prior Authorization (PA) to the SHCN office. A separate procedure code and reimbursement have been established for the first month that HCY Case Management services are provided. (This includes the assessment and development of a care plan and a face-to-face encounter that includes an educational component.) The initial month should be written on a separate line, with the appropriate procedure code, than the subsequent months. The ‘from’ date in the initial month is the date the services were initiated. The ‘through’ date in the initial month is the last day of that calendar month. Subsequent months should be entered on separate lines with the appropriate code. (The Procedure Code for subsequent months cannot be billed during the same month as the initial case management visit.) The PA cannot be written to exceed more than 6 calendar months.

The HCY Facilitator shall review the PA upon SHCN receipt to assure the accuracy and completeness of the required information.

The HCY SC shall review the plan of care prepared by the Case Management Provider. The plan of care must indicate the date of the full/partial/interperiodic screen that resulted in the establishment of the medically necessary case management services and the date of the most recent full HCY screen. If the participant has not received a full screen, the Case Management Provider must make arrangements for a full screen and follow up that the screen was obtained, including all age-appropriate immunizations and lead screening, if indicated. The plan must contain the type of interventions, frequency of visits, if home visits are necessary, and an end date. The SC shall indicate the approval or denial of HCY Case Management services, sign the PA, and the HCY Facilitator will process the PA.

Family Partnership

Medically Complex Children and Youth Guidebook

The Family Partnership Program strives to enhance the lives of individuals and families impacted by special health care needs, providing resources and information to empower families to live a good life.

The Family Partnership Program hosts regional and statewide events to benefit families through development of leadership skills, networking among peers and staying current with trends and issues regarding special health care needs.

The Family Partnership Program serves individuals with special health care needs as well as their parents, family members, and legal guardians. The Family Partnership Program employs individuals known as Family Partners who are parents of individuals with special health care needs. In addition to providing information and resources to individuals, the Family Partners plan, schedule, and facilitate the Family Partnership Program meetings.

The goals of the Family Partnership Program are to:

Provide families the opportunity to offer each other support and information.
Give families the opportunity to provide SHCN input on the needs of individuals with special health care needs.
Build public and community awareness of the unique needs and issues facing families of individuals with special health care needs.

SCs shall provide Family Partnership information to all participants upon initial enrollment and encourage participation in the Family Partnership Program. When appropriate, the SC will make referrals to the designated Family Partner to assist participant, parent(s), and/or responsible party(ies) requesting peer support, mentoring and/or resource information. The SC will complete a Family Partnership Internal Referral Form and email it to the Family Partner, the RC, and the Family Partner supervisor.

Responsible Party/Alternate Contact Person

Medically Complex Children and Youth Guidebook

n an effort to maintain lines of communication, a responsible party and an alternate contact person shall be identified for each program participant. The SC will request the participant/family identify both a responsible party and an alternate contact person during the initial interview, on an annual basis thereafter, and as needed to ensure the information remains accurate. Contact information shall be submitted to designated staff for entry in the SHCN Information System.

Responsible Party

The responsible party is identified as the individual who holds legal responsibility for the participant. The responsible party is a person whom:

Shares protected health information with the SC or designated representatives of SHCN;
Completes and signs all SHCN required forms;
Provides documentation verifying legal custody, guardianship, or relative caregiver; this documentation must be placed in the participant’s legal record and noted in the SHCN Information System.

The responsible party is determined as one of the following:

A participant who is an emancipated minor
A participant 18 years of age or older
Any parent who has legal custody of his/her minor child
Any minor parent for him/herself and any child in his/her legal custody
Any legal (court appointed) guardian for the participant
The appointed caseworker from the Children’s Division when the participant is in foster care

(Note: A step-parent/step-grandparent cannot be listed as the responsible party and therefore is not approved to sign SHCN documentation authorizing the HCY Program for the participant unless they have been awarded legal guardianship.)

Alternate Contact Person

The alternate contact person is someone who will know how to get in touch with the participant, parent(s) and/or responsible party(ies) and can assist in facilitating contact with the family. Protected health information may not be shared with the alternate contact person unless a release of information has been signed by the participant, parent(s) and/or responsible party(ies) authorizing this type of communication with SHCN.

Prior Authorization

Medically Complex Children and Youth Guidebook

Authorization of services by SHCN staff signifies that the service is medically necessary but is not a guarantee of payment. Requests for services requiring prior authorization must be accompanied by documentation demonstrating medical necessity (e.g., physician orders or certification of need). Based on the information obtained during the SHCN assessment of the participant, the frequency, amount, and duration of services are determined and indicated on the PA document. SHCN only prior authorizes those services that are required to educate the participant, parent(s), and/or responsible party(ies) in the medically necessary care of the participant or to provide the needed care to stabilize/maintain the participant’s condition. Reimbursement of authorized services requires the submission of the PA document signifying the SHCN authorization for the delivery of all HCY services. A PA request form must be submitted to MO HealthNet Division Fiscal Agent for data entry.

SHCN SC has the responsibility to determine medical necessity and prior authorize the following services:

Private Duty Nursing (PDN)
Prescribed Pediatric Extended (PPEC)
Personal Care Aide (PCA)
Advanced Personal Care Aide (APCA)
Authorized Registered Nurse Visit (ARN)
Home Health Skilled Nursing (SNV)
Home Health Aide

Initial Prior Authorization

The creation of the PA form varies depending upon the type of services being authorized.

PCA, APCA, ARN, and/or SNV services – the provider agency creates the PA and submits it to the SHCN Regional Office along with the supporting Plan of Care and Physician Orders/Certification of Need documentation for processing
PDN and PPEC services (including those with both PDN and PCA services in the home) – the provider agency submits the Plan of Care (i.e., 485) with the correct Start of Care and certification dates to the SHCN Regional Office for the PA to be created by the SC and/or the Facilitator.
On the PA, there are different procedure codes/modifiers (sections 17 and 18) for each type of service being authorized, it is imperative that the correct code and modifier are entered on the PA. The codes and modifiers are as follows:
- PCA – T1019 with modifier EP
- APCA – T1019 with two modifiers TF/EP
- ARN – T1001 with modifier EP
- SNV – G0299 (this code changes frequently - confirm prior to using)
- PDN – T1000
- PPEC – T1025
The From and Through dates on the PA (sections 19 and 20) represent the days of each month being covered by the authorization. Each Line is to be designated for a separate month and the authorization cannot be more than six months.
There are two places in which the types of services being authorized are indicated on the PA. In section 21, a general description of the services authorized such as “Personal Care Aide” will be entered. In section 24, a detailed explanation of the services authorized is indicated such as “PCA 20 hours/week”. The detailed description should match what is written on the VC.
The quantity of approved units is indicated in section 22 of the PA.
- PDN, PCA and APCA services are authorized in 15-minute units and are calculated by multiplying the total number of hours/week x the number of weeks in the month x 4
- ARN and SNV services are authorized in visits/month or visits/week and are calculated by adding the total number of approved visits per month
- PPEC services are authorized as a full day per diem rate and are based on the number of weekdays (Monday – Friday) per month, regardless of the hours per day listed on the POC
  - If half days are served by the PPEC provider agency, they are required to bill MHN accordingly
Part IV “Provider” section on the PA indicates which service agency has been authorized to provide the services for the participant. Please note that all provider agencies have a NPI number that must be included and at times there is a Taxonomy number that must also be included. The Facilitator is responsible for maintaining an up to date list of this information.
Part V “Prescribing/Performing Practitioner” section of the PA indicated that Physician’s name and address. Lines #32 - #35 may be left blank in this section. The physician’s signature is not required on this form.
At the bottom of the PA, in the section stating “If approved: services authorized to begin”, the date written in must be the same as the initial “From” date indicated on Line #1 section 19.
The SC demonstrates approval by placing a check mark in the ‘Approved’ column corresponding to each service line item in column 16. The PA must be signed by the SC with their credentials written behind their signature along with the date that it is signed. The SC’s dated signature indicates that the PA has been reviewed/approved for accuracy regarding the authorization of services to be provided and total number of service units allowable for the designed timeframe.
At the top of the PA form, the code “PT 16” should be written to indicate that it is a HCY PA.
The Facilitator completes a final review of all PA related documentation for accuracy to ensure all requirements are met and then forwards the PA to MO HealthNet Division Fiscal Agent for data entry.

Program Manager (PM) Change Requests

A PM change request is completed upon initial request and annually thereafter with completion of the participant’s SCA for a variety of reasons which include, but are not limited to:

The authorization for PDN services or a combination of PDN and PCA/APC services exceeds 112 hours/week, including PRN hours,
PDN split shift services authorized in conjunction with PDN school based services,
PRN hours authorized for PCA/APC services,
Requests for more than one nurse in the home at the same time for one participant or multiple PDN participants same residence,
PDN and PCA to be served concurrently or overlapping for any period of time,
When the participant’s PDN Assessment Tool results in less than 50 points.

PM Change Requests are not required for the addition of PRN hours for PDN or PCA/APC that are authorized solely to be shared between multiple providers for shift coverage purposes and worded as such that the overall authorization should not be exceeded between the providers.

The SC completes all the sections of the PM Change Request form and submits it to the RC. The RC assigns it to another SC for peer review, as needed. The PM Change Request is then returned to the RC for review and recommendations. The RC will send the PM Change Request form to the HCY PM and copy the Associate Bureau Chief for review and approval. When applicable, the original PM Change Request form will be used to complete required updates for re-approval. Re-approval to continue the current authorization should only be submitted annually at the time of the SCA visit. The information on the new addendum will be designated by documenting in a different color corresponding to the date of the new request. Every addendum submitted must address each section of the document.

Continuation of Prior Authorizations

The re-certification of prior authorized services is done at least six months (or more frequently if needed) and is completed using the same steps indicated above. The provider agency must submit a new Plan of Care/485 with doctor’s orders up to four weeks in advance of expiration of the previous PA Request to ensure continuity of care for the participant provided the following criteria are met:

The start date of the next PA must be encompassed within the certification dates on the Plan of Care/485
The Plan of Care/485 must be updated to document continued medical necessity

If, at any time the SC requires further information to determine a continuation of a PA, the SC is allowed to request any of the following documents from the provider agency: Participant's progress, prognosis, or summary, a verbal report of known facts by the provider or a 30/60 day summary.

Services are Changed, Reduced, Terminated or Denied

Changes in authorizations may occur for a variety of reasons including, but not limited to:

A change in the level of care required for the participant,
Not utilizing hours previously authorized,
Family requests a change in services authorized,
Not following program requirements, responding to contact attempts by the SC, or attending home visits as scheduled,
The participant moves out of state,
The participant no longer qualifies for HCY services,
Services are requested but the participant does not qualify due to lack of medical eligibility, or
No present need for SHCN services due to availability of a caregiver.

When a change to the active authorization is needed, the participant, parent(s), and/or responsible party(ies) must be fully informed by the SC prior to any action taken. Any planned change in services should be documented by the SC in the SHCN Information System. Documentation should reflect the participant and parent(s)/responsible party(ies) understanding of planned services. A face-to-face assessment is required when any SHCN action adversely affects the request for, or amount of, authorized services unless this action is initiated by the family.

Written Notification of 10 Calendar Days

SHCN shall provide notice at least 10 calendar days prior to the expected change in service even if the participant and parent(s)/responsible party(ies) is in agreement by sending a letter using the Denial/Reduction/Change letter template and identifying the appropriate reason for the authorization change. The 10 calendar day period begins the day after the date on the letter and does not include weekends or state holidays. The effective date of the change occurs on the 11^th business day.

Exceptions to the 10 Calendar Day Rule

The 10 day calendar rule is not in effect when any of the following circumstances occur:

SHCN has factual information confirming the death of a participant,
SHCN receives a clear written statement signed by a participant/family stating that they no longer want services,
The participant has been admitted to an institution where they are eligible under the plan for further services,
The participant’s whereabouts are unknown and the post office returns SHCN mail directed to the participant indicating no forwarding address is known, or
SHCN establishes the fact that the participant has been accepted for Managed Care MO HealthNet coverage.

Cancellation of Authorized Services by a Provider Agency

Service providers are required to give a minimum of 21 days written notice to the participant, parent(s), and/or responsible party(ies), and SHCN prior to the discontinuation services, except in the case of an unsafe environment for the provider staff. The existing provider agency shall continue to provide care in accordance with the plan of care for these 21 days, or until alternate arrangements can be made by SHCN and/or the participant, parent(s), and/or responsible party(ies). The SC will assist the participant, parent(s), and/or responsible party(ies) in making appropriate arrangements to locate and transfer care (if possible and necessary) to a new provider. Reasons the provider may decide to discontinue services may include, but are not limited to:

Noncompliance by the participant, parent(s), and/or responsible party(ies) to the agreed upon plan of care,
The provider is no longer able to meet the service needs of the participant, or
The participant, parent(s), and/or responsible party(ies) requests a change.

The provider shall notify the SHCN within 72 hours of closure of a case due to the following circumstances:

Death of the participant,
Participant’s admission to a health care facility,
If the participant is no longer in need of care, or
The environment has become unsafe for the provider staff.

Changing Prior Authorizations

When a change from the initial authorization occurs, a change PA must be completed. The appropriate number of units requested and authorized are indicated with the corresponding “Requested From and Thru Date” and the “Authorized From and Thru Date” on the Professional Prior Authorization document obtained through eMOMED. Upon completion of this form, the SC reviews, signs, and dates the change PA indicating approval and forwards the form to the Facilitator. The Facilitator will process the form through the Department of Social Services, MO HealthNet Division Fiscal Agent to assure accurate provider reimbursement. The SC is required to document the nature of the change in the SHCN Information System. A changed or corrected PA Request Form (i.e., MO HealthNet Service Screen print from eMOMED) is required when:

The amount of authorized units increases or decreases,
The participant is discharged from services prior to the end date on the approved PA,
The type of service or procedure code is changed,
The service dates are changed, or
Provider information is changed or corrected.

Exceptions

Initial Authorization Requests Received Outside of Business Hours

If the provider agency receives physician orders for services during non-business hours, the request should be faxed to the appropriate SHCN office within 72 hours. The SC should review requests for services that are initiated on evenings, weekends, and holidays during the next regular business day. Once this review has been completed and medical necessity criteria have been established, the official start date will be determined by the SC in consultation with the RC. The SC will send a VC to the providing agency with the service authorization clearly stated. It is expected that the provider agency will sign the VC acknowledging understanding of the services to be provided and then send it back to the SC. A copy of the VC is kept in the participant’s file.

Appeals and Complaints

Medically Complex Children and Youth Guidebook

Appeals

The participant, parent(s), and/or responsible party(ies) shall have written notification of any agency action that adversely affects the request for, or amount of, authorized HCY services. These agency actions include, but are not limited to, any change (i.e., decrease or closing of an HCY service), denial of a request for change (i.e., increase or an additional HCY service), or denial of an initial request for HCY services. When a participant, parent(s), and/or responsible party(ies) is in agreement with or requests a reduction, denial, or closing of HCY services, this is not considered an adverse action but a notification letter will be sent.

The HCY Program participant, parent(s), and/or responsible party(ies) have the right to request an appeal of a SHCN decision within 90 calendar days of the date of the notification letter by contacting the Department of Social Services (DSS) by telephone at (800) 392-2161, email at MHD.PSURefferrals@dss.mo.gov , or by U.S. Postal Mail at:

Department of Social Services
MO HealthNet Division, Constituent Services Unit
P.O. Box 6500, Jefferson City, MO 65101-6500

If the participant, parent(s), and/or responsible party(ies) the hearing within 10 calendar days of the date of the notification letter, they may request services to continue at the current level until the hearing officer makes a decision. If the SHCN decision is upheld by the hearing officer, the State has the right to request payment from the participant, parent(s), and/or responsible party(ies) for the difference in services that were delivered during the appeal process.

When an appeal request is received, SHCN will be notified by the DSS. SHCN must immediately respond with a list of SHCN witnesses and dates of availability. Upon receiving the appeal notification, the SC, assisted by the RC and PM, will gather and submit supporting evidence for the decision made by SHCN to DSS/MO HealthNet Division. All relevant policies and SHCN specific documents from the case record used to support the decision for the adverse action shall include, but are not limited to:

State Statutes,
Code of State Regulation (CSR),
MO HealthNet Guidelines, and
SHCN documents used in the regular course of business.

Using the information that has been collected, the SC, in consultation with the RC and PM, creates a summary of the pertinent information and identifies the order of the exhibits to be presented at the hearing. The prepared packet is then provided to the PM for final review and to be submitted to the Hearing Officer along with a list of SHCN witnesses, contact information, and the exhibits each will present.

A legal hearing will be scheduled by DSS/MO HealthNet Division. The participant, parent(s), and/or responsible party(ies) will be notified of the time and place of the hearing by DSS/MO HealthNet Division. SHCN staff typically attends the hearing via conference call. There may be variations in how each Hearing Office conducts the appeal hearing. Below is an outline for the general process of an appeal hearing.

The Hearing Process

The Hearing Officer will place a call to all parties involved including, but not limited to, the participant, parent(s), and/or responsible party(ies) and their representatives, SC, RC, PM, MHN representative, and DHSS Office of General Counsel representative.
The hearing is audio recorded.
The Hearing Officer will read an introductory statement.
Individuals present for the hearing (by phone or in person) will be sworn in by the Hearing Officer.
The Hearing Officer will ask DSS/MO HealthNet Division to initiate the presentation of the agency’s case.
The PM, RC, SC, and others designated as witnesses from SHCN will be asked to present exhibits as follows:
- Exhibits are presented in sequential order, one at a time.
- Identify each exhibit by explaining what it is (e.g., home visit progress note, PDN assessment, participant contact progress note, provider nursing notes, etc.) and how it relates to the case.
- Request that each exhibit be entered into the legal record.
- Keep explanations as short as possible but do not omit important information for the sake of time.
The participant, parent(s), and/or responsible party(ies) may be allowed to ask questions during the presentation of SHCN exhibits before the Hearing Officer accepts the exhibit into the legal record.
The participant, parent(s), and/or responsible party(ies) and/or their representatives will be asked to present their testimony/exhibits.
The Hearing Officer may allow the participant, parent(s), and/or responsible party(ies) and/or their representative to ask additional questions of SHCN staff.
The SHCN staff are allowed to respond but are not allowed to question or rebut the participant, parent(s), and/or responsible party(ies) and/or their representatives testimony.
The hearing will be closed. The Hearing Officer may give the participant, parent(s), and/or responsible party(ies) additional time to submit exhibits for review by the Hearing Officer.

SHCN will be notified of the decision by DSS/MO HealthNet Division. SHCN will not change the authorization for services until the participant, parent(s), and/or responsible party(ies) have been formally notified of the hearing appeal outcome.

Complaints

All concerns or complaints should be immediately forwarded to the RC for resolution. The RC will consult with the PM and Bureau management if necessary.

Guardianship

Medically Complex Children and Youth Guidebook

The law presumes all adults (age 18 and over) have the capacity for decision-making.

Each month designated SHCN Regional Office staff will develop a report listing all participants turning 16 during that month. The designated SHCN Regional Office staff will then send the following information to the parent(s) and/or responsible party(ies):

A signed copy of the Guardianship Cover Letter
Guardianship Information Packet

SHCN strongly encourages the participant, parent(s), and/or responsible party(ies) to use this information to assist them in exploring and pursing the appropriate level of guardianship, or alternatives to guardianship, by the participant’s 18^th birthday.

Therefore, at age 18, unless a person has been declared incompetent through a court proceeding, each participant will be the person responsible to make decisions regarding their participation and services provided through the HCY Program. At age 18, these participants, or their responsible parties, are also required to sign all program related documents. See Responsible Party/Alternate Contact Person policy to identify each participant’s responsible party. If the responsible party also has legal custody, guardianship, or durable power attorney, that documentation must be retained in the participant’s legal record and documented in the SHCN Information System identifying the named legally responsible party(ies) and their role. The contact type for this entry is ‘legal custody’.

Children’s Division Custody and Guardianship

Whenever Missouri Children’s Division has legal custody the Children’s Division staff assigned as the participant’s caseworker is required to sign all SHCN documents.

Transition Policy for HCY Participants

Medically Complex Children and Youth Guidebook

Transition Process for HCY Participants Turning 21

SHCN collaborates with DSDS/FOPS and DMH/DD to provide a smooth transition for HCY participants who are moving to MO HealthNet adult coverage at the age of 21 and will no longer qualify for HCY services. All three agencies offer home and community based services for individuals 21 years of age and older. HCY SCs will begin discussing transition options at least one year prior to the participant’s 21^st birthday and follow the transition process, as outlined in the DSDS-DMH Transition Process for Participants Aging Out of HCY, to offer the participant/responsible party(ies) all available options for services after the participant’s 21^st birthday. If the participant/responsible party(ies) requests the MFAW Program, proceed with a referral to MFAW. Referral to the MFAW Program should take place at least three to six months prior to the participant’s 21^st birthday.

Referral to MFAW Program

The SC enters an Incoming Referral in the Referral screen in the SHCN Information System for the date the participant/responsible party requests the MFAW Program. This date cannot be more than six (6) months prior to the participant’s 21^st birthday.
The SC enrolls the participant in MFAW Service Coordination in the SHCN Information System, effective the date the participant/responsible party requests the MFAW Program.
The SC completes the MFAW Referral Screening (see the MOHSAIC User Guide for details on how to complete) in the SHCN Information System.
The SC completes a summary of the participant’s needs and services on the MFAW Enrollment Request Summary and submits it to the RC at least three to six months prior to the participant’s 21^st birthday.
- If a referral for MFAW is received from a referral source outside of the HCY Program and the individual is already over the age of 21, the SC must obtain documentation of the individual’s medical needs prior to the age of 21 that could only be met by four or more hours of continuous skilled nursing care that are equivalent to the PDN requirements for HCY.
- The SC will outline to the referral source that they will need to submit the medical records documenting this need for MFAW eligibility review. If the individual is a previous HCY and/or MFAW participant and was authorized for PDN during their program enrollment, the SC will outline this in the MFAW Enrollment Request Summary as proof of the medical need for PDN prior to the age of 21.
The RC will review the MFAW Enrollment Request Summary, follow up with the SC on any questions/concerns and then submit to the HCY/MFAW PM for review.
The HCY/MFAW PM will review the MFAW Enrollment Request Summary, following up with the RC and/or SC with any questions/concerns.
If the participant is enrolled in a DMH waiver at the time of the referral, verification of waiver termination prior to the participant’s 21^st birthday is required before MFAW Paid Service enrollment can be completed and services can begin.
- The HCY/MFAW PM will review the participant’s DMH enrollment information in CIMOR when reviewing the MFAW Enrollment Request.
- If there is an end-date on the DMH waiver enrollment prior to the participant’s 21^st birthday in CIMOR, the PM will note this in the response to the MFAW Enrollment Request and proceed with the approval process.
- If there is not an end-date listed in CIMOR prior to the participant’s 21^stbirthday, the HCY/MFAW PM will notify the RC and SC to make a request to the DMH/SB40 SC for a DMH waiver termination request signed by the participant/responsible party and the DMH representative.
  - If the SC completes documented good faith attempts to obtain DMH waiver termination verification from the DMH/SB40 SC and is unsuccessful, they will contact the RC to request assistance no later than one month prior to the participant’s 21^st birthday
  - The RC will then contact DMH Central Office staff, copying the PM, for assistance verifying DMH waiver termination
  - A scanned copy of the signed DMH waiver termination form is sent to the RC from the SC.
- The RC forwards this document to the HCY/MFAW PM.
Once the HCY/MFAW PM reviews the MFAW Enrollment Request Summary, they will send their recommendation for approval/denial to the RC. The HCY/MFAW PM makes the final determination of MFAW eligibility and authorization of services. If a DMH waiver termination is needed, the approval will be contingent on receipt of proof of the DMH waiver termination prior to the participant’s 21^st birthday.
The RC will notify the SC of the MFAW recommendation determined by the HCY/MFAW PM.
If the HCY/MFAW PM recommends MFAW enrollment, they will approve the MFAW Referral Screening in the SHCN Information System. If there is a pending DMH waiver termination, this will not be completed until proof is obtained.
If the participant is approved for a MFAW slot, the SC will proceed with the steps for MFAW Enrollment.

MFAW Enrollment

The SC completes the MFAW SCA, Level of Care (LOC), Client Assessment (CA) and has the MFAW paperwork signed by the participant/responsible party one to three months prior to the participant’s 21^st birthday or within 10 business days of receipt of the MFAW referral for individuals over the age of 21 and not currently enrolled in HCY.
During the MFAW SCA, the SC will review provider selection and service information. The SC should provide a copy of the MFAW provider list for the participant/family to assist with provider selection.
- If the participant is approved to receive specialized medical supplies through MFAW, they will need to select a MFAW provider for the newly authorized services since these are not covered through HCY.
- If the participant is approved to receive PDN, PCA, APC and/or ARN, it is likely that their current HCY provider will also be an enrolled MFAW provider and they will be able to continue using the same provider agency(ies). MFAW provider enrollment will need to be verified prior to selection and, if the provider agency is not an enrolled MFAW provider, the participant/responsible party will need to select a different agency.
Once the participant/responsible party notifies the SC of their provider choice, the SC will complete a VC for each agency and email to the respective provider agency staff. Please see the example for a MFAW New Enrollment VC in the HCY-MFAW VC Templates, Instruction & Examples resource for how to complete a MFAW New Enrollment VC.
Once the provider agency(ies) submit their PA supporting documentation, the Facilitator will complete the MFAW PA(s) and the SC will review and approve and the PA(s).
If MFAW enrollment is pending receipt of DMH waiver termination information, once the DMH termination documentation is received in Central Office, the HCY/MFAW PM will then approve the MFAW Referral Screening in the SHCN Information System allowing enrollment in Paid Service in the MFAW Program.
On the first working day on or after the participant’s 21^st birthday, the SC will enroll the participant in MFAW Paid Services, effective the date the participant turns 21. If the referral is already over the age of 21, the paid service enrollment date will be the date of approval.
The SC should then continue to follow the MFAW home visit schedule that aligns with their MFAW SCA. Please note that the previous HCY visit schedule may need to be adjusted, dependent on how the participant’s 21^st birthday aligns with the current visit schedule.

Regional Case Transfers

Medically Complex Children and Youth Guidebook

In order to ensure a smooth transition when a participant moves from one Regional Office coverage area to another this process should be utilized.

As soon as it is known that a participant will be moving into another area, the current SC will gather and submit the following information to their RC:

Participant name and DCN,
Participant program enrollments: HCY, MFAW, CYSHCN,
Date of next home visit and SCA date,
Type of services and amount authorized,
Current service providers,
Address to which participant will be moving, including zip code, and
Date of move.

Once the RC has all the required information they will forward it to the RC for the area to which the participant is moving. The RC for the area to which the participant is moving will review the information, assign a SC, and forward the information to the assigned SC.

The RCs and SCs for the two areas will then schedule a conference call (preferred) or draft an email to coordinate the transfer of the participant’s services and case to the new area. Some of the items to be discussed and/or resolved during the call are:

Participant’s needs, concerns, issues,
Who will take the lead in arranging services in new area (Current SC),
If needed, who will send participant, parent(s), and/or responsible party(ies) provider list for new area,
Is family working on transfer of other participant services such as DMH, DSDS, CYSHCN, therapies etc.,
Are there other resources participant may need in the new area (Ex: New physician, schools, transportation),
Who will conduct next home visit and/or does it need to include both SCs, and
When will responsibility for case transfer to new SC (No more than 30 days after the move).

Other items to be completed prior to transfer of case to another Regional Office:

Sending SC completes all pending documentation and forms,
Participant file is complete and up to date
RCs will facilitate a review of both the participant MOHSAIC and physical files to ensure both are complete and up to date prior to transfer,
RCs will coordinate transfer of physical file from one Regional Office to the new Regional Office, and
A change of SC letter will be sent to the participant, parent(s), and/or responsible party(ies) by the new Regional Office staff.

Interpreter Services

Medically Complex Children and Youth Guidebook

SHCN must coordinate interpreter services (language, Braille, or sign) for a participant, parent(s), and/or responsible party(ies) when the provision of service coordination is not possible due to a communication barrier.

In an effort to promote a higher degree of independence and health literacy, consideration of referrals to resources to reduce language barriers are encouraged.

Language barriers may interfere with the provision of services to the participant/family leading to misunderstandings and impacting Program effectiveness. Effective language services through a professional interpreter can help prevent these problems. Service Coordinators must offer and encourage the utilization of professional interpreter services during any communication with the participant/family when there is a language barrier present. If professional interpreter services are refused by the participant/family, this refusal must be documented in progress notes to justify the use of a non-professional interpreter (i.e. bilingual family member, friend, etc.)

Service Coordinators should use the current state contract for providing interpretation and translation services. All interpreter services must be documented in the SHCN Information System services screen and limited to direct Program service coordination. Participants/families should be instructed in the use of interpreter services, if applicable. Applicable billing information is obtained and given to the designated Regional Office staff person for processing.

NOTE: There are different providers for phone and in-person home visit interpreter services. Please review the current state interpreter service providers.

Required Form for Processing Payment of Interpreter Services

Service Coordinators will complete the below interpreter form for the corresponding interpreter service used and submit to the Regional Office Reporting Email. The Regional Office LASA will then submit to the Central Office Email for processing. Please see the HCY-MFAW Interpreter Process and Resource Guide for additional detail.

HCY-MFAW Interpreter Usage Data Sheet

Subpoenas and Legal Name Changes

Medically Complex Children and Youth Guidebook

Subpoenas

SHCN is required to respond to a subpoena for participant records and/or staff testimony but there are different processes to be followed for each situation.

Subpoena of Participant Records: A subpoena for a record cannot be accepted by a Regional Office. The server of the subpoena should be directed to DHSS Office of General Counsel.
Subpoena of SHCN Staff Person: The subpoena for a SHCN staff person shall only be accepted by the named staff person in the subpoena. Within the first 24 hours of being received, the SHCN staff person shall notify the RC and the RC will then notify the Bureau Chief. It is pertinent to note that the instructions in the subpoena must be followed.

Participant Legal Name Changes

Program participants who change their name must provide written proof (legal document) of the change before the name can be officially changed in the participant record or in the SHCN Information System.
A copy of the legal document will be obtained. A designated Regional Office staff person will update the name in the SHCN Information System and document the information (including effective date) in a progress note. A copy of the legal document must be kept in the participant’s file.
If there are two Departmental Client Numbers (DCNs), the Central Office staff in charge of the SHCN Information System changes should be notified.

Dually Enrolled Participants

Medically Complex Children and Youth Guidebook

In order to meet their needs, a participant may be enrolled in more than one SHCN Program at a time.

The HCY Program authorizes medically necessary in-home services, such as private duty nursing, personal care aide, and skilled nurse visits, that enable individuals to remain safely in their homes with their families. To be eligible for HCY, a participant must be birth to age 21, require in-home services as described above, and be enrolled in MO HealthNet (Fee for Service).

If a CYSHCN participant meets these criteria, they may also be enrolled in HCY. When this occurs the participant is said to be dually enrolled and has a SC assigned to them for each program. Outlined below are the responsibilities of each SC for these dually enrolled participants.

HCY SC Responsibilities (as the lead SC)

All HCY Program requirements.
Referral to and collaboration with the regional CYSHCN SC as appropriate.
- Referral to CYSHCN is warranted when a need is identified that MO HealthNet does not cover and with which CYSHCN can provide financial assistance.
- To avoid duplication of service, CYSHCN cannot provide service coordination only if the participant is already receiving service coordination through HCY.
SCA interview and entry (notify the CYSHCN SC of visit date/location).
If there is a HCY closure, notify the CYSHCN SC so they are aware of the situation and can assume the lead SC responsibilities.
Participant/family questions, concerns, complaints regarding the HCY Program or services.

CYSHCN SC Responsibilities

All CYSHCN Program requirements.
Referral to and collaboration with the regional HCY SC as appropriate.
- Referral to HCY is warranted when a need for in-home service (PDN, PCA, Skilled Nurse Visits) is identified and the participant has MO HealthNet (Fee for Service).
AFER (Annual Financial Eligibility Review) requirements.
CYSHCN Prior Authorizations (including obtaining MO HealthNet denials and letters of medical necessity) and Service Plan entry.
One annual face to face visit.
- Although not required, the most optimum time to complete the visit would be in conjunction with the HCY SCA home visit.
- Do not enter a separate SCA from the HCY SCA.
If there is a CYSHCN closure, notify the HCY SC before the closure takes place to ensure all current needs/requests of CYSHCN have been satisfied.
- There must be a current or ongoing financial need that CYSHCN is addressing for a HCY participant to remain dually enrolled in CYSHCN.

***The CYSHCN PM and RC should be copied on all email correspondence between HCY and CYSHCN SCs.

Emergency Status Guidelines

Medically Complex Children and Youth Guidebook

The frequency of home visits may be adjusted when reductions to the SHCN staff occur and in the event of local or natural disasters including weather events, bioterrorism attacks, and other threatening situations.

The HCY PM, taking into consideration input from the RC, and other Bureau Management as necessary, will determine when a specific Regional Office changes the home visit requirements. In addition, the HCY PM will determine the duration of the implementation of this process.

The HCY PM will assess the situation in the affected Regional Office and investigate all other possible alternatives prior to initiation of this process. Upon initiation of Emergency Status, SHCN Staff will comply with measures outlined below.

Private Duty Nursing (PDN)

Quarterly Home Visits

Routine quarterly home visits may be suspended for each participant receiving PDN services.
The SC will make phone calls to the participant, parent(s), and/or responsible party(ies) to gather information required to complete the home visit template. Documentation of the contact will be completed using the home visit template and utilizing contact type of “HCY Home Visit Exception Contact” in the SHCN Information System.
If there are significant concerns regarding the participant at the time the quarterly visit is due (i.e., medical status, caregiver availability, and/or provider issues), the quarterly visit must be made. If there are issues identified during home visit exception contact phone call, the SC will discuss the situation with the RC and a determination will be made if a home visit needs to be made.
Requests for increases in services indicate a change in the current status, therefore, a home visit is required.
If there are no problems identified by either the participant, parent(s), and/or responsible party(ies), the home visit may be suspended and the authorization shall remain unchanged.
Participants receiving PDN services must have a home visit at least every six months.
The Good Faith Effort process is used when completing required contacts.

Personal Care Aide (PCA)/Advanced Personal Care Aide (APCA)

Semi-annual home visits may be suspended for each participant receiving PCA/APCA services.
The SC will make phone calls to the participant, parent(s), and/or responsible party(ies) to gather information required to complete the home visit template. Documentation of the contact will be completed using the home visit template and utilizing contact type of “HCY Home Visit Exception Contact” in the SHCN Information System.
If there are significant concerns regarding the participant at the time the semi-annual visit is due (i.e., medical status, caregiver availability, and/or provider issues), the semi-annual visit must be made. If there are issues identified during home visit exception contact phone call, the SC will discuss the situation with the RC and a determination will be made if a home visit needs to be made.
Requests for increases in services indicate a change in the current status, therefore, a home visit is required.
If there are no problems identified by either the participant, parent(s), and/or responsible party(ies), the home visit may be suspended and the authorization shall remain unchanged.
Participants receiving PCA/APCA services must have a home visit at least every 12 months.
The Good Faith Effort process is used when completing required contacts

Records Management

Medically Complex Children and Youth Guidebook

Documents that are filed in the participant's legal record should be maintained according to the following procedure:

Documents should be filed in each section in descending chronological order.
Duplicate copies of documents should not be filed in the record.
- Staples and tape should not be used.
When the participant's record exceeds folder capacity, an additional folder should be created.
- Each folder will be marked with the participant's name and DCN and maintained according to the procedures outlined in this guideline.
- A notation will be added to the record tab indicating that additional folders are on file.
Mailed records should be sent via certified mail, with reinforced envelope/packaging closure, and email notification going from sender to recipient (if both are internal). Confirmation email should also be sent from recipient to sender once the records have been received (if both are internal).
Both sender and recipient (if internal) should document the transfer of the record from one location to another in MOHSAIC Progress Notes using the contact type ‘Record Custody’.

Order of the Participant Record

(Includes outdated forms)

Section 1 - Enrollment:
- Enrollment Information (CC-1)
- Exceptions Denial letter
Section 2 - Services:
- Assessment/Service Plans
  - CAT (outdated)
- Participant Information (CC-7) (outdated)
- Nutrition Screening (outdated)
- Transition Plan (CC-8) (outdated)
- Prior Authorizations, in the following order, each section in descending order by date:
  - Private Duty Nursing Assessment tool
  - Personal Care Assessment tool
  - Level of Care Determination
  - Prior Authorization (8809) with:
    - Home Health Agency Plan of Care (485 & 487),
  - Prior Authorization (CC-9,CSHCN)
  - Prior Authorization (CC-9D, CSHCN)
Section 3 – Medical Information:
- Information Request (CC-62) (outdated)
- Revocation Form (outdated)
- Acknowledgement Form
- Refusal Of Consent to Share Health Care Information (BGDP2) (outdated)
- Consent to Share Health Care Information (BGDP-1) (outdated)
- Authorization for Disclosure of Consumer Medical/Health Information (MO 650-2616)
- Medical Reports (all sources)
- Medical Report (CC-5) (outdated)
Section 4 – Correspondence:
- Confirmation of Verbal Service Authorization
- Services/Participant Preferences
- Form Letters
- Letters received concerning the participant
- SSI Referral for Rehabilitation Services (DD-AFP)
- SSI or Camp Applications
- Medical Source Statement - Mental (for Social Security) (outdated)
Section 5 - Forms:
- Emergency Response Information
- HCY PDN Acceptance
- Rights and Responsibilities Acknowledgement
- Expectations for In-Home Services Authorized
- Client Choice Statement
- Participants Rights & Responsibilities (HI - outdated)
- Insurance Information (CC-2) (outdated)
- SSI Disability Program Form (SSI-9)
- PDW Referral Screening tool

On Site Record Maintenance

Participant records will be locked in a centralized filing system.
The participant's legal record should not be removed from the Regional Office or Contracting Agency Office.
The Regional Office Coordinator shall appoint a Records Administrator.
- The duties of the Records Administrator should include:
  - Maintenance of the record system.
  - Destruction of records according to the Central Office retention schedule.
  - Researching of record information at the request of Central Office staff.
  - Assuring that the microfilming process is carried out according to policy.

Records Retention

The following records should be retained in the Regional Office or Contracting Agency office:
- Participant records that have been actively enrolled on any SHCN service. Upon closure of SHCN Program(s) the record will retained in the inactive files until requested by Central Office for microfilming.
  - Upon receipt of the Microfilming List from Central Office, the records requested will be prepared for microfilming and sent to Central Office. This process should be documented.
  - All closure dates of the inactive charts should be reviewed when selecting charts for microfilming and any chart with program closure date(s) on or prior to the microfilming cut-off date should be added to the microfilming list and also sent for microfilming. This process must be documented.
The following records/referrals should be retained for 3 months after the participant information screen closure date.
- Referrals that are not made active on any program and cannot be added to a previous chart still housed in the Regional Office or contract office.
  - After 3 months, and no further activity, the chart/referral paperwork may be shredded. Documentation should be done to explain the process.
Provider Monitoring Logs
- Retain for 3 years, then may shred.

Lost/Missing Participant Records

Central Office will be notified when a participant's legal record cannot be located.
Central Office will contact all Regional Offices in an effort to locate the participant's lost legal record.
When the participant's lost legal record cannot be located, a memorandum will be prepared by Central Office outlining the details of the record search.
- The Bureau Chief will indicate acceptance of the information by authorizing that the participant's lost legal record be officially closed.
- The memorandum and accompanying documentation should be microfilmed in lieu of the participant's lost legal record according to the retention schedule.