Introduction

The Division of Senior and Disability Services (DSDS) is the initial point of contact for Home and CommunityBased Services (HCBS). DSDS operates a Customer Service Contact Center within the Bureau of HCBS Intake and PCCP, where initial referrals are received and processed. Potential participants must meet the Nursing Facility Level of Care (LOC) to be considered for HCBS.

Purpose

The Bureau of HCBS Intake and PCCP receive referrals from potential participants, HCBS providers and professional community partners. The bureau determines if a potential participant is appropriate for an initial assessment in their home.

Process

HCBS referrals shall be submitted utilizing the Online HCBS Referral Form. In instances where referrals cannot be submitted online, referrals can be submitted by completing the HCBS Referral Form and emailing to HCBSCallCenterReferrals@health.mo.gov. 

Upon receipt of a completed referral for HCBS, DSDS shall determine if the potential participant is eligible for HCBS and is appropriate for an initial assessment by:

• Obtaining the potential participant’s Departmental Client Number (DCN) and either the date of birth or last name to access information in the participant’s electronic case record
• Verify whether the potential participant has the appropriate Medicaid type and age eligibility from the “Participant” screen in the electronic case record.

Note: Special intake requirements exist for Show-Me Home.

Processing Limits

Managed Care Health Plans

Individuals enrolled in certain Managed Care Health Plans are not eligible to receive HCBS or certain HCBS authorized by DSDS. If a referral is received for an individual enrolled in a Managed Care Health Plan where requested services cannot be authorized, DSDS shall refer the individual to the Managed Care Health Plan contact information provided in the electronic case record.

SPENDDOWN

Referrals will not be processed if spenddown liability is not met at time of referral. Individuals who appear eligible for Home and Community Based (HCB) Medicaid and potentially eligible for an Aged and Disabled Waiver service will be referred to the Department of Social Services (DSS) Family Support Division (FSD).

FSD will determine HCB eligibility and initiate the HCBS referral if appropriate.

A referral will not be accepted for individuals who are not Medicaid or age-eligible on the date of the request.

MILLER TRUST

In addition, an IM-54A referral from the Family Support Division (FSD) indicating a Qualified Income Trust (QIT) or “Miller Trust” is being processed through FSD shall be accepted for those spenddown recipients who do not have Medicaid benefits in effect but are potentially eligible for an ADW service. IM-54A referrals from FSD indicating a SLMB-2 and/or a Division of Assets shall also be accepted and processed.

Referral Process

HCBS Intake will only process appropriate referrals. Incomplete referrals are considered inappropriate and will not be processed. They will be dispositioned as inappropriate. The applicable action will be chosen, and the referral will be closed.

Upon determination that the potential participant is an appropriate referral for HCBS The information gathered and/or verified at the time of intake is as follows:

• If the Participant applied for HCBS in the last ninety (90) days
• Participant’s name
• Participant’s DCN
• Participant’s DOB
• Participant’s physical address
• Participant’s mailing address
• Participant’s primary phone number
• Alternate phone number
• Other responsible person information (name, relationship, phone numbers, address)
• Communication needs
• Is the participant currently in the hospital? If so, the hospital name/address/contact person/phone number?
• Marital status
• Living arrangement
• Other household members receiving HCBS
• Primary medical conditions related to the participant’s need for HCBS
• Unmet needs of person being referred (tasks)
• Reason for referral
• Safety concerns
• Referrer’s information (name, relation, contacting information)

Note: The military status question needs to be asked per SB 120 – Section 42.051 RSMo. When a potential participant answers “yes” to this question, DSDS staff shall provide them the MO ATQ Resource Page either electronically or by mail.

The participant’s electronic case record shall be reviewed, completed, and updated with the required information on the HCBS Referral Form. Information regarding any safety concerns shall be addressed in the “Safety Concerns” section within the electronic case record. Information in the participant's electronic record shall be changed or updated at any time during the life of a case when DSDS or its designee becomes aware of the change or update. Other responsible person information shall be included when applicable.

Note: A case shall be added on the same day it is determined that the referral is appropriate for HCBS processing. A case shall remain open as long as there is an authorization for HCBS.

Introduction

Individuals seeking Home and Community Based Services (HCBS) must meet nursing facility Level of Care (LOC). This measures the same eligibility criteria required for entry into a nursing facility as outlined in 19 CSR 30-81. LOC is determined during (re)assessments completed by Division of Senior and Disability Services (DSDS) staff or their designee.

Purpose

DSDS utilizes the InterRAI HC tool to conduct assessments. Based on the information gathered, algorithms within the electronic case record system determine the LOC score in individual categories. With an assessed LOC score of 18 points or higher, an individual is determined to be qualified for LOC and eligible for HCBS. If the individual does not meet LOC, they are determined to be ineligible and appropriate adverse action steps should be taken.

Categories

Cognition

• Determine if the participant has an issue in one or more of the following areas:
  • Cognitive skills for daily decision making and ability to complete task in a sequence
  • Memory or recall ability (short-term, procedural, situational memory)
  • Disorganized thinking/awareness – mental function varies over the course of the day
  • Ability to understand others or to be understood

Eating

• Determine the amount of assistance the participant needs with eating and drinking. Includes intake of nourishment by other means (e.g. tube feeding or TPN).
• Determine if the participant requires a physician ordered therapeutic diet.

Behavioral

• Determine if the participant:
  • Receives monitoring for a mental condition
  • Exhibits one of the following mood or behavior symptoms – wandering, physical abuse, socially inappropriate or disruptive behavior, inappropriate public sexual behavior or public disrobing; resists care
  • Exhibits one of the following psychiatric conditions –abnormal thoughts, delusions, hallucinations

Toileting

• Determine the amount of assistance the participant needs with toileting. Toileting includes using the toilet (bedpan, urinal, commode), changing incontinent episodes, managing catheters/ostomies, and adjusting clothing.
• Determine the amount of assistance the participant needs with transferring on/off the toilet.

Bathing

Determine the amount of assistance the participant needs with bathing. Bathing includes taking a full body bath/shower and the transferring in and out of the bath/shower.

Treatments

• Determine if the participant requires any of the following treatments:
  • Catheter/Ostomy care
  • Alternate modes of nutrition (tube feeding, TPN)
  • Suctioning
  • Ventilator/respirator
  • Wound care (skin must be broken)

Dressing and Grooming

• Determine the amount of assistance the participant needs with:
  • Personal Hygiene
  • Dressing Upper Body
  • Dressing Lower Body

Rehabilitation

• Determine if the participant has the following medically ordered therapeutic services:
  • Physical therapy
  • Occupational therapy
  • Speech-language pathology and audiology services
  • Cardiac rehabilitation

Meal Prep

• Determine the amount of assistance the participant needs to prepare a meal. This includes planning, assembling ingredients, cooking, and setting out the food and utensils

Medication Management

• Determine the amount of assistance the participant needs to safely manage their medications. Assistance may be needed due to a physical or mental disability.

Mobility

• Determine the participant’s primary mode of locomotion
• Determine the amount of assistance the participant needs
  • Locomotion – how moves in the home, between locations on the same floor (walking or wheeling). If wheeling, how much assistance is needed once in the chair?
  • Bed Mobility – transition from lying to sitting, turning, etc. while in bed

Safety

• Preliminary safety LOC score
  • Determine if the individual exhibits any of the following risk factors:
  • Vision Impairment
  • Falling
  • Balance – moving to standing position, turning to face the opposite direction, dizziness, or unsteady gait.
• After determination of preliminary score, history of institutionalization in the last 5 years and age will be considered to determine final score.
  • Institutionalization – long term care facility, RCF/ALF, mental health residence, psychiatric hospital, settings for persons with intellectual disabilities
  • Age – 75 years and over

Introduction

The Home and Community Based Services (HCBS) assessment process determines the current level of independent support and unmet needs necessary to enable the potential or current participant to remain in the least restrictive environment.

Purpose

The purpose of the assessment shall: • Establish eligibility or continued eligibility for HCBS • Ensure adequacy in the development of the Person-Centered Care Plan (PCCP) • Offer the appropriate services available • Identify and facilitate referrals outside of the HCBS program • Inform the participant of qualified HCBS providers in the participant’s area • Coordinate HCBS with the selected HCBS provider to ensure delivery of services

Legal Representative/Confidentiality

For potential or current participants who have a legal representative (e.g., guardian, or someone with a Durable Power of Attorney (DPOA) in effect), it is required the legal guardian be informed of the assessment, sign necessary documents (e.g., Participant Choice Statement) and approve the authorization of services. In addition, if there is a signed Authorization for Disclosure of Consumer/Medical Health Information in effect, the person listed shall be informed. Additional information may be needed to complete the assessment. Care should be taken to ensure the confidentiality of the potential or current participant is not compromised. When assistance from a third party is necessary to complete the assessment process, this information shall be thoroughly documented in case record of the participant’s electronic case record.

InterRAI HC Assessment

The InterRAI HC guides comprehensive care and service planning in community-based settings. It focuses on the person’s functioning and quality of life by assessing needs, strengths, and preferences. Completion of the InterRAI HC shall be done at initial referral of services and at each annual reassessment. Based on the information gathered from the completed assessment, algorithms within the electronic case record system determine the participant’s nursing facility level of care for eligibility purposes. Additional guidance for facilitating an accurate and uniform assessment with the InterRAI HC is available in the InterRAI HC manual.

Scheduling An Assessment/Reassessment

Initial Assessment

Upon receipt of a request for an initial referral for HCBS, the Division of Senior and Disability (DSDS) staff shall schedule and complete a face-to-face visit with the potential participant for an initial assessment. The scheduling and completion of all initial assessments must be completed within fifteen (15) business days of the date the referral was received.

To schedule an initial assessment, DSDS staff shall:

• Make a minimum of one (1) attempt by phone to contact the participant and/or legal guardian
• Leave a message and include their contact information, and the date the initial referral will be closed if attempts to contact are unsuccessful
  • The closing date of the referral shall be at least ten (10) calendar days from the day the message was left.

NOTE: If the closing date is on a State Holiday or weekend, the next business day shall be considered the date to close the referral (e.g., if the 10th calendar day ends on Saturday, the next business day is Monday).

If a message cannot be left, DSDS staff shall:

• Send the Participant Contact Letter, outlining a response date
  • The response date shall be at least ten (10) calendar days from the day the letter is sent.

DSDS staff shall close the case if no response is received by the date provided in the letter. The participant must initiate a new referral through the initial referral process.

The HCBS provider and/or the referring entity shall be notified of DSDS staff's attempts to contact the potential participant and informed of the closing date of the referral if no contact has been made. This provides an opportunity for the provider to assist with locating the potential participant.

If the participant and/or legal guardian contacts DSDS within the ten (10) calendar days, an assessment shall be scheduled. However, if the participant fails to attend the scheduled appointment as agreed upon, the HCBS referral will be closed on the same day. DSDS staff will send the Participant Contact Letter with the “Initial Missed Appointment” reason for closing. The participant must initiate a new referral if there is still a need for services.

Reassessment

All participants authorized for HCBS shall have a reassessment completed within 365 days from the last level of care determination. DSDS staff shall attempt to schedule a face-to-face reassessment; however, in certain instances, a reassessment may be performed by telephone.

To schedule a reassessment, DSDS staff shall:

• Make a minimum of one (1) attempt to contact the participant and/or legal guardian by phone
• Leave a message and include their contact information along with a response date if attempts are unsuccessful
  • The response date shall be at least ten (10) calendar days from the day the message was left.
  • An adverse action shall be sent if there is no response by the date outlined in the phone message. The participant and/or legal guardian have at least 10 calendar days to respond to the adverse action. If they fail to respond, the care plan and case shall be closed.
    NOTE: If the 10th calendar day is a weekend or holiday, the next business day shall be considered the response date (e.g., if the 10th calendar day ends on Saturday, the next business day is Monday).
• If a message cannot be left, DSDS staff shall send an adverse action. The adverse action shall include the reason for contact.
  • The participant and/or legal guardian have at least ten (10) calendar days to respond from the day it was sent. If no response, the case shall be closed.

NOTE: The current care plan shall only be reauthorized if the closing date on the adverse action exceeds the end of the current authorization date.

If the participant and/or legal guardian contacts DSDS before the closing date on either of the above adverse actions, an assessment shall be scheduled. However, if the participant fails to attend the scheduled appointment as agreed upon, DSDS will initiate an adverse action. The participant and/or legal guardian must contact DSDS within ten (10) calendar days of the adverse action to reschedule the assessment.

If the assessment is rescheduled and the participant fails to attend the second appointment, DSDS will close the case based on the closing date of the original adverse action. No other contact attempts are needed. The participant must initiate a new referral if there is still a need for services.

NOTE: DSDS staff shall contact the HCBS provider to ensure the provider is aware of the attempt to contact the participant and assist in locating them.

Participant Contact Letter

The Participant Contact Letter shall include at a minimum, the following information:

• DSDS staff's inability to contact the participant to schedule an HCBS face-to-face (re)assessment visit
• The date the participant and/or legal guardian is to respond by
• The legal reference
• A DSDS staff contact number

The ten (10) calendar days shall begin the first business day after the Participant Contact Letter is mailed. If the 10th calendar day ends on a weekend or State Holiday, the next business day shall be considered the 10th day (e.g., if the 10th calendar day ends on Saturday, the next business day is Monday).

Assessment/Reassessment Process

The (re)assessment process provides a basis in establishing a PCCP and the decisions regarding HCBS authorization. A complete thorough assessment to include information and related documentation obtained during the assessment process will establish an appropriate PCCP.

Initial Assessments

Upon receipt, all initial referrals shall be prioritized by the immediacy of the need for an initial assessment and HCBS. The following are examples of high priority referrals:

• Immediate discharge from a hospital or nursing facility
• Significant breakdown of current support system
• Catastrophic event
• Adult Protective Services request to assist with the participant’s safety and well-being
• Family Support Division referrals requesting Home and Community Based Medicaid (HCB) Medicaid, Qualified Income Trust (QIT) and Division of Assets

The assessment and all PCCP activities, including completion of the following, shall be completed as soon as possible, but not to exceed fifteen (15) business days from the receipt of the referral.

• InterRAI HC
• Participant Choice Statement
• Privacy Policies Acknowledgement Form
• Development and completion of the PCCP

If the potential participant does not meet the necessary level of care for HCBS, DSDS staff shall initiate an adverse action. The case shall be closed with the appropriate action and date upon completion of the adverse action process.

Reassessments

A participant shall have a reassessment completed by DSDS staff or its designee to establish continued eligibility for services. The end date, which reflects the last full month within 365 days from the previous level of care determination, will be indicated as the due date for the reassessment. (The month the current care plan authorization expires.)

DSDS staff shall verify the participant’s Medicaid eligibility prior to a reassessment. If the participant is a Medicaid spenddown recipient, spenddown must be met at least once within the last three (3) months to remain eligible for HCBS. DSDS staff shall verify with the Family Support Division (FSD) if the participant has pending expenditures waiting to be entered before closing the case. DSDS staff shall thoroughly document contacts with FSD and any attempts for additional information in the electronic case record.

If the participant is no longer Medicaid eligible, DSDS staff or its designee shall follow the Adverse Action policy.

Individuals enrolled in certain Managed Care Health Plans are not eligible to receive HCBS authorized by DSDS staff. If HCBS cannot be authorized for the participant, DSDS staff shall send a Notice of Closure to the individual and include their Managed Care Health Plan information on it.

The InterRAI HC shall be reviewed by DSDS staff or its designee.

• The reassessment shall reflect any change from the previous assessment.
• All information discussed during the reassessment interview shall be thoroughly documented.
• During the reassessment, DSDS staff, or its designee, shall determine the participant’s satisfaction with the HCBS they receive. DSDS staff or its designee shall follow the Provider Complaint protocol regarding any provider complaints.

DSDS staff or its designee shall develop a new PCCP to ensure the continuity of HCBS. All required documents shall be reviewed and completed at each reassessment including the Participant Choice Statement.

COOP Priority

Risk indicators will display on the participant screen of the participant’s electronic case record. This indicator is determined at the (re)assessment. These indicators are intended to assist the HCBS provider in prioritizing service delivery in instances such as temporary staffing shortages, natural or other disasters, and acts of terrorism.

Document the level of priority by evaluating circumstances (e.g., support system, confusion, and noncompliance) on the assessment tool. Risk indicator of one (1) shall be used when the lack of HCBS would pose a serious threat to the health, safety, and welfare of the participant. Discretion shall be used in assigning high risk. A fragile, unreliable or insufficient support system must be documented in the electronic case record justifying high risk status.

Goals

During the (re)assessment process, DSDS staff shall work with the participant to identify a personal goal. DSDS staff shall ensure the PCCP supports the goal when possible. Any barriers that may prevent the goal from being achieved shall be documented.

An appropriate goal shall reflect what the participant hopes to achieve through HCBS. DSDS staff shall encourage the participant to express a goal in their own words, which may reflect:

• To remain in their home
• To be able to walk again

A goal shall not be a statement of fact, such as:

• They don’t feel well
• They enjoy the meals they receive

Goals may come from the participant or legal representative. In the rare circumstance when a participant cannot verbalize a goal, a primary caregiver may provide the goal for the participant. Thorough case record documentation would be required in these instances. Case record documentation shall include:

• The participant is unable to express a goal
• Who the goal was provided by (the legal guardian or primary unpaid caregiver)
• Name and relationship of the person providing the goal

Backup Plan

DSDS staff shall identify, in collaboration with the participant and/or legal guardian, details of a backup plan to be used in the event of an emergency, and when events such as weather or illness prevent service delivery by the HCBS provider(s). If the aide or attendant is not available, the participant and/or legal guardian shall provide a support system to ensure needs are met and continuation of services. Available assistance may vary, but all availability should be considered.

The backup plan shall identify a specific individual(s) available to assist when needed and may consist of the following:

• Family, friends, a neighbor, collateral contacts, etc.

A brief, detailed summary of the support shall be provided and documented in the participant’s electronic case record to include:

• The name, phone number and relationship of the individual providing the support
• The specific tasks to be provided
• The frequency of each task being provided (e.g., all meals prepared Monday, Wednesday and Friday, bathing on Tuesday and Thursday)

NOTE: If multiple supports are identified, DSDS staff shall ensure all contact information, specific tasks, and the frequency of each task are documented specifically for those providing the support. 911 should only be used in rare instances and as the last option for participants with no other alternatives or support system (i.e. family, neighbor, friend, etc.). If 911 is the only alternative for an emergency contact, case record documentation shall thoroughly explain there are absolutely no other options available.

Provider Selection

DSDS staff shall allow fifteen (15) calendar days following the initial assessment for the participant and/or legal guardian to select an HCBS provider. If an HCBS provider is not selected by the end of the fifteen (15) calendar days, DSDS staff shall refer to the Adverse Action policy and initiate an adverse action. DSDS staff shall close the case if a response is not received within ten (10) calendar days from the date the adverse action was sent.

If within ninety (90) calendar days of the adverse action a participant and/or legal guardian notifies DSDS staff that a provider has been selected, a new assessment does not need to be completed. The DSDS staff who completed the initial assessment shall open the case and authorize HCBS using the initial assessment. If no HCBS provider is selected within the ninety (90) calendar days of the adverse action, the case remains closed. If an HCBS provider is selected after ninety (90) calendar days, a new assessment shall be completed.

NOTE: ‘Assessment—State Designee’ is only used if no HCBS provider is available to serve the participant.

For initial assessments, DSDS staff or its designee shall contact the referring HCBS provider when the participant has chosen another provider for authorization of HCBS. DSDS staff or its designee shall inform the referring HCBS provider the authorization was processed per the request of the participant and did not result in authorization to the referring provider.

As part of the reassessment process DSDS staff or its designee shall ensure an HCBS provider is selected. If a participant has a circumstance that requires a selection of a different provider, DSDS staff shall refer to the Person Centered Care Planning and Maintenance policy.

Physician Notification Of Care Plan

Per 13 CSR 70-91.010, the participant’s primary care physician shall be informed of, and have the opportunity to be involved with the development of the PCCP.

DSDS staff shall notify the participant’s physician of the initial PCCP for HCBS via the Physician Notification of Care Plan (HCBS-11) within three (3) business days of the date of approval.

• The associated copy of the PCCP shall be attached to the Physician Notification of Care Plan for forwarding to the physician.
• This notification is required only at initial authorizations of all HCBS, regardless of the service authorization.
  • The Physician Notification of Care Plan informs the physician of the availability of electronically monitoring their patient’s PCCP.
• Physicians may contact DSDS staff or their designee to discuss the PCCP and make recommendations. The PCCP shall comply with the recommendations or requests of the physician, unless sufficient justification is documented to the contrary. Any modification that adversely impacts the participant shall require notification as outlined in the Adverse Action policy.
  • Any decision not to comply with physician recommendations or requests (i.e., statutory or regulatory violation, etc.) shall be reviewed and approved by the DSDS supervisor and documented in the participant’s electronic case record. Notification to the physician shall be made, in writing, as to why the physician’s recommendation or request is not being followed. All documentation shall be maintained within the electronic case record.
  • The completed Physician Notification of Care Plan shall be scanned and attached to the participant’s electronic case record.

Case Record Documentation

All documentation, contacts and actions made regarding the (re)assessment and the development of the PCCP shall be electronically recorded in the participant’s electronic case record. This provides a summary and justification of the participant’s circumstances and provides a record of the interaction between the participant, collateral contacts and HCBS providers. The Case Record Documentation Policy and the Case Record Documentation Quick Guide shall be utilized to ensure all appropriate documentation is completed for all case actions.

NOTE: HCBS provider reassessors shall include their email address at the conclusion of each case note entered.

Finalization

HCBS (re)assessments, corresponding documentation and information shall be entered into the electronic case record. DSDS staff shall ensure the following:

• The authorization of units and cost of the care plan does not exceed the cost maximum
• Documentation justifies the PCCP
• Goals and backup plans are identified and appropriate
• An HCBS provider has been selected

All HCBS participants shall receive a copy of the completed and signed Participant Choice Statement. The completed Participant Choice Statement shall be attached to the participant’s electronic case record.

HCBS providers shall be instructed to provide the participant with a copy of the PCCP detailing the authorization of their HCBS via the electronic case record. DSDS staff shall send the PCCP upon the participant's request.

Introduction

The development of a person centered care plan (PCCP) is the result of a thorough review of the participant’s needs. PCCPs are individualized in accordance with the unmet needs of the participant and outline what services are necessary to keep the participant living independently in their home. HCBS authorized within the PCCP shall be mutually identified as necessary by the participant and the Department of Health and Senior Services (DHSS), Division of Senior and Disability Services (DSDS) or its designee. The PCCP process assesses the health and safety factors of the participant and outlines the participant’s personal goals in order to remain in their least restrictive environment.

Purpose

The PCCP translates identified participant specific needs into a plan for action. The identification of functioning problems, current resources (formal and informal), unmet needs, and related documentation shall serve as the foundation for developing the PCCP. The HCBS authorized under the PCCP shall strengthen and enhance the current support system of the participant.

The following basic principles shall be used as a guide for PCCP development:

• A comprehensive, thorough review of the participant’s current abilities shall determine the needs of the participant
• The participant and anyone asked by the participant, may be involved in the PCCP development process
• Planning shall involve both formal and informal supports
• The PCCP shall reflect cost awareness

Note: For a participant who has a legal representative (e.g., guardian, or someone with a Durable Power of Attorney (DPOA) in effect), it is required the legal guardian be notified and given the option to assist with the development of the PCCP. If a guardian has been identified, DSDS staff, or its designee shall obtain copies of the guardianship paperwork and attach them to the electronic case record.

Person Centered Care Plan Development

Process

A PCCP shall be developed with and agreed upon by the participant and/or legal guardian during the development process and authorization of HCBS.

Authorized HCBS shall not replace or duplicate existing formal or informal support systems without adequate documentation that such support will no longer be available to the participant.

The following shall be determined:

• If there are any support systems currently in place that will not be continued, and the reason why
• The tasks requiring the authorization of HCBS or referral to another entity

Authorizing certain HCBS when the participant lives with others who are able to perform those services or tasks is not appropriate, as explained below:

• Tasks such as cleaning shared areas, (areas used by other household members of the residence), shall not be authorized.
• Tasks that are a primary benefit to a household unit or when members of the participant’s household may reasonably be expected to share or do for one another shall not be authorized (unless such tasks are above and beyond typical activities household members may reasonably provide for one another).

Note: Assistance with meal preparation based on preference (e.g. eating at different times or prefer different foods) shall not be authorized for participants who live with others and have the availability of shared meals.

Thorough documentation shall support the reasons why other household members or current support systems cannot complete necessary tasks. Services authorized shall only be those required to meet the participant's needs.

As part of the PCCP development, the following shall be taken into consideration:

• The aide’s ability to perform multiple tasks within the same timeframe
• Size of the participant’s living area
• Assistance provided by others in the household
• Assistance provided by other formal and informal supports
• Access to transportation, including the availability of MO HealthNet Non-Emergency Medical Transportation (NEMT)
• Availability of laundry facilities
• Any other factors that may influence the type and amount of services required to meet the participant’s needs

In all instances, DSDS staff or its designee shall authorize HCBS necessary to meet the participant’s identified unmet needs within the appropriate services guidelines as described in the HCBS Policy, Chapter 3. All service authorizations must be supported by thorough documentation within the electronic case record and must be reasonable and necessary according to the participant's condition and functional capacity.

A referring entity can make suggestions as a collateral contact during the development of the PCCP. However, DSDS staff or its designee must primarily consult with the participant and/or legal guardian to determine unmet needs and arrange the services necessary.

Collateral Contacts

Additional information may be needed to assist in the PCCP development and coordinate care for the participant. Independent collateral contacts shall not compromise the rights and confidentiality of the participant. When considering collateral information during the design of the PCCP, sufficient documentation shall explain any discrepancies in the expressed wishes of the participant. Collateral contacts should be an individual(s) familiar with the needs of the participant.

Unless prevented by circumstances, a discussion shall be conducted with the participant and/or legal guardian during the PCCP process, indicating what information will be obtained and sources contacted. The appropriate privacy policies in HCBS Policy, Chapter 9, shall be reviewed with the participant and/or authorized representative.

Resources which may assist in PCCP development include:

• Medical sources: Information regarding the current medical condition, prior authorizations, history, and limitations may be obtained through the participant’s electronic case record, physicians, hospitals, clinics, and home health agencies.
• Relatives, neighbors, and friends: These individuals may be able to provide additional observations and information regarding the participant when identified as a part of the informal support system.
• Other Social Agencies: Information may be available through local community agencies providing support or services to the participant.
• Agencies: Services may be accessed through various state agencies and funding sources designed to care for participants with specific medical conditions. Participants in need of such services shall be referred, and care will be coordinated in an effort to maximize state and federal resources. Information shall be obtained to determine and coordinate services currently authorized by:
  • Department of Mental Health
  • Department of Social Services
  • Other Divisions within DHSS
  • Home Health
  • Hospice

DSDS staff or its designee shall complete all related PCCP activities including entry of the service authorizations for HCBS as soon as possible.

Backup Plan

As part of the PCCP maintenance process, DSDS staff shall determine if the backup plan is still appropriate. If necessary, DSDS staff shall work with the participant to ensure the backup plan is updated and current information is provided.

The backup plan shall be provided in the event of an emergency and when the HCBS provider is unable to deliver services due to temporary staffing shortages, natural or other disasters, and acts of terrorism. A backup plan may include more than one individual. The following shall be included for each individual listed as part of the plan:

• Name
• Relationship to the participant (e.g., family, friend, neighbor, etc.)
• Contact information (phone number)
• A brief summary of the assistance the individual will provide in the event HCBS are unable to be delivered.

Note: 911 should only be used in rare instances and as the last option for participants with no other alternatives or support system (i.e. family, neighbor, friend, etc.). If 911 is the only alternative for an emergency contact, case note documentation shall thoroughly explain there are absolutely no other options available.

COOP Priority

A COOP priority risk indicator will display on the participant screen of the participant’s electronic case record. This indicator can be updated at any time during the authorization period. These indicators are intended to assist the HCBS provider in prioritizing service delivery in instances such as temporary staffing shortages, natural or other disasters, and acts of terrorism.

Document the level of priority by evaluating circumstances (i.e., support system, confusion, and noncompliance) in the electronic case record. Risk indicator of one (1) shall be used when the lack of HCBS would pose a serious threat to the health, safety, and welfare of the participant. Discretion shall be used in assigning high priority. A fragile, unreliable or insufficient support system must be documented in the electronic case record, justifying high priority status.

Authorization

Specific services may have associated tasks. Suggested tasks that are mutually identified and agreed upon shall be selected. Suggested times and frequencies are provided for these tasks as a standard baseline. Task frequencies that are significantly different from the suggested time and frequency shall be documented within the participant’s electronic case record.

When developing a PCCP the following shall be taken into consideration:

• Personal Care (PC) shall be included in the overall cost of care for the participant as referenced in the HCBS Cost Maximums policy.
• PC services shall not exceed 60% of the cost maximum
  • The combination of agency model PC and CDS shall not exceed 60% of the cost maximum.
  • The cost of authorized nurse visits is not included in the 60% monthly maximum cost for basic personal care.
• The 60% cost maximum can be exceeded by the cost of APC and RN visits, but only up to the full monthly cost of 100%.

Note: When the PCCP includes an authorization for RN services, the cost of one RN visit shall be excluded from the calculation of a PCCP’s cost. These costs will not display in the total calculated cost maximum in the participant’s electronic case record.

• When the combination of PC, other State Plan services, and an HCBS Waiver (e.g., Aged and Disabled Waiver (ADW) or Independent Living Waiver (ILW)) exceeds 100% of the monthly cost maximum, approval is required from the Bureau of Federal Programs (BFP).
  • The appropriate supervisor for DSDS staff shall review all PCCP requests over the 100% cost cap to ensure the participant’s unmet needs require the amount of service requested.
  • If documentation supports the request, the case shall be forwarded to BFP for consideration and approval prior to authorization over 100% of the cost cap.
    • Pending the approval from BFP to exceed the cost maximum, PC services in combination with other State Plan or ADW or ILW services can be authorized up to 100% of the cost maximum.
• When a PCCP includes Adult Day Care authorized through the ADW or the Adult Day Care Waiver (ADCW), the total cost of care cannot exceed 100% of the cost maximum.

Note: Pursuant to federal guidelines, a participant can only be enrolled in one HCBS waiver at a time, regardless of which department administers the waiver program.

Provider Selection

Choosing an HCBS provider is the right and responsibility of the participant and/or legal guardian. DSDS staff or its designee shall explain that selecting an HCBS provider is part of the PCCP process. Upon request, a list of all qualified HCBS providers in their geographic location shall be provided to assist in the selection process. Participants shall contact potential HCBS providers to discuss specific company practices, such as policies, hours, etc.

DSDS staff or its designee shall coordinate all service authorizations with the selected HCBS provider to ensure they are able to accept the new care plan. This may involve multiple contacts to ensure the provider’s capacity to deliver HCBS. The HCBS provider may review the participant’s electronic case record prior to accepting the participant. All contacts made with or on behalf of the participant shall be thoroughly documented in the electronic case record.

Active HCBS participants will have ten (10) business days to select another HCBS provider whenever a twenty-one (21) day notice has been issued from their current provider or Missouri Medicaid Audit and Compliance (MMAC) notifies DSDS that a provider’s contract will be closing. In areas where it is known that HCBS providers are experiencing staff shortages, the participant and/or legal guardian shall be asked to note a backup HCBS provider in the event the first choice is not able to accept a new case.

If the participant and/or legal guardian does not select a new HCBS provider that can accept the PCCP the following may occur:

• DSDS staff shall initiate an adverse action, referring to the Adverse Action policy
• DSDS staff shall allow ten (10) calendar days from the date of the adverse action for the participant and/or legal guardian to choose an HCBS provider that is able to accept the PCCP
• If a new HCBS provider is not chosen within ten (10) calendar days, DSDS staff shall close the relevant service type(s) and/or case.

If the participant and/or legal guardian contacts DSDS staff within ninety (90) calendar days from the date of the adverse action with a new HCBS provider that can accept the PCCP:

• DSDS staff who initiated the adverse action will open the case and enter the selected HCBS provider if an assessment was completed ninety (90) calendar days prior to the date of the adverse action.

Note: DSDS staff should refer the participant to the Bureau of HCBS Intake and PCCP Customer Service Contact Center to initiate a new referral for services if the participant and/or legal guardian contacts DSDS after ninety (90) days of the adverse action.

After exhausting all qualified HCBS providers in the geographic location, if an HCBS provider is still not available, the participant shall be moved into State Designee Status. DSDS staff shall refer to the Adverse Action policy.

Person Centered Care Plan Completion

Upon completion of the selection of all requested services, DSDS staff, or its designee shall review and complete the PCCP with the participant. All information on the applicable Rights and Responsibilities form(s) shall be discussed with the participant and/or legal guardian.

HCBS providers shall be instructed to access the PCCP via the participant’s electronic case record and will receive an alert regarding a PCCP authorization. This will remain in the ‘My Agencies Participant's” queue. When a change has been made to the care plan, an alert will display in the provider's queue to accept or reject the care plan changes and start date.

All HCBS participants shall receive a copy of the PCCP detailing the authorization of their HCBS. HCBS providers shall provide a copy of the PCCP to the participant. DSDS staff shall send the PCCP upon participant request.

Note: Pursuant to Section 191.656, RSMo HCBS providers serving an individual with HIV or AIDS may only disclose the health status of the individual to employees providing direct health care services to the individual only after the provider has determined the employee has a reasonable need to know. Such disclosure should be done in strictest confidentiality and prohibit further disclosure.

Person Centered Care Plan Maintenance 

DSDS staff or its designee shall conduct all PCCP maintenance activities within the electronic case record. A participant’s PCCP shall be modified to address unmet needs resulting from changes in the participant’s health, supports, safety and abilities.

• Increasing or decreasing services/tasks
• Adding or deleting services/tasks
• Changing HCBS providers
• HCBS case closure

DSDS staff or its designee may receive a request for a PCCP change through several different sources, including, but not limited to:

• The participant and/or legal guardian
• The HCBS provider
• Formal or informal support
• A community resource (e.g., senior center, hospital, etc.)
• Participant’s physician
• MMAC

Administrative oversight of HCBS includes timely action and closing of cases with an expired PCCP. However, extenuating circumstances may preclude closing a case on a timely basis. These may include, but are not limited to:

• Participant is deceased and DSDS staff did not receive notification
• Participant has requested a hearing due to an adverse action
• Participant is waiting for a hearing decision
• DSDS staff is waiting for the return of physician or other collateral information.

When such circumstances delay the timely closing of cases with an expired PCCP, DSDS staff or its designee shall make the appropriate documentation in the participant’s electronic case record with follow-up as necessary until the closing action is completed.

As with any maintenance activity, the basic principles of the PCCP process shall be followed:

• The participant and/or legal guardian shall be consulted in all instances when a change to the PCCP has been requested. DSDS staff or its designee shall make additional contacts, as necessary, to verify status changes that warrant the requested modification to the PCCP.
• DSDS staff or its designee shall coordinate with the participant’s HCBS provider on all changes to the PCCP.
• If a new service type is added to the PCCP, a copy of the appropriate Rights and Responsibilities form shall be provided to the participant.
• When changes are made to a PCCP for a participant authorized for services through the Department of Mental Health (DMH), a copy of the new PCCP shall be forwarded to the Division of Developmental Disabilities (DD) support coordinator.
• All maintenance activities that adversely affect the participant’s PCCP shall be subject to the Adverse Action process.

Person Centered Care Plan Change Request

In instances of a PCCP change request:

• DSDS staff shall make one (1) attempt to contact the participant and/or legal guardian at each number listed on the request.
  • If a voicemail can be left, DSDS staff shall leave a detailed message, including the purpose of the call and the date on which the participant must return the call to proceed with the request. DSDS staff shall provide the participant and/or legal guardian ten (10) calendar days to respond.
  • If a voicemail cannot be left, DSDS staff shall send a Participant Contact Letter.
• All contacts shall be thoroughly documented in the participant’s electronic case record.

Note: The ten (10) calendar days shall begin the first calendar day after the Participant Contact Letter is mailed. If the 10th calendar day ends on a State Holiday or weekend, the next business day shall be considered the 10th day (e.g., if the 10th calendar day ends on Saturday the next business day is Monday).

Adverse actions are not required if the reductions or closing requests are agreed upon through a discussion between DSDS staff and the participant and/or legal guardian. In instances where a participant and/or legal guardian requested a reduction or closure of services, DSDS staff shall verify the identity of the participant and/or legal guardian and document in the electronic case record. Actions of this nature may be taken immediately.

PCCP changes resulting in a decrease only are to be authorized with an effective date on the first day of the month following the date of change. If an adverse action has been initiated, the change will take affect the first day of the next month following the expiration of the adverse action.

When a PCCP change includes an increase, even if a particular task(s) was decreased or removed, the effective date is based on participant need and provider availability. Therefore, effective dates for PCCP changes with both an increase and a decrease may occur anytime during the month.

All contacts shall be thoroughly documented in the participant’s electronic case record, referring to Case Notes Documentation.

Introduction

In order to continue to improve efficiency and operations in the reassessment and care planning process for Home and Community Based Services (HCBS), HCBS providers may enroll as Medicaid Type 27 providers to gather the information necessary for the Division of Senior and Disability Services (DSDS) to determine the continued eligibility for HCBS as authorized by DSDS. Enrollment in the HCBS provider reassessment program is voluntary. This policy outlines the reassessment process for HCBS providers approved to complete reassessments for DSDS. Enrolled HCBS providers shall ensure the qualified reassessors have completed the required DSDS sponsored training prior to completion of any reimbursable reassessment. HCBS provider assessors are expected to follow policy and procedures outlined in the DSDS sponsored training, HCBS policy, memorandums and any additional HCBS guidance. The Provider Reassessment Information page contains additional information.

Purpose

The purpose of the reassessment is to:

• Establish continued eligibility for HCBS (i.e. Medicaid, Nursing Facility Level of Care (LOC) and continued unmet needs)
• Ensure the adequacy of the Person Centered Care Plan (PCCP)
• Assess new unmet needs that may require additional HCBS authorization
• Complete all necessary documentation and required forms
• Determine the participant’s satisfaction with the current HCBS provider

All participants authorized for HCBS shall have a reassessment completed within 365 days from the last LOC determination. HCBS providers enrolled to perform reassessments shall perform face-to-face visits to complete the reassessment with the participant, utilizing the InterRAI HC.

HCBS providers shall not bill for any reassessment that was not assigned unless communicated and approved by DSDS. Additional information regarding reassessment reimbursement rates and claim filing is included on the Provider Reassessment Information page.

Confidentiality

HCBS providers involved in the reassessment process gather personal and confidential information regarding HCBS participants to determine the continued eligibility and need for HCBS. HCBS providers shall keep all protected health information (PHI) confidential and shall only use PHI to perform functions, activities or services related to the delivery of HCBS. All PHI must be exchanged securely. When communicating with DSDS by email, HCBS providers shall utilize the Proofpoint Email Encryption software available through DSDS.

Policy Fundamentals

HCBS providers enrolled as a reassessment providers shall ensure their reassessors have, in addition to this policy, a thorough working knowledge of all applicable HCBS policies to include but not limited to:

• Eligibility components
  • Medicaid
  • Nursing Facility Level of Care (LOC)
• All HCBS available for authorization
  • State Plan (Agency)
  • State Plan Residential Care Facility (RCF)/Assisted Living Facility (ALF)
  • State Plan (Consumer Directed Services (CDS)
  • Adult Day Care Waiver (ADCW)
  • Aged and Disabled Waiver (ADW)
  • Independent Living Waiver (ILW)
  • Structured Family Caregiving Waiver (SFCW)
  • Brain Injury Waiver (BIW)
• Understanding of the PCCP process
• Case Record Documentation
• Safety and Special Accommodations
• Identification and mandated reporting of potential abuse, neglect and/or exploitation
• Participant’s electronic case record functionality
  • Updating demographics:
    • Address, county and phone number(s)
    • Primary Language
    • Marital Status/Living Arrangement
  • Physician Information added as a contact
  • Adding a reassessment
  • Completion of the InterRAI HC
  • Enter the requested PCCP
  • Adding Case Notes
  • Adding Attachments
  • Manage Household
    • Select if participant resides with others

Reassessment Preparation

Standardized criteria are applied to determine the assignment of monthly reassessments. Assigned Reassessments will be accessed using the electronic case record system and HCBS providers shall be granted access to obtain their reassessments. Only those assigned to the HCBS provider by DSDS are to be completed. HCBS providers shall review their assigned reassessments monthly to identify changes.

If a provider has been assigned a reassessment and has experienced a PCCP update leading to a provider change or multiple providers, the HCBS provider may still complete the reassessment if the participant agrees. HCBS providers will be reimbursed for the completed reassessment as long as it has been assigned to them.

If the HCBS provider chooses not to complete an assigned reassessment, they must immediately notify the DSDS Provider Reassessment Review Team by selecting the action ‘unable to complete’ and reason ‘unable to complete the assessment’ in the month in which they receive their assigned reassessment and/or as soon as the decision is made not to complete it.

HCBS providers shall check the Medicaid Eligibility (ME) Code in the participant’s electronic case record to ensure the participantis eligible for a reassessment and reauthorization of services. When the HCBS provider reassessor identifies a potential Medicaid eligibility problem, the HCBS provider reassessor shall not complete the reassessment. The action ‘unable to complete’ and the reason ‘inactive Medicaid’ shall be selected.

• Individuals enrolled in a Managed Care Health Plan ME code other than E2 (e.g. 05) are not eligible to receive HCBS authorized by DSDS.
• If the participant is a Medicaid spenddown recipient, spenddown must be met at least once within the last three (3) months to remain eligible for HCBS.

The DSDS Provider Reassessor Review Team (PRR) must always be notified immediately of any identified circumstances that prevent the completion of assigned reassessments.

Case History

After the assigned reassessments have been reviewed and Medicaid eligibility has been established, HCBS providers shall review the participant’s case history. HCBS providers shall determine if there were changes to the previous authorization period that would need to be addressed and documented during the reassessment visit, e.g. changes in mental status that would impact the ability to self-direct for CDS participants. This review includes the following:

• InterRAI HC
• Current PCCP and Utilization History
• Case Notes
• Demographics and Living Arrangement
• Attachments
• The need for interpreter services
  • Interpreter services are provided by DSDS free of charge. If Limited English Proficiency (LEP) is utilized, the LEP form located on the Provider Reassessment Information/Quick Guides and Resources shall be completed and submitted to the PRR team at Providerreassessmentreview@health.mo.gov. 

Note: The case record shall be reviewed for any care plan change requests that are pending. The HCBS provider reassessor shall discuss the requests with the participant and make the necessary updates to the care plan.

When the provider reassessor will not have a portable computer device or internet connectivity in the participant’s home, they shall take copies of the participant’s most recent (re)assessment and the current care plan to review and update during the face-to-face visit. These materials can be printed from the electronic case record.

The reassessment dates entered shall reflect the date of the actual face-to-face visit. If the reassessment is not completed on the same day, the date the reassessment isfully completed shall be entered in Section T of the InterRAI HC. Additional instructions for portions of the InterRAI HC can be found below.

Section A: Goal  – During the reassessment process, the HCBS provider reassessor shall work with the participant to review and update their goal for HCBS and ensure the PCCP works toward supporting the goal when possible. Any barriers that may prevent the goal from being achieved shall be documented.

An appropriate goal shall reflect what the participant hopes to achieve. The HCBS provider shall encourage the participant to express a goal in their own words, which may reflect:

• I want to be living on my own and retain my independence.
• I would like to ensure I have consistent help available to help with my day to day needs. A goal shall not be a statement of fact such as:
  • I want to continue to receive services.
  • I don’t know, or I’m really not sure.

Goals may come from the participant or legal representative. In the rare circumstance when a participant cannot verbalize a goal, a primary unpaid caregiver may provide the goal for the participant. Thorough case note documentation would be required in these rare instances. Case note documentation shall include:

• The participant is unable to express a goal
• Who the goal was provided by (the legal guardian or primary unpaid caregiver)
• Name and relationship of the person providing the goal

Section S: Backup Plan - The HCBS provider reassessor shall review and ask the participant and/or legal guardian for details of their backup plan to be used when events such as weather or sickness prevent service delivery by their HCBS provider(s). If the aide or attendant is not available, the participant and/or legal guardian shall provide a support system to ensure needs are met and continuation of services. Available assistance may vary, but all availability should be considered.

The backup plan shall identify a specific individual(s) available to assist when needed and may consist of the following:

• Family, friends, a neighbor, collateral contacts, etc.

A brief detailed summary of the support shall be provided and documented in the participant’s electronic case record and include:

• The name, phone number and relationship of the individual providing the support
• The specific task(s) to be provided
• The frequency of each task being provided (e.g., all meals prepared Monday, Wednesday and Friday, bathing Tuesday and Thursday)

Note: If multiple supports are identified, HCBS provider reassessors shall ensure all contact information, specific tasks, and the frequency of each task is documented specifically for each individual providing the support.

911 should only be used in rare instances as the last option for participants with no other alternatives or support system (i.e. family, neighbor, friend, etc.). If 911 is the only alternative for an emergency contact, case note documentation shall thoroughly explain there are absolutely no other options identified.

Section T: Assessment Information (Signature) – The signature area in Section T of the InterRAI shall include the provider reassessors signature.

The provider reassessor shall determine if there is a newly appointed legal guardian. If a newly appointed legal guardian has been identified, the HCBS provider reassessor shall update the information in the participant’s electronic case record. The HCBS provider reassessor shall attempt to obtain copies of the guardianship paperwork and attach them in the participant’s electronic case record. When these attempts are unsuccessful, the HCBS provider reassessor shall document this in case notes.

Person Centered Care Plan Development

An essential component of a quality reassessment process is the development of a PCCP. All PCCPs developed by the HCBS provider reassessor are completed in a ‘requested’ status and require review and approval by DSDS. Therefore, HCBS provider reassessors shall ensure that all requested PCCPs are:

• Supported by a thorough, well documented reassessment, and associated case notes that identify functioning problems, current resources (formal and informal), and unmet needs
• Developed with the participant and/or authorized representative to address identified unmet needs while being supportive of the right to self-determination
• Developed within the guidelines of HCBS programmatic policies
• Built on the participant's unmet needs without duplicating current formal and informal supports

During the annual reassessment the HCBS provider reassessor shall determine the participant’s satisfaction with the HCBS they receive and document the participant’s satisfaction in case notes.

Collateral Contacts

When additional information is needed to assist in PCCP development and coordinate care for the participant, collateral contacts (an individual familiar with the needs of the participant) shall be made by the HCBS provider reassessor. These contacts shall not compromise the rights and confidentiality of the participant. Possible resources to assist in the PCCP development may include formal and/or informal supports:

• Medical sources (Formal): Information regarding the current medical condition, history, and limitations may be obtained through the electronic case record system under the Claims tab
• Family members, neighbors, and friends (Informal): These individuals may be able to provide additional observations and information regarding the participant
• Social and/or State Agencies: Information may be available through local community agencies providing support or services to the participant
  • Area Agencies on Aging (AAA’s)
  • Department of Mental Health (DMH)
  • Centers for Independent Living (CILs)
  • Division of Community and Public Health (DCPH)
  • DRL (Home Health/Hospice)

Service/Tasks Guidelines

The PCCP identifies the services and tasks based on the participant’s needs. The HCBS authorized under the PCCP shall provide reinforcement and enhancement to the current support system of the participant

Authorized HCBS shall not replace or duplicate existing formal or informal support. It is not appropriate to recommend certain HCBS when the participant lives with other person(s) who are able to perform those services or tasks. The following shall be taken into consideration when developing a PCCP:

• The aide’s or attendant’s ability to perform multiple tasks within the same timeframe
• Size of the participant’s living area
• Assistance provided by others in the household
• Space/Tasks shared with others residing in the household
• Assistance provided by other formal and informal supports
• Meal preparation
• Cleaning
• Availability of laundry facilities

Note: Assistance with meal preparation based on preference (e.g. eating at different times or prefer different foods) shall not be authorized for participants that live with others and have the availability of shared meals. Thorough documentation shall support the reasons why other household members or current support systems cannot complete necessary tasks.

When authorizing CDS Essential Transportation, there must be an identified need for personal care assistance even if that need is met by supports other than CDS. Personal care does not need to be performed while Essential Transportation is being conducted.

CDS Transportation does not include transporting to medical appointments when those appointments are covered under the MO HealthNet Non-Emergency Medical Transportation (NEMT) program. To determine if NEMT covers the medical appointment and to determine availability, contact the NEMT provider at 1-866- 269-5927. For more information regarding NEMT, visit the Department of Social Services webpage.

The In-Home Services Worksheet/Instructions and/or CDS Worksheet/Instructions may be used as a tool to temporarily develop the PCCP. The worksheets assist in the development of a more uniform and consistent approach when determining the appropriate amount of services necessary to meet a participant's unmet needs. The worksheets are designed to provide information identifying suggested times and frequencies to be considered with the care needs of the participant in mind.

Note: HCBS provider reassessors shall utilize the CDS Worksheet and/or In-Home Services Worksheet to include justifications of tasks when completing an Independent Living Waiver (ILW) reassessment. The completed worksheet(s) shall be placed in the participant's electronic case record for review by the DSDS Provider Reassessor Review Team

Upon completion of the PCCP development, the HCBS provider shall enter and submit the PCCP in the participant’s electronic case record. The pending PA shall include accurate provider selection. Instructions are located in the electronic case record user guide.

COOP Priority

A COOP priority risk indicator must be determined during the reassessment process and entered in the participant’s electronic case record. This indicator is intended to assist the HCBS provider in prioritizing service delivery in instances such as temporary staffing shortages, natural or other disasters, and acts of terrorism. To determine the level of risk, the HCBS provider reassessor shall evaluate the participant’s circumstances (i.e., support system, cognitive ability, and noncompliance) and the importance of service delivery during any staffing shortage.

The risk indicator of one (1) shall be used when the lack of HCBS would pose a serious threat to the health, safety, and welfare of the participant. Discretion shall be used in assigning the risk. A fragile, unreliable or insufficient support system must be documented in case notes justifying risk status.

Forms

Forms are to be completed per HCBS policies and specific programmatic requirements. Should the participant have a legal guardian, it is necessary to obtain the legal guardian’s signature on official forms/documents. It may also be necessary to obtain signatures from authorized representatives (Medical Durable Power of Attorney, etc.). In addition to the reassessor, forms shall only be signed by the participant, legal guardian, or authorized representative.

The provider reassessor shall have two (2) copies of each form and obtain the appropriate signatures on both copies. The provider reassessor shall keep one copy of the signed form and the additional copy shall be provided to the participant, legal guardian, or authorized representative. If a participant is unable to understand the information in the forms presented and does not have a legal guardian or authorized representative, a case note shall be made stating why a signature could not be obtained.

• The Participant Choice Statement must be reviewed and completed at each reassessment and attached in the participant’s electronic case record.
• The Participant Rights and Responsibilities shall also be reviewed at each reassessment. However, the forms are not required to be attached to the participant’s electronic case record. Some participants may require more than one type of Rights and Responsibilities.
• Agency Participant Rights and Responsibilities
• CDS Participant Rights and Responsibilities
• RCF/ALF Personal Care Participant Rights and Responsibilities
• Structured Family Caregiver Waiver Rights and Responsibilities

Additional forms may be required dependent on the situations specific to the participant. The forms shall be attached in the participant’s electronic case record upon completion of the reassessment. Such forms may include, but are not limited to:

• St. Louis University Mental Status (SLUMS) (Instructions)
• Self-Direction Assessment Questions Instructions

Case Notes Documentation

The participant’s electronic case record must contain all documentation involving the participant. All contacts made and actions regarding a participant’s HCBS shall be electronically recorded. Case notes summarize the participant’s circumstances, justify the actions taken and provide a record of the interaction between the participant, collateral contacts and HCBS providers. The Case Record Documentation Policy and the Case Record Documentation Quick Guide should be utilized to ensure all appropriate documentation is completed for all case actions.

To facilitate effective communication provider reassessors shall include in their case note signature and their email address associated with the agency, or an agency email address that would be best for the provider reassessor to be contacted. Personal email addresses should not be used. Case notes shall not be entered or signed by any other individuals employed with the provider.

Identification of Adverse Action

Any action that adversely affects the request for, or amount of, authorized HCBS shall be communicated to DSDS and documented thoroughly in case notes. HCBS provider reassessors shall be aware of the following actions that would adversely affect HCBS:

• Reduction of HCBS
• Closing of an HCBS
• No documented need
• LOC not met
• Inability to self-direct
• Entering a facility
• Non-compliant
• Program eligibility
• Threatening behavior
• Unable to locate the participant
• HCBS provider reassessors shall educate the participant of the potential adverse action and provide DSDS with the necessary information and documentation when a change to the participant's HCBS adversely affects the PCCP. DSDS requires the following information to determine if an adverse action is to be initiated.
• Case notes
  • Documentation shall provide a clear explanation of a needed adverse action.
  • Document the conversation was held with the participant and if they agree or disagree with the changes being made to the care plan.
• Forms (when applicable)
  • St. Louis University Mental Status (SLUMS)
  • Self-Direction Assessment Questions

Upon review of the information submitted, DSDS will contact HCBS providers for additional information if necessary.

Finalization and Submission

HCBS reassessments and corresponding documentation shall be entered into the participant’s electronic case record within five (5) business days of the reassessment. All reassessments not submitted by the last calendar day of the month on which the reassessment is due will automatically be electronically returned to the DSDS PRR Team. Weekends, holidays, and/or office closures do not affect the due date.

HCBS Provider Review and Submission

Prior to submitting a reassessment, the HCBS provider reassessor shall review and ensure all documentation and information is present in the participant’s electronic case record. Provider reassessors shall ensure:

• All necessary forms are attached
• Selection of appropriate tasks
• Appropriate HCBS provider is selected
• Case note documentation is clear and accurate
• The reassessment and PCCP are entered correctly and in pending status
• Collateral contacts are entered and updated in the participant's electronic case record

Upon verifying the appropriate documentation and information has been entered, choose the ‘Submit Care Plan for Review’ action to notify the PRR Team.

DSDS Review and Remediation

The DSDS PRR Team will review each reassessment and the PCCP, ensuring all information is complete and accurate, and that all requirements are met. The review will also consist of the following:

• The authorization of units and cost of the PCCP
• Documentation justifies the pending PCCP
• Provider selection

Reassessments found to be inadequate and/or incomplete by the DSDS Provider Reassessor Review Team includes:

• Insufficient documentation and/or information
• DSDS PRR Team has not been notified of an entry of a reassessment by the last calendar day of the month prior to when the reassessment is due
• DSDS PRR Team has not been notified of the inability to complete a reassessment by the last calendar day of the month prior to when the reassessment is due

When the DSDS PRR Team determines the reassessment, PCCP and/or documentation are inadequate, the HCBS provider will be contacted for remediation. To ensure sufficient time for review and approval of the reassessment, the HCBS provider shall have three (3) business days to complete the remediation and notify the DSDS PRR Team of its completion. If the HCBS provider reassessor is not available to complete the necessary remediation, the provider agency must ensure completion by the required timeframe.

Approval of the PCCP

The HCBS provider shall check the participant’s electronic case record to access information related to each participant’s reassessment and PCCP approval status. The HCBS provider should notify the DSDS PRR Team through encrypted email of any questions or concerns regarding a reassessment or PCCP at ProviderReassessmentReview@health.mo.gov. 

Introduction

All contacts made and actions taken regarding a participant’s Home and Community Based Services (HCBS) shall be recorded in the electronic case record. The electronic case record is the participant’s official case record and must contain all documentation involving the participant.

Purpose

Division of Senior and Disability Services (DSDS) staff, HCBS, and other providers and stakeholders have access to the case notes in the participant’s electronic case record. The transparency of the electronic case record allows for information to be shared among all HCBS bureaus, HCBS providers and physicians involved in coordinating and maintaining the participant’s services. Case notes are also reviewed by all parties involved in any administrative hearing.

Case Note Guidelines

The participant’s electronic case record shall only be used to document HCBS situations specific to the participant. Information unrelated to the participant, such as system issues, work order assignment, and tracking, shall not be recorded in the electronic case record.

Case notes documentation shall provide the link between information gathered through:

• Screening and assessment,
• Development of a Person Centered Care Plan (PCCP), and
• Any subsequent action taken by DSDS staff, providers, or collateral party not contained elsewhere in the participant’s electronic case record.

The following documentation principles shall guide all case note entries:

• Accuracy
  • Accurate documentation of the information received effectively communicates to the reader the participant’s care needs and associated service delivery.
• Clarity
  • Clarity can best be achieved using plain language. Simple words and sentences are preferable to jargon, bureaucratic language, slang words and excessive wordiness.
• Concise
  • Concise case notes are easier to read, save time, and improve the quality of the documentation.
  • Avoid vague or general terms, such as some, sometimes, often, many, several, etc. Instead, use phrases such as, “three times a week”.
• Facts
  • Facts shall document who, what, when, where, why and how as it relates to the participant and any associated PCCP.
  • Avoid using judgmental phrasing.
  • Cite any professional conclusions or comments regarding the participant with a fair background and context.
  • Avoid the use of “feel” and “think”. Instead, use “observe” and “conclude”. o Avoid diagnosing a participant who has not been established by a medical or psychological professional. Instead, record the facts of what was observed.

Case Note Entry

Every contact and attempt to contact made regarding a participant and their receipt of HCBS shall be documented. The contact documentation shall include:

• Note Type
• Date of the contact
  • The ‘contact date’ entered shall reflect the actual date the contact was made regarding the participant. Multiple contacts on the same day may be entered within the same case note; however, there shall be a clear distinction for each contact (e.g., separate paragraphs). Contacts with differing dates must be documented in separate case note entries.
• Identification and contact information of the contact person
• Summary of the discussion
• Identification of the type of contact (e.g. face-to-face contact, phone contact, email correspondence, etc.) for each case note entry

At the conclusion of a case note, the electronic case record will auto-populate the following for DSDS staff:

• First name
• Last name
• Title

NOTE: HCBS provider reassessors shall include their email address at the conclusion of each case note entered.

Throughout the assessment process, DSDS staff entering the case note have the ability to edit and delete the case note until the final action is taken on the case and saved.

Case Action Guidance

The following guidance provides a documentation framework for the various HCBS Case Actions. HCBS is person-centered; therefore:

• Each participant and associated case documentation is unique.
• Only applicable aspects of the guidelines below shall be documented
• Information not included in the case action guidance below that is pertinent to the participant’s case record shall be included in the documentation.
• More than one set of guidelines outlined in the case action guidance may need to be used during a contact.
• PCCP maintenance applies to multiple documentation instances provided in the case action guidance. Refer to the Person Centered Care Planning subsection below on PCCP change requests and processing PCCP guidance when appropriate.

NOTE: Case notes shall be entered at the time of contact unless specific completion timeframes are stated below.

Case Actions

Referral Intake

Referrals may be received via phone, email, or online. All referrals are entered into the Online HCBS Referral Form to document the details of the referral request. Additional documentation outside of the information included in the referral form includes:

• Date received
• Notation that the referral form was uploaded to the documents section of the case record
• Online submission number (if submitted online)

Documentation for an inappropriate referral includes:

• Date received
• Reason it was inappropriate
• Online submission number (if applicable)

NOTE: Inappropriate referral documentation is only entered if the participant has a historical case record. A new case record shall not be opened only to enter an inappropriate referral.

Person Centered Care Plan Change Request Intake

PCCP Change Requests may be received via phone, email, or online. All requests are entered into the Online PCCP Request Form to document the details of the PCCP change request. Additional documentation outside of the information included in the request form includes:

• Date received
• Key details of change(s) being requested
  • Provider changes should include the details of the new requested provider
• Notation that the request form was uploaded to the documents section of the case record
• Online submission number (if submitted online)

Documentation for an inappropriate/no longer needed request includes:

• Date received
• Reason it was inappropriate or no longer needed
• Online submission number (if applicable)

Assessment

Documentation for an initial assessment and reassessment includes, but is not limited to, the following:

• Who was present and who responded to the assessment questions
  • If there is a guardianship relationship, ensure appropriate documentation has been uploaded to the participant’s electronic case record.
• Condition of the home and any needed referrals to address identified issues
• Participant’s living arrangements
  • If other persons in the home are authorized for HCBS, document how services are to be coordinated to avoid duplication of tasks.
  • If other adults are living in the household, identify shared spaces and the other adults’ abilities/responsibilities.
  • If the participant is currently in a hospital, skilled nursing facility, or rehabilitation facility, include name of facility, the reason for stay and date of discharge.
• Formal (e.g. Home Health/Hospice) and/or informal supports providing assistance and how the requested HCBS will be integrated with the supports
• How the participant’s health condition(s) necessitate the need for the HCBS requested by the participant
• Elaboration on the coding of vague assessment questions (e.g. Physician ordered diet type)
• Risks and needs identified outside of HCBS supports, along with any resources provided to assist, shall be thoroughly documented
• Denials, reductions, and closings information (e.g., LOC, unmet need, or Medicaid ineligibility). See section below.
• Any difficulties the participant has with signing the required forms and the associated accommodations made
• Any paperwork sent to the participant (if applicable) o At initial assessment, document the forwarding of the Physician Notification.
• PCCP documentation (see section below)

Case note documentation related to an assessment may require multiple contacts and entries. Each action during the assessment process shall be entered as soon as possible, but no later than five (5) business days following the assessment.

Person Centered Care Planning

The following outlines general PCCP documentation guidelines that may be applied during an (re)assessment or a PCCP change request:

• Document any discrepancies between the coding of the assessment and the tasks on the PCCP (e.g. if a participant is coded as needing bathing assistance due to safety risks but refuses assistance due to modesty concerns).
• Provide explanation when task frequency exceeds or deviates significantly from the suggested times and frequencies.
• Provide specifics related to denials, reductions, closings information. See section below.
• Provide the reason for underutilization when the PCCP remains the same or are increased despite recent underutilization.
• Provide explanation of vague PCCP tasks (e.g. treatments, clean/maintain equipment, other nursing task, transfer device assistance.)
• Document referrals or information provided to the participant to assist with risks or needs that could not be addressed in the PCCP.
• Document the participant’s provider choice and/or satisfaction.
  • At initial assessment, document the participant’s preferred provider.
  • At reassessment/PCCP change request, document the participant’s satisfaction with the current provider(s) or document the preferred provider when a change is requested.
• Contact with the provider(s) regarding the PCCP (re)authorization. Include PCCP specifics reviewed, effective date of the change(s), provider staff name and phone contact number/email address.
• Any paperwork sent to the participant (if applicable)

PCCP change specific documentation includes, but is not limited to the following:

• Identity of PCCP change requestor
  • If not the participant, document name, relationship to the participant and phone contact number.
  • If there is a guardianship relationship, ensure appropriate documentation has been uploaded to the participant’s electronic case record.
• Change(s) being requested, e.g. increase or decrease of service, new service type, or provider change.
• The contributing factors to the change(s) being requested.
  • New health condition or change in status of an existing health condition.
  • Change in living arrangement.
• Reason for requesting a new provider when related to future PCCP needs
• Any formal (e.g. Home Health, Hospice, etc.) and/or informal supports providing assistance and how the requested HCBS change will be integrated with the supports
• Provider change request information, including provider name and contact information (if applicable)
• Any paperwork sent to the participant (if applicable)

NOTE: HCBS provider complaint information shall not be documented within the case record, but staff shall indicate an appropriate referral was made.

CDS Ability to Self-Direct

CDS ability to self-direct documentation includes, but is not limited to the following:

• Participant’s ability to participate in the assessment and communicate their needs during the PCCP process
• Concerns with the ability to self-direct, which may include:
  • Participant deferring to others present during assessment for answers.
  • Participant displays confusion regarding PCCP needs and completion.
  • Participant not understanding how to use the Electronic Visit Verification (EVV) system or concerned with learning the process if they are new to CDS.
  • Any other observations that led to cognitive or memory coding on the assessment.
  • Documents obtained and/or contacts made that validate a participant’s inability to self-direct.
  • Summarization of the results of the St. Louis University Mental Status (SLUMS) Exam and Self-Direction Assessment Questionnaire.
    • If applicable, identify if another individual responds to the Self-Direction Assessment Questionnaire on behalf of the participant
• Information given regarding the availability of other services when the participant is determined unable to self-direct

Provider Reassessments Review

Provider reassessment review documentation includes, but is not limited to:

• Confirmation the provider reassessment was reviewed
• Denials, Reductions, Closings information (e.g. LOC, unmet need, or Medicaid ineligibility)
• Follow-up contact(s) with the provider and/or participant
• Necessary when information is incomplete
• Approved PCCP
  • Notification provided to the provider (including provider staff name and phone contact information) and participant.
• Paperwork sent to the participant (if requested)

Show-Me Home

Show-Me Home (SMH) Money Follows the Person (MFP) documentation shall include, but not limited to:

• When the initial referral was received and from whom
• Document the current situation
  • Name of facility
  • Reason for stay
  • Date of admission
  • Date of discharge (if known)
  • Name and phone contact information for facility discharge planner (if applicable)
• SMH eligibility
  • Document whether the participant meets all criteria for participation in the SMH, and if applicable, documentation that the Show-Me Home Approval Notice has been uploaded to the participant’s electronic case record and a copy of the Show-Me Home Approval Notice has been sent to the contractor of the region where the participant will reside.
  • The participant’s proposed living arrangements if able to transition to the community, including other household members and shared spaces.
  • If there is a guardianship relationship, ensure appropriate documentation has been uploaded to the participant’s electronic case record.
  • Completion of the Show-Me Home Referral Assessment for participants who do not need HCBS.

Case note documentation shall be entered as soon as possible, but no later than ten (10) business days after the contact was made or information received.

Denials/Reductions/Closings

Documentation shall include, but not limited to the following:

• Reasons the service/task/request was denied, reduced, or closed
  • Such action must be supported by the citation contained on the Adverse Action Notice.
• Level of Care (LOC)
  • Describe InterRAI HC responses and other observations in relation to each of the categories in LOC.
• Ability to Self-Direct
  • Describe the inability to self-direct, referencing information gathered during the completion of the InterRAI HC, SLUMS, Self-Direction Assessment Questions and related contacts.
• Service Reduction
  • Document the reasons why the service/task is being reduced.
• Contact and discussion regarding adverse action
  • Document contact and discussion with the participant and/or authorized representative, including whether the participant agreed with the action.
• Notice of Closure
  • Document the participant’s understanding that an Adverse Action Notice or Notice of Closure will be mailed and their right to appeal, if applicable.
  • Date the Adverse Action Notice or Notice of Closure is mailed.
• Changes to PCCP
  • Document any changes made to the PCCP including contacts to the participant and the appropriate provider.

Adverse Actions/Hearing Requests/Hearing Proceedings

Documentation shall include, but not limited to:

• Hearing Request
  • Document how the hearing request was received from the participant (through mail, telephone, or in person).
• Additional information
  • Document follow-up with participant for any additional pertinent information that would affect the adverse action.
• Review Time Frames
  • Document if the request was received within the appropriate time frame.
• Participant Contact
  • Document the discussion with the participant regarding the appeal process, including whether the participant wants to maintain level of services, if applicable.
• Hearing Application
  • Document the date the Application for a State Hearing is forwarded to the DSDS Supervisor and supervisory review of the Application for a State Hearing.
• Hearing Documents
  • Document the description of the information and documents, and the date sent to the Division of Legal Services (DLS) and the participant.
• Date of receipt of Notice of Administrative Hearing
• Date of receipt of the Final Decision and Order

Case note documentation shall be entered as soon as possible, but no later than ten (10) business days after the contact was made or information received.

Documentation of Concerns and Special Circumstances

Protective Services

Protective service investigations and interventions are documented in the DSDS Adult Protective Services (APS) case management system and shall not be documented in the participant’s electronic case record.

When a contact indicates a potential protective service situation, DSDS staff or designee shall make the mandated hotline report and enter a note in the participant’s electronic case record stating an ‘Appropriate referral was made’.

Safety Concerns

Pertinent information regarding the participant and/or household to ensure continuity of care and alert DSDS staff and HCBS providers of special circumstances shall be documented in the ‘Safety Concerns’ field on the participant’s main screen in the electronic case record.

• ‘Safety Concern’ includes situations that pose a safety risk (e.g., drug use, weapons, etc.) to individuals entering and working with a participant in their home.
• Include the date of the case note(s) referencing the concerns.
• Further details surrounding the potential safety risk may be documented in case notes if needed.

Address Notes

If needed, enter the directions to the participant’s residence in the ‘Address Notes’ field on the participant’s main screen in the electronic case record.

Interpreter Services

If a participant requires an interpreter, they should be encouraged to use DSDS provided interpreter services. The offering of interpreter services shall always be documented along with the participant’s decision to use or refuse them. If the participant refuses DSDS provided interpreter services and chooses an adult family member or friend as the interpreter, this preference must also be recorded. Documentation shall be entered in the ‘Accommodations’ field on the participant’s main screen in the electronic case record.

Other Special Circumstances

The electronic case record provides additional fields to select that are specific to the special circumstances below. These fields are located on the participant’s main screen in the electronic case record, and only limited DSDS staff can make the selection. Additional documentation may be included in the case record as applicable.

• Notification the participant is Consumer Directed Services (CDS) Restricted
• Notification of SMH participation
• Notification of a (Department of Mental Health) DMH waiver
• Notification of dual waivers
  • This will only occur in very rare situations as Medicaid participants are not permitted to be in more than one (1) waiver at a time.
• Shared households shall be documented
• Bureau of Federal Programs (BFP) notification of approval to exceed cost maximum
  • Provides notice the participant has been approved to exceed the cost maximum through an Aged and Disabled Waiver (ADW) service.
• Other necessary information in each individual participant’s record to facilitate the PCCP development

NOTE: All requests to exceed the cost maximum shall be sent to BFP for approval. If a PCCP is over the cost maximum and no documentation is provided, BFP shall be contacted to determine if approval was granted. The ‘Cost Cap Pre-Approved’ in the participant's electronic case record shall be selected when approval is granted.

Contact Tab

The following shall be entered in the electronic case record using the ‘Contacts’ tab:

• List the name and contact information (phone number) of the primary family or friend caregiver(s). Include any relevant information in the ‘Contact Notes’ box regarding availability and caregiving role. (This is not the assigned caregiver of a provider agency.)
• Add name and contact information (phone number) for providers outside of HCBS (e.g., home health, hospice, therapy services, specialty care, mental health, etc).
• List the name and contact information (phone number) for key individuals involved in the care planning process and include any additional relevant information in the “Contact Notes”.
• List the name and contact information (phone number) of the participant’s primary care physician (PCP).

Participants may already be receiving or be eligible to receive services through various federal, state and community-based programs and/or agencies. Staff shall ensure coordination of each participant’s personcentered care plan with other services the participant is receiving. Participants not currently receiving, but potentially eligible for such services shall be referred as appropriate, and the care plan coordinated in an effort to maximize state and federal resources.

The following policies provide a guide in determining potential eligibility for services and the process for care plan coordination.

Introduction

The Missouri Department of Mental Health (DMH) has various community-oriented or Home and Community Based Services (HCBS) available through the Division of Behavioral Health (DBH) and the Division of Developmental Disabilities (DD).

Purpose

Coordination of HCBS provided by the Department of Health and Senior Services (DHSS), Division of Senior and Disability Services (DSDS) is necessary with DBH and DD so that services best meet the needs of the individuals served.

The Division of Behavioral Health (DBH)

The Division of Behavioral Health (DBH), manages programs and services to assist individuals with their mental illnesses and/or substance use. DBH works to assure prevention, evaluation, treatment, and rehabilitation. Available DBH services include:

• Outpatient Community-Based Services
• Targeted Case Management
• Day Treatment/Partial Hospitalization
• Residential Services
• Inpatient (Hospitalization) Respite
• Treatment Family Home Program
• Community Psychiatric Rehabilitation (CPRP)

These services are accessed through regional service areas, with each service area responsible for specific counties of the state. Community Mental Health Centers and/or their affiliates are responsible for providing these services. These agencies determine a person's eligibility and arrange for the provision of services.

Coordination of Services with the Division of Behavioral Health 

When it is necessary to coordinate DSDS authorized HCBS or refer participants for DBH services, a Community Mental Health Center can be contacted.

Participants who meet the guidelines for DSDS authorized HCBS can receive HCBS while also receiving services through DBH. The exception would be when a participant resides in a skilled institutional setting. Those participants cannot receive HCBS services.

Division of Developmental Disabilities (DD)

Division of Developmental Disabilities (DD) serves a population that has developmental disabilities such as intellectual disabilities, cerebral palsy, head injuries, autism, epilepsy, and certain learning disabilities with the goal to improve lives through supports and services that foster self-determination. DD operates four Home and Community Based waivers.

Community Support Waiver

The Community Support Waiver is for persons who have a place to live in the community, usually with family. However, the family is unable to provide all the services and supports the person requires, which may include 24-hour care or supervision, seven days a week. The services provided in this waiver include; day habilitation, in home respite, personal assistant, prevocational services, supported employment, support broker, Applied Behavior Analysis (ABA), assistive technology, career planning, community integration and transition, community specialist, counseling, crisis intervention, environmental accessibility adaptations, individualized skill development, job development, occupational, physical, and speech therapy, out of home respite, person centered strategies consultation, specialized medical equipment and supplies, and transportation. This waiver has an individual cost limit of $28,000 per year.

Comprehensive Waiver

The Comprehensive Waiver requires individuals to have needs that cannot be met by the Community Support Waiver. The services available through this waiver are the same as those available through the Community Support Waiver; however, this is the only DD waiver that provides residential services. This waiver does not have an individual cost limit on the amount of service an individual may receive annually through the waiver.

Missouri Children with Developmental Disabilities Waiver (MOCDD)

The MOCDD Waiver provides services until the individual's 18th birthday. The services provided in this waiver include; personal assistant, respite care, transportation, environmental accessibility adaptations, specialized medical equipment and supplies, support broker, day habilitation community specialist, crisis intervention and ABA services.

The Partnership for Hope Waiver (PFH)

The Partnership for Hope Waiver (PFH) serves adults and children. Eligibility requirements for participants include active Medicaid status, met eligibility criteria for DD services, the participants’ needs must be able to be met with current community support system and waiver services not to exceed an annual cost of $12,362, the participant must meet intermediate care facility for individuals with intellectual disabilities (ICF/ID) Level of Care, participant must reside in a participating county, and participant must meet crisis or priority criteria. The services provided in this waiver include personal assistant, temporary residential, transportation, environmental accessibility adaptations, specialized medical equipment and supplies, support broker, ABA services, community integration and transition, physical, occupational, and speech therapy, individual skill development, dental, assistive technology, and day habilitation.

Coordination of Services with the Division of Developmental Disabilities

It is a federal requirement that Medicaid State Plan services be expended prior to accessing a comparable service within a HCBS Waiver program. Medicaid State Plan Services authorized by DSDS include Basic Personal Care, Advanced Personal Care, Authorized Nurse Visits, and Consumer Directed Services (CDS.)

Personal assistant services available in the DMH waivers are considered comparable to State Plan Personal Care services authorized by DSDS. Therefore, when a DD support coordinator has determined that personal assistant services are needed, they must contact DSDS to ensure that State Plan Personal Care, as authorized by DSDS, is exhausted before the authorization of personal assistant services in a DD waiver. A participant can receive personal care services from DSDS and personal assistant services from DD. A DD support coordinator may also determine if a participant is in need of other services authorized by DSDS.

Division of Developmental Disabilities Responsibilities

Upon determination that a DD participant needs services authorized by DSDS, the DD support coordinator shall:

• Inform the participant of this requirement
• Initiate a referral to DSDS

Note: As outlined in both the Basic Personal Care – Agency Model and the Personal Care Consumer Directed Model, encouragement (prompting and cueing) and instruction of participants in self-care may be a component of a task; however, encouragement and instruction do not constitute a task in and of themselves. Therefore, if a DD participant only requires prompting and cueing to perform a personal care task independently, a referral to DSDS is not appropriate and should not be made.

Division of Senior and Disability Services Responsibilities

DSDS shall process the referral to determine eligibility.

• When eligibility has been met, DSDS staff shall contact the DD support coordinator prior to the initial assessment visit to discuss the participant’s unmet needs. Additionally, DSDS staff shall consult the DD support coordinator regarding the Special Considerations when applicable.
• DSDS staff shall complete the assessment with the participant to determine Level of Care (LOC) eligibility. If LOC is met, DSDS staff shall develop a proposed Person Centered Care Plan (PCCP) in the electronic case record or with the In-Home Services Worksheet (HCBS-3a) and/or Consumer-Directed Services Worksheet (HCBS-3c) identifying all service options available. If using the worksheets, they shall be uploaded to the electronic case record once completed and shared with the DD support coordinator.
  • If it is determined upon completion of the assessment that the participant is not eligible for services, DSDS staff shall thoroughly document all contacts, follow the adverse action process and close the case in the participant’s electronic case record. A copy of the adverse action shall be sent to the DD support coordinator.
  • If the participant chooses not to participate in an assessment for State Plan Personal Care, DSDS staff shall advise the participant that the cost maximum for State Plan Personal Care will be deducted from the DD Waiver Individualized Support Plan (ISP). This may encourage the individual to participate. DSDS staff shall notify the DD support coordinator if they still choose not to participate. All contacts shall be thoroughly documented, and the case will be closed in the participant’s electronic case record.
• If the participant accepts State Plan Personal Care, DSDS staff shall finalize the PCCP in the electronic case record. A copy of the PCCP shall be forwarded to the DD support coordinator, who utilizes the care plan to develop the ISP for DD services.
• If the participant chooses not to accept State Plan Personal Care, DSDS shall advise them that a copy of the proposed PCCP will be forwarded to the DD support coordinator, and the cost of the proposed PCCP may be deducted from the DD Waiver ISP. No Adverse Action Notice is required.

Note: When changes are made to the PCCP, at reassessment or through care plan maintenance, DSDS staff shall provide a copy of the new PCCP to the DD support coordinator.

Special Considerations with the Division of Developmental Disabilities

Self-Direction

Participants may only be enrolled in one self-direction program at a time. For participants who qualify for State Plan CDS, DSDS staff shall coordinate with the DD support coordinator to inform the participant they may only be enrolled in one self-direction program at a time. The DD support coordinator will assist in educating the participant about their self-directed service options through DD programs so the participant can make an informed decision.

Note: Participants qualifying for both self-directed programs who choose to receive self-directed services through DD must utilize State Plan-Agency model services prior to the authorization of DD waiver services. If the participant chooses not to accept State Plan-Agency model services, this information shall be documented in Case Notes and provided to the DD support coordinator. No Adverse Action Notice shall be sent to the participant in these circumstances.

Restrictions

Participants authorized for the following services through DD are not eligible to receive State Plan Personal Care services through DSDS.

• Shared Living (also known as Host Home or Companion Home)
• Residential Habilitation
• Individualized Supportive Living (ISL)

Note: View the Licensed/Certified Provider Directory to confirm the type of facility placement.

To determine if a potential participant is authorized for one of the residential habilitation services listed above, DSDS shall either:

• Utilize DMH’s Customer Information, Management, Outcomes and Reporting (CIMOR) system to determine if the participant is authorized for the above services. Authorization is reflected by a procedure code:
  • S5136 (Shared Living)
  • T2016 (ISLs or Residential Habilitation).
• Utilize the Claims tab – Residential Habilitation services will be identified as ‘Habil res waiver per diem’ with the associated procedure code listed above.
• Contact the appropriate DD regional support coordinator to verify the authorization.

Division of Senior and Disability Waiver Services

As outlined in the Home and Community Based Services Introduction policy, DSDS has oversight responsibility of Home and Community Based Waivers under the authority in §1915(c) of the Social Security Act.

• Aged and Disabled Waiver
• Adult Day Care Waiver
• Brain Injury Waiver
• Independent Living Waiver
• Structured Family Caregiving Waiver

HCBS waivers allow state agencies the flexibility to develop specialized services for a targeted group of people. State agencies can design each waiver program and select the mix of services that best meets the needs of the population they wish to serve. However, Medicaid participants can only receive services through one Medicaid HCBS waiver at a time, regardless of the state agency administering the waiver.

During the course of any HCBS process, DSDS staff shall make the necessary contacts to validate information that indicates the participant may be receiving services through another waiver. If it is determined the participant is receiving services through another waiver, DSDS shall coordinate with the participant and the DD support coordinator to determine which waiver service best meets the participant’s needs.. Refer to the DHSS and DMH waiver resources for a comprehensive list of these waiver services. Adverse Action processes shall be followed when a participant selects participation in a DD waiver over an HCBS waiver.

Introduction

The Healthy Children and Youth (HCY) Program provides service coordination and authorization for medically necessary services for MO HealthNet recipients with special health care needs from birth to age twenty-one (21).

Purpose

The Bureau of Special Health Care Needs (BSHCN), the Bureau of Home and Community Based Services Field Operations and the Department of Mental Health (DMH) collaborate to provide a smooth transition for HCY participants who are moving to MO HealthNet adult coverage at the age of twenty-one (21) and will no longer qualify for HCY services. All three offer services for participants twenty-one (21) years of age and older.

Process

HCY Service Coordinators (SC) will begin discussing transition options with the participant/responsible party at least one year prior to the participant’s twenty-first (21st) birthday. HCY SCs will also offer to schedule interagency transition meetings for participants aging out of HCY who are eligible for the Medically Fragile Adult Waiver (MFAW). These transition discussions allow participants and families to learn about all agencies and the programs offered. The Transition for Aging Out of HCY resource guide provides information on available programs.

Participants receiving only Advanced Personal Care Assistance/Personal Care Assistance (APCA/PCA) who are not eligible for MFAW will be referred to available DSDS and DMH programs. DSDS and DMH will coordinate a joint transition meeting for those participants without SHCN representation.

SHCN maintains a list of participants who will age out of HCY. This list will be sent to the available DHSS/DSDS and DMH/DD program's designated contacts biannually to make them aware of upcoming HCY transitions. The following information is included on the list:

• Participant
• DCN
• Date of Birth
• Age
• SHCN Program Enrollment
• Anticipated HCY Closure
• HCY Authorized Services
• HCY Service Coordinator (SC)
• HCY Region
• County Residence
• Indicator of whether the participant has an active DMH waiver

New HCY enrollments that will reach the age of twenty-one (21) within twelve (12) months of their initial enrollment and need a multiagency transition meeting will be sent to the designated contacts at time of enrollment. Discussions on transitioning are as follows:

• Twelve (12) months prior to the participant’s twenty-first (21st) birthday
  • HCY SC will discuss transition information and multi-agency options with the participant/responsible party.
• Six (6) months prior to the participant’s twenty-first (21st) birthday
  • HCY SC will schedule an interagency transition meeting to occur three (3) months prior to the participant’s twenty-first (21st) birthday. This will include participants who would benefit from receiving additional information regarding options offered through available DSDS and DMH programs to make the most informed decision regarding their future services.

Note: SHCN will not schedule or participate in transition meetings for participants who receive only APCA/PCA services and are not eligible for MFAW. The HCY SC will notify the DSDS and DMH program contacts of these referrals. The families will be informed that DSDSS and DMH will contact them to schedule a transition meeting to provide information about options available through each agency.

The transition meeting will be conducted with the participant/responsible party, HCY SC (as applicable), and DSDS and DMH contacts (preferably at a face-to-face home visit). This meeting allows the participant/responsible party to discuss options with all representatives, address their questions, and make an informed decision regarding their future service options.

Introduction

The Program of All-Inclusive Care for the Elderly (PACE) is a Medicare and Medicaid program that helps people meet their health care needs in the community instead of going to a nursing or other care facility.

Purpose

PACE provides comprehensive health care services to eligible individuals. PACE covers all Medicaid covered services as well as additional services necessary to improve and maintain health, which includes:

• Adult Day Care (including physician, nursing, and therapy services)
• Home care
• Meals
• Medical specialty services
• Physician and nursing services
• Prescription drugs
• Transportation to the PACE center and medical appointments

Eligibility

The eligibility for PACE includes the following:

• Must be 55 years of age or older,
• Live in a designated PACE service area,
• Require nursing facility level of care, and
• Be able to live safely in the community with PACE supports.

Enrollment determination for PACE can be made by contacting the PACE organization.

Note: A participant enrolled in the PACE program is not eligible for any service authorized through the Home and Community Based Services (HCBS) program.

PACE Enrollment Process

As part of the PACE enrollment process the MO HealthNet Division (MHD) will:

• Verify if there is an active authorization for HCBS.
• Notify the PACE organization of an authorization for HCBS.

The PACE organization will inform the participant that all HCBS authorizations will close upon enrollment into the PACE program. If the participant chooses to continue with enrollment, the PACE organization will assist the participant in submitting a letter to the Division of Senior and Disability Services (DSDS) requesting HCBS closure due to enrolling in the PACE program and include the effective date. The Person Centered Care Plan (PCCP) team will process the request the day before the effective date of PACE enrollment.

PACE Disenrollment/HCBS Referral Process

The process for a PACE participant to voluntarily disenroll from the PACE program to access HCBS is as follows:

• The PACE organization will submit an HCBS referral, utilizing a referral form specific for PACE.
• The referral shall be submitted at least 30 business days before the tentative PACE disenrollment date.
• DSDS will process PACE coordinated referrals outside of the electronic case record.
• DSDS will complete the initial assessment, develop a proposed PCCP worksheet ( In-Home Service Worksheet and/or CDS Worksheet), and coordinate with the selected HCBS provider.

Note: The tentative effective date for HCBS services must be the first day of the following month, as PACE services can only end on the last day of the month.

DSDS will send notification to MHD.PACE@dss.mo.gov and obtain confirmation on the date the PACE participant will be disenrolled from the program. DSDS will not be able to enter actions or authorizations into the electronic case record until the PACE lock-in has ended. PACE coordinated referrals will be handled as standard priority, as PACE services can be accessed up to the date HCBS is authorized.

PACE Complaint Process

The Division of Senior and Disability Services (DSDS) shall direct any grievances or complaints about PACE services to the PACE organization to file a complaint. An official PACE grievance policy specific to each PACE organization must be followed. Participants will be informed of the official grievance policy in their participant enrollment agreement. MHD must allow the PACE organization an opportunity to address all grievances before MHD can take action. Additional grievance guidance is located in the Code of Federal Regulations for PACE.

If the participant refuses to contact the PACE organization to file a complaint, DSDS shall send a detailed summary of the reported concerns to MHD.PACE@dss.mo.gov. 

Introduction

The Brain Injury Waiver (BIW) is a Home and Community Based Services (HCBS) waiver offered through the Division of Senior and Disability Services (DSDS). BIW aims to promote and support an individual to reach their highest degree of independence after a traumatic brain injury (TBI).

Purpose

The service is designed to be person centered, outcome oriented and relies on community inclusion. It provides a variety of services which includes home modifications, assistive technology, and therapy services.

Eligibility

All BIW participants must meet the following eligibility criteria:

• Be between the ages of 21 to 65
  • Once a participant reaches the age of 65, the participant shall be disenrolled from the BIW. The participant shall be offered eligible services provided through the Division of Senior and Disability Services.
• Be in active Medicaid status
  • Participants who are eligible for Medicaid on a spenddown basis may be authorized to receive the BIW during periods when they meet their spenddown liability.
  • A participant is responsible for the cost of services received during periods of time when they have not met their spenddown liability.
  • Participants who receive Medicaid due to eligibility for Blind Pension (BP) may not be authorized for the BIW.
  • Authorization of the BIW does not meet the requirements for an individual to be eligible for Home and Community Based (HCB) Medicaid.
• Have an appropriate Medicaid Eligibility (ME) code
• Meet Nursing Facility Level of Care (LOC)
• Have medical documentation of a Traumatic Brain Injury

Restrictions and Limitations 

Initial and continued enrollment in BIW is subject to the following:

• BIW services may not exceed $32,000 a year per participant.
• May not be enrolled in any other waiver programs (ILW, SFCW, ADW).
• The BIW year runs from October 1st of each year through September 30th of the following year.

Note: If a participant leaves the BIW during a waiver year for any reason, the slot is still considered occupied for the period of the waiver authorization.

Process

An initial assessment is completed within 15 business days of receipt of referral. An individual is required to meet nursing home level of care to qualify for the BIW. Once nursing home level of care is met, the appropriate services and needs of the participant are determined through the Service Coordination Assessment (SCA). A reassessment is then conducted at least twice a year to determine if the participant’s needs have changed.

Brain Injury Waiver Services

Physical Therapy

Physical Therapy (PT) treats physical motor dysfunction through various routes. The service includes evaluation, plan development, direct therapy, and consultation/training of caretakers and others who work with the individual. Therapies available to adults under the state plan are for rehabilitation needs only.

Occupational Therapy

Occupational therapy (OT) assists individuals to learn or regain skills of daily living. OT requires a prescription by a physician and evaluation by a certified Occupational Therapist or Certified Occupational Therapy Assistant under the supervision of an Occupational Therapist. The service includes:

• Evaluation
• Plan development
• Direct therapy
• Consultation
• Training of caretakers and others who work with the participant.

Speech Therapy

Speech Therapy is for individuals who have speech, language, or hearing impairments. The need for services must be identified in the care plan and prescribed by a physician. Services must be provided by a licensed speech language therapist. Speech Therapy provides treatment for:

• Delayed speech
• Stuttering
• Spastic speech
• Aphasic disorders
• Hearing disabilities that require specialized auditory training, lip reading, signing, or use of a hearing aid.

Note: The services may also include consultation provided to families, other caretakers, and habilitation service providers.

Home Modifications

These are modifications to the home required by the participant’s plan of care, which are necessary to ensure the health, welfare, and safety of the individual; or which enable the individual to function with greater independence in the community; and without which, the recipient would require institutionalization. Such adaptations may include the installation of ramps, widening of doorways, modifications of bathroom facilities, or installation of specialized electric and plumbing systems which are necessary to accommodate a medical need.

Note: There is a $5,000 annual cost limit per participant. This is part of the $32,000 annual cost maximum for the participant.

Personal Care

Personal care (PC) services are intended to meet personal requirements that enable the participant to remain in his/her home and maintain a functional capacity by fulfilling needs that cannot be met by other resources. PC services are authorized when the participant requires hands on assistance in one or more of the following categories that exceeds typical level of care for an individual of that age: dressing, grooming, bed mobility, toileting, bathing, eating, ambulating, transferring, and/or housekeeping. PC services only occur in the home of the participant.

Note: Consumer Directed Services (CDS) is not an option under BIW and state plan services must be utilized first.

Applied Behavioral Analysis

Applied Behavioral Analysis may be provided to assist a person in learning new behaviors directly related to existing challenges. Services may also be provided to increase/reduce existing behaviors or to omit behaviors under environmental conditions. The service shall include monitoring of data from continuous assessments of the individual’s skills in the following areas:

• Learning
• Communication
• Social competence
• Self-care

Assistive Technology

Assistive Technology (AT) is assistive, adaptive, and rehabilitative devices for people with disabilities and the elderly. They can be used by individuals with disabilities to perform functions that might otherwise be difficult or impossible and protect the health and welfare of the participant.

Note: There is a $5,000 annual cost limit per participant. This is part of the $32,000 annual cost maximum for the participant.

Cognitive Rehabilitation Therapy

Cognitive Rehabilitation Therapy (CRT) therapy includes goal-oriented counseling to maximize strengths and reduce behavior problems and/or functional deficits which interfere with a participant’s personal, familial, vocational, or community adjustment. CRT can be provided to the participant and families when the participant is present. This service is not available to adults when State Plan psychology services are appropriate to meet the individual’s needs.

Neuropsychological Evaluation

Neuropsychological Evaluation and Consultation consists of the administration and interpretation of a standardized battery of neuropsychological tests to provide information about a participant’s cognitive strengths and weaknesses following a TBI. It includes consultation with the participant, guardian, family, or other significant key persons designated by the participant and BIW staff for information gathering and/or interpretation of results.

Coordination Process

Referrers Responsibility

• Confirm all eligibility requirements are met
• Submit referral to the following:
  • Waivers.LTSS@health.mo.gov
  • Phone: (573) 751-6246 or Toll-free: (800) 451-0669

When submitting a referral, the following information is required:

• Name of participant (full, legal name)
• DOB (must be between the ages of 21-64)
• Responsible Party:
  • Is the referral their own responsible party?
  • Do they have a legal guardian?
  • Do they have a DPOA-HC? If so, who is that person and what is their contact information?
• Contact information to include current home/mailing address, phone number, email contact, etc.
• What services does the referral source believe would benefit the referred?

BIW Support Coordinators (SC) responsibility

• Process the referral to determine eligibility.
• Ensure there is a slot available for the participant, as there are a limited number available.
  • If slot is not available, participant will be added to wait list.
• Complete the assessment and discuss service options with the participant.
• Authorize appropriate services with approval of state waiver manager.
• Conduct monthly phone calls and bi-annual home visits to ensure services are still active and appropriate for participants.
• Participate in care planning/treatment team meetings with participants and stakeholders. May include treatment planning, waiver updates, concerns.