Children with serious emotional disorder ... - wvaso.kepro.com
S U O I R R E S DE H R T I SO W DI N L E R NA D O W L I I
) IE T W ERV H C MO D O V E SEI D E R (CR O V P KEPRO KEPRO INTRODUCTION Since 1985, KEPRO has helped members lead healthier lives through clinical expertise, integrity and compassion. KEPRO was founded by physicians and clinical expertise is at the core of our organization. Currently servicing 250 commercial, public and
federal clients URAC accredited in UM, CM, DM, pursuing IRO accreditation in 2019 15 offices and more than 1,400 employees More than 3,000 credentialed physicians and 500 clinicians on our Advisory and Review panel STRENGTHENING HEALTH STATUS THROUGH QUALITY AND CLINICAL EXPERTISE
KEPRO offers a platform of capabilities for complex populations with clinicallydriven, technology-enabled services that meet the needs of our government client markets. Care Management Utilization Management Case Management Pharmacy Management Care Coordination EAP & Absence Management Quality Management
Appeals & Grievances External Quality Review Healthcare Effectiveness Data and Information Set (HEDIS) Standard of Care Reviews 15+ year Average Customer Relationship Length
Assessments & Clinical Eligibility Administrative Services Levels of Care Assessment Health Risk Assessments Preadmission Screening & Resident Review
(PASRR) Behavioral Health Needs Assessment Application Processing Center Payment Integrity Claims Adjudication Network Management
Provider Credentialing and Training Experienced with the customization needed for health plans AGENDA What is serious emotional disorder? CSEDW primary goals CSEDW eligibility criteria CSEDW medical eligibility criteria CSEDW services Person Centered Service Planning Provider Reviews Annual Re-Assessments Provider question and comment period WHAT IS SERIOUS EMOTIONAL
DISORDER ? West Virginia defines the term children with serious emotional disorder as children from age 3-21 who currently, or at any time in the past year, have had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet the diagnostic criteria specified within the Diagnostic and Statistical Manual of Mental Disorders (of ICD equivalent) that is current at the date of the evaluation that results in functional impairment, which substantially interferes with or limits the childs role or functioning in family, school and /or community activates. CSEDW PRIMARY GOALS The CSEDWs primary goal is to support children with severe emotional disorders by helping to keep them with their families, in their home and with a support network while receiving the services they need to improve their outcomes. This waiver prioritizes children/youth with serious emotional disorder (SED) who are placed in Psychiatric Rehabilitation
Treatment Facilities (PRTFs) or other residential treatment providers out-of-state, and those who are in such facilities in state. Medicaid-eligible children with SED who are at risk of residential placement will become the target group after children in placement are prioritized. HOW IS THIS WAIVER DIFFERENT? CSED Waiver is meant to be a short-term If for any reason the member is discharged from CSEDW services, they are still eligible to reapply for services as long as it is before the members 21st birthday Focuses on family and community supports Once the youth reaches age 15, the team assists with transition planning which focuses on vocational or higher education goals to prepare the youth for independence ADMINISTRATIVE SERVICE
ORGANIZATION (ASO) Conducts trainings to providers, parents, community members, ect. Performs Annual Member Re-Assessments to determine medical re-eligibility Providers Audits, Plan of Corrections, and subsequent trainings if needed Provides technical assistance and trainings for Atrezzo Manage enrollment CLIENT DATABASE Starting February 1st, 2020 a new software system will be utilized for CSEDW called Atrezzo. Atrezzo will be used instead of CareConnection for the CSED Waiver. Trainings will be available via webinars, Skype, or in person with KEPRO staff. KEPRO staff will track eligibility and referrals.
Independent Evaluators will automatically gain access to Atrezzo once they self enroll. Supervisors can then give access to support staff who need access. MANAGED CARE ORGANIZATION RESPONSIBILITIES (MCO) CSEDW Provider Agreements Prior Authorizations Utilization Management Care Coordination/Care Managers Incident Management System (IMS) Alternative language requests Written and Verbal Provides Member Handbook upon enrollment into the CSEDW Provides education materials Freedom of Choice Form CSEDW ELIGIBILITY CRITERIA
Must meet financial eligibility; Must meet medical eligibility; Must be between the ages of three and 21; Must be a resident of West Virginia, and be able to provide proof of residency upon application; and Must have chosen Home and Community-Based Services over
services in an institutional setting (Freedom of Choice Form). If applicant is denied a Request for Medicaid Fair Hearing form can be submitted to the Board of Review within 90 days of the denial in order to appeal the decision. CSEDW MEDICAL ELIGIBILITY CRITERIA Applicant must have an overall Child and Adolescent Functional Assessment Scale (CAFAS) or Preschool and Early Childhood Functional Assessment Scale (PECFAS) score of severe which is considered such with a score of 90 or higher. Applicant must currently or at any time during the past 12 months have had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria specified within the most current edition of the Diagnostic and Statistical Manual (DSM). Disorders include any mental disorders listed in the DSM with the exception of the V codes.
Substance use and developmental disorders are excluded unless they co-occur with another diagnosable serious emotional disorder. ELIGIBILITY FLOWCHART ELIGIBILITY FLOWCHART CONT. ANNUAL RE-DETERMINATION The ASO will conduct the reassessment for medical eligibility redetermination up to 90 calendar days prior to each members anchor date All members presently receiving CSEDW services will be evaluated annually utilizing a CAFAS/PECFAS and the Child and Adolescent Needs and Strengths (CANS). At the time of the annual reassessment by the ASO, each member or parent/caregiver/legal representative must complete the Freedom of Choice Form (WV-BMS-CSED-2) indicating their choice of level of care settings, Case Management agency, other providers of CEDW services.
CSEDW SERVICES AND RATES T1016-HA Case Management $9.70 per unit H2033-HA - Independent living/skills building - $5.26 per unit T2021-HA - Job development- $5.26 per unit T2019-HA Supported employment, individual- $5.26 per unit *H0004-HO-HA - In-home family therapy- $78.71 FOR 50 min * *H0004-HA In-home family support$5.26 per unit * T1005-HA-HE Respite, in-home and out-of-home- $5.01 per units G0176-HA Specialized therapy- $1.00 per unit up to $500.00 per year in combination with Assistive equipment T2035-HA Assistive equipment- up to
$500 in combination with Specialized therapy T2038-HA Community transition-up to $3,000.00 lifetime H2017-HA Mobile response- $5.26 per unit A0160-HA Non-medical transportation-$.54 per mile H0038-HA Peer parent support- $5.26 per unit DENIALS AND APPEALS If an applicant is denied by the MECA: The Written Notice of Decision, Request for Medicaid Fair Hearing Form, and a copy of the IPE is mailed to the applicant via certified mail; Appeals must be received within 90 days by submitting the Request for Medicaid Fair Hearing form to the Board of Review; A second IPE is then conducted by a separate provider within 60 days;
If applicant is denied a 2nd time by the MECA, they may submit the Request for Medicaid Fair Hearing form to the Board of Review within 90 calendar days in order to schedule a hearing; The applicant may request a pre-hearing conference at any time prior to the Medicaid Fair Hearing. COMPLAINTS AND GRIEVANCES PROCESS A member receiving services has the right to obtain oral and written information on the CSEDW provider agencys complaints and grievance policies. If the member or the parent/legal representative is dissatisfied with the quality of services or the provider of service, it is recommended that they follow the CSEDW provider agencys grievance process. If the issue is not resolved at this level, the member or the parent/legal representative may file provider complaints directly to the Secretarys office (DHHR) and OHFLAC outlines the process within the behavioral health regulations in Section 4.7,
Complaint Investigations. Complaints are handled through the MCO Provider Services Department and reported to BMS quarterly. PERSON CENTERED SERVICE PLANNING CSEDW services will emphasize the importance of combining natural supports from the community with professionals to create a PCSP that supports the recovery of the member. PCSPs will be developed using the strengths model in combination with information gathered during the enrollment process. The Person-centered Service Planning Team (PCSPT) consists of the member and/or parent/caregiver/legal representative, the members Case Manager, representatives of each professional discipline, provider and/or program providing services to the member, and the MCO coordinator (if requested). The Case Manager is responsible the facilitation of the initial PCSP and all updates to the plan document but development of the plan is the responsibility of the entire team. (The Case Management provider agency cannot provide any additional CSEDW services.)
INITIAL PERSON-CENTERED SERVICE PLAN (PCSP) Developed within seven days of the members enrollment and must Include: Description of any further assessments or referrals that may need to be performed; A listing of immediate interventions to be provided along with objectives; A date for development of the Master PCSP (within 30 days), if a program is not an intensive service, the master PCSP must be completed within seven days; The signature of the member and/or parent/caregiver/legal representative, case manager, and other persons participating in the development of the initial plan, their credentials, and start/stop times. MASTER PERSON-CENTERED SERVICE
PLAN (PCSP) A Master PCSP is developed within 30 days and must include: A statement of the member centered positive and outcome-oriented goal(s) of services; A listing of complete objectives that the service providers and the member hope to achieve or complete; The measureable component objectives that provide steps toward achievement of specified outcomes, with realistic dates of achievement for each;
The technique(s) and/or services (intervention) to be used in achieving the objective; Identification of the individual responsible for implementing the services related to statement(s) of objectives and their frequency of intended delivery; Discharge Criteria. SIGNIFICANT LIFE EVENT PCSPT MEETING A face to face meeting must be held under any of the following circumstances: All team members do not agree with services or service mix;
A new goal will be implemented for the member; The member changes residential setting (example: moves from natural family to a Licensed Group Home, foster care, or institutional setting or vice versa); The member goes into crisis placement; The member has a change in legal representative status; The primary caregiver changes or passes away; The member receives a new service; The member receives a new service not previously received; The member receiving services has had a documented change in need between the times the annual reassessment was conducted. DISCHARGE/TRANSFER PLANNING This meeting is held when a member transfers from one CSEDW provider to another or when the member no longer meets medical eligibility. The transfer from agency is responsible for scheduling and documenting the transfer as well as sending the members PCSP to the transfer to agency within 14 days.
The transfer-from agency must also submit a transfer and attach Transfer/Discharge Form (WVBMS-CSED-10) to the MCO within seven calendar days. If member is admitted to a PRTF while enrolled in the CSEDW, the case manager is responsible for requesting a continuation of services for 30 days from the MCO. If member does not receive direct services for 180 days they are no longer eligible for the CSEDW. RIGHTS Members and legal representatives have the right to: Choose between HCBS as an alternative to institutional care by the ASO through the completion of a Freedom of Choice form (WV-BMS-CSED-2) upon enrollment in the program and at least annually thereafter. Choose their CSEDW providers. Address dissatisfaction with services through the CSEDW providers grievance procedure. Access the Medicaid Fair Hearing process consistent with state and federal law. Be free from abuse, neglect and financial exploitation. Be notified and attend any and all of their PCSPT meetings, including Significant Life Event meetings.
Choose who they wish to attend their PCSPT meetings, in addition to those attendees required by regulations. Obtain advocacy if they choose to do so. File a complaint with the ASO regarding the results of their reassessment. Have all assessments, evaluations, medical treatments, and PCSPs explained to them in a format they can understand, even if they have a legal representative making the final decisions in regard to their health care. Make decisions regarding their services. Receive reasonable accommodations afforded to them under the ADA. RESPONSIBILITIES The member and their legal representative have the following responsibilities: To be present during PCSPT meetings. In extremely extenuating circumstances, the legal representative or other team members may participate by teleconferencing if they do not bill for the time spent in the PCSPT. The member must be present and stay for the entire meeting if they do not have a legal representative
To understand that this is an optional program and that not all needs may be able to be met through the services available within this program To participate and supply correct information in the annual assessments for determination of medical eligibility To comply with all CSEDW policies including monthly home visits by the case manager To implement the portions of the PCSP for which they have accepted responsibility
To maintain a safe home environment for all service providers To notify their case manager immediately if the members living arrangements change, the members needs change, the member is hospitalized or if the member needs to have a Significant Life Event meeting PROVIDER REVIEWS Reviews will be conducted at least every 12 months or after an incident. The provider will be notified of the review at least two weeks prior unless there is a documented incident. Within two weeks of the completed review, a draft exit report and Corrective Action Plan (CAP) will be given to the provider. Provider has 30 days to submit any documentation and the completed CAP to the ASO.
If CAP if not received within 30 days BMS may place a hold on payments for service. CORRECTIVE ACTION PLAN - CAP Must Include: How the deficient practice for the persons cited in the deficiency will be corrected; What system will be put into place to prevent reoccurrence of the deficient practice; How the provider will monitor to assure future compliance and who will be responsible for the monitoring; The date the CAP will be completed; Any provider-specific training requests related to the deficiencies. ABUSE & NEGLECT Anyone providing CSEDW services who suspects an incidence of abuse or neglect is considered a mandated reporter.
Reports of abuse and/or neglect may be made anonymously by calling the CPS hotline at 1-800-352-6513, seven calendar days a week, 24 hours day. Reporters must also follow licensing reporting standards. PERFORMANCE MANAGEMENT MEASURES Measure will be tracked regarding health, safety, effectiveness and quality. While KEPRO and Aetna are the sources of the information, providers are also responsible.
More information will be discussed once the final approval has been received from CMS. CSEDW TIMELINE The application was submitted to CMS on June 14, 2019 for approval. The CSEDW Manual was sent out for public comment from November 1, 2019 November 30, 2019. Services are anticipated to be available February 1, 2020. WHO DO WE CALL WITH QUESTIONS? KEPRO: Number: 844-304-7107 Email: [email protected] Fax: 866-473-2354 Service Support Facilitators: Derek Johnson, MSW (304) 320-0098 [email protected] Melissa McIntyre, MBA (304) 203-3302
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