Medicaid Personal Care Services Reimbursement: Issue Status and Updates

Please read below to see the issues and the progress made towards resolving them. The most recent entries are at the top. To read in chronological order, please start at the bottom and work your way up.

OVERVIEW:

• The federal Centers for Medicare & Medicaid Services (CMS) has notified the state that we are out of compliance with Medicaid Personal Care Services (PCS) reimbursement guidelines.
• A failure to get into compliance may result in a stoppage of federal Medicaid PCS funding in NC.
• North Carolina’s plan to address this issue involves what is known as the 1915(i) State Plan.
• An initial part of implementing this plan (beginning July 23, 2012) involves independent, third-party assessments of Medicaid PCS recipients (your residents) for continued eligibility. These assessments will be conducted by The Carolinas Center for Medical Excellence (CCME). The CCME Independent Assessment Help Line is: (800) 228-3365 or PCSAssessment@thecarolinascenter.org. If you want to discuss the assessments with state personnel, the DMA Home and Community Care Section can be reached at: (919) 855-4340.

 

Medicaid Personal Care Services:
Regional Training and Provider Forum for Licensed Adult Care Home Providers and Licensed Home Care Providers
April 2013 – Raleigh | Greenville | Winston Salem | Asheville | Fayetteville
 

Medicaid Bureaucracy Pinching Some NC Group Homes
 

Guidance for Family Supplementing Payment to the Medicaid Benefit
 

Older NC Residents Need Action From Legislature, Advocates Say
Advocates for older North Carolinians have a full list of requests for the General Assembly session that begins Wednesday—from strengthening criminal background checks for long-term care workers to reducing unneeded use of psychotropic medicine for people with Alzheimer’s. Read the article at newsobserver.com.

Disabled, Elderly Fear Loss of Medicaid
“Now we’re at the crisis point, where people are going to be impacted.”
- Greensboro News & Record

Preadmission Screening and Resident Review (PASRR)
PASSR Help Is Available!
Beginning January 1, 2013, any individual being considered for admission to an adult care home must be screened by an independent screener to determine whether the individual has SMI/SPMI. The state will connect any individual with SMI/SPMI to the appropriate LME for a prompt determination of eligibility for mental health services. To learn more, please read this DMA bulletin.

New Medicaid Rules Creating Headaches for Adult Care Homes
Recent state changes to the eligibility rules for Medicaid patients has left adult care homes scrambling to pay their bills after their claims for payments were rejected. About 70 percent of adult care homes that submitted claims this month had them rejected …
Read more at News & Observer.
 

DMA PCS Technical Assistance Webinar (Q&A)
This webinar is designed to provide billing guidance for Licensed Residential providers who are experiencing claim denials using the CMS 1500 professional billing claim form.
 
When: January 15, 2013 at 2:00 pm–3:30 pm
To join the meeting: https://dhhs.ncgovconnect.com/billing/
 

Frequently asked questions (FAQs) for the PCS Billing and Special Payment to ACH Providers
 

Personal Care Services Provider Webinar
The webinar is designed to provide an overview of the appeals process, QiRePort functionality, and updates on the Personal Care Services (PCS) transition as it relates to Licensed Home Care Providers and Licensed Adult Care Home Providers (including Adult Care Homes, Family Care Homes, 5600a and 5600c Supervised Living Homes, and combination facilities with ACH beds). This training is designed for facility administrators, owners, operators, and supervisory staff.
 

12/31/12 Personal Care Services Webinar: PCS Billing & Special Payment to ACH Providers Power Point Presentation
 

New North Carolina law to have devastating impact on seniors
 

Message from Sandra Terrell Concerning Mediation:
This is in response to the stakeholder meeting on December 2, 2012, at which it was reported that someone told staff that beneficiary is required to go to mediation before the appeal. This is not true. While NC is mandated to offer the opportunity for mediation, mediation is voluntary for the beneficiary. DMA staff has reached out to CCME to follow up on the comment.
 

State Finds $1 Million To Help Group Homes Stay Open Through January
Mentally disabled group home residents facing eviction at the end of the year will be able to stay in those homes through the end of January with the help of $1 million from a rental assistance fund, state officials said Tuesday. Read more at charlotteobserver.com …
 

The state has received a response from CMS concerning the 1915(i) Medicaid State Plan Amendment Application (specific to Medicaid recipients in special care units in assisted living communities) submitted in September, 2012. CMS states that it is unable to approve the SPA as submitted because it does not meet the requirements of sections 1902(a)(23) and 1915(i) of the Social Security Act. Read the letter here …
 
Alice Watkins on the Federal Government’s Fumble on Alzheimer’s Funding
 

 

Personal Care Services Rate Effective January 1, 2013
On November 30, 2012, the Centers for Medicare & Medicaid Services (CMS) approved the Personal Care Services (PCS) State Plan Amendment with an effective date of January 1, 2013. The new PCS rate will be $3.88 per 15-minute unit. The fee schedule is posted on the DMA Web site. The current codes for ACH-PCS and In-Home Care providers will be end-dated effective December 31, 2012.
 

Provider Interface Registration for Licensed Facility PCS Providers
The PCS QiRePort Provider Interface is a web-based information system to support PCS Independent Assessments. The interface helps collect, store, and communicate beneficiary information such as decision notices and independent assessments that are required to develop beneficiary plans of care. After the January 1, 2013 implementation of the new PCS program, additional Provider Interface functions will be introduced to support processes such as change of status assessment requests and facility discharge reporting.

Licensed facility provider registration for the PCS Provider Interface began on November 29, 2012. To register to use the Provider Interface, please complete the Provider Registration For Licensed Facility PCS Provider Use of QiRePort form and send to The Carolinas Center for Medical Excellence (CCME) via fax at 877-272-1942 or mail: CCME, ATTN: PCS Independent Assessment, 100 Regency Forest Drive, Suite 200, Cary, NC 27518-8598.
 

On the Record: Group home crisis
WRAL News anchor David Crabtree goes “On the Record” about a looming crisis for people in North Carolina’s group homes. If the government doesn’t step in, thousands of state group home residents could be out on the street by January.
 

Medicaid Personal Care Services: Regional Training for Licensed Adult Care Home and Home Care Providers
 

Medicaid changes could leave residents in adult care facilities homeless
Home operators, residents scramble in wake of new guidelines
“I feel like, in this particular arena, we’re on a high-speed bus and we don’t have a driver,” Randy Jackson, executive director of Spring Arbor of Kinston, said Monday.
 

Update on Independent Eligibility Assessments for Consolidated Personal Care Services
Independent assessments of residents of licensed adult care home—Adult Care Homes (ACH), Family Care Homes, 5600a and 5600c Supervised Living Homes, and combination facilities with ACH beds—are ongoing and expected to continue through November 2012. Please consult the updated timeline of estimated independent assessment dates by facility on the DMA Consolidated PCS Web page. Learn more at DMA …
 

Transition Planning for Implementation of New Personal Care Services Program
 
    Memo from DMA for Facility Administrators, Owners, and Operators
    A Follow-up for ACH Providers in August’s Medicaid Bulletin
 

Independent Assessment Information Center
 
The North Carolina Division of Medical Assistance (DMA) has contracted CCME to conduct Independent Assessments (IA) of In-Home Care (IHC) Services for Medicaid recipients in North Carolina. The IHC Program is intended to provide person-to-person, hands-on assistance with common Activities of Daily Living (ADLs). CCME has created the IA Information Center to help IHC providers easily find:

• IA Forms
• IA Important Links
• IHC Training Resources and Educational Tools
• Archived IA Announcements

All of these tools can be found here.
 

Forms for residents who move in new or have a change in condition after CCME does their Initial Assessments:
 
     FORM: Request for Independent Assessment for In-Home Care Services (IHC) Change of Status
     FORM: Request for Independent Assessment for In-Home Care Services (IHC) New Referral
 

Announcements from DMA:
 
1. Licensed Adult Care Home Projected Assessment Timeline [UPDATED 8-20-2012]
There is an Excel spreadsheet of the licensed adult care home projected assessment timeline that allows providers to sort and search. This document may also be found under the What’s New section on the DMA Website Main Page: http://www.ncdhhs.gov/dma/index.htm.
 
2. Proposed Policy 3L Re-Posted for 45-day Public Comment
The Proposed Policy 3L for Personal Care Services (PCS) has been posted for public comment at: http://www.ncdhhs.gov/dma/mpproposed/index.htm.
 

Transition Planning for Implementation of Consolidated Personal Care Services
The Centers for Medicare & Medicaid Services (CMS) approved North Carolina’s State Plan Amendment revising the scope and nature of Personal Care Services effective May 1, 2012. This approval extended the sunset deadline for In-Home Care (IHC) and Adult Care Home (ACH) personal care services from April 30, 2012 to December 31, 2012. Effective January 1, 2013, Medicaid personal care services for recipients in all settings, including licensed care home facilities (Adult Care Homes, Family Care Homes, combination facilities with ACH beds, etc), will be provided under a consolidated Personal Care Services (PCS) benefit.

DHHS will apply for a Medicaid State Plan Amendment to implement the new consolidated PCS benefit and develop PCS polices. The State will not pursue CMS approval to provide these benefits under the 1915(i) Home and Community Based Services (HCBS) option. DHHS and DMA will apply to CMS for approval to provide personal care under the 1915(i) HCBS option to elderly individuals with dementia who are typically served in Special Care Units (SCUs) and memory care units.

Effective January 1, 2013, individuals must meet the program functional eligibility requirements to qualify for PCS services. DMA contracted with the Carolinas Center for Medical Excellence (CCME) to conduct recipient eligibility assessments for all recipients seeking authorization for PCS, including current licensed home residents. Recipient eligibility and authorized service levels will be determined by an independent assessment conducted in the recipient’s residence. To qualify for services, adults must demonstrate unmet need for assistance with three qualifying activities of daily living (ADLs), or with two ADLs, one of which is assessed at the extensive-assistance or full-dependence level. The five qualifying ADLs are bathing, dressing, mobility, toileting, and eating. CCME will contact facilities a minimum of two weeks in advance to schedule resident assessments. The Resident Assessments are scheduled to begin on July 23, 2012.

CCME is using the facility phone number on file with the Division of Medical Assistance (DMA) Provider Enrollment to contact facilities. To ensure that all current Medicaid residents will be scheduled to receive independent assessments, please ensure that your facility’s contact information on file with DMA Provider Enrollment is current. To update your facility’s contact information with DMA, please contact the Medicaid provider enrollment, verification, and credentialing (EVC) Call Center at 866-844-1113. For more information about the EVC Call Center, please refer to the DMA Provider Enrollment Web page.

• Read the July Medicaid Bulletin for more complete information
• DMA’s Consolidated Personal Care Services Web page (many useful, related links)
• Estimated CCME assessment dates (by community and county)
• Personal Care Services (PCS) Medical Attestation for Licensed Care Home Residents (form)
• Instructions For Personal Care Services (PCS) Medical Attestation for Licensed Care Home Residents Form

 

Special Medicaid Bulletin on Transition to 1915(i) Personal Assistance Services

PCS Reimbursement Extension to Dec 31, 2012

NC Adult Care Homes Personal Care Services to Expire in 2012?

On April 24, 2012, President Obama was hand-delivered a letter advocating for resolution on the recent actions of CMS that threaten to push low-income seniors out of adult care homes and into institutional settings. This could potentially make more than 11,000 frail seniors, including those with Alzheimer’s disease and related dementias, homeless. Rep Butterfield hand-delivered this letter to President Obama aboard Air Force One. The North Carolina Assisted Living Association and ALFA will continue to work on this issue and still hope to gain resolution by April 30. More …

Medicaid State Plan Amendment:
Extension of Termination Date for Personal Care Services Reimbursement from April 30, 2012 to December 31, 2012
 
Read coverage on WRAL (also, see below).

Rep Kissell Discusses Protecting Seniors with NCALA
WASHINGTON, DC—Representative Larry Kissell (NC-08) recently met with officials from NCALA in Kissell’s Washington office. The group met with Kissell to discuss concerns about proposed budget cuts that would affect seniors and those who rely on assistance, as well as efforts to ensure that those in need are protected. Read full story …

David Crabtree and Cullen Browder go “On The Record” with former DHHS secretary Lanier Cansler about potential changes to the state healthcare system and how it will impact people in North Carolina.

From WRAL: Federal rule change threatens funding
“[Adult Care Home] owners say they need the higher reimbursement rate they have been getting to help pay for round-the-clock care and the higher standards to which the state holds them.”

Read the NCALA PCS Fact Sheet/Position Paper

Sunset of ACH PCS and In-Home PCS