Procedure Manual /
July 2016
Table of Contents
Introduction
Office of Aging and Disability Services Overview
Definitions
ORC Services
Introduction to Section 20: Home and Community Services for Adults with Other Related Conditions
Eligibility for ORC Waiver
Services Covered by ORC Waiver
Non-Covered Services
Applying for Services
Change/Transition from Children’s to Adult Services
Change/Transition from other HCBS Waiver to ORC Services
Beginning Services
Implementing Services
Terminating Services
Suspending Services
Vendor Calls
ORC Providers
Professional Boundaries
Provider Roles
OADS Care Monitor
Care Coordinator
Conflict Free Care Coordination
ORC Waiver Providers
Provider Enrollment and Maintenance
Care Plan
Writing the Care Plan
Revising the Care Plan
Changing ORC Providers
Transfer of Member Records
Renewing the Care Plan
MED Assessment
Care Plan Schedule
ServiceLimits
Legal
MaineCare Appeals
Public Guardianship and Conservatorship
Levels of Authorization Delegated by the Commissioner
Motion for Change of Venue
Reportable Events
Reporting
Documenting
Confidentiality and Disclosure
Standards and Procedures
Employment
Entitlement Programs and Benefits
Housing Options
Evaluations, Consultations, and Other Covered Services
Prior Authorization Process
Consultation and/or Request for Evaluation
Assistive Technology Devices
Communication Aids
Consultation Services and Assessment
Home Accessibility Adaptations
Non-emergency Transportation Services
Non-Traditional Communication Assessments
Non-Traditional Communication Consultation
Occupational Therapy (Maintenance) Services
Physical Therapy (Maintenance) Services
Specialized Medical Equipment
Speech Therapy (Maintenance) Services
Appendix A – Safety Risk Assessment
Appendix B – Other Related Conditions BMS 99
Appendix C – Other Related Conditions Choice Letter
Appendix D – Other Related Conditions Care Plan
Appendix E – Care Plan Schedule
Introduction
Office of Aging and Disability Services Overview
The Office of Aging and Disability Services (OADS) is responsible for planning, developing, managing, and providing services to promote independence for elders and adults with brain injuries, intellectual and physical disabilities through the provision of services. These services include evidence based prevention programs, comprehensive home and community based services, Adult Protective Services, and Public Guardianship and Conservatorship Programs.
OADS Vision
We promote individual dignity through respect, choice and support for all adults.
OADS Mission
To promote the highest level of independence, health and safety of older citizens, vulnerable adults and adults with disabilities.
OADS Values
Appropriate Levels of Support
Dignity of Risk
Family Caregiver Support and Informal Supports
Individual/Person Centered
Optimizing Independence
Quality of Care and Services
Definitions
Abuse means the infliction of injury, unreasonable confinement, intimidation or cruel punishment that causes or is likely to cause physical harm or pain or mental anguish; sexual abuse or sexual exploitation; or the intentional, knowing or reckless deprivation of essential needs as defined in 22 MRSA §3472.
Assessing Services Agency (ASA) is an Authorized Agent of the Department of Health and Human Services (DHHS) for Medical Eligibility Determinations that conducts face-to-face assessments, using DHHS Medical Eligibility Determination form or other DHHS approved form.
Authorized Agent is the organization authorized by the Department of Health and Human Services (DHHS) to perform specified functions pursuant to a signed contract or other approved signed agreement.
BMS 99 is the assessment tool used to determine functional limitations of the member.
Care Coordinator is a provider organization staff person who is responsible for the development and ongoing support of the implementation of the Care Plan. This includes monitoring of the health, welfare and safety of the Member.
Care Plan is a comprehensive document that specifies the services a member will receive under this section and the manner in which those services will be provided. Care Plans are only effective for 365 days.
Care Plan Schedule is a schedule agreed to by the Member and ORC Waiver Providers and helps to ensure both parties know when services are expected to take place.
Choice Letter is a letter that identifies the Member’s (and their Guardian’s, if applicable) decision to receive Waiver services instead of institutional care.
Enterprise Information System (EIS) is a data collection tool managed by DHHS’ OADS and OIT (Office of Information Technology). EIS is utilized to ensure proper documentation and allow oversight of services Members are receiving
Exploitation means the illegal or improper use of an incapacitated or dependent member or that member’s resources for another’s profit or advantage as defined in 22MRSA §3472.
Habilitation is a service that is provided in order to assist a member to acquire a variety of skills, including self-help, socialization and adaptive skills. Habilitation is aimed at raising or retaining the level of physical, mental, and social functioning of a member. Habilitation is contrasted to rehabilitation which involves the restoration of function that a person has lost.
Health and Welfare means the wellbeing of the Member. The Member’s health and welfare must be assured by an approved ORC care plan that the Member and their guardian (if applicable) agree to participate in, and the environment must be safe enough to ensure services can be provided without risk of harm or injury to the Member and individual providing services.
Intellectual Disability means a diagnosis of Mental Retardation as defined in Section 317-319 in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (American Psychiatric Association), that manifested during the developmental period, in accordance with the definition of Intellectual Disability codified in 34-B MRSA § 5001.The terms “mental retardation” and “intellectual disability” are used interchangeably in these regulations.
Letter of Medical Necessitymeans a letter completed by a licensed physician that confirms an individual has a certain medical diagnosis or has multiple certain diagnoses.
Mandated Reporter means persons who must report to the Department when they know or have reasonable cause to suspect that an incapacitated or dependent adult has been or is likely to be abused, neglected or exploited as defined in 22 MRSA § 3477.
Medical Eligibility Determination (MED) Tool means the form approved by DHHS to assess the medical service needs of the member. The information provided by the MED tool will be used in determining the eligibility for the waiver and authorizing services.
Member is a person determined to be eligible for MaineCare benefits by the Office for Family Independence (OFI) in accordance with the eligibility standards published by the OFI in the MaineCare Eligibility Manual. Some members may have restrictions on the type and amount of services they are eligible to receive.
Money Follows the Person-Homeward Bound Transition Coordinator is the person who is chosen by the member to provide transition Assistance from the agencies contracted by the Department for the Money Follows the Person-Homeward Bound program.
Natural Supports include the relatives, friends, neighbors, and community resources that a member or family goes to for support. They may participate in the treatment team, but are not MaineCare reimbursable.
Neglect means a threat to an member’s health or welfare by physical or mental injury or impairment, deprivation of essential needs or lack of protection from these as defined in 22 MRSA §3472.
OADS Care Monitor is the Department of Health and Human Services (DHHS) professional who assiststhe member with the member’s enrollment in the waiver services and monitors the services received to assure they are meeting the health and safety needs of the member.
Other Related Conditions (ORC), based on 42 C.F.R. § 435.1011,means a severe, chronic disability that meets all of the following conditions identified in 20.03 of MaineCare Benefits Manual.
ORC Waiver Providers: Are agencies and organizations, and their affiliated staff, which provide waiver services to Section 20 ORC Members.
Preliminary Care Plan is the Care Plan developed by the Care Monitor. On the date a Member starts to receive Section 20 ORC Waiver Services (known as the Start Date) the Preliminary Care Plan becomes the Care Plan.
Prior Authorization(PA) is the process of obtaining prior approval as to the medical necessity and eligibility for a service.
Renewal Dateis the annual date a Member who is receiving Section 20 ORC Waiver Services must have a revised and approved Care Plan in place in order to continue services. Renewal Date is determined by the Member’s Start Date.
Reportable Events are events that happen or may happen to Members that have or may have an adverse impact upon the safety, welfare, rights or dignity of adults with other related conditions.
Start Date is the date a Member begins to receive Section 20 ORC Waiver Services.
Utilization Review is a formal assessment of the medical necessity, efficiency and appropriateness of services and Care Plans on a prospective, concurrent or retrospective basis. The provider is required to notify DHHS or its Authorized Agent upon initiation of all services provided under Section 20 in order for the Authorized Agent to begin utilization review.
Vendor Calls are a formal process of seeking a service for a Member that is identified in the approved Care Plan.
ORC Services
Introduction to Section 20: Home and Community Services for Adults with Other Related Conditions
Section 20 Other Related Conditions refers to Chapter II, Section 20 of the MaineCare Benefits Manual. This service, typically referred to as “Section 20” or “ORC”, is a Home and Community Based Service (HCBS) Waiverthat is also regulated by the Federal Center for Medicare and Medicaid Services (CMS). According to CMS: “Waivers are one of many options available to states to allow the provision of long term care services in home and community based settingsunder the Medicaid Program.States can offer a variety of services under an HCBS Waiver program.Programs can provide a combination of standard medical services and non-medical services.”
ORC services were developedto provide a comprehensive service package that allows Members to be served in the community. The ORC waiver is designed to maximize the opportunity for members to achieve the greatest degree of self-sufficiency and independence chosen by the Member. Member choice in all services and components of services is a primary goal. Additionally, the principles of conflict-free care coordination, services provided in the least restrictive modality and effective use of assistive technology for communication, environmental control and safety are inherent to this waiver.
Eligibility for ORC Waiver
The process for determining eligibility for Other Related Conditions waiver is defined in 20.03 of MaineCare Benefits Manual.
Services Covered by ORC Waiver
- Assistive Technology Device and Services
- Non-Traditional Communication Assessments
- Care Coordination Services
- Non-Traditional Communication Consultation
- Communication Aids
- Occupational Therapy (Maintenance) Services
- Community Support Services
- Personal Care Services
- Consultation Services and Assessment
- Physical Therapy (Maintenance) Services
- Employment Specialist Services
- Specialized Medical Equipment
- Home Accessibility Adaptations
- Speech Therapy (Maintenance) Services
- Home Support Services
- Work Support Services
- Non-emergency TransportationServices
Non-Covered Services
- Services not authorized by the Care Plan
- Services to any member who is hospitalized, a nursing facility resident or ICF/IID resident
- Any service otherwise reimbursable under the Rehabilitation Act of 1973 or the Individuals with Disabilities Education Act, including by not limited to job development and vocational assessment or evaluations (Vocational Rehabilitation Services).
- Room and Board
- Services provided directly or indirectly by the legal guardian
- Work Support or Employment Support Services when the member is not engaged in employment
- Specialized Medical Equipment and Supplies, Communication Aids, or Home Accessibility Adaptations unless the service has been determined non-reimbursable under other sections of the MaineCare Benefits Manual.
- Services funded by other sections of MaineCare
- Section 20 Waiver services may not be provided in a residence where other HCBS waiver services are provided. Exceptions considered on a case-by-case basis by the Department.
Applying for Services
Anyone can apply for ORC services, though not everyone is eligible. To apply, ask for the OADS ORC Care Monitor at 1-800-262-2232. TheOADS Care Monitormust be provided the following:
- ORC Application
- A completed and signed Authorization to Release Information
- Letter of Medical Necessity
The OADS Care Monitor will then complete the Safety Risk Assessment and BMS 99. This documentation is reviewed with the Brain Injury Program Manager to determine if the applicant is eligible based on Chapter II, Section 20.03 of MaineCare Benefits Manual.
A letter will be sent to the Applicant regarding their eligibility status. The OADS Care Monitor refers for the initial Medical Eligibility Determination (MED) assessment, but it is the Care Coordinator’s responsibility to refer for the subsequent annual MED assessments.
Change/Transition from Children’s to Adult Services
Although a youth may have received DHHS services as a child they may not meet the qualifications for DHHS programs or services that serve adults due to varying eligibility standards. Youth must apply for, and meet the eligibility criteria of the Section 20 waiver to receive services. This includes submitting an application, a comprehensive assessment and evaluation, and meeting the eligibility criteria of the program.
It is crucial that the transition from Children’s to Adult services include joint planning to ensure the youth’s need for services such as housing, education, workforce and/or employment supports, medical care and monitoring, and community integration are addressed across the systems of care.
For those youth who may qualify for more than one service, including Section 20 Services, it is recommended that a referral be made to all desired services.
Beginning Services
If determined eligible, the OADS Care Monitor will reach out to the Member and arrange an initial planning meeting. The Member will be assigned an ORC number to be used in all correspondences to protect Private Health Information. This meeting involves the Member, Guardian (if applicable), and OADS Care Monitor. The goal of the meeting is to determine what ORC services the Member would like to receive and to identify providers for those services. Once the Member’s desired services and providers are identified the OADS Care Monitor will create a preliminary Care Plan and reach out to the Member’s chosen providers.
The OADS Care Monitor will provide the Member with a list of providers to choose from and the list of services which each provide. If the Member would like a provider that is not listed the OADS Care Monitor will make an effort to reach out to the desired provider and invite them to become an ORC provider should they qualify Those providers who are interested can work with OADS Care Monitor and ORC program staff to become an authorized ORC provider. The Member may request to meet with providers before making a final decision.
Coordinating with all the chosen providers, the OADS Care Monitor will set up an initial Start date. The Start Date is when ORC services will be authorized and establishes the Renewal Date, which is the date the Care Plan must be renewed by each following year. Prior to the Start Date the OADS Care Monitor will provide the chosen Care Coordinator with the signed Care Plan (Care Plan Services Authorization/ Revision Request-Service Form,ORC Prior Approval Authorization Request-AT Formand Care Plan Schedule included),Medical Eligibility Determination (MED) Assessment and Date, BMS 99, Choice Letter, and Renewal Date. If the Care Coordinator does not receive this information they must contact the OADS Care Monitor and request it.
As Care Coordination is a Waiver Service, Care Coordination cannot begin until the Start Date. The OADS Care Monitorprovides the role of Care Coordination only until the Start Date. All future Care Plan renewals and revisions are the responsibility of the Care Coordinator. Within 48 hoursof the Start Date the Care Coordinator makes contact with the Member to schedule the initial meeting and confirm waiver services have started.
Implementing Services
All ORC Services are individualized in each MembersCare Plan. Care Plans are as varied as the Members, although they all use the same template.
The Care Coordinator is responsible for maintaining the Care Plan. The Care Coordinator must provide all ORC Waiver Providers with updated and signed Care Plans, in their entirety, and Care Plan Services Authorization/ Revision Request-Service Forms as they are revised or renewed.
The Care Coordinator must meet with the Member face to face at least every 30 days to ensure that services and the living arrangement is still appropriate. This meeting can be a 1 on 1 meeting, a team meeting, or can include anyone theMember would like to invite.