Managed care


This information was obtained from Aaron Nangle’ newsletter.  To receive Nangle’s newsletter, visit his website at waiverinfo@aol.com

Emergency Rule Lifted By Rick Scott

Details About How/When Rates Are Restored

Provider Update

The APD emergency rate reduction to provider rates will end at midnight, April 15. Provider rates will return to their March 2011 levels effective Saturday, April 16.

Rates for services provided between April 1 and April 15 will remain at the reduced rate.

To keep from issuing over 150,000 new service authorizations, APD is changing current service authorizations (April 1 – June 30). These service authorizations will have an approved amount based on the reduced rate for services provided between April 1 through April 15 and the old (higher) rate from April 16 through the service authorization end date.

Changed service plans will be available in ABC by close of business Monday, April 18.

Service authorization requests will be submitted to FMMIS the evening of April 18. Service authorizations are anticipated to be available Tuesday, April 19.

Billing is suspended until system changes are complete. APD anticipates that service authorizations will be available to Waiver Support Coordinators on Tuesday, April 19.  WSC must review and distribute these service authorizations. Once a provider has received a service authorization, they may begin billing for April services.

If you have any questions or problems with your service authorization, Area Office staff can answer questions and make corrections to service plans.

Rates

The rate shown on the service authorization will be the old (higher) rate. The approved amount on the service authorization may not be equal to the old rate shown on the service authorization multiplied by the number of units. The service authorization for April may show an amount slightly less than the original rate multiplied by the number of units because of the reduced rate used from April 1 through April 15.

When billing for April, please remember to reduce the amount billed for services provided before April 16.   

Because of the rate change, services (other than monthly) should be billed daily by date in April. Please do not “roll-up” service rates used after April 15 with services provided during the April 1 through April 15 period.

Service Scenarios

The sections below describe how reduced rate service authorizations will be handled to increase the rates.

Service Plans with Approved Amount <= $1.00 or Rate = $0.00 : 

 Service Plans with Approved Amount <= $1.00 or Rate = $0.00 will not be updated by this process.

 Monthly Services (One unit per month billed)

The services below will be handled as follows:

For April,    

The reduced rate will be multiplied by 50% (.5).              

The old rate will be multiplied by 50% (.5).

These two amounts will be added together to get the blended amount for April

Each remaining month (May and June) will be billed at the old rate ($100.00)

New Service Authorization Amount (April-June) 92.50 + 100 + 100 = $292.50

 Example:

Reduced rate = $85, Old rate = $100, 4/1/2011-6/30/2011

For April,

$85 x .5 = $42.50

$100 x .5 = $50

$42.50 + $50 = $92.50 (blended amount for April)

92.50 + 100 + 100 = $292.50 New Service Authorization Amount (April-June)

Monthly Services

Res Hab Basic – Standard

Res Hab Ext 1 – Behavior Focus

Res Hab Ext 1 – Standard

Res Hab Ext 2 – Behavior Focus

Res Hab Ext 2 – Standard

Res Hab Min – Behavior Focus

Res Hab Min – Standard

Res Hab Mod – Behavior Focus

Res Hab Mod – Standard

Support Coordination – Limited

Support Coordination – Full

Support Coordination – Transitional

Support Coordination CDC+ – Limited

Support Coordination CDC+ – Full

 Unit Based Services

The services below will be handled as follows

Calculate number of days between begin date and 4/15/2011 = Reduced rate days (DaysReduced)

Calculate the number of days between 4/16/2011 and service authorization end date = remaining days (DaysRemain)

DaysReduced + DaysRemain = DaysSA

Approved amount / reduced rate = number of units (Units)

Units / DaysSA = units per day (UnitsDay)

UnitsDay * DaysReduced * reduced rate = 4/1/2011-4/15/2011 amount (ReducedAmt)

UnitsDay * DaysRemain * old rate = 4/16/2011-end of service authorization amount (RemainingAmount)

ReducedAmt + RemainingAmount = New Service Authorization Amount

 Example:

Reduced rate = $85, Old rate = $100, Period 4/1/2011-6/30/2011, Amount $8500

4/1/2011 – 4/15/2011 = 15 (DaysReduced)

4/16/2011 – 6/30/2011 = 76 (DaysRemain)

15 + 76 = 91 (DaysSA)

$8500 / $85 = 100 (Units)

100/91 = 1.0989 (UnitsDay)

1.0989 * 15 * $85 = $1401.0975 (ReducedAmt)

1.0989 * 76 * $100 = $8351.64 (RemainingAmount)

$1401.0975 + $8351.64 = $9752.7375 (New Service Authorization Amount)

Unit Based Services

In – Home Supports (Live-In Staff)

Res Hab Basic – Standard – Daily

Res Hab Ext 1 – Standard – Daily

Res Hab Ext 2 – Standard – Daily

Res Hab Min – Standard – Daily

Res Hab Mod – Standard – Daily

Residential Habilitation – (Live In Staff) – Daily

Respite Care – Day

Adult Day Training – Facility Based

Adult Day Training – Off Site

Behavior Analysis Level 1

Behavior Analysis Level 2

Behavior Analysis Level 3

Behavior Assistant Services

Companion

Dietitian Services

In – Home Supports (Awake Staff)

Occupational Therapy

Personal Care Assistance

Physical Therapy

Private Duty Nursing – LPN

Private Duty Nursing – RN

Residential Habilitation – (Quarter Hour)

Residential Nursing Services – LPN

Residential Nursing Services – RN

Respiratory Therapy

Respite Care – Quarter Hour

Skilled Nursing – LPN

Skilled Nursing – RN

Specialized Mental Health – Therapy

Speech Therapy

Supported Employment   Group

Supported Employment – Individual Model

Supported Living Coaching

Services Reduced by a flat 15 percent

The services below will be handled as follows

Calculate number of days between begin date and 4/15/2011 = Reduced rate days (DaysReduced)

Calculate the number of days between 4/16/2011 and service authorization end date = remaining days (DaysRemain)

DaysReduced + DaysRemain = DaysSA

Approved amount / reduced rate = number of units (Units)

Units / DaysSA = units per day (UnitsDay)

Reduced rate / .85 = old rate

UnitsDay * DaysReduced * reduced rate = amount prior to 4/16/2011 (amount 1)

UnitsDay * DaysRemain * old rate = amount after 4/15/2011 (amount 2)

Amount 1 + amount 2 = New Service Authorization Amount

 Example:

Reduced rate = $85, Period 4/1/2011-6/30/2011, Amount $8500

4/1/2011 – 4/15/2011 = 15 (DaysReduced)

4/16/2011 – 6/30/2011 = 76 (DaysRemain)

15 + 76 = 91 (DaysSA)

$8500 / $85 = 100 (Units)

100/91 = 1.0989 (UnitsDay)

$85 / .85 = 100 (old rate)

1.0989 * 15 * $85 = $1401.0975 (ReducedAmt)

1.0989 * 76 * $100 = $8351.64 (RemainingAmount)

$1401.0975 + $8351.64 = $9752.7375 (New Service Authorization Amount)

 Services Reduced by a flat 15 percent

CONSUMABLE MEDICAL SUPPLIES

IN HOME SUPPORTS MONTHLY – S.L.WAIVER

Personal Emergency Response – Service

Res Hab Basic – Behavior Focus

Residential Habilitation – (Day) Intensive Behavior in a Licensed Facility

Special Medical Home Care

Transportation – Mile

Transportation – Month

Transportation – Trip

One time or infrequent services

The services below will be handled as follows:

A list of these service authorizations is being provided to the Area Offices. Changes for these services will be handled manually by the Area Offices

Services

Adult Dental Services

Behavioral Analysis Services Assessment

Durable Medical Equipment

Environmental Accessibility Adaptations

Home Accessibility Assessment

Occupational Therapy Assessment

Personal Emergency Response – Installation

Physical Therapy – Assessment

Respiratory Therapy Assessment

Specialized Mental Health – Assessment

Speech Therapy – Assessment

Special Case for Res Hab Behavior Focus

The services listed below have the same procedure code of either “T2020U6” or “T2023U6” in the Rate table. However Res Hab Basic does not have any given rates as this service comes under services with negotiated rates. The business rule being applied is:

a) Take the pre-April 1 ABC service plan rate (old) and compare it with all the rates available in the old rate table.

 b) If a perfect rate match is found for the procedure code and rate, the matched rate will be used in the current service plan. Otherwise the ABC old service plan rate will be used in the current service plan.

Services

Res Hab Basic – Behavior Focus

Res Hab Min – Behavior Focus

Res Hab Mod – Behavior Focus

Res Hab Ext 2 – Behavior Focus

Res Hab Ext 1 – Behavior Focus – Daily

Res Hab Ext 2 – Behavior Focus – Daily

Res Hab Min – Behavior Focus – Daily

Res Hab Mod – Behavior Focus – Daily

 Problems That Might Occur

One time or infrequent services are being handled manually

Units may not be used on a daily basis so the calculated amount is not correct

Source:  http://apdcares.org/news/news/2011/new-rule.htm

  ______________________________________________________

Message From Aaron Nangle

The aim of win-win negotiation is to find a solution that is acceptable to both parties, and leaves both parties feeling that they’ve won, in some way, after the event.  I don’t believe that has happened  for either party, and that worries me.  Providers and families are very, very thankful to The Governor and to the Legislators for restoring rates, yet they are also  fully aware that there is not enough funding to serve everyone and future cuts are likely. The Governor has made it very clear that APD must stay within its budget, and he has an obligation to tax payers to balance the Florida budget.  

There are about 50,000 people who need services from The Agency For Persons With Disabilities- just over 30,000 are on the waiver and 19,000 on the waiting list.   Historically, the budget has not been enough to provide services for the 30,000 on the waiver.  Furthermore, many people have been waiting for services for five years or more. 

In this crisis, we have come together and worked towards solutions.  We need to continue to do so.  The absolute worst thing we can do is to panic and start blaming each other.  Let’s face it, the money wasn’t wasted on private jets for our workers or exotic retreats, it was spent on medically necessary services. 

In order to balance the APD budget and also serve everyone on the waiting list, people would need to cut their service utilization nearly in half.  In most cases that is an impossible request.  We can not tell people they can only live in their group homes for 182 days per year.  From this experience we have also learned that provider rates can not be cut by 30-40 percent.  The law requires that agencies pay their employees at least minimum wage, and minimum wage is usually not enough to keep dependable, quality, caring providers. 

The second rule of successful negotiation is to understand the wants and needs of the other party.  

http://www.youtube.com/watch?v=yA7nCI1Q8Kg

(video of meeting in the Governor’s office)

We have a lot of work to do.

__________________________________________

Ever Care Adult Care Services LLC,

Is Ready To Help

  We have beds available immediately and are prepared to help anyone in need during these difficult times. Behavior focused adult male, Standard female and male beds are available. Live near the beach, enjoy great daily activities. Contact – Mary Jo, 727-449-7045 or Email: mhscan@aol.com 

 See our website at http://evercareadultservices.com/

______________________________________
 

Call to Advertise your company & be listed on our websites.
We want people to have a true choice.

SupportCoordinators.Com  –  WaiverProvider.Com

FloridaGroupHome.Com  –  FloridaUnites.com

FloridaAutism.org  –  FloridaGuardianship.com

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In every negotiation, there are winners and losers.  Perhaps there are other winners yet to be revealed. 

Who wins in Medicaid overhaul? | Top Story | Health News Florida.

Medicaid bill eyes HMO profits

By Jim Saunders
03/14/11 © Health News Florida

As Florida lawmakers get ready to transform Medicaid into a managed-care system, they are split on a complex question: How do you make sure HMOs don’t receive a windfall at the expense of patient care?  For more, see original at Health News Florida

 

The Networks Self-Advocates traveled to Tallahassee to see the Florida legislators.  Here is several links to some of the articles their visit engendered.  The two people holding the sign are self-advocates from Titusville.

http://m.floridatoday.com/news.jsp?key=361250&rc=ne

http://miamiherald.typepad.com/nakedpolitics/2010/11/as-senate-opens-medicaid-reform-hearings-potential-clients-worry-about-hmos.html

http://www.tallahassee.com/article/20101118/CAPITOLNEWS/11180322/Lawmakers-take-on-Medicaid-reforms
http://floridacapitalnews.com/article/20101118/CAPITOLNEWS/11180322&theme=
http://staugustine.com/news/local-news/2010-11-18/lawmakers-mull-medicaid-overhaul
http://floridaindependent.com/15175/lawmakers-weigh-plans-for-medicaid-overhaul
http://www.pnj.com/article/20101118/NEWS01/11180320/Legislators-dive-into-Medicaid-reform

FLORIDA UNITED FOR CHOICE –

________________________________________________________________________

WHY INCLUDING THE DEVELOPMENTALLY DISABLED OF FLORIDA INTO AN HMO MODEL IS NOT GOING TO WORK:

*We are fundamentally opposed to the aspect of Medicaid Reform that entrusts the coordination and care of the developmentally disabled of Florida to Health Maintenance Organizations (HMO’s). The current system of identifying, providing, overseeing, and funding of needed supports and services to the disabled of the state involves thousands of private contract HCBS Medicaid Waiver support and service providers who advocate for the needs of their caseloads and strive to get the needs of the developmentally disabled citizens of the State met. These providers work in concert with the state’s Agency for Persons with

Disabilities (APD) playing a significant role in quality assurance and oversight of the system. Surrendering the entire service system over to contracted HMO’s would eliminate choice, eliminate adequate oversight, and it would create a system nearly impossible for a developmentally disabled citizen and/or their family to navigate. Our reasons for opposing an HMO take over of the support and services system for the developmentally disabled of Florida are:

HMO is Not the Model That Best Serves the Developmentally Disabled Population

*There is something fundamentally different about being developmentally disabled versus any other kind of public assistance recipient — HMO is not geared for them.*

  • · Developmentally disabled (“DD”) recipients had absolutely no choice being born with their conditions and situations. They made no mistakes, errors in judgment and the nature of their assistance is hardly ever temporary.
  • · They will need life long care and support from an established cadre of specialized providers knowledgeable in DD issues. This care involves much more than merely medical concerns.
  • · There are social, self-care and self-advocacy issues that are unique to them. Many are non-verbal and nearly all could not successfully understand and navigate an HMO’s 1-800 number access system nor be able to advocate for their own needs effectively against an HMO’s opposition to funding services. Disabled people are easily intimidated and confused. Frequently they are cared for by highly stressed single caregivers. Yet they are lumped together with non-disabled welfare recipients.
  • · 30,000 people with disabilities and their families including over 2.7 million other voting Floridians will be negatively impacted. HMOs and PPNs are based on a medical model not on the special needs of DD consumers.

 

CHOICE

The thousands of service providers in the current system are hired and fired by the recipients of services THEMSELVES.

  • · In other words, the disabled of Florida now have the greatest choice in the freest fair-market system anywhere in the country. They have an independent case manager–a Support Coordinator whom they can hire and fire–whose overriding responsibility is to advocate for their preferences, help them identify their needs, and then assist them in navigating many complex service systems.
  • · When a disabled recipient is unhappy with the service provider (Support Coordinator, Respite provider, Companion, etc.), they can immediately terminate them and then be assisted in interviewing and locating a replacement provider that will best meet their needs.
  • · Going to an HMO model would eliminate this choice-based fair-market model. It would require them to rely on an HMO-funded case manager—a case manager WITHIN the HMO itself to push for support and service approvals and navigate the HMO’s complex requirements for these service approvals. In other words the HMO-funded case manager would be tasked with advocating against his own employer on behalf of the disabled person. This represents a debilitating conflict of interest as the HMO’s essential concern is profit and that case manager works for them. HMO’s have no established history of dealing effectively with this inherent conflict.
  • · A developmentally disabled recipient would essentially go from a model offering thousands of providers to a small handful. Opting for an HMO take-over of services for the developmentally disabled of Florida removes choice for these citizens and needlessly eliminates the highly specialized providers that these disabled individuals have known for years, come to trust, and who have developed an accurate and effective understanding of them and their needs. *This is a process that takes years with this population and equates in many cases to their avoiding institutionalization. Eliminating the independent provider system in favor of approximately 4 HMO’s carving up the state eliminates the current independent advocate provider system. This represents removing independent third party advocacy for the most vulnerable, poor and disabled population of the state.

Fiscal Responsibility:

It is understood that the state is in difficult financial times and that spending must be reduced.

  • · The developmentally disabled of Florida and their caregivers as well as the provider system that works for them understand the need for a sustainable system. The current Agency for Persons with Disabilities

(APD) and HCBS Medicaid Waiver systems afford the state an effective infrastructure to enforce accountability and compress funding when times are tough.

  • · Rather than paying HMO’s a fully-funded contract UP FRONT for five years, the current system allows the state to enact reductions at any time until the economic situation improves. Simply put, the current system allows the Florida state government real, dynamic flexibility. (*You can tear pages out of the

Waiver Services Handbook but keep the book so that when you can you add those pages BACK IN.)

  • · The current ‘Tier system’ places recipients into capped budgets. This is a ready infrastructure that allows you to decrease budgets for individuals receiving services when you have no other choice because of the economic situation. And again, when the budget improves, you can increase the Tier budgets for recipients.
  • · Once in a contract with an HMO you are stuck with that system for 5 years, regardless of how well or poorly the HMO performs. Historical data throughout the history of HMO’s in this country shows it is extremely difficult and costly to recoup funding from them when improprieties are discovered.

________________________________________________________________

This entry comes from the Department of Justice website

Department of Justice

Office of Public Affairs
FOR IMMEDIATE RELEASE
Thursday, June 24, 2010
Judge Orders State of Florida to Provide Community Services to Jacksonville Woman at Risk of Institutionalization

WASHINGTON – The state of Florida must provide Michele Haddad with services that will enable her to remain in her home, a U.S. District Court in Jacksonville, Fla., ruled Wednesday. Haddad, who has quadriplegia as a result of a motorcycle accident with a drunk driver in 2007, has successfully resided in the community since the accident, but is at risk of entry into a nursing home due to changes in her caregiver situation. Haddad, who has been on the waiting list for Medicaid community-based waiver services for two years, notified the state of her increased need for services, but was told that community services would only be available if she was willing to enter a nursing home for 60 days.

The court ordered the state to provide community-based services as required by the Americans with Disabilities Act’s (ADA) integration mandate as set forth in Olmstead v. L.C. The United States argued in a brief filed on May 25, 2010, that Haddad would suffer irreparable harm if forced to enter a nursing home to receive necessary services.

The court issued this order in the week that marks the 11th anniversary of the landmark Olmstead decision.

“In the Olmstead case, the court recognized that the unnecessary segregation of individuals with disabilities stigmatizes those individuals as unworthy of participation in community life,” said Thomas E. Perez, Assistant Attorney General for the Civil Rights Division. “By supporting Ms. Haddad in this case, we seek to ensure that individuals with disabilities can receive services in the most integrated setting appropriate, where they can participate in their communities, interact with individuals who do not have disabilities, and make their own day to day choices.”

The U.S. government’s participation in this case is part of the administration’s efforts across the nation to affirm the fundamental right for Americans with disabilities to live independently, in what the president has deemed “The Year of Community Living.”

The full and fair enforcement of the ADA and its mandate to integrate individuals with disabilities is a major priority of the Civil Rights Division. The ADA protects individuals with disabilities from discrimination by public entities. People interested in finding out more about the ADA can call the Justice Department’s toll-free ADA Information Line at 1-800-514-0301 or 1-800-514-0383 (TTY), or access its ADA website at www.ada.gov/.

10-741
Civil Rights Division

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Here is a question received from one teacher of mentally challenged persons and it is answered by another teacher.  Thought you might like to easedrop in on the conversation.

I have a question about people with mental disabilities and learning. Would you call people with mental disabilities literate learners or oral learners or both?

Do you use lessons and teachings that are basically simplfied language, lesson handouts and take home papers that they can read and think about and discuss? Or do you use basically oral communication? I am reading that information must come to oral learners through stories, drama, song, and other similar formats.

Do you have any reference material in this area? Do you use simple versions of the Bible for those who can read or do you use a Dramatized version of the Bible they can hear being read? We are working on a one year Christian Education curriculum for people with low functioning mental disabilities. We have simplified the language to their basic level of understanding. How would you create a curriculum for oral learners?

ANSWER:  I think of there being three types of learners:

1. Auditory (what I think you are calling Oral)

2. Visual

3. Kinesthetic

These are the pathways into the brain (ears, eyes and touch). You see this play itself out in the way people spell. If you ask some people how to spell a word they sound it out (Auditory). My wife will tell me how to spell a word then want to come look at it (Visual). Yet others will need to write it themselves (Kinesthetic).

So for auditory learners hearing the Bible read is fine, but a dramatized reading of a Bible story even better. For visual learners, seeing a video of the Bible story helps. For a kinesthetic learner acting out the Bible story is helpful.

Question, if someone is a visual learner does acting out the story help? In acting out the story they cannot SEE the whole and do they miss the forest for the trees (so to speak)? I think in developing a lesson every lesson needs to address each type of learner.

The literate learner I think is what I would call a concrete learner (do not really know the term literate learner). I think this is a totally different discussion. Before the discussion is about pathways into the brain and now we are talking about the ability of the brain to process information.

I do think mentally challenged persons are concrete learners and we have to be careful to teach that way. I think it is a major problem in what I often see people do in teaching mentally challenged persons. I was at a camp last year for mentally challenged folks. They had a speaker who spoke on how God sees us. The speaker had a lot of different types of glasses. Most of them were funny goofy glasses. He was very funny. People had a good time. But I do not think they had a clue about the point he was trying to make. It was too abstract.

At Special Gathering, we use the term symbolic object lessons vs concrete object lessons. If the object we are using in an object lesson represent something else we do not use that object lesson. An object has to be what it is.

As an example – I use to have a set of chemistry tubes that I used in my sermons. I would talk about sin entering the world and pour one tube into a second tube turning the second tube black. Then I had a third tube that was red. I would talk about how Jesus came into the world and died to take away our sin. I would pour the third tube into the second tube. As the red liquid hit the black liquid it turned clear. It was really cool, but I do not think it helped anyone (but the volunteers) understand anything. It was too abstract. You have to cognitively connect one tube to Satan, one tube to people and yet a third tube to Jesus. Not only does that not help the learning process I think it harms the learning process. Just my two cents worth.

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