Waiver Assurances and Performance Measures 2011 Waiver Renewals Waiver Assurances and Performance Measures Presented By: Val Bradley Margy Mangini

6 Waiver Assurances Level of Care Service Plan Provider Qualifications Health & Welfare Financial Accountability Administrative Authority

Level of Care Sub- Assurance a: Performance Measure: An evaluation for LOC is provided to all applicants for whom there is reasonable indication that services may be needed in the future. Performance Measure: Number and percent of all new enrollees who have a completed assessment indicating a need for ICF/MR LOC prior to receiving services.

Level of Care Sub-assurance b: Performance Measure: The levels of care of enrolled participants are reevaluated at least annually or as specified in the approved waiver. Performance Measure: The number and percent of waiver participants who received an annual level of care redetermination within 12 months of their last annual LOC evaluation.

Level of Care Sub-assurance c: The processes and instruments described in the approved waiver are applied appropriately and according to the approved description to determine participant level of care.

Level of Care (continued) Sub Assurance c: Performance Measures: Number and percentage of LOC determinations for applicants completed by a qualified staff person Number and percentage of LOC determinations that used instruments and processes described in the waiver application. Number and percent of LOC determinations that were completed accurately.

Service Plan Sub-assurance a: Service plans address all participants’ assessed needs (including health and safety risk factors) and personal goals, either by the provision of waiver services or through other means.

Service Plan (continued) (Sub-assurance a continued) Performance Measures: Number and percent of plans of care in which services and supports are aligned with assessed need Number and percent of waiver participants who have plans of care that address health risks as indicated in the assessment

Service Plan (continued) (Sub-assurance a continued) Number and percent of waiver participants who have plans of care that address their desired outcomes as indicated in the assessment. Number and percent of waiver participants who have plans of care that address safety risks as indicated in the assessment.

Service Plan (continued) Sub-assurance b: The State monitors service plan development in accordance with its policies and procedures. Performance Measure: Number and percent of plans of care that are completed within the required planning guidelines

Service Plan (continued) Sub-assurance c: Service plans are updated/revised at least annually or when warranted by changes in the waiver participant’s needs. Performance Measures: Number and percent of plans of care update/ revised at least annually. Number and percent of participants who had a change in need and the plan of care was updated.

Service Plan (continued) Sub-assurance d: Services are delivered in accordance with the service plan, including the type, scope, amount, duration and frequency specified in the service plan. Performance Measures: Number and percent of waiver participants who receive services in the type, amount, frequency, and duration specified in their plan of care.

Service Plan (continued) Sub-assurance e: Participants are afforded choice between waiver services and institutional care; and between/among waiver services and providers. Performance Measures: Number and percent of waiver participants whose records contained an appropriately completed and signed Medicaid Waiver Choice Statement form that specifies that choice was offered between waiver services and institutional care

Service Plan (continued) (Sub-assurance e continued): Number and percent of waiver participants whose records contained a completed and signed Medicaid Waiver Client Choice of Provider Statement. Number and percent of waiver participants who were offered choices of waiver services

Provider Qualifications Sub-assurance a: The State verifies that providers initially and continually meet required licensure and/or certification standards and adhere to other standards prior to their furnishing waiver services. Performance measures: Number and percent of initial provider applications that met enrollment criteria

Provider Qualifications (continued) (Sub-assurance a continued) Number and percent of providers who initially met applicable DMH/DD licensure/certification/accreditation criteria Number and percent of providers who maintained on-going DMH/DD licensure/certification/accreditation criteria

Provider Qualifications (continued) Sub-assurance b: The State monitors non-licensed/non-certified providers to assure adherence to waiver requirements. Performance Measure: Number and percent of non-licensed and non-certified providers, who met waiver provider qualifications

Provider Qualifications (continued) Sub-assurance c: The State implements its policies and procedures for verifying that provider training is conducted in accordance with state requirements and the approved waiver. Performance Measures: Number and percent of providers meeting provider training requirements.

Health and Welfare Sub-assurance: Performance Measures: The State, on an ongoing basis, identifies, addresses and seeks to prevent the occurrence of abuse, neglect and exploitation. Performance Measures: Number and percent of waiver participants who are informed of how to report suspected abuse/neglect/misuse of funds Number and percent of incidents reported within required time frames.

Health and Welfare (continued) Number and percent of incidents reported in which an inquiry was conducted within required time frames. Number and percent of potential incidents of abuse/neglect/misuse of funds in which an investigation was initiated within required timeframes Number and percent of investigations that were substantiated for abuse/neglect.

Health and Welfare (continued) Number of substantiated cases of abuse involving unauthorized use of restraint. Number and percent of potentially preventable deaths that resulted in appropriate follow-up

Financial Accountability Sub-assurance: State financial oversight exists to assure that claims are coded and paid for in accordance with the reimbursement methodology specified in the approved waiver. Performance Measure: Number and percent of claims processed for eligible participants Number and percent of claims paid for services included in the approved service plan

Financial Accountability (continued) Number and percent of claims paid for waiver services that adhere to the reimbursement methodology of that waiver. Number and percent of provider agreements/contract that comport with the state’s requirements for contracting

Administrative Authority Sub-assurance: The Medicaid Agency retains ultimate administrative authority and responsibility for the operation of the waiver program by exercising oversight of the performance of waiver functions by other state and local/regional non-state agencies (if appropriate) and contracted entities. Performance Measures: Number and percent of waiver policies/procedures approved by the Medicaid agency prior to implementation.

Administrative Authority (continued) Number and percent of unduplicated participants exceeding the maximum enrollment limits. Number and percent of waiver service claims paid that exceeded the maximum allowable rate. Number and percent of MO HealthNet remediation actions requested of Division of DD, by type of remediation, that were properly resolved by Division of DD.

Administrative Authority (continued) Number and percent of waiver enrollment complaints received by MO HealthNet that were resolved by Division of DD within timeline requested. Number and percent of waiver service units authorized that were delivered based on billed units of service. Number and percent of untimely initial level of care determinations that were properly remediated by Division of DD.

Administrative Authority (continued) Number and percent of complaints received by DMH-Office of Consumer Safety for waiver participants that were properly resolved. Number and percent of plans of care Division of DD properly remediated that had a finding that the plan was not adequate and appropriate to meet the needs in the plan.

Administrative Authority (continued) Number and percent of Division of DD findings of provider failure to initially meet or continue to maintain required licensure/certification that were properly remediated. Number and percent of waiver services paid that did not go through the Division of DD prior authorization system.

Administrative Authority (continued) Amount and percent of variance between actual factor D + D’ and G+G’. (Total of D+D’/Total of G+G’) Measures cost effectiveness over ICF/MRs level of care. Number and percent of untimely reevaluations of level of care determinations that were properly remediated by Division of DD.

Administrative Authority (continued) Number and percent of redeterminations of level of care made by persons other than a QDDP that were properly remediated by Division of DD Number and percent of initial level of care determinations where the proper forms were not used that were properly remediated by Division of DD. Number and percent of redeterminations of level of care where the proper forms were not used that were properly remediated by Division of DD

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