IDD Directors’ Consortium CFC Summit MCO Functional Assessment Panel

MCO General Process Receipt of status and intake of documents from the SFTP site Review of documentation by the service coordinator Contact to LIDDA within 7 days Joint meeting with the member Following provider selection by the member: Negotiation of service start date Transmission of authorization with copy of H6516 Verification that services are in place Ongoing service coordination

Exceptions Processes Member is under 21 or in STAR Health ID/RC completed by the LIDDA Functional assessment completed by the MCO ID/RC reassessment completed by the LIDDA Member has been upgraded to STAR+PLUS Waiver CFC eligibility will be based on the member’s MN/LOC (which is required for SPW), rather than an ID/RC No ID/RC is needed from the LIDDA MCO performs the functional assessment

Exceptions Processes (cont’d) All reassessment activities performed by the MCO Member changes MCOs Upload of documentation to SFTP site LIDDA/MCO collaboration Continuity of care Member requests an increase in services Referral via SFTP site Functional assessment by the LIDDA Review and authorization by the MCO

Recent Updates to LIDDA/MCO Functions LIDDA and MCO staff highlight updates to the shared spreadsheet when changes are made LIDDA staff schedule the joint meeting with the member at the time the assessment is conducted (3 weeks out from the assessment date) LIDDA staff obtain the member’s preference for receipt of a provider list from the MCO Changes to the H6516 after the joint meeting (if any) are made by the LIDDA and uploaded to the SFTP site within 3 business days

Recent Updates to LIDDA/MCO Functions (cont’d) MCOs have two established contact points: Leadership – contracting and MOU questions, triage or escalation of questions or concerns Operational – referral questions, verification of member contact information, confirmation of send/receipt through the SFTP site Reference material for this information is available on the DADS website via this link: https://www.dads.state.tx.us/providers/CFC/lidda-responsibilities.html

Member Appeals Members have the opportunity to appeal: When a service is denied When a service is reduced When they disagree with the initial hours for a service When a service is denied or reduced, members exercise their appeal rights by following the instructions on the denial letter they receive from the MCO When there is disagreement with initial hours, members exercise their appeal rights by declining to sign the H6516, which will trigger the MCO to initiate the denial/appeal process

Process Elements Pending/Under Development Reassessment submission packet contents Habilitation documentation for providers Community First Choice Fair Hearing Processes (effective 05/02/16) Pertains to notification processes for LOC denials Revisions to Appendix XVI, Long Term Services and Supports Codes and Modifiers (effective 06/01/16) Pertains to S+P members under age 21

Troubleshooting The MCO service coordinator should be involved if: The provider or LIDDA are having difficulty contacting the member There has been a disruption of the member’s services The member indicates he or she is unhappy with their services, or would like an increase The member has questions regarding their benefits or other services they might access The member has a need not met by CFC

Troubleshooting (cont’d) The MCO Leadership Contact should be involved if: The MCO service coordinator has been unable to assist with a need or concern Urgent or escalated needs arise There are global questions regarding the MCO’s processes for CFC There are questions regarding other MCO functions – provider support, contracting, claims, etc.

Questions/Discussion What questions did we not answer today? What if any are the current pain points around CFC processes? What can we work together to do even better where CFC is concerned?