CALIFORNIA DEPARTMENT OF AGING DEPARTMENT OF HEALTH CARE SERVICES MSSP S ITE A SSOCIATION (MSA) MULTIPURPOSE SENIOR SERVICES PROGRAM (MSSP) MODULE FOUR A DMINISTRATION & O VERSIGHT 1 November 14, 2013

W EBINAR “H OUSEKEEPING ” “ Raise your hand” button—please hit if you can hear us If calling in (instead of listening through your computer speakers, be advised that there may be charges) If we get disconnected, please follow the link you received after registering to sign back in Type your questions in the question or chat box (typically on the upper right- hand side of your screen) Keep questions brief and clear – it will be helpful if you indicate the subject of your questions first. For example: “Feedback – Where do I send suggestion's for waiver amendments?” Many questions will be answered at the end of the presentation as time permits Questions not answered today will be answered and posted on CDA’s website in the following weeks. 2

O BJECTIVES Overview of Wait List Policy Grievance Process Reporting Requirements Financial Integrity and Accountability Budget Basics Payment Processes Management Information System & Encounter Data National Provider Identifier (NPI) 3

MSSP W AIT L IST Home and Community Based Waivers 1915 (c) require a statewide wait list policy to ensure fair and equitable access. Enrollment in the MSSP Waiver is limited to the maximum number of slots for each MSSP Site. MSSP Sites receive a fixed annual budget amount that limits the number of individuals served at any given time. Once a MSSP Site reaches capacity they maintain a list of individuals eligible for enrollment. 4

MSSP W AIT L IST P OLICY 5 Enrollment into the MSSP Waiver is based on the “imminent need” for services determined through a standardized process to ensure fair and equitable access to the MSSP. Procedure for placement on Wait List includes; Assign priority for enrollment into the MSSP Waiver based on risk level. Risk Level is determined based on deficits in functioning and need for assistance. Enroll the MSSP applicant. Enrollment is based on the Care Manager’s clinical judgment of the applicant’s level of risk for poor outcomes.

MSSP G RIEVANCE P ROCESS MSSP has two Grievance Procedures: Site Level State Medi-Cal hearing process Site Level – Provides the Waiver Participants with a structure to submit and track and resolve objections/complaints about MSSP services. State Medi-Cal Hearing Process – Waiver Participant submits request for a State Fair Hearing when they disagree with decision made by the Site. These decisions can include non-enrollment, reduction in services, denial of services or termination. 6

MSSP R EPORTING R EQUIREMENTS MSSP Sites submit the following reports for Waiver oversight. Monthly Client Count Annual Closeout Report Quarterly Status Reports 7

F INANCIAL I NTEGRITY AND A CCOUNTABILITY CDA ensures the integrity of payments made for waiver services. MSSP Providers must have an annual independent audit. CDA Audit Branch performs financial audits to ensure the integrity of the MSSP provider billings for Medicaid payment of waiver services. MSSP pays only for services that are authorized, approved and delivered. CDA must assure that the annual costs for individuals participating in the MSSP Waiver are less than the costs of those residing in a nursing facility. 8

A NNUAL MSSP S ITE B UDGETS The site budget is a fixed total amount based on the number of funded Waiver Participant slots multiplied by the annual allotment of $4,285. Example: 480 slots x $4,285 = $2,056,800 (annual budget allocation) MSSP Budget Categories 9 Care Management Care Management Support Waiver Services MSSP Site Budget

MSSP F EE - FOR -S ERVICE P AYMENT P ROCESS MSSP sites receive reimbursement payments from Medi-Cal for Waiver Services provided. Sites cannot receive reimbursements in excess of the Site’s annual allocation. Each MSSP budget amount is capped annually and is based on the number of funded Waiver Participant slots. The Sites submit claims for Care Management, Care Management Support and Purchased Waiver Services. MSSP sites submit claims using site specific billing software. Sites receive payments and Remittance Advice Details (RAD) from the California Medicaid Management Information System (CAMMIS). 10

MSSP/CCI P AYMENT P ROCESS FROM H EALTH P LANS MSSP sites will submit a monthly claim to the Health Plan by the fifth day of each month. (COHS) counties have a separate payment process. The monthly claim submitted to the Health Plan will include: Waiver Participant Name Client Identification Number (CIN) MSSP Provider number Month of Service Health Plan will pay the MSSP Site a fixed amount equal to one- twelfth of the annual amount budgeted per MSSP Waiver Participant slot ($357 = Per Member, Per Month). Health Plan shall pay the MSSP Site no later than 30 days after receipt of the claim. 11

MSSP D ATA S UBMISSION P ROCESS The MSSP Sites submit Waiver Participant and Service data to CDA. Fee for Service claims submitted to CAMMIS by the MSSP Sites are used for the annual CMS 372 cost-neutrality report. 12

MSSP E NCOUNTER D ATA S UBMISSION TO H EALTH P LANS MSSP sites will submit zero-cost electronic encounter data for Waiver Services provided to Plan Members. MSSP Provider shall submit encounter data (zero-based claims) for each Plan Member to the Health Plan within three months from the end of the month that service was provided. Zero-based claims will also be submitted to CAMMIS for tracking and reporting purposes. This data will be used in demonstrating cost neutrality to CMS. 13

N ATIONAL P ROVIDER I DENTIFIER (NPI) N UMBER NPI numbers are required to bill for health services under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). All MSSP sites will obtain an NPI number by MSSP sites operating in a CCI county will use NPI numbers when submitting their monthly claims to the Plans. Eventually all MSSP sites will use NPI numbers instead of the current legacy numbers when billing fee-for-service claims through CAMMIS. MSSP sites are not to submit NPI numbers to DHCS until instructed to do so by CDA (pending billing system changes). 14

Q UESTIONS Contact Person: Mary Sibbett, Operations Manager California Department of Aging, MSSP Branch Thank you for your participation 15