Negotiating a MemberCenter Plan:

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Long-Term Care Summer Camp August 25, 2009

• Negotiating a Member-Center Plan
• How the Process Should Work What To Do When It
  Doesnt

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The Benefit Package

• The Partnership and Family Care contracts list
  the services available to members
• But, members may request, and MCOs may provide,
  any service, not just those listed as part of the
  benefit package

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The Benefit Package

• Services Necessary to Achieve Outcomes
• Identified in Member-Centered Plan
• Outcomes-Based
• Two Categories
• Medically Necessary
• Necessary LTC Services Supports

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What Are Outcomes?

• New name, same principle
• 1970s-1980s Normalization
• ?
• 1980s-present
• Person-Centered Planning
• Futures Planning Path Planning
• ?
• Personal Experience Outcomes

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12 Outcome Areas

• 1. I decide where and with whom I live
• 2. I decide how I spend my day
• 3. I make my own decisions regarding my supports
  and services
• 4. I have relationships with family and friends I
  care about
• 5. I do things that are important to me

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12 Outcome Areas

• 6. I am involved in my community
• 7. My life is stable
• 8. I am respected and treated fairly
• 9. I have time, space and privacy
• 10. I have the best possible health
• 11. I feel safe
• 12. I am free from abuse and neglect

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Examples

• NOT I want a new back exit door and it can be
  built for 10,000.
• ?-- I want to be able to leave my house safely
  and
• NOT I want a new roommate.
• ?-- I want to live with people Im close to and
  share my interests and..

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Outcomes Are Personal

• Each members outcomes are unique
• A members services will depend on his or her
  outcomes
• Different outcomes Different services

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MCOs Comprehensive Assessment

• Looks at members
• Needs
• Strengths
• Resources
• Preferences
• In person
• Include others chosen by member
• Discuss option to self-direct services
• Begins the development of the Member-Centered
  Plan

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The Member-Centered Plan

• Members Outcomes
• Comprehensive Assessment
• Resource Allocation Decision (RAD) Method
• The Member-Centered Plan

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Family Care Funding DecisionsThe RAD Method

• Cost-effective way to meet outcomes
• Creatively looks at options, including
  informal/natural supports
• Includes gifts and strengths of person, family,
  community
• DOES NOT EQUAL cheapest

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The RAD Method

• Used to determine services needed to meet
  outcomes
• Completed by the Interdisciplinary Team,
  including
• Member
• Others the member invites to be part of the IDT
• Social Worker
• Nurse
• (In Partnership, IDT includes Nurse Practitioner)
• Focuses on creative options for meeting a
  particular outcome

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The RAD Method

• Six Questions
• What is the need, goal, or problem?
• Does it relate to members assessment, service
  plan, and desired outcome?
• How could the need be met?

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The RAD Method

• 4. Are there policy guidelines to guide the
  choice of option?
• 5. Which option does the member (and/or family)
  prefer?
• 6. Which option is most effective and
  cost-effective in meeting desired outcome(s)?

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The Individual Service Plan

• Incorporated into Member-Centered Plan
• Lists approved services and supports
• Amount
• Frequency
• Duration
• Provider
• Both paid or unpaid/natural supports
• Both if provided or arranged by MCO or not

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Self-Advocacy

• Consider personal outcomes before meeting with
  interdisciplinary team
• Assert personal choices MCP should document any
  differences of opinion
• Request that friends/family members be present
  during discussions with team about outcomes and
  services

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Service Authorizations

• The MCO shall not deny services necessary to
  reasonably and effectively achieve long-term care
  outcomes identified in the comprehensive
  assessment as well as those necessary to assist
  the member to be as self-reliant and autonomous
  as possible. 2009 Family Care Contract, page 37.

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Service Authorizations

• The IDT is authorized by its MCO to provide or
  arrange for most services
• RAD Method
• Consultation with appropriate health care
  professionals
• Written notice to member of decisions
• Decisions and written notice on direct requests
  for services may not exceed 14 days

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Service Authorizations

• Some authorizations may require the IDT to refer
  to someone else
• Department-approved policies on the criteria for
  these decisions
• Members may request copies of these policies
• RAD Method must still be used as part of the
  decision-making process

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Transition to FC What might change?

• Case manager
• Plan of services if outcomes and/or needs
  change
• Providers or may stay the same
• Depends on MCO networks
• May request a provider out of network or choose
  to self-direct a particular service

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Flexibility

• Members can always request a change in
• Program/MCO/Team/Provider
• Type of service
• Amount of service
• Staff
• Living situation
• Employment situation

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Transition

• Participants should receive comprehensive
  services
• Notice of any changes in services
• Options counseling!
• Family Care (with SDS?)
• Family Care Partnership (with SDS?)
• IRIS
• PACE (Milwaukee/Waukesha)

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• Member Rights,
• Grievances and
• Appeals
• What To Do When Things Dont Work

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Grievances Appeals

• Right to receive written notice of MCO decisions
  about services (i.e., a Notice of Action)
• Must receive Notice of Action at least 10 days
  before the effective date of the action

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Grievances Appeals

• Notice of Action Requirements 1 of 2
• Effective date
• Description
• Reasons
• Any laws
• Right to appeal
• How to file an appeal

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Grievances Appeals

• Notice of Action Requirements 2 of 2
• Right to appear in person at MCO appeal
• Assist with filing an appeal
• Free copies of records relevant to appeal
• Right to continuing benefits if MCO intends to
  terminate or reduce services

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Grievances Appeals

• Right to continuing benefits
• Must request before effective date of the
  intended action
• MCO must grant all timely requests
• Member may be liable for cost of continuing
  benefits

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Informal Negotiation

• State has employees assigned to each MCO
• Member Care Quality Specialists
• Contract Coordinators
• Each MCO has employees assigned to work with
  state on specific issues
• Self-Directed Supports Coordinators
• Employment Coordinators

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Informal Negotiation

• Family Care and Partnership Ombudsman
• Disability Rights Wisconsin
• For members 18-59
• Board on Aging and Long-Term Care
• For members 60 and older
• IRIS Ombudsman
• Disability Rights Wisconsin
• For members 18-59
• DRW will work with members 60 and older

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Grievances Appeals

• Appealing MCO Decisions
• If a member disagrees with a MCOs decision,
  member has the right to appeal the decision
• Two Appeal Options
• MCO Grievance Appeals Committee
• State Fair Hearing

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Grievances Appeals

• Do not have to meet with Committee to request a
  State Fair Hearing
• But, if consumer wants to meet with Committee, he
  or she must do so before State Fair Hearing

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Grievances Appeals

• MCO Grievance Appeals Committee
• Committee made up of MCO employees and at least
  one person who is eligible for the Family Care
  benefit
• May bring advocate, friend/family member,
  witnesses, and evidence

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Grievances Appeals

• MCO Member Rights Specialist can assist with
  obtaining records and filing appeals
• Will not represent consumer
• Will not gather evidence to support his/her case

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Grievances Appeals

• State Fair Hearing
• May file an appeal with the State (the Division
  of Hearings and Appeals)
• Held in front of an Administrative Law Judge
  (ALJ)
• May bring advocate, friend/family member,
  witnesses, and evidence

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Grievances Appeals

• Deadline to file appeals
• File as soon as possible
• File no later than 45 calendar days from receipt
  of the Notice of Action
• To request continuing benefits, must file appeal
  before effective date of intended action

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Grievances Appeals

• Right to request Department of Health Services
  review
• MetaStar, DHSs external quality review
  organization
• Attempts to resolve concerns informally
• Cannot require MCO to change decision
• Automatically reviews requests for State Fair
  Hearings
• MetaStar can ask State to change MCOs decision

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DRWs Ombudsman Program

• Our Process
• Members/Potential Members Age 18-59
• Types of Assistance
• Information
• Investigation and informal negotiation with
  ARC/DRC/MCOs/CMUs
• Representation

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• Questions?
• Sarah Schwenker
• Email sarahs_at_drwi.org
• Phone [phone] Ext 19