Waiver Billing Questions
Agenda for Teleconference November 7, 2008 12-1
Please put your phone on mute unless you are speaking and please give your name and agency when you have a question or comment.
1. Introduction and Background (1/2 Minutes) Devon and Lori
2. Review of Q and A from the State – listed below (30 minutes) Christy
- care coordination
- billing
3. Discussion (25 minutes) all
4. Next Steps (5 minutes) all
Questions to re Billing Under Waiver
1. Can the Care Coordinator also provide nursing/social work services (any other non-waiver service on the CCP) as an interdisciplinary team member or do they have to be a separate person? Concern that this will be very costly to providers and hard to plan. (#11 related)
We will allow the Care Coordinator to perform other services (from the treatment plan) for the patient, regardless of whether they are waiver services or not.
2. Does the Care Coordinator do assessment for entire team and then assign services to the team or will each discipline do assessment like the hospice model?
They need to do an assessment of the whole child. We have not specified a ‘team’ structure for the waiver. Waiver doesn’t require the provider to have a team in place to bill for. The CC will need to work with a wide variety of people (SCC, CCS, family, PCP, community etc.) in order to coordinate all of the child’s services and care.
3. How will in-home nursing be authorized? (non-respite nursing)
Shift nursing in home is authorized by county as EPSDT to enrolled Medi-Cal HHA and independent nurse providers. In home respite nursing is a waiver service and can be provided by an approved waiver provider.
4. Should children be disenrolled from managed care under the waiver?
No reason for disenrollment from managed care plans… all CCS Medi-Cal children residing in counties where the waiver will be operating will be potentially eligible for the waiver. And services will be provided on a fee-for-service basis.
5. Will paneled Primary Care Providers (PCPs) be paid when authorized in this waiver?
They provide state plan not waiver services and will get a CCS authorization for their services.
6. When a nursing agency contracts with a DME provider, they are paid a flat per diem rate. How will we work with DME vendors? Go out of the nursing agency contracted circle and pay fee for services? Work with a different vendor who will accept fee for service?
The waiver provider is not responsible for the provision of DME. these are state plan services and are authorized by CCS and reimbursed by Medi-Cal.
7. Nursing agencies work with certain pharmacies who can provide compounded and unusual dosage drugs to pediatric patients. What can we do to ensure that they get paid? Fee for service?
Unrelated to the waiver
8. Will nursing agencies need to obtain another NPI for the waiver services?
HHA’s do not need to obtain another NPI for waiver services…
9. How will the State’s budget cuts affect the provision of waiver services?
There are no anticipated cuts to waiver services in the budget at this time, beyond the cuts put in place July
10. (See Appendix B-6, page 40 of the numbered letter)
What is this referring to?
11. IDT Meeting – Who gets paid for time? Will there be a separate billing code? (#1 related)
Under the waiver, the Care Coordinator can bill for their time.
12. Does the Medical Director of a pilot agency have to be CCS-paneled in order to authorize changes to a plan of care? If the Medical Director is not a pediatrician, how do they become CCS-paneled?
Unclear what you are asking… waiver care plan vs. Agency treatment plan? If a physician is not paneled, they can fill out an application (found online) http://www.dhcs.ca.gov/formsandpubs/forms/Forms/ChildMedSvcForms/dhcs4514.pdf
13. Can a hospice provide nursing services under the numbered letter?
Intermittent nursing in the home is provided by HHA. Shift nursing in home is provided by HHAs and independent RNs. These are state plan services.
14. Will a hospice have to outsource the nursing services to a licensed home health agency?
Yes, or become a licensed HHA to provide non waiver state plan nursing services. Approved waiver providers including hospice agencies can provide waiver nursing services (see chart at bottom).
15. What about existing services that are not yet coded?
We are in the process of coding waiver services, please clarify your question.
16. Do I have to be within a pilot county to bill under the numbered letter?
No. Non-pilot counties may also bill under the Numbered Letter.
State plan services as defined in the numbered letter are open to children living in all counties. Waiver services are limited to residents of a pilot county.
17. Under the waiver, will a newly-diagnosed child enter the system as a “hospice” patient?
A newly diagnosed child, who is Medi-Cal full scope no SOC and has a CCS eligible condition, will enter the system if the medical condition meets waiver eligibility. They will not need to enroll in the Medi-Cal hospice program to get these services.
18. What clearances do I need to bill for medication or DME?
These are not waiver services; they are authorized by CCS and billed by the pharmacy or DME dealer as state plan benefits.
19. Is a waiver provider responsible for receiving all bills for services and waiting to be reimbursed?
The waiver provider is responsible for billing for waiver services that they provide or for which they contract.
20. How will CCS know about residency requirements? What if a child moves?
Please clarify what information you are looking for.
21. Are chaplaincy services covered under the waiver?
Chaplaincy services are not included in the waiver
22. How are on-call services reimbursed? On a continuous 24-hour basis or strictly when used?
The only on-call services provided through the waiver is included in the responsibilities of the Care Coordinator. See definition of Care Coordinator codes.
23. Can a chaplain provide expressive therapy? (art/music/play, etc.)
A chaplain can only provide billable expressive therapy if he/she possesses the proper credentials (MFT, SW, etc.)
24. The services provided under the waiver stress a continuum of care that extends through bereavement after the child dies; however, the records for a child close at death. How will bereavement services be provided and tracked if the records are closed?
Under the waiver, bereavement services will be available for up a year after death.
25. When will waiver reimbursement rates be established?
We are in the process of developing the reimbursement methodology for waiver services.
26. Our agency knows about the turn-around time that usually accompanies reimbursement; however, we are particularly concerned about excessive reimbursement waiting periods for services, medication, or equipment that is needed immediately. Are there any plans for expediting the payment process?
There is currently no plan in place to expedite the reimbursement process.
27. For services that have a set number of hours or days in a given period (i.e. “30 days of respite per year), will those dates revolve around a plan year, calendar year, or enrollment year?
Those services will be based on a waiver enrollment year.
28. Currently, nursing codes exist that are specific to particular agency types, such as home health agencies. Will the waiver develop a nursing code that is specific for hospices?
See # 14 answer.
29. Who must provide a social work visit in order for the visit to be billable?
Social work visits must be made by an MSW in order to be billed.
30. How is the reporting of the provision of waiver services done?
- a. Form 392 will be filed with the State by waiver providers and agencies. The State will then gather the data for reporting to Federal CMS.
Please clarify what you are asking…
31. Our agency currently has two provider numbers; one for _________ and the other for ________. Will we require a third provider number for waiver services?
You need to be an active Medi-Cal provider with a currently registered NPI for your agency.
32. What are the documentation requirements for billing
Documentation must be retained for future review, but it will not have to accompany claims
33. When is the waiver scheduled to take effect
Pending the result of the federal review in progress, the waiver is expected to take effect January 10, 2009.
34. As a hospice with a hospice license only, are we licensed to bill fees for service?
If you have a Medi-Cal provider number, you may bill waiver services.
35. When is our agency responsible for billing?
An agency must bill for the services for the staff and sub-contractors who are not Medi-Cal providers.
36. Where and how are home/hospice visits recorded?
Unclear as to the meaning of this question, does it relate to something other than the required documentation of medical services that you maintain?
37. How can out-of-home respite providers bill for services?
Out of home respite providers, with an active Medi-Cal provider number, can bill the Medi-Cal program after getting approval from the care coordinator and authorization from the CCSNL.
38. Why were the pilot counties chosen over other counties?
The pilot counties were chosen based on county CCS program interest and availability of potential waiver providers.
39. Will the rates for the various kinds of expressive therapies be varied?
There will be the same rate applicable to each of the expressive therapies.
40. Is there any system of material reimbursement for expressive therapies (i.e. art supplies, CDs, instruments, etc.)
There is currently no system in place for material reimbursement for expressive therapy.
41. Is transportation to/from a child’s tertiary care center covered under the waiver?
Transportation is not covered by the waiver. Medical transportation is a state plan benefit. Refer to the numbered letter (N.L. 01-0104)
42. Will there be a Southern California wage index adjustment for billed hour reimbursement as MediCal does for other programs?
No
43. It appears that the care coordinator’s salary will be paid by the State. Will our hospice bill per visit, or will our hospice be reimbursed for a 40 hour per week salary?
No, the salary will not be reimbursed. The Care Coordinator’s services will be reimbursed from the HHA or Hospice billing Medi-Cal using appropriate waiver codes.
44. There is a minimum of four hours per week for care coordination. Is there a maximum?
We will be providing clarification as the waiver is finalized.
45. How many care coordination hours are included in the startup rate?
We will be providing clarification as the waiver is finalized.
46. What is the difference between a monthly maintenance rate versus a supplemental hourly rate? Are there limits on either of them?
The monthly rate will cover a specified range of hours. The supplemental hourly rate will cover hours that exceed the monthly maintenance. We will be providing clarification as the waiver is finalized.
47. Will there be a cap, per patient or aggregately, on billing by the care coordinator?
There will be a cap on the hourly rate and the number of hours per month per patient.
48. Are additional hours above the number of hours for start-up and monthly maintenance billed as supplemental hourly
Yes
49. What is included within admin?
Case Management Admin is no longer a covered waiver service/code
50. What documentation will be required for billing care coordination hours?
See #32 answer. We will provide specific direction on documentation that must be maintained by each waiver provider.
51. Will the documentation be discipline-specific?
We will provide specific direction on documentation that must be maintained by each waiver provider.
52. Will the waiver employ a fee-for-service billing structure? If so, codes will be needed for care coordination start-up, monthly maintenance, and supplemental.
Yes, we will be providing you with the specific codes and the reimbursement rates.
53. Who specifically does an agency bill for services?
The Department’s Fiscal Intermediary, currently EDS.
54. Will our agency bill at the current hospice rate, a flat Medi-Cal rate per visit, or at the CCS MediCal rate?
The agency will bill the specific waiver codes for waiver services and be reimbursed at the Medi-Cal rate.
55. Will there be a system for billing electronically?
Yes
56. Will new codes be created? Computerized billing systems will need to have these new codes entered into their systems with fee schedules, so there would be a for some lead time.
Yes, we will be providing you with the specific codes and the reimbursement rates.
57. Will physician home visits be reimbursed using the waiver fee schedule or traditional MediCal FFS?
These are state plan services and will be payable through CCS authorization of physician care.
58. Who is specified as an interdisciplinary team, and what disciplines are included in that distinction?
We will be providing clarification as the waiver is finalized.
59. Will our hospice be providing care coordination and contracting out nursing visits, or will our hospice also be providing skilled nursing visits? Or some combination thereof?
The hospice (waiver provider) will be providing care coordination including the coordination of nursing services either intermittent skilled nursing visits or shift nursing in the home.
60. Will patients on the waiver ever elect their hospice benefit, or will they continue as a waiver recipient through the end of life?
It is possible that families would elect hospice as part of the continuum of care.
61. Will there be any type of IDG or team meetings, including CCS, to discuss the points on an ongoing basis?
Yes. We will be providing clarification as the waiver is finalized.
62. How is “respite” defined under the waiver?
Respite care must be identified by the participant, parent/and or legal guardian, Care Coordinator, documented in the CCP, and prior authorized. Respite Care includes appropriate care and supervision to protect the participant’s safety in the absence of family members. Respite care should not be confused with regular shift nursing or intermittent visits which are not limited to 30 days per year, the parent or caregiver are expected to be present for this service, and the care is to provide medical care not relief for the parent.
Respite care is defined as:
• A parent-oriented service where care is provided to the waiver participant for the purpose of providing an interval of rest, relief, or absence for family members from the constantly demanding responsibility of caring for a child with serious complex medical condition;
• Assist the family in maintaining the waiver participant at home;
• care provided in the participant’s home or out of home;
• care which meets the individual participant’s medical needs and ADL’s which would ordinarily be performed by family members or primary caregiver;
• care may require different provider skill levels to meet the individual needs of the participant ( example, RN & CNA; or LVN & CNA with RN supervision);
• care which may be short term, intermittent or regularly scheduled; and
• limited to 30 days per year (Combined home and out of home respite care);
o 96 units per day; 1 unit = 15 minutes; 4 units = 1 hour ( this may not be appropriate at this time)
o 2880 units per year = 30 days.
The following providers may provide respite care in the home:
• Relatives who are qualified RN or LVN
• RN
• LVN
• HHA
o RN
o LVN
o CNA with supervision
• Hospice Agency
The following facility may provide out of home respite:
—Congregate Living Health Facility
63. Will children receiving shift care through hospice be eligible for the palliative care waiver as well?
Shift nursing services are a state plan benefit (for individuals under age 21) and are provided either by independent nurse providers or home health agencies. Shift nursing services are not currently provided under the Medi-Cal hospice benefit. The family must either choose the waiver or the hospice benefit.
64. Are all the services outlined in the plan of care (social work, spiritual care, etc.) billable? And if so, under what category (bereavement, etc.)?
Please clarify your question…
65. Will MSW services be billed under the current CCS codes (if yes, under the HHA service code Z6910 or under the EPSDT service code z5816)?
It depends on the service provided by the MSW and whether the MSW is an HHA employee or an individual practitioner enrolled as an EPSDT Medi-Cal provider.
66. Under what code can chaplaincy services or spiritual counseling be billed? Will it be billed in 15-minute increments, hourly, or per visit?
It will not be payable.
67. The current benefit includes 30 days of respite. Is the benefit equal to 30 dates, or (30 x 24 hours)? For example, if a family receives 8 hours of respite, have they used up one full day, or are the other 16 hours still available?
The 16 hours will still be available. We will be providing clarification as the waiver is finalized.
68. If a waiver provider used a non-waiver provider to do a visit, could the non-waiver provider bill CCS directly, or would it need to go through the waiver provider?
Please clarify your question…
69. Do children need to be on a home ventilator to qualify for the waiver?
Please refer to the description of medical eligibility for the waiver (Appendix B-1:b).
70. If a child is receiving intermittent BiPAP, will that be sufficient to qualify for the waiver?
Please refer to the description of medical eligibility for the waiver (Appendix B-1:b).
71. Our hospice is not a special care center. Do we need any specific designation by CCS to bill under the waiver?
No specific designation but the hospice must be an enrolled Medi-Cal provider.
72. Can our hospice contract to provide in-home respite only?
Please clarify your question…
73. Will the State increase the reimbursement rates to meet the UC rates of the facility?
No
74. Will the State be willing to modify the respite criteria from CHLF to Skilled Nursing Criteria and pay at the pre-established Medi-Cal rate of $29.41 per hour?
Skilled Nursing Facilities, that are enrolled as Medi-Cal providers, could be authorized to provide respite if the child meets SNF level of care. These are state plan services not waiver services and are paid at the current Medi-Cal rate for the facility.
75. Do I need to be a CCS paneled physician to bill for Physician services that I provide to waiver patients?
yes, here is the link to the application.
http://www.dhcs.ca.gov/formsandpubs/forms/Forms/ChildMedSvcForms/dhcs4514.pdf
76. San Diego Hospice is not a special care center. Does San Diego Hospice need any specific designation by CCS to bill under the waiver?
There is no need for a specific designation by CCS. The hospice needs an active Medi-Cal provider number to bill for services under the waiver.
77. Can the existing state plan billing codes for home health be utilized by hospice? If not, can they be amended to apply to hospice? If not, will new billing codes for hospice providers be developed when the new codes are created for the additional waiver services? How long does this process take?
No, they will not be amended to apply to hospices. The waiver codes can be reimbursed to a hospice agency. We will be providing clarification as the waiver is finalized.
Questions from Alameda County
- 78. Shift nursing through In Home Operations Medi-Cal Waiver- how will these be authorized by CCS?
Shift nursing is available as needed for CCS children as a state benefit, it is NOT a waiver service Please refer to Numbered Letter 05-0207 “Short-Term Nursing Services” for authorization of this non- waiver (State Plan benefits) service. In addition, CCS & In-Home Operations (IHO) have a “Work Around” process in place when a CCS child is enrolled in a Medi-Cal Managed Care Plan that is carved-out; IHO receives the request from the HHA or INP for the nursing services, and IHO makes the determination, communicates with CCS and CCS authorizes on behalf of IHO.
- 79. Child Life Services- Will these be available only to the patient or also siblings? In home or only in a facility?
CCLS can provide expressive therapies in the home. Do they need to be individual MediCal providers or can the agency bill for these services under expressive arts? Expressive therapies can be provided as a waiver service if the need is documented in the CCP. The therapists will be contracted by the hospice/HHA where the care coordinator is. The objective of the waiver will be to minimize the use of institutions, especially hospitals, and improve the quality of life for the participant and Family Unit (siblings, parent/legal guardian, and significan others).
- 80. Bereavement Services- We know the 12 month anniversary is very hard. Will it be authorized beyond that? Not for the demonstration pilot to start.
- 81. Expressive Therapies- Available in the home?
YES, this is a home and community based waiver – offering the services in the home are what is hoped with keep kids out of the hospital or institution (provided by HHA/hospice with providers credentialed by them and meeting the criteria described in the waiver.
- 82. Psychological or Psychosocial Services- To patient and to the family?
Yes
The waiver provides for care coordination, respite care, family training, expressive therapies and bereavement services. Mental health services per se are not a part of the waiver except as they fit into the above services. In addition to “Waiver Services” comprehensive care coordination include State plan services, EPSDT and community services. The “comprehensive care plan is the integration of waiver, State plan and community resources.
- 83. Spiritual Care (chaplain) Services- Very important piece of the care. Will they be authorized?
No, chaplains are not under the waiver. However if they happen to be an MFT/LCSW for example then they could be under that licensure. Two goals for Care Coordination in the home setting are the following: Patient-focused, family centered, holistic health care that incorporated the physical, emotion, social and SPRITAL needs of the child and family to enhance their capacity to cope with a life threatening condition and Preserve the integrity of the family during the condition progression, addressing anticipatory grief and bereavement support following the death.
- 84. Respite Care- How will this be authorized? Is there a way to authorize George Mark Children’s House?
Respite is a waiver services and GMCH as a congregate living facility is available for respite
- 85. For Per Diem Services billed as a lump sum to the home health agency, how will CCS authorize these?
All billing must be fee for service
- 86. When will we have codes and definitions to identify these services and other PPC or Hospice services?
This is currently being developed and will be disseminated as soon as it is ready;
- 87. The pilot will be for full-scope Medi-Cal recipients. Will this include those with managed care plans?
Yes
There were many questions and no answers at the last State phone conference held in Capitola on Aug 11th. Would you please direct me to the documents that answer any of the above? For other questions, it would be beneficial to have some guidelines by the time the PPC Pilot starts, although I realize there will still be questions and concerns that will come up during the pilot. I appreciate any information regarding this. Thank you,
The coalition and state are working on information ‘fact’ sheets or FAQ’s to help answer questions and explain info about the waiver. With the BEST program there will also be REPs, a set of professionals within the State, who will be experts on the waiver and available to answer questions and help educate
A document with responses to the questions from 8//11 will be sent to Children’s Hospice and stakeholders within a week.