Administrative Memorandum (ADM) #2014-01

Supervised IRA Unit of Service Questions and Answers

Service Requirements

1. Is this change for both voluntary and state operated IRA´s?

A: This change applies to BOTH Voluntary and State Operated IRA´s.

2. How does the change for supervised IRA Res Hab on 7/1/14 relate to individuals in Family Care?

A: This has no impact on Family Care; the unit of service change applies only to services provided in a Supervised IRA.

3. Once we go to a daily rate, will new liability letters need to be sent since the rate will change?

A: No. Since only the frequency of the service changed, and not the service itself, the Medicaid liability remains the same.

4. Will the requirement for enrollment in the service for 22 days to be eligible for billing be eliminated?

A: Yes. A person needs only to be enrolled in the IRA for one day, and a service be provided in accordance with the person´s plan in order for the RH provider to bill for that day.

ISP Changes

5. Should the MSC´s do an addendum to the ISP to indicate the frequency of the IRA-RH service to be daily (in the waiver section of the ISP) in July of 2014 or could they change the frequency as the ISP´s come up for reviews?

A: ISP/Hab Plans must be updated by 8/31/2014. This is noted on the last page of the ADM.

6. Will CHOICES be updated to reflect the change in frequency for Supervised IRA Res Hab?

A: Yes, we anticipate CHOICES to be updated 7/1/2014 to reflect the change in frequency.

7. Can an update to the ISP be done prior to July 1st ?

A: If you make the change prior to July 1st, you must indicate that it is effective July 1st. Something along the lines of: frequency: "month" through 6/30/14, "day" beginning 7/1/14. Otherwise it could have an impact on the provider´s billing and claims.

8. Is crossing out, "monthly" and hand writing "daily" in the current ISP good enough, or do we have to do an addendum for each person?

A: If you are working with a paper format, you may handwrite the change in frequency indicating that the new frequency takes effective 7/1/2014; then initial or sign and date the change.

9. Regarding the therapeutic leave, we are obtaining ISP addendums to add this to the ISP. Should this be added as a "valued outcome" or under another area of the ISP? And, is there any recommendation phrasing of this statement?

A: An agency should be obtaining an ISP addendum to modify the unit of service from Month to Day. A valued outcome can be added to the ISP, if appropriate, however, it is not required. The Therapeutic Leave Day description is required in the habilitation plan, not the ISP.

10. Under therapeutic leave day, the RH plan might describe leave days as follows: "the individual will typically use therapeutic leave days during holidays to spend time with family". Should the ISP also have something to this effect under Valued Outcomes?

A: There is no requirement that the ISP reflect information regarding Therapeutic Leave.

11. Once it is identified in the ISP, is therapeutic leave also noted on the Residential Habilitation Plan? If so, is it noted as a Service Activity?

A: The Therapeutic Leave is required to be identified in the habilitation plan. It is not required in the ISP. Therapeutic Leave is not a service activity, instead, the documentation should include a way to record whether the day should be billed as a service day, a Therapeutic Leave day, or a Retainer Day. A sample documentation format is posted with the ADM on the OPWDD website.

12. Does the date of service change to 7/1/14 for all existing participants or stay at the current date?

A: The effective date stays the same (i.e., the original service authorization date).

13. When does the ISP have to be updated to show the new Frequency?

A: The ISP must be updated by 8/31/2014.

14. Do we have to complete an Addendum so all of the ISP´s reflect the change in frequency, or can we note in the general comment section on the ISP in CHOICES (or another electronic record system) that the frequency changed from month to daily effective 7/1/14 for Residential Habilitation and then change the ISP at their next meeting?

A: Unlike a paper document, where changes can be made and initialed/dated, changes made to an ISP in an electronic system require an addendum to the ISP.

15. If we need to complete an addendum reflecting the new frequency, does it need to be distributed to all of the parties?

A: As per the ISP instructions found in ADM # 2010-04, the following rules apply to an addendum:
"Addendums require only the signature of the service coordinator. A note must be written in the MSC record indicating the change was discussed with and agreed upon by the individual and/or advocate. Addendums are filed with the current ISP and distributed to all appropriate parties."

Habilitation Plan Changes

16. What should an agency do if an individual is incapacitated due to illness, but not hospitalized. In this instance, the person would then not participate in actions related to their Res Hab plans, and I am unsure that we would be able to document anything that would allow for us to bill. It seems it would be classified as a "service day", however, no services were provided. Would we classify this as Therapeutic Leave? A day of vacancy?

A: Please see the information provided in ADM #2012-01 which describes the requirements for Habilitation Plans. Pages 4 and 5 describe allowable staff actions; this information should be helpful in determining appropriate habilitative services. If your agency, determines that the day cannot be billed as a service day, the day should not be billed as therapeutic leave.

17. How should the Res Hab plan identify Therapeutic Leave?

A: The Residential Habilitation plan should identify any anticipated times that a person would be outside of the residence. Words like occasionally, sometimes, frequently, and usually are helpful in allowing for the flexibility an agency needs to support the billing without creating undue billing vulnerabilities.

18. Is it recommended that an agency use a "standard" statement for notation regarding Therapeutic Leave Days, then a second statement which is specific to the person?

A: A person´s plan should be specific to him/her. Therefore, the information in the plan regarding a Therapeutic Leave Day should be specific to his/her life.

19. If a person currently has no family or friends who they spend overnight visits, or has not gone on a vacation, should we include a statement which states this fact, but recognizes if in the future there is an opportunity, he/she may enjoy Therapeutic Leave?

A: See A #18 above. An agency should update the habilitation plan to reflect specific activities that a person will enjoy, once they are arranged. A hab plan can be reviewed and updated as needed, and does not need to be kept on a six month review schedule if a part of a person´s life has changed, in this case for example, s/he is invited to visit new friends for a few days.

20, Therapeutic Leave Day - the ADM (page 4) states "The Residential Habilitation Plan should generally describe the purpose of therapeutic leave that the person uses and the general frequency of the leave". Is this going to be noted on the Hab Plan template? I don´t see any reference for documenting therapeutic leave on the current Hab Plan template. I think this may get lost unless we have something prompting staff to include.

A: Each agency should develop a method to include language regarding the general purpose of therapeutic leave and the anticipated days that a person will be outside of the IRA on the habilitation plan to ensure it is included.

Billing Documentation

21. Will there be a change in the billing documentation template? If so, how soon will it be available to the providers?

A: The template is only a suggested format, and agencies can develop their own documentation which is required to include the elements outlined in the ADM. A sample documentation format is posted with the ADM on the OPWDD website.

22. When we document therapeutic leave on the billing document, should it be identified as a service or should it be noted as an absence from the IRA - with a code to represent that it is a therapeutic leave day?

A: It is recommended that there be a code on the service document, if a checklist is used. In this way, the day can be coded for billing as a Service day, Therapeutic Leave Day, or Retainer day. A sample documentation format is posted with the ADM on the OPWDD website.

23. Is there a requirement to document the use of therapeutic or retainer days in the monthly note?

A: If the person is out of the residence during the month, the agency should note this information in the monthly note, as this likely impacts service provision such as when the individual received service at a location other than the IRA (offsite) or absence was due to presence in another Medicaid funded facility, or for a visit with family/friends or a vacation.

24. On Page 4, first paragraph, it states that a service day is allowable when the person is on vacation or with family if services are delivered by "staff regularly assigned to the resident´s IRA". The people we support often go on vacation with DSP´s who do not regularly work with them. Does that mean we cannot bill on those days?

A: Since the staff is not the regularly assigned staff, it would be more appropriate to bill these days as Therapeutic Leave Days, with appropriate documentation.

25. If an individual served attends an overnight summer camp, would it be appropriate to bill this time as therapeutic leave? Agency staff do not accompany the campers.

A: As long as the camp is not being funded by Medicaid or the individual is not attending camp by using Medicaid funding, then the camp could be billed as Therapeutic Leave, provided it is appropriately documented in the person´s plan and billing documentation.

26. If a medical leave or therapeutic leave occurs, should the "description of services provided" be left blank?

A: Yes. If there is no service provided, then there should not be a description of services.

Rate Development and Payment

27. I understand that the day of hospital admission cannot be counted toward the person´s presence in the IRA, and therefore, this day would typically not be billable. However, could this day of hospital admission be counted as a retainer day, provided the person has not already used his/her 14 days? Or is this day not billable under any circumstances at all?

A: The day of hospital admission is not billable as a service day, but may be billed as a retainer day.

28. In a scenario where a person receiving services is at the IRA during the day and staff provide and document services at that time, then the person goes with family in the evening and stays over night with family, would this be billed as a therapeutic day (based on where the person slept), or would it be billed as a "regular" billable day since the person was present at the IRA at the time of service delivery?

A: Since the person is sleeping at the family´s home, the agency should bill for a Therapeutic Leave day, regardless of what services were provided at the IRA residence.

29. If an individual went on a home visit with his/her family on a Monday at 4pm and returned on Tuesday at 4pm which day is considered the therapeutic leave day. If we go by a 24 hour day I would think that it would be 12a-11:59p which would mean the leave would be for Tuesday. I am aware that if an individual gets admitted to a hospital on Monday and discharged on Tuesday the Retainer day is Monday as long as IRA services were provided on Tuesday following discharge. Would like some clarification on this.

A: Your analogy to Retainer days is correct. If the person were to leave the IRA on Monday, then the Therapeutic Leave Day would be Monday. Basically, wherever the person sleeps dictates which billing day to use - the 24 hour day is better considered from bedtime to bedtime, rather than from midnight to midnight.

30. Do the 14 retainer days follow the year from July 1st - June 30th, or are they pro-rated to the end of the year to then go by the calendar year (Jan-Dec), or is there another way?

A: The annual period for retainer days will be July 1 through June 30.

31. To help facilitate our budgeting process, what is the expected year one rate for our agency?

A: DOH will issue draft rates to providers in mid-June 2014.

32. On page three of the memorandum it states that the day of admission to a hospital, or other specified certified location may not be billed by a provider. However, on page five it states that a provider can bill for absences from the residence for the purposes of receiving services from a hospital... Can you clarify this? It sounds contradictory? When would it be o.k. for the provider to bill the retainer day? Page three, same paragraph uses language such as certified, licensed or government. On page five, this terminology is not used. Is there a reason for this?

A: When an individual receives services from Residential Habilitation staff and then is admitted to a hospital, the provider may not count this as a "service day." For a day when the individual is admitted to the hospital, this would be counted as a "retainer day." For a "service day" all service documentation requirements must be met, and for a "retainer day" the location of the other Medicaid funded facility the individual was in should be included in the service documentation.

33. How many therapeutic leave days are allowed?

A: Therapeutic Leave Days are not limited, provided they are appropriately documented.

34. On page five it states that the frequency for the plan is "day"? What about the frequency of the actual service provided. Some services are provided twice a week or once a month? Not sure where this goes.

A: The frequency of the residential habilitation service is day. The frequency at which direct services/staff actions are delivered do not need to be identified in the ISP. If agencies want to include a schedule of staff actions or direct services, it may be on the habilitation plan and identified as an "anticipated" or "expected" calendar or schedule.