August 13, 2013
Extension of Implementation Deadline for In-Home Day Services
The department is aware of a continued degree of confusion relating to the new In-Home Day Service implementation. Within the department and our State Medicaid Agency partners at TennCare, a decision has been made to extend the deadline applicable to the provision of In-Home Day Services for persons wishing to remain in the home for Day Services.
This extension will be granted until September 1, 2013. As indicated previously, approval for this service will be contingent on the submission of a service plan and required supporting documentation as previously outlined and discussed with the provider community. It should be noted that all service requests in process for approval of this service should remain in process, as the effective date of their service approval may fall before the September 1 deadline. Additionally, effective September 1, provision of Community Based Day Services will not be reimbursable if provided within the home. To state as clearly as possible, the provision of Day Services in the home will only be reimbursed by virtue of approval of In-Home Day Service represented on the cost plan of the person supported. To address concerns, we have included a list of questions and answers below.
Questions & Answers
1. Do providers need signed service plans for persons in order to bill for In-Home Day immediately?
Yes. The only exception to this would be in the case of emergency approval. In these instances, agencies will follow the same emergency approval process as with any other service. After business hours, the regional AOD may be contacted and an agency is able to receive an Emergency Authorization CODE. This code will authorize the service until the following business day, at which time a service plan should be submitted requesting the service based on the crisis and inclusive of the required supporting documentation.
2. Can agencies continue to bill for CB services delivered in the home (if authorized in the ISP) until a signed service plan is received for the new service?
Effective September 1, 2013. Community Based Day Service must be provided in accordance with the currently approved service definition.
3. Do ISPs need to be revised if the wording in the current ISP has been sufficient to authorize payment for CB when delivered in the home?
No. An ISP amendment will only be required if In-Home Day Services are requested. In all other instances revisions to the ISP must occur during the annual ISP cycle. Community Based Day Services cannot be provided in the home.
4. Will signed service plans authorizing In-Home Day Services be automatically generated for all persons currently receiving CB services?
No. Service approval for In-Home Day service must meet the criteria outlined in the currently approved HCBS Waiver documents. In-Home Day Services will be authorized for medical crisis or in some cases, chronic medical conditions, behavioral crisis and retirement.
a. Requests for In-Home Day Services on the basis of medical criteria must be accompanied by a Physician's order that is specific to the individual requesting the service, specific to the crisis or long term condition that could prohibit the person supported from accessing integrated community activities and must also describe, if applicable, the symptoms that would prevent community integrated Day Services.
b. Requests for In-Home Day Services based on Behavioral/Psychiatric criteria must be accompanied by a Physician's order from the treating Psychiatrist indicating the crisis and justification for the need for provision of services in the home. The documentation provided should also include the symptomatic criteria that would warrant this less integrated setting. Also acceptable for supporting documentation meeting Behavioral/Psychiatric criteria would be documentation from the treating Behavior Analyst indicating information synonymous with the aforementioned justification from the treating Psychiatrist. Additionally, a plan for re-assimilation into a fully integrated Community Day Service setting must be indicated in the Behavior Support Plan and provided for review with submission of the service request.
c. Requests for In-Home Day Services based on the choice of a Retirement lifestyle must be supported by indication within the ISP that the person supported and their COS have discussed this option and support the request. While it would not be prudent to specifically adhere to retirement parameters applicable to federal Social Security guidelines with an understanding that some persons supported may require this lifestyle at an earlier age, general adherence will be applied and requests will be reviewed on a case-by-case basis.
5. What should be in the doctor’s order for In-Home Day Services for medical reasons?
A physician's order supporting a medical basis for In-Home Day Service must detail the condition and symptoms that would require services to be provided in the home as opposed to a more integrated setting. An example may look like, "Due to the sometimes painful symptoms associated with John's diagnosis of chronic arthritis, on days where he is experiencing pain or discomfort, it is recommended that he be supported in limited activity.”
6. Can a person receive both CB and In-Home Day Services?
Yes. In fact, there will be very few cases in which the department approves In-Home Day Services as the only available Day Service. This would indicate an unjust confinement of a person supported to their home. However, it is important to note that only one Day Service can be billed per day.
7. Do persons in retirement status need to be approved for In-Home Day services?
8. What needs to be in the BSP in order for a person to be authorized for In-Home Day services due to behavior?
The Expectation is that approval for In-Home Day Services for Behavioral or Psychiatric destabilization is crisis based. The BSP should indicate the crisis and components of a re-assimilation plan that allows for community integration at the most expeditious opportunity that is clinically prudent.
9. Does the new In-Home Day Service apply to the Family Model Program?
10. Can plans that add In-Home Day Services be approved retroactively to August 1, 2013? Or will it be back to the log on date by RO?
No. In-Home Day Services will be approved in accordance with all other service request submissions and retroactive approvals are not permitted.
I hope this information has been helpful and that it thoroughly addresses the concerns of our provider network. Have a great afternoon!