Self-Directed Community Benefits HSD/MAD/SDCB

04

Care Coordinators and Support Brokers Every SDCB member must have a Care Coordinator (CC) and a Support Broker (SB).
Both are equally responsible for ensuring that the member is successful in SDCB.
Some duties are similar. It is the MCO’s responsibility to have internal policies to ensure that tasks are not duplicated.
The CC and SB must work hand-in-hand to ensure the member’s needs are met. 4

05

Other SDCB Entities Every SDCB member must have an Employer of Record (EOR) to submit requests for payment.
The Financial Management Agency (FMA) for SDCB is Xerox.
The FMA subcontracts with TNT to process payroll and vendor payments.
The FMA subcontracts with FOCoSonline to provide a web-based computer system for SDCB tracking.
The Income Support Division (HSD/ISD) completes the financial eligibility for Community Benefits.
ASPEN is HSD/ISD eligibility system.
Omnicaid is HSD/MAD’s Medicaid system. 5

06

Member Responsibilities Members must have a solid understanding of the SDCB program, prior to enrolling in the SDCB.
Members must cooperate with the CC and SB in order to utilize the SDCB program.
Members must understand the consequences of not complying with the SDCB rules.
Members must not rely on the CC and SB to manage their SDCB program.
CCs and SBs are not Case Managers.
SDCB is not for everyone. 6

07

Care Coordinator Responsibilities (pg 1) Conducts Comprehensive Needs Assessment (CNA) and Nursing Facility Level of Care (NFLOC) assessment
During CNA/NFLOC, explains to member:
120 day mandatory enrollment in Agency-Based Community Benefits (ABCB)
roles & responsibilities of member and Employer of Record (EOR), employees/vendors
working relationship between the Support Broker (SB) and Care Coordinator (CC)
what SDCB is, and how it works 7

08

Care Coordinator Responsibilities (pg 2) After initial SDCB discussion and member decides to transfer to SDCB, the CC:
Obtains signed SDCB statement from member
Provides the SBA Selection Form to member
Sends SBA Selection Form to SBA
Provides the LRI, Authorized Agent, Authorized Representative Forms to the Member (if requested)
Provides the LRI, Authorized Agent, Authorized Representative Forms to the SBA and the Financial Management Agency (FMA) 8

09

Care Coordinator Responsibilities (pg 3) Completes Employer of Record (EOR) Self-assessment (form MAD 614) with member
Provides the SBA with the member’s current ABCB CNA/NFLOC documentation
Coordinate transfer of services & providers
ABCB to SDCB
SDCB to ABCB
Mi Via to SDCB includes Category of Eligibility (COE) change
Enter SDCB Setting of Care (SOC) on MCO to HSD interface file with future, anticipated SDCB start date 9

10

Care Coordinator Responsibilities (pg 4) Add member into FOCoS
Add SBA, CCL, and NFLOC dates on FOCoS View User page
Determine SDCB budget amount:
pro-rated when member transfers from ABCB
Add SDCB budget amount into FOCoS General Plan Information and in General Plan Notes
When the SDCB budget amount is entered, FOCoS sends an alert to the SB that the SDCB budget amount has been entered and the SB can begin developing the Working Plan. 10

11

Care Coordinator Responsibilities (pg 5) Receive notification from SB that the Working Plan is ready for CC review (via FOCoS General Plan Note)
Review the Working Plan in FOCoS for accuracy
Submit SDCB care plan to MCO-UR for review in FOCoS.
Monitor utilization to ensure the SDCB benefits are being used appropriately and effectively according to the SDCB care plan approved goals. 11

12

Care Coordinator Responsibilities (pg 6) Ensure SB is monitoring SDCB care plan utilization
Monitor the quality of the services provided by the SB and address any concerns.
Report all critical incidents using the appropriate process as outlined by HSD/MAD/QAB
Assist member with annual renewals:
CNA/NFLOC
SDCB annual budget and SDCB care plan 12

13

Support Broker Responsibilities (pg 1) Assign individual SB and make initial contact with the member to review SB and members responsibilities
Create the Working Plan shell in FOCoS
Enter future, anticipated SDCB care plan begin and end dates
Build Working Plan goals to address needs identified in the CNA/NFLOC and as noted in the ABCB care plan
Notify CC that the Working Plan is ready for review/submission in FOCoS (via General Plan Notes)
Assist the member with recruiting and hiring employees/vendors
Assist the member with completing and submitting Xerox hiring packets 13

14

Support Broker Responsibilities (pg 2) Monitor SDCB care plan and budget utilization.
Review SDCB monthly expense report with member to find unprocessed payments or payment errors.

REMINDER:
Overutilization and under-utilization may result in Involuntary Termination. 14

15

Support Broker Responsibilities (pg 3) Assist member with timely responses to Requests for Administration/Information (RFA/RFI)
Assist member with researching and resolving provider payment problems
Monitor SDCB care plan for
Submission
Denial
Approval
Create revisions in FOCoS, as necessary
Respond timely to SDCB member requests 15

16

Support Broker Responsibilities (pg 4) Report all critical incidents using the appropriate process as outlined by HSD/MAD/QAB
Be attentive to ASPEN notices (approvals, closures, COE changes)
Work with ISD to resolve ISD Medicaid eligibility issues
annual recertification
closure
eligibility gaps 16

17

Communication between Care Coordinators and Support Brokers (pg 1) It is the MCO’s responsibility to create an effective and reliable means of communication to manage the workflow between the CC and the SB 17

18

Communication between Care Coordinators and Support Brokers (pg 2) The MCO shall have policies and procedures in place to ensure that SBs and CCs work in a collaborative manner and do not duplicate activities or functions.
Centennial Care Contract
PSC 13-630-8000-0021
Section 4.6.3.2 18

19

Communication between Care Coordinators and Support Brokers (pg 3) The CIU (MAD 054) is not to be used between the CC and SB.
The CC and SB should not rely on the State as a means of communication.
Xerox MCO Liaison should only be contacted for Xerox/FOCoS issues, not eligibility issues.
Do not use Mi.Via@xerox.com for SDCB issues. 19

20

Communication between Care Coordinators and Support Brokers (pg 4) CC informs SB:
Member transferring to ABCB
SB must complete SDCB close-out budget prior to transferring.
SDCB statement and SBA selection
SBA may not begin working with member until SBA receives SDCB Statement.
SBA change
Current SBA and new SBA must receive SBA Change document. 20

21

Communication between Care Coordinators and Support Brokers (pg 5) CC informs SB:
SDCB CNA/NFLOC and SDCB Budget amount
CNA/NFLOC documents must be given to the SB so the SB can ensure all identified needs are being addressed when developing the SDCB care plan.
SDCB Budget amount must be provided to SB in order for the SB to add dollar amounts to the goals in the Working Plan. 21

22

Communication between Support Brokers and Care Coordinators SB informing CC:
Response noted in FOCoS RFI/RFA (Request for Info/Admin)
Working Plan is ready for CC review/submission
FOCoS General Plan Notes alert (required)
Email (follow-up)
Phone call (if experiencing system problems)
Hand-delivered (last resort if having system problems) 22

23

Contacting HSD/MAD CCs and SBs work closely together to resolve issues before asking the State and/or Xerox for assistance. 23

24

Community Benefit Criteria To be eligible for Community Benefits, a member must meet all four (4) criteria:
Be classified as a CCL2 or a CCL3 (Care Coordination Level); and
have at least one Full Medicaid COE; and
have a current NFLOC; and
be assessed to need Community Benefits. 24

25

Category of Eligibility (pg 1) Prior to Centennial Care, a member must have had a waiver COE and NFLOC to receive waiver services.
Waiver COEs are still used in ASPEN even though waiver services are called Community Benefits in Centennial Care.

090 AIDS
091 Elderly – over age 65
092 Brain Injury
093 Blind
094 Disabled – under age 65 25

26

Category of Eligibility (pg 2) With the implementation of Centennial Care, any member with a full Medicaid COE and NFLOC is eligible to receive Community Benefits
In Centennial Care, the waiver COEs and the following COEs qualify for Community Benefits:

001, 003, 004 SSI Medicaid Extension
028 Transitional Medicaid
052 Breast & Cervical Cancer/pretreatment
072 Jul Medicaid
074 Working Disabled Individual (WDI) 26

27

Setting of Care (SOC) SOC = Setting of Care
Designates how a member is receiving Long-Term Care benefits, based on COE(s)
SOC changes are entered by the CC on the MCO to HSD interface file
Correct data entry of the SOC is critical to ensure accurate benefit delivery and payments to providers. 27

28

Setting of Care Four (4) SOC codes for Community Benefits depending on the member’s COE determined by the SSA or ISD:

ANW (Agency Based No Waiver)
ADB ( Agency Directed Benefit)
SNW (Self-Directed No Waiver)
SDB (Self-Directed Benefit) 28

29

Setting of Care - SNW Member does not need a waiver allocation in order to receive Community Benefits.
SNW: (Self-Directed No Waiver)
Member has a full Medicaid COE, and
Example: Member only has COE 004 (SSI Full Medicaid)
Member has a current NFLOC
Member has been assessed to need the Community Benefits 29

30

Setting of Care - SDB Member must receive an allocation in order to receive Community Benefits
SDB: (self-directed benefits)
Member has a Medicaid waiver COE
Example: Member only has COE 090-094
Member has a current NFLOC
Member has been assessed to need the Community Benefits 30

31

SOC Begin and End Dates The initial SOC begin/end dates must match the NFLOC begin/end dates
When a member transfers from ABCB to SDCB the SOC must be changed to reflect SDCB
The SDCB SOC is entered by the CC, and is based on when the member anticipates the SDCB services will begin 31

32

Member Active in FOCoS In order to process SDCB payment requests to SDCB providers, a SDCB member must have an active, full Medicaid COE and a SDCB SOC.
If one of these two criteria are missing, the member will become inactive in FOCoS, and SDCB vendor payments will not be processed. 32

33

Becoming Inactive in FOCoS CCs and SBs receive FOCoS alerts when a member becomes Active and Inactive.
When a member becomes Inactive:
Check Medicaid portal for current COE + SOC
If COE appears incorrect, contact HSD/ISD
If SOC appears incorrect, contact internal management
If this will affect timely payments, contact the member and explain the situation. 33

34

Community Benefit-Transfers Centennial Care member can receive Community Benefits via three (3) different circumstances:

ABCB to SDCB
SDCB to ABCB
Mi Via to SDCB

Clear documentation in FOCoS describing the actions and effective dates must be noted. 34

35

Transfer – ABCB to SDCB 1) ABCB to SDCB: member has received ABCB for at least 120 consecutive days and wants to transfer to SDCB.
120 days is counted from ABCB SOC start date.
ABCB SOC date span corresponds with NFLOC date span.
SDCB SOC will begin with initial SDCB care plan start date and end with existing NFLOC end date. 35

36

Viewing Member in FOCoS The MCO can view a member in FOCoS after the MCO updates the SOC to reflect SDCB
The CC enters a SDCB SOC on the MCO to HSD interface file, with the future anticipated SDCB care plan start date
MCO to HSD interface file updates to Omnicaid,
information then interfaces from Omnicaid to FOCoS on the nightly eligibility file.

The CC must monitor the interface file for errors to ensure this process is successfully completed 36

37

Transfer - ABCB to SDCB (pg 1) Member tells CC he wants to switch to SDCB
CC and member discuss proposed date of transfer
CC gives member the SDCB Statement and SBA Selection Form
CC gives SBA the returned SDCB Statement and SBA Selection form, and notifies the SBA of the proposed date of transfer
CC sends CNA/NFLOC documents to SBA
SBA contacts member
CC changes SOC to SDCB using future, anticipated care plan start date
CC enters member into FOCoS 37

38

Transfer - ABCB to SDCB (pg 2) CC enters SBA, NFLOC dates and CCL into FOCoS
CC determines prorated budget amount, provides the budget amount to the SB
SB creates Working Plan shell
CC enters SDCB budget amount in FOCoS
Member and SB create the Working Plan goals for CC review
CC reviews and submits Working Plan for MCO-UR review
MCO-UR reviews care plan
approve/deny submitted goals, or
sends an RFI to the CC/SB for more info. 38

39

Transfer – SDCB to ABCB 2) SDCB to ABCB: member has been receiving SDCB and wants to voluntarily transfer to ABCB or has been involuntarily terminated to ABCB.
SDCB close-out budget ends on the last day of the month and the ABCB begins the first day of the following month.
CC enters the ABCB SOC on the MCO to HSD interface file with anticipated ABCB start date.
ABCB SOC will begin with the first day of the ABCB start date, which would be the first day of the month 39

40

Transfer – Mi Via to SDCB (pg 1) 3) Mi Via to SDCB (COE change): member is receiving Mi Via waiver services and receives an allocation to Centennial Care Community Benefits:

The 120 days in ABCB are waived
Member must meet NFLOC
Member must complete all steps at ISD to change their Category of Eligibility 40

41

Transfer – Mi Via to SDCB (pg 2) Current Mi Via members with COE 095/096 must receive an Centennial Care allocation in order to receive Centennial Care Community Benefits if they don’t have a full Medicaid COE
Current Mi Via members with COE 095/096 and a full Medicaid COE may choose to transfer to SDCB without receiving a Centennial Care allocation 41

42

Transfer – Mi Via to SDCB (pg 3) A transfer meeting must occur between the member, the Mi Via Consultant and the SDCB CC to avoid a break in service from Mi Via to SDCB
CC updates the SOC to reflect SDCB via the MCO to HSD interface file, and
CC adds member to FOCoS Centennial Care container 42

43

Transfer – Mi Via to SDCB (pg 4) CC creates SDCB Working Plan for 12-months and enters budget amount in FOCoS
Mi Via consultant creates Mi Via close-out budget in FOCoS-Mi Via container
Mi Via Third Party Assessor (TPA) reviews/approves Mi Via close-out budget
Mi Via SSP must end on last day of month and SDCB care plan and NFLOC must start on 1st day of the next month 43

44

Facilitating the COE Change at ISD(if member only has COE 095/096) CC sends a CIU to ISD with the anticipated SDCB care plan and COE start date
This should be done 30 days in advance of the proposed start date
CC waits for ISD response regarding proposed start date
COE eligibility must be determined at ISD, including new Medicaid application and receipt of NFLOC information 44

45

Facilitating the COE Change at ISD(if member only has COE 095/096) If ISD responds to CC with a different COE start date, the transfer to SDCB will be delayed
If this occurs, the proposed SDCB begin date and the Mi Via end date must be changed in all systems
CC must change the SOC date on the MCO to HSD interface file 45

46

Changing the SOC timely IMPORTANT: Once the SOC is changed, the member will stop receiving services on the current service delivery model:
This is why it’s crucial to have communication between all parties regarding all stop dates and start dates
There must never be a gap in services due to the SOC and/or the COE being changed too early or too late 46

47

Transfer Timelines (pg 1) All transfers must be completed and finalized within:
30 calendar days of receipt of notification to transfer;
ensure there is no delay in member receiving the community benefits identified in the CNA, and
avoid uncompleted transfers, and
allow enough time to complete the many steps in the transfer process 47

48

Transfer Timelines (pg 2) When a member initially contacts their CC to request to transfer from ABCB to SDCB:

CC conducts initial transfer meeting with member within 2 working days of request to transfer to SDCB;
explains SDCB roles and responsibilities
gives SDCB Statement to member
gives Support Broker Selection form to member 48

49

Transfer Timelines (pg 3) completes the EOR self-assessment form with member (MAD 614)
completes the EOR designation form with member and informs SBA
completes the EOR enrollment form and CC sends EOR enrollment form to Xerox 49

50

Transfer Timelines (pg 4) Upon receipt of SBA selection form, CC sends the SBA selection form to the SBA, within 2 working days:
Current ABCB CNA/NFLOC documentation
This is needed to ensure:
the SDCB Care Plan will address all identified needs in the CNA, and
the member receives Continuity of Care for Community Benefits. 50

51

Transfer Timelines (pg 5) Within 5 working days of transfer meeting:

CC determines SDCB budget amount
CC enters into FOCoS: new member, including CC name & SB Agency name
CC enters the NFLOC date span and Care Coordination Level (CCL) on View User page
SB creates Working Plan shell in FOCoS 51

52

Close-out Budget (pg1) A close-out budget is used to end a care plan prior to the original end date. This ensures:
the self-directed services are discontinued
everyone is aware of the SDCB care plan end date
the new services begin timely
there is no break in service in service delivery

A close –out budget is used when:
A member leaves SDCB to receive a different type of Medicaid benefit, or
A NFLOC and SDCB care plan date span need to be aligned 52

53

Close-out Budget (pg 2) The close-out budget must always be submitted and approved prior to the new care plan being submitted.
CC submits close-out budget in FOCoS
MCO-UR approves close-out budget
CC submits new SDCB care plan
MCO-UR approves new SDCB care plan
If these steps are done out of order, FOCoS will delete the original plan submitted. 53

54

Close-out Budget (pg 3) The care plan is shortened or truncated:
The CC changes the original end date of the care plan in FOCoS.
FOCoS will update the available budget by deleting the months after the close-out budget end date.
Xerox provided written instructions to all MCOs on how to process a close-out budget 54

55

SDCB to ABCB(Voluntary Termination) Members may voluntarily terminate from SDCB and transfer to ABCB, once per calendar year.
All transfers should be completed and finalized within 30 days from the member’s decision to transfer, in order to avoid prolonged transfers.
A SDCB close-out budget must be completed in FOCoS.
HSD requires ending the SDCB care plan on the last day of the month and beginning ABCB services on the first day of the next month.
The SOC must be changed to ANW or ADB on the MCO to HSD interface file using the anticipated start date of ABCB services. 55

56

SDCB member wants ABCB(Voluntary Termination) Member informs CC that he wants to transfer to SDCB
CC documents the member decision to Voluntary Terminate from the SDCB
CC and member discuss a proposed date of transfer, and CC informs SB of proposed date.
SB creates SDCB close-out budget in FOCoS and informs CC to review/submit
CC reviews/submits close-out budget to MCO-UR in FOCoS
MCO-UR reviews/approves SDCB close-out budget in FOCoS
CC determines the necessary ABCB services
CC ends SDCB SOC and begins SOC to ABCB with no break in service 56

57

SDCB to ABCB (pg 1) (Involuntary Termination) Reasons for SDCB involuntary termination:
Member/EOR refuses to follow rules (3 technical assistance attempts by the CC, SB, or FMA/Xerox)
Immediate risk to member’s health & safety
Health-related services not on care plan or not used
Exhibits behaviors that may endanger member/others
Member misuses budget after repeated technical assistance
Member expends budget prior to end of care plan year
Member intentionally misuses services/goods 57

58

SDCB to ABCB (pg 2) (Involuntary Termination) CC documents all actions, informs SB of intent to involuntary terminate the member from SDCB
CC submits involuntary termination request to HSD/MAD including all supporting documentation and attempts to resolve the issue
HSD/MAD reviews and approves/denies the involuntary termination request
If approved by HSD/MAD, CC informs HSD/MAD and the SB of the involuntary termination date
MCO provides written involuntary termination letter to the member specifying the reason and effective date

59

SDCB to ABCB (pg 3)(Involuntary Termination) CC creates SDCB close-out budget in FOCoS
SB revises each goal to indicate close out reason
CC reviews/submits close-out budget to MCO-UR in FOCoS
MCO-UR reviews/approves SDCB close-out budget in FOCoS
CC ends SDCB SOC and begins SOC to ABCB with no break in service

60

LUNCH (On Your Own) 60

61

Review of Morning SessionQuestions??? Aligning NFLOC and SDCB Care Plan Date Spans
Roles & Responsibilities
Internal Communication
COE and SOC
Transfers
Aligning LOC and SDCB care plan
Question/Answers 61

62

SDCB Care Plan Dates & NFLOC Dates The SDCB care plan and NFLOC must start on the 1st day of the month to avoid a break in service
SDCB care plans and the NFLOC date span must never exceed more than a 12 month period
All actions must be done timely so the NFLOC and SDCB care plan is approved prior to the SDCB care plan start date
SDCB retro-active start dates are not permissible 62

63

Alignment: NFLOC Expiring Before SDCB Care Plan Example: SDCB care plan needs to be truncated
NFLOC 10/15/13-10/14/14
SDCB care plan 12/6/13-12/5/14
In August 2014, CC prepares to align NFLOC and SDCB care plan
complete annual CNA/NFLOC to start 10/15/14
complete close-out budget to truncate current SDCB care plan to end on 10/14/14
complete annual SDCB care plan to start 10/15/14
NFLOC and SDCB care plan is for 12 months:
10/15/14-10/14/15 63

64

If the SDCB care plan wasn’t aligned when the NFLOC was completed Today’s date: 8/1/14
Annual NFLOC : 7/15/14-7/14/15
SDCB: care plan 10/6/13-10/5/14
SDCB care plan should’ve been truncated to end on 7/14/14 and the new SDCB care plan should’ve started on 7/15/14 to match the annual NFLOC
New NFLOC determination is not necessary if the current NFLOC occurred within the previous 90 days 64

65

If the SDCB care plan wasn’t aligned when the NFLOC was completed NFLOC end date must be changed to 10/5/14 to match the current SDCB care plan end date
The new NFLOC date span must be entered as 10/6/14 – 10/5/15
Member/EOR and SB develop annual SDCB care plan for 10/6/14 – 10/5/15
NFLOC and SDCB care plan are aligned for 1 year: 10/6/14-10/5/15 65

66

Working Plan shell dates The SB must create the Working Plan shell to allow the CC to enter the SDCB budget
Member and SB can then begin developing the Working Plan goals
The Working Plan shell starts from the future, anticipated SDCB care plan start date and ends with the current NFLOC end date 66

67

FOCoS entry : NFLOC and SDCB Budget The CC enters the NFLOC dates on the View User Page and enters the SDCB Budget in the General Plan Notes. General Plan Notes View User Page 67 1)

68

Changing the Working Plan shell dates If the original anticipated Working Plan shell start date is not going to work:
The CC must change the Start date in FOCoS a later start date.
The CC must re-determine and assign a new pro-rated budget amount in FOCoS to match the new pro-rated SDCB care plan dates.
The CC must change the SDCB SOC to a future date to ensure the ABCB SOC, or Mi Via SOC, remains in effect until SDCB is ready to begin. 68

69

Determining the SDCB Budget Transferring from ABCB to SDCB
SDCB Statement signed 6/15/14
Anticipated SDCB start date is 8/1/14
CC determines and pro-rates the SDCB budget for months remaining on NFLOC date span
The first year the member transfers from ABCB to SDCB, the SDC B member will not have a full 12-month SDCB care plan. 69

70

Determining the SDCB Budget 70 The SDCB budget is calculated on the current services a member is receiving in ABCB and the needs identified in the CNA/NFLOC
SDCB members receive similar Community Benefits as in ABCB, however the SDCB budget can be used the way the member sees fit, as long as the member’s needs are met, as identified in the annual CNA/NFLOC.

71

How to Pro-Rate a SDCB Budget Example: current ABCB services 2/1/14-1/31/15 (12 months)
CC reviews current CNA/NFLOC and ABCB services.
CC determines how much each ABCB service costs
CC calculates total annual cost for each ABCB service
Medicaid provider reimbursement rate x number of hours x 12 months
Total cost of all ABCB services becomes the SDCB annual budget before pro-rating.
CC pro-rates the SDCB budget for number of months left in ABCB
CC enters the SDCB pro-rated budget amount in FOCoS
SDCB Care Plan: 8/1/14-1/31/15 (6 months) 71

72

Building a SDCB Budget (version 1) Current ABCB services for 12 months
Personal Care Services ($10.00hr for 20hr/week) $10,400
Physical Therapy Sessions ($760/month) 9,120
Emergency Response ($40/month) 480
$20,000
CC pro-rates SDCB budget for # of months left on CCP
$20,000 / 12 months = $1666/mo
$1666 x 6 months = $9996

SDCB Budget can be divided up any way member chooses as long as the needs that are identified in the CNA/NFLOC are adequately addressed
SDCB Prorated Budget = $9996
Homemaker Services ($11.00hr for 20hr/week) $5,720
$11.00 includes rate + workman's comp /employer tax burden
Skilled Maintenance Therapy Sessions ($500/month) 3,000
Emergency Response ($40/month) 240
Transportation (bus pass $35/month) 210
Related Goods (exercise machine) 150
Related Goods (adult diapers/bed-liners) 140
$9,460 72

73

Building a SDCB Budget (version 2) 73

74

Ongoing SDCB care plans The first SDCB budget is usually pro-rated based on the ABCB dates and services
When the annual CNA/NFLOC is completed, the annual SDCB budget amount is again based on the ABCB cost to provide the needed services identified in the CNA/NFLOC 74

75

Ongoing SDCB care plans The SDCB budget may decrease or increase due to the annual CNA/NFLOC results
The SDCB budget will never increase higher than the amount it costs to provide care in a private nursing facility
SDCB members who transitioned from Mi Via with budget amounts higher than the current cost of care in a private nursing facility, their SDCB budgets are already at the maximum 75

76

Employer of Record (EOR) Every member must designate an Employer of Record (EOR) before they can transfer to SDCB
If the EOR Assessment form (MAD 614) indicates the member is not able to direct his/her own SDCB services, and member is unable to locate an EOR, SDCB may not be the appropriate service delivery model 76

77

Request for Additional Services Member notifies SB that he/she needs additional services or goods due to a loss of natural supports, or a change in their health condition:
SB notifies CC and requests a new CNA
CC completes new CNA
CC enters new total budget amount in FOCoS
Member and SB create revision related to CNA results for the CC review/submittal in FOCoS
CC submits SDCB care plan revision to MCO-UR for review/decision 77

78

Request for Environmental Modifications SDCB member discusses with SB the need for an Environmental Modification
A member is allowed $5000 every 5 years. The $5000 is separate from the SDCB budget
A new CNA/NFLOC not required, but may be necessary
CC enters available EMOD budget amount in FOCoS
Member & SB creates revision in FOCoS with new EMOD goal
SB notifies CC to review the e-mod revision
CC submits EMOD revision to MCO-UR 78

79

Assisted Living Assisted Living is an ABCB service, however, the member must reside in a NM Medicaid-approved Assisted Living Facility (ALF)
The CC must begin working with the SDCB member at least 60 days prior to SDCB care plan or NFLOC end date, whichever comes first, to ensure member understands all options and is prepared to make decisions 79

80

Assisted Living Members who currently have Assisted Living on their SDCB care plan have 3 options:

OPTION 1
If member resides in a NM Medicaid approved ALF:
Transfer to ABCB, no break in service
CC creates SDCB close-out budget
MCO-UR approves the close-out budget
CC ends SDCB SOC and enter new ABCB SOC 80

81

Assisted Living OPTION 2
If member resides in a non-approved NM Medicaid ALF and the member is willing to move to another facility:
Transfer to ABCB, move to an approved ALF
CC creates SDCB close-out budget
MCO-UR approves the SDCB close-out budget
CC ends SDCB SOC and enters new ABCB SOC 81

82

Assisted Living OPTION 3
If member resides in a non-NM Medicaid approved ALF and wants to remain in the same facility:
Stay on SDCB,
remove AL service from the SDCB care plan,
add other available SDCB services, as necessary
Member pays ALF out-of-pocket (private pay) 82

83

FOCoS Data Entry It is highly recommended that the CC and SB enter descriptive notes into FOCoS at the same time that the action is completed.
Information is added to the
General Plan Notes
View User page 83

84

FOCoS Data Entry FOCoS View User page and General Plan Notes is where important information is entered.
CCs and SBs will be able to get an idea of what is happening with a member by first checking these notes in FOCoS
FOCoS View User notes are not visible to members 84

85

FOCoS General Plan Notes Alert When the SB has the Working Plan ready for the CC to review and submit to MCO-UR, the SB enters a note similar to this into FOCoS

Descriptive notes are also entered in FOCoS by CC and SB for RFI and RFA submissions
FOCoS generates alerts between CC and SB 85 Support Broker Name

86

General Timelines No SDCB care plan revisions:
within 60 calendar days of expiration of SDCB care plan or NFLOC unless related to a health or safety issue and is noted as such in the revision
CC must submit annual SDCB care plan in FOCoS for MCO-UR review:
30 calendar days prior to expiration
CC and SB must assist with:
NFLOC, SDCB care plan, and ISD recertification
60 calendar days prior to annual expiration 86

Self-Directed Community Benefits HSD/MAD/SDCB

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Self-Directed Community Benefits HSD/MAD/SDCB

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