2016 Minnesota Senior Health Options (MSHO) Care Coordination (CC) and Minnesota Senior Care Plus (MSC+) Community Case Management (CM) Requirements Updated 11.1.16 All Minnesota Senior Health Options (MSHO) members and Minnesota Senior Care Plus (MSC+) members are automatically enrolled in care coordination and receive care coordination until disenrollment. The assigned Care Coordinator (CC) must meet the required definition of a “qualified professional”. Care coordination/case management services incorporate complex case management and consist of a comprehensive assessment of the member’s condition, the determination of available benefits and resources, the development and implementation of an individualized care plan with performance goals, monitoring and follow-up, as described in the grid below. All UCare forms can be found, HERE, all DHS forms can be found HERE, all DHS Bulletins can be found HERE. Table of Contents Initial Assignment and Contact With Member

Unable to Contact/Refusal Care Plan

New Member

Health Risk Assessment

Part C Log

Collaborative Care Plan

Financial Eligibility for EW

OBRA Level I

Transferred Members from UCare Non-Delegates CC Requirements for Termed Members

Transferred Members from UCare Delegates

Product Change

Nursing Home Admissions

Transitions of Care

Annual Reassessment

Change in Care Coordinator MA Eligibility Renewal

DTR’s

Policies and Procedures Requirements

CAC, CADI, DD, BI Members

MSHO MOC Training Requirements

Members That Move

Death Notification

Documentation Notes

Revised 11.1.16

1

Community Non-Elderly Waiver Members Initial assignment

Initial contact with member Unable-toContact Outreach Care Plan/Refusal Care Plan

Community Elderly Waiver Members

The CC must provide the member with the name and telephone number of the Care Coordinator (CC) within 10 calendar days of initial assignment. This may be done by phone or letter, and must be documented in the case record. If contact is by letter, the CC must use UCare’s approved MSHO/MSC+ Welcome Letters found on UCare’s website. Initial assignment is the first day the care system or county receives the enrollment list. The CC must make 4 attempts to contact the member within 30 calendar days of enrollment. Contact may be by letter, face-to-face or by phone. (The welcome letter is not considered an attempt to contact member). The unable to contact letter should be used. If the CC is unable to contact the member within the first 30 days of enrollment, an entry in MMIS must be completed with activity type 39 (refusal of HRA) and the activity date as the first date the CC attempted to reach the member. The CC must also complete an “Unable-to-Contact Outreach Care Plan” and attach in members file. The CC must attempt to reach the member in 6 months. The CC must continue to document attempts to reach the member and annually update MMIS. Four (4) contact attempts must be made:  Plan A -3 calls and a letter  Plan B - call attempt-3 letters  Plan C – no number or disconnected • Contact financial worker • Call UCare customer services • Call provider of current services • Send letter Member records must have documentation of the 4 attempts that were made.

If the member is contacted but refuses a face-to-face assessment and/or assistance with care coordination, the CC must gather as much information as possible via phone about what is important to the member and develop a “refusal” care plan. The “refusal” care plan is a brief document that allows for documentation of attempts to reach the member, barriers to reaching the member, refusal by the member to participate in an assessment and/or POC, and a service back-up plan, if appropriate. New member - This is a member that is newly enrolled with UCare and has not had a previous HRA entered into MMIS within the last 365 days. CC requirements for all new members include completion of the following: initial face-to-face HRA, collaborative care plan (POC) with documentation of the member’s Interdisciplinary Care Team (ICT), and OBRA Level I assessment. (see below for specifics on each requirement for new members). Revised 11.1.16

2

Community Non-Elderly Waiver Members Initial health risk assessment (HRA)

Caregiver* support

Entry of health risk assessment into MMIS Entry of assessments on monthly Part C logs.

Community Elderly Waiver Members

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The initial HRA must be completed with the member face-to-face within 30 calendar days of enrollment. The CC must use the Long Term Care Consultation (LTCC)/DHS form #3428 and the assessment should address medical, social, environmental and mental health factors, including the physical, psychosocial, and functional needs of the member.  The LTCC is also the form used for annual reassessments. The CC may also conduct a reassessment in the event of a care transition that would involve significant health changes, repeated or multiple falls, recurring hospital readmissions or emergency room visits.  When completing the LTCC, all questions and sections must be completed or marked as “not applicable”, including the Caregiver Support section, if section E states “yes” to a caregiver.  If a member is open to EW or will be opened to EW and indicates “Prefer to live somewhere else”, or “Don’t know” on question E.13 of the LTCC, the care coordinator is required to complete the My Move Plan Summary document DHS-3936. If a caregiver is identified in the “Caregiver Supports/Social Resources” section “E” of the LTCC, the CC must complete the “Caregiver Assessment” section “O” of the LTCC; and incorporate caregiver needs into the POC, if needs are identified. If the caregiver declines the assessment, they must document this. If a caregiver is not identified, the CC must indicate “NA” (not applicable) in the caregiver assessment section of the LTCC. If the LTCC is received during a transfer, the CC must ensure the caregiver section is complete at the next annual reassessment. If the caregiver assessment is not completed during the face-to-face visit, the CC must document at LEAST one attempt to call the caregiver to request it be returned, mail an additional copy if needed, or complete the caregiver assessment via phone. UCare strongly recommends that CCs complete the caregiver assessment while out in the field or call and complete it via phone. *A caregiver is a non-paid person that without their help, paid services would have to be put into place, also someone who provides care beyond reimbursed hours/service. Any time an HRA (face-to-face initial or reassessment) is completed, the screening MUST be entered into MMIS, using an activity type code 02 or 06 within 30 calendar days of assessment. All MSHO assessments and reassessments must be entered on the monthly Part C Log and submitted to [email protected] by the 10th calendar day of the following month.

Revised 11.1.16

3

Community Non-Elderly Waiver Members Collaborative care plan (POC) *A care plan is required for ALL MSHO and MSC+ members regardless of rate cell.

Community Elderly Waiver Members

A person centered collaborative care plan (POC) must be developed at the time of the initial or annual assessment using the Collaborative Care Plan form. The POC must be sent to the member/rep within 30 calendar days of the HRA. The CC has the lead responsibility for creating, implementing, and updating the care plan. The care plan must be updated every time services are modified. The care plan must meet all care plan requirements as outlined in the DHS care plan audit protocol, including the following:  Identification of member needs and concerns.  Identification of health & safety risks.  The care coordinator develops person centered prioritized goals on the POC for active problems noted in the HRA/LTCC. UCare does not expect care coordinators to develop a goal for problems that are not currently active - i.e. when a member is chronic and stable.  Goals and target dates, with a month and year.  Interventions.  Documentation of monitoring progress toward goals, interventions, and services. (CC needs to date and document progress or revision on the POC under section VII. “Monitoring Progress/Goal Revision date” at a minimum during the 6-month assessment).  Outcomes and achievement dates with a month & year. It is not acceptable to state “ongoing” or will carry goal to next care plan.  Follow-up plan regarding preventative care, long term care, community support, medical care, mental health care, or any other identified concern at a minimum of every 6 months.  Caregiver support is planned, if applicable.  Community-wide disaster plan.  Identified members of the ICT. The care plan must also include:  Cultural and linguistic needs, preferences, or limitations.  Person centered prioritizing goals.  Identifying and addressing any underlying barriers to achieve goals. (Barriers are any issue that may be an obstacle to members. Examples include language or literacy issues, lack of transportation to get to a medical appointment, cultural or spiritual beliefs, visual or hearing impairments.)  Discussing members’ self-management of goals and determining if the self-management activities are realistic and doable. (Self-management is activities or interventions that the member will do to achieve their goals. Examples include maintaining a prescribed diet or charting daily readings (e.g., weight, blood sugar). Revised 11.1.16

4

Community Non-Elderly Waiver Members

Community Elderly Waiver Members

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Advance directives

List of services on budget worksheet of care plan: amount, frequency, duration and cost of each service. Type of provider and name of provider if known, including non-paid care givers and other informal community supports or resources. The CC must document on an annual basis that they addressed or discussed advance directives with the member; or if an advance directive was not discussed, document the reason.

Annual preventive care

The CC must document on member’s POC that a conversation was initiated with member about the need for an annual, age–appropriate comprehensive preventive health exam.

Safety Plan (previously called Personal risk management plan (PRMP)) Service back-up plan

Not applicable.

Financial eligibility for elderly waiver (EW) services

Not applicable.

If the member refuses recommended services, the CC must document the refusal and discuss (and document discussion of) a safety plan or document the member’s refusal to discuss a safety plan. The CC must make another attempt to assess no later than at the time of the six month check-in. For members receiving medical services (e.g., PCA) or EW services, the CC must document a discussion of what the member would do in the event EW services or caregivers become unavailable. The member’s financial eligibility for EW services must be verified prior to initiating EW services. The CC must communicate with the county financial worker, using the Lead Agency Case Manager/Worker Communication form (DHS form #5181, which includes verification of completeness of the DHS form #3543) to determine the member’s eligibility for EW services and implement those services only upon verification of eligibility (receipt of approval via the DHS form #5181). The CC should place a copy of the #5181 form in the care coordination chart. EW services should NOT be initiated if financial eligibility is not documented via the #5181 form or verbal notification of eligibility from the financial worker is not received. The CC must make a best effort to obtain the form. If the member is not financially eligible for EW services, the CC should notify the member via DTR form, and update the POC to exclude waiver services.

Revised 11.1.16

5

Community Non-Elderly Waiver Members Interdisciplinary care team collaboration

Case mix service caps

Care plan signature page

Community Elderly Waiver Members

The CC must ensure the care plan employs an interdisciplinary approach by incorporating the unique primary, acute, long term care, mental health and social service needs of each member with appropriate coordination and communication across all providers. At a minimum, the ICT includes the care coordinator, the member and/or member’s family/authorized representative, caregiver (as applicable), and the PCP. ICT members may also include any and all other health and service providers (including Managed Long Term Supports & Service providers/Home & Community Based Service providers) as needed, as long as they are involved in the member’s care for current health problems. These may include but are not limited to: specialty care providers, social workers; mental health providers; nursing facility staff; and others performing a variety of specialized functions designed to meet the member’s physical, emotional, and psychological needs. The CC must document a list of ICT members on the ICT section of the POC. Not applicable. All state plan home care and EW services must be based on assessed need and must not exceed the case mix monthly cap amount. This includes UCare’s monthly case management fee of $180. If costs are over budget, the CC and member (or member’s rep) must evaluate and make a determination regarding service needs and priorities in order to ensure that service costs do not exceed the monthly case mix cap. If the member and/or CC feel strongly that the member must receive services that exceed the monthly case mix cap, the CC must request a budget exception from UCare. When requesting a budget exception, the CC must provide a detailed cost benefit analysis for review by UCare. If the budget exception request is denied, service costs must not exceed the monthly waiver cap. The member or member’s representative must sign the POC on an annual basis to document that they have discussed their care plan with their CC, are in agreement with the services, and with the care plan. It also must state that they were given a choice between Home and Community Based Services (HCBS) and nursing home services; that they have been offered a choice of providers; that they have received their annual appeals rights; they are aware of their Data Privacy Rights; they have discussed their POC with CC and chose the services they want; and that they agree with the POC.

Revised 11.1.16

6

Community Non-Elderly Waiver Members

Primary care clinic (PCC)/Primary care physician (PCP) contact Ongoing contact with the member and care plan updates. OBRA Level I assessment Documentation notes Admission to a nursing home for communitybased members

Community Elderly Waiver Members

The Care Plan is not considered valid unless signed by the member or member’s representative. The CC should ask the member to sign the signature sheet of the care plan during the face to face visit, stating that the care plan has been discussed with the member and the member agrees with the plan. If the CC is unable to get a member signature at the time of the visit, the CC must send the completed care plan out to the member for signature and document that they sent it out. If not received within 2 weeks, a second attempt must be made to get the signature, and documented. The CC must make a face-to-face visit to get the POC signature page signed if unable to get via mail. The POC or summary must be shared with PCP within 30 days of face-to-face assessment. This contact may be by phone, written communication (PCP summary letter on UCare website), EMR, fax of care plan/summary, or face-to-face. Communication must occur as needed, at least annually, and the CC must document this communication. The CC must have ongoing contact or check-in with the member at a minimum of every 6 months (30 day leeway before and after the 6 month contact) to update the plan of care, which includes documenting monitoring of progress or goal revisions (with date) directly on the POC. Contact may be by phone or face-to-face. An OBRA Level I assessment must be completed by the CC for all members at the time of the LTCC assessment. A new OBRA Level I must be completed at the time of the annual reassessment. The CC must document in the member’s care coordination record all evidence that care coordination requirements as stated in this document are being met. If any of the requirements were attempted but not completed, the CC must document all attempts in the member care coordination record. An OBRA Level I is required on admission to the facility. UCare is completing ALL OBRA/PASRR activity in house, which includes: – Completing OBRA Level 1, faxing it to the NF and making a referral for OBRA Level 2 if applicable. – Completing telephone screening (#3427T) and entering it into MMIS if applicable, (nonwaiver members). CC requirements are as follows: • Monitor the daily authorization report for admissions. • Assist with transitions and complete TOC log.

Revised 11.1.16

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Community Non-Elderly Waiver Members

Community Elderly Waiver Members

•

Annual reassessment

MSHO and MSC+ reassessments when member is

Send the Communication Form, DHS #5181 to the county financial worker on the 31st day, if the member’s stay is longer than 30 days, indicating the date the member was admitted into the nursing facility. • For members that are on EW, exit them from elderly waiver 30 days after the first day of admission into NF. • For members that are on EW, complete a DTR for each Waiver service the member is receiving including one for Eligibility. The reassessment must be completed face-to-face with the member and the following must be completed:  

The CC must complete the HRA within 365 days of the previous assessment for all members. The CC must use the Long Term Care Consultation (LTCC)/DHS form #3428 and the assessment should address medical, social and environmental and mental health factors, including the physical, psychosocial, and functional needs of the member. (Reminder: obtain members signature on the POC signature page while doing the face-to-face assessment.)  When completing the LTCC, all questions and sections must be completed or marked as “not applicable”, including the Caregiver Support section if section E is marked “yes”.  The LTCC must be entered into MMIS within 30 calendar days of reassessment.  Reminder: All MSHO reassessments must be entered on the monthly Part C log.  The previous year’s POC must have the column “Date Goal Achieved/Not Achieved” with a month and year documented and retained in member’s file.  The CC must develop a new POC with ongoing and new goals within 30 days of the HRA. (The POC or POC summary must be sent to the PCP and member/rep within 30 calendar days of the HRA, using the Collaborative Care Plan form).  The OBRA Level I must be completed and attached in member’s file.  If a member is open to EW or will be opened to EW and indicates “Prefer to live somewhere else”, or “Don’t know” on question E.13 of the LTCC, the care coordinator is required to complete the My Move Plan Summary document DHS-3936. MSHO members: If a MSHO member’s Medical Assistance (MA) terms, the CC must continue care coordination per usual for 90 days. If their annual reassessment is due during the 90 day term window, the CC must complete the annual reassessment and any ongoing care management as needed. The completed assessment documents should be retained in the member’s file and the DHS form #3427 should be entered Revised 11.1.16

8

Community Non-Elderly Waiver Members in the 90 day grace period after MA terms.

Community Elderly Waiver Members

into MMIS when the member’s MA is reinstated. If the member’s MA is not reinstated, resulting in disenrollment from the health plan, the DHS #6037 transfer form and all supporting documentation (see below) must be provided to the county for EW members only.

MSC+ members: If a MSC+ member receiving EW services MA terms, the CC must continue to monitor their MA status for 90 days and complete activities as stated in DHS 6037a scenario #10. If their annual reassessment is due during the 90 day term window, the CC must complete the annual reassessment, POC and OBRA Level I, and retain the completed assessment documents in the member’s file. The DHS form #3427 must be entered into MMIS when the member’s MA is reinstated. If the member’s MA is not reinstated, resulting in disenrollment from the health plan, the CC must provide the DHS #6037 transfer form and assessment to the county for EW members only. Refer to DHS Bulletin # 15-25-10 for CC requirements. Transferred members from non-delegates - this is a member that is newly enrolled with UCare and has had a HRA entered into MMIS within the last 365 days. CC requirements for all these members include completion of the following: a face-to-face or telephonic HRA collaborative care plan (POC) with documentation of the member’s Interdisciplinary Care Team (ICT). (see below for specifics on each requirement). *For rate cell A members, enter the HRA/LTC DHS-3427 in MMIS using activity type 01. CC requirements The health risk assessment: for transferred  Welcome letter must be sent within 10 days of enrollment. members from non-  Must be conducted within 30 calendar days of enrollment. delegates:  May be conducted via phone, or in person.  Transitional Health Risk Assessment form must be completed and attached to the most current LTCC.  Must include a review of pertinent areas of the LTCC #3428 using #3427-LTC assessment form (at a minimum, those elements of the LTCC #3428 marked with a “SD”, that refer to the questions on the DHS form #3427-LTC screening document). This should also include any questions that are pertinent to completion of an effective care plan. (The #3427T-Telephone Screening Document is NOT appropriate because it does not include review of ADLs). In order to do a telephonic assessment, the CC must receive the following from the previous case management entity:  The previous LTCC, copy of the MnCHOICES summary, or verification of a face-to-face HRA entered into MMIS within the past 365 days, using activity type 02 or 06. The full MMIS entry must be in the member’s file, not just the first page). Revised 11.1.16

9

Community Non-Elderly Waiver Members

Community Elderly Waiver Members

 The most recent plan of care (POC), signed by the member. o The POC must meet UCare’s care plan requirements. If appropriate information is not received on the transferred POC, the CC must revise the received POC, or complete a new POC using the “Collaborative Care Plan” form. If the received POC is not sufficient to determine service needs, the CC should conduct a full LTCC, face-to-face, and complete a new POC. Upon completion of the telephonic HRA, the CC is required to:  Ensure the member has a face-to-face reassessment within 365 days of the prior assessment.  Inform the member of a change in CC within 10 calendar days of change in assignment.  Document the review of the POC and existing LTCC assessment or MMIS screen.  Update the CC information in MMIS.  For rate cell A members, enter the HRA/LTC DHS-3427 in MMIS using activity type 01. A face-to-face, full HRA using DHS form #3428/(LTCC) and care plan IS REQUIRED when:  The CC does not receive a previous LTCC, MnCHOICES summary, and/or cannot verify that a face-toface HRA has been conducted within the past 365 days. (MMIS entry)  The CC does not receive a copy of the signed POC. A new care plan IS REQUIRED when:  The LTCC was received, but a care plan was not received. The CC must create a new POC and make sure it is signed by the member.  The previous plan of care was not signed by the member, and the CC decides to create a new POC for the member to sign. Transferred members from a UCare delegate- this is a UCare member that was previously case managed by a UCare delegate (transfers from one delegate to another in the same health plan, e.g., Health East to UCare; UCare to county); and has had a HRA entered into MMIS within the last 365 days. CC requirements for all these members include: CC requirements  The current care coordination delegate (sender) completes the DHS #6037 Transfer Form and sends for Transferred or faxes it with the most recent LTCC, OBRA Level I, POC, POC signature page, and the electronic Members version of the CL tool (if applicable), to the new care coordination delegate (receiver) as soon as the enrollment with the new agency occurs. For members on the monthly enrollment list that need to be transferred, the CC must send the DHS 6037 Transfer Form and supporting documentation to the new CC by the 15th of the month. Revised 11.1.16

10

Community Non-Elderly Waiver Members

Community Elderly Waiver Members

If the previous LTCC is not received or verified in MMIS or if a plan of care is not received, a new, a full LTCC assessment must be done face-to-face. The CC receives all of the following from the previous case management entity:  The previous LTCC (or verification of an LTCC entered into MMIS within the past 365 days, using activity type 02 or 06); and,  The most recent plan of care (POC). Upon receipt or verification of the LTCC and receipt of the POC, the CC is required to:  Send a change in CC welcome letter.  Ensure that the member has a face-to-face reassessment within 365 days of the prior assessment, when possible; but, no later than every 12 months. The CC may keep the current annual assessment schedule as long as a yearly LTCC is done.  Inform the member of a change in CC within 10 calendar days of change in assignment.  Document the review of the POC, HRA/LTCC assessment or MMIS screen.  Update the CC information in MMIS.  Transitional Health Risk Assessment form must be completed and attached to the most current LTCC. *For clinic changes please refer to the Primary Care Clinic change process on the UCare website. Product Change-this is a UCare member that has had a product change (i.e. MSHO to MSC+ or vice versa): CC requirements for Product Change:



 

The CC must provide the member with the name and telephone number of the Care Coordinator (CC) within 10 calendar days of initial assignment. This may be done by phone or letter, and must be documented in the case record. If contact is by letter, the CC must use UCare’s approved MSHO/MSC+ Welcome Letters found on UCare’s website. Initial assignment is the first day the care system or county receives the enrollment list. Transitional Health Risk Assessment form must be completed and attached to the most current LTCC. May be conducted via phone, or in person.

Revised 11.1.16

11

Community Non-Elderly Waiver Members

Community Elderly Waiver Members

 Must include a review of pertinent areas of the LTCC #3428 or LTC #3427 assessment form (at a minimum, those elements of the LTCC #3428 marked with a “SD”, that refer to the questions on the DHS form #3427 – LTC screening document, or all elements of the LTC #3427. This should also include any questions that are pertinent to completion of an effective care plan. (The #3427T – Telephone Screening Document is NOT appropriate because it does not include review of ADLs).  *For rate cell A members, enter the HRA/LTC DHS-3427 in MMIS using activity type 01. The new Care Coordinator (CC), Case Manager (CM) must notify the member of their name and phone Change in care number within 10 calendar days of change in assignment. This can be done by phone or letter. The contact coordinator must be documented. If by letter, the CC must use UCare’s approved Change in Care Coordinator Letter found on UCare’s website. Actions for when The CC must send the DHS-5181 communication form to the county to inform them of the member’s new a member moves address and date of move. CC will keep record of this in member’s file. CC will inform the member to update their address with the county financial worker. The CC must submit a Member Death Notification Form to UCare Actions for when The CC must submit a Member Death Notification Form to UCare. and close the waiver span in MMIS (using DHS #5181). a member dies Transitions of Care

MSHO: Assist with the member’s planned and unplanned movement from one care setting (e.g., member’s home, hospital, and skilled nursing facility) to another care setting. Each movement, when due to a change in the member’s health status, is considered a separate transition* and requires:  A consistent CC to support the member throughout the transition.  Sharing of essential information with the receiving facility within one business day of date the CC learns about admission; essential information includes: o services member currently was receiving; o names of service providers; and, o PCP contact information (resource for current medications, chronic conditions and current treatment).  PCP notification of admission within one business day of date the CC learns of admission, if PCP/clinic is not involved with the admission.  Communication with facility, providers, member, and/or responsible party about the transition process and changes in member’s health status and care needs.  Communication with discharge planner, regarding services member used, new services/equipment that may be needed, and who will arrange services. Revised 11.1.16

12

Community Non-Elderly Waiver Members

Community Elderly Waiver Members



Follow up with member or representative (by phone or in person) within one business day of notification regarding: o medication changes and filling new prescriptions; o DME and supplies; o follow up appointment and transportation needs; o changes in functional status (e.g., bathing, eating, etc.); and, o what to do if condition changes or worsens.  Enter each transition* onto a “Transition of Care (TOC) Log” form (and file forms in member’s record). *Example: The member leaves home and is admitted to a hospital=one transition; the member is discharged from hospital to a skilled nursing facility (SNF) =one transition; the member returns home=one transition. The member has a total of three transitions and each one would have its own log.  When the CC is made aware of a care transition involving an outpatient surgical center, UCare requires the CC to use professional judgment to determine if transition assistance is needed.  In general, transition assistance may be required for orthopedic procedures such as arthroscopic knee surgery, carpal tunnel surgery, repair of fractures, simple amputations, or eye surgeries such as cataracts. Care coordinators may also conduct a reassessment in the event of a care transition that would involve significant health changes, repeated or multiple falls, recurring hospital readmissions or emergency room visits. If Care Coordinator finds out about the transition(s) 15 days or more after the member has returned to their usual care setting, no TOC log will be required. The Care Coordinator, however, should follow-up with the member to discuss the care transition process, any changes to their health status and plan of care, and provide education about how to prevent readmission. Document this discussion in case notes. The 15day exception only applies if the CC finds out about all of the transitions after the member has returned to the usual care setting. MSC+: TOC requirements for MSC+ members are as follows: CC no longer needs to follow previous TOC requirements and complete multiple logs for different phases of transition. The Care Coordinator, however, should follow-up with the member to discuss the care transition process, any changes to their health status and plan of care, and provide education about how to prevent readmission. Document this discussion in case notes. Revised 11.1.16

13

Community Non-Elderly Waiver Members Medicaid eligibility renewals DTR requirementsmedically necessary services DTR requirements – waivered services

Community Elderly Waiver Members

To the best of their ability, the CC is encouraged to remind members that they are at risk of losing Medicaid eligibility due to failure to complete and return Medical Assistance paperwork; and, to assist members with the completion of renewal paperwork. UCare, or one of its utilization review delegates, must review all services that require a medical necessity review. A DTR letter must be sent to the member any time services that require prior authorization and review of medical necessity according to UCare’s prior authorization grid are denied, terminated, or reduced. DTR of these services requires review and determination by a Medical Director and must be referred to UCare, if applicable, or one of its utilization review delegates. Not applicable, unless member The Minnesota Department of Human Services (DHS) requires that requests a waiver service. If a MSHO members receive a Denial, Termination, or Reduction service is requested, complete a (DTR) letter when previously authorized waiver services are denied, DTR Notification Form and use terminated, or reduced. Tips for determining when a DTR letter is reason code 1114. required include the following:  A DTR notice is required when a CC denies, terminates, or reduces a waiver service that has been requested by the member, ordered by a participating provider, ordered by an approved, non-participating provider, ordered by a care manager, or ordered by a court.  If a member initiates the termination or reduction of a waiver service, a DTR notice is required.  If a member is exiting the waiver for any reason, a DTR must be completed for each waiver service they are currently receiving. A separate DTR for waiver eligibility (service code 2150) must also be completed.  If a member is receiving extended medically necessary services (extended PCA; extended home health care, including home health aide and skilled nursing services), and the case manager/care coordinator or member initiates a termination or reduction of those services, a DTR notice needs be issued. To issue a DTR for extended medical services, complete the Care Coordinator UR Communication form and fax to UCare.

Revised 11.1.16

14

Community Non-Elderly Waiver Members

Policies and procedures MSHO Model of Care training

Community Elderly Waiver Members

CCs from delegated counties and care systems must submit a completed DTR Notification Form to UCare within 1 business day of the decision date to initiate UCare’s DTR letter generation process. At a maximum, UCare needs the DTR Notification Form within 10 calendar days from the service request date in order to issue the DTR in a timely manner. UCare will generate the actual DTR letter upon receipt of the DTR Notification form. The DTR notice provides the member with information about the service being denied, terminated, or reduced, and provides appeal rights. The county Notice of Action should not be used for UCare members. All UCare delegates are required to have policies and/or procedures that support all the above stated requirements. UCare requires that all CCs attend initial Model of Care training within three months of hire. CCs may access this training via WebEx contained on the provider page of UCare’s website (MSHO MOC Training). Additionally, UCare will provide in-person Model of Care training to CCs at least annually during quarterly in-person training meetings and webinars. Delegates are required to submit a roster annually by the fourth quarter of all CCs who attended MOC training to their UCare Clinical Liaison.

Revised 11.1.16

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CAC, CADI, DD, or BI MEMBERS New Member or Transferred Member: Members on a CAC,CADI,DD The CC must contact the CAC/CADI/DD/BI waiver case manager (CM) to notify them the member is on MSHO or MSC+ and that they will be contacting the member and sending a Welcome Letter. The CC must request the or BI Waiver assessment and plan of care and let the Waiver CM know they will be completing an assessment within 30 days of enrollment using the CADI/CAC/DD/BI (CCDB) assessment form. This form can be completed either face-to-face or by reviewing the current assessment and plan of care developed by the Waiver CM. When completed, the CC must send the CCDB assessment to both the Primary Care Provider and Waiver CM. The dates sent are documented on the CCDB assessment form. A plan of care is not required for these members. The CC must coordinate a face-to-face visit with the Waiver CM when the next face-to-face visit is scheduled. If coordination is not possible, the CM must make arrangements to visit the member within 6 months of the transfer or enrollment. Entering assessments into the MMIS system is the responsibility of the CAC/CADI/BI/DD waiver CM. Care systems and counties do not enter any assessments into MMIS. However, The CC must record the CCDB assessment on the Part C Monthly log for MSHO members. Annual Reassessment: On an annual basis, the CC must request the Waiver CM’s assessment and plan of care. The CC must complete a new CCDB assessment and coordinate a face-to-face visit with the Waiver CM. If coordination is not possible, the CC must make arrangements to visit the member within the month the annual reassessment is due. Ongoing Contact with the member: CC must have ongoing contact with the Waiver CM and/or member at a minimum of every 6 months and update the CCDB assessment form as necessary. Members residing in an Intermediate Care Facility for persons with developmental disabilities (ICF-DD): if the member is on a CAC, CADI, DD, or BI Waiver the above process must be followed. If the member resides in an ICFDD but is not on one of these waivers the ICCD form for institutionalized members needs to be used.

Revised 11.1.16

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