November 20, 2001
MANAGEMENT
BULLETIN
TO:
Home and Community
Services Regional Administrators
Area Agency on Aging
Directors
Residential Care
Services Regional Administrators
Financial Program Manager (Rates Management)
SUBJECT: UPDATE ON THE COPES SKILLED NURSING
SERVICES
Aging and Disability Services Administration has received additional funds from the
legislature for the 2001-2003 Biennium to improve access to skilled nursing
services for recipients who are eligible for The Community Options Program
Entry System (COPES program). Skilled
nursing visits are provided by a registered nurse (RN), or a licensed practical
nurse (LPN), under the supervision of a RN.
This service is available under the COPES waiver for all clients who
meet the eligibility criteria as defined in WAC 388-71-0415. The additional funding will allow for a
higher maximum rate for this service.
In addition, the current per client visit limit is eliminated, and the
service is to be based on client need.
This
MB will provide clarification for client eligibility; define the scope of COPES
skilled nursing visits; and update the authorization requirements for using
qualified contracted providers to provide the nursing care. It will also outline the following:
Ø
The new rate structure for COPES skilled nursing providers;
Ø
Social Service Payment System (SSPS) Service Code Data;
Ø
Procedure for requesting headquarters approval for payments
outside range;
Ø
Eligibility and service plan requirements;
Ø
Case management guidelines and scenarios (Attachment A); and
Ø
Contracting requirements and elements (Attachment B).
WAC 388-71-0415(6)(a)(b)
Clients
are eligible for COPES skilled nursing when the client has temporary skilled nursing
needs beyond the scope which can be provided by non-licensed staff, and the
COPES skilled nursing services are medically necessary, as documented in the
MB-AASA-HCS/AAA/RCS-01-
November
20, 2001
Page
Two
Comprehensive
Assessment (CA) and service plan. These
services are necessary to ensure the client’s health, welfare and safety and
without them the client would require placement into a nursing facility. The waiver requires that these services are
not available through any other source.
The
development of the service plan may include the nurse, social worker, or case
manager who completed the Comprehensive Assessment (CA) of the client’s needs,
as well as the client, the client’s representative, family members, service
provider, and any other individuals involved in the care of the client. The service plan will contain at a minimum:
1.
The specific type of nursing tasks or skills to be provided.
2.
The amount, frequency and the duration of the COPES skilled
nursing visits; and
3.
The plan for review of the nursing notes, collateral
contacts, and ongoing need for COPES skilled nursing to determine if the SP is
continuing to meet the care needs of the client. Targeted Case Management
guidelines could be utilized for client’s receiving COPES skilled nursing that
are experiencing frequent changes in care needs or health status.
The
final SP is approved by the HCS/AAA staff after each review and presented to
the client for signature.
HCS/AAA
social workers, community nurse consultants and contracted case managers can
authorize COPES skilled nursing when all program factors for COPES waiver
services are satisfied. These factors are:
AASA
cannot claim federal match until the service plan has been developed and
the COPES skilled nursing is identified and written as such in the individual
client’s service plan.
Some
nursing services provided by Home and Community Services are mutually exclusive
and service payments may not be duplicated. For example; COPES skilled
nursing
would not be appropriate for a resident in an Assisted Living or Enhanced Adult
Residential Care Boarding Home as the facility is licensed to provide Limited
Nursing Services. COPES skilled nursing
would also not be available to a client that was
MB-AASA-HCS/AAA/RCS-01-
November
20, 2001
Page
Three
receiving
home health skilled nursing services through their Medicare/Medicaid home
health benefit, and met the eligibility criteria for that program. On a
case-by-case basis clients that are currently covered by MAA through an ETP related
to chronic care needs, will require case manager/supervisory review prior to
transfer to COPES skilled nursing.
COPES
skilled nursing is paid on a per visit rate schedule. This rate amount includes
all of the associated costs and time required to provide the nursing care to an
eligible client, such as travel, visit, collateral contact, and documentation
time. There is no exception to the policy (ETP/flex rate) to the range of
payments for the two SSPS codes for nursing visits.
The
waiver and federal statute requires staff to document the need for the COPES
skilled nursing and the care to be provided in the Comprehensive Assessment
(CA) and the Service Plan (SP).
The
previous rate that was available to contracted COPES skilled nursing providers
was a maximum of $ 28.50/visit. The new
rate that has been approved for the COPES skilled nursing service (5243)
allows a maximum amount of $50.00/visit.
The waiver identifies home health agencies or licensed individuals as qualified
providers. AAA contract staff will be able to offer this new rate to both
current and future providers as of 12/01/01.
In
addition a new service code and rate has been developed to allow access to
COPES skilled nursing services when circumstances are extraordinary and would
require a provider to be reimbursed outside of the standard payment range
available in SSPS service code 5243. Parameters for this new service code may
be evidenced by; unusual client care need; remote location of the client; and
the pursuance of provider and resource development at the local level for the
rate established in SSPS code 5243.
Approval
of either the AASA COPES program manager or Nursing Services Program Manager
will be required prior to authorization of this special rate. This new code is 5290, the rate range is $50.01 to $85.15,
and will also be available as of 12/01/01. A CA and SP must be faxed to the Program
Manager at AASA with the attached cover sheet (Appendix C). The response will
be faxed back to authorize the special rate, or request additional information.
Note:
This is not considered an ETP or flex-rate.
Utilization
projections
The
assumptions regarding utilization of COPES skilled nursing was based on a
projected target population of three percent of the COPES caseload, or 468
clients receiving services. The target
diagnoses were diabetes, spinal cord injury, and
MB-AASA-HCS/AAA/RCS-01-
November
20, 2001
Page
Four
traumatic
brain injuries combined with treatment needs such as wound/decubitus care,
administration of injections, bowel programs and catheter insertions.
The
allocation of $900,000/year for COPES skilled nursing, with a projection of 468
clients potentially needing COPES skilled nursing visits, would allow for an
average of $ 1923.00/client/year. Over-expenditure of COPES skilled nursing may
result in the elimination of this service.
SSPS
Service Code
COPES
Skilled Nursing Services will be reimbursed using one of the following two
codes.
Ø SSPS 5243: SSPS code
5243 is the reimbursement code for most of the skilled nursing services
identified in the CA and SP.
Ø SSPS 5290: If the client
has special circumstances; the AASA COPES or Nursing Services program manager
has given prior approval; and a contracted provider is available, the
reimbursement would be under SSPS code 5290.
Ø Note: Appendix
A with revisions for 5243 and the new code 5290 will be issued to the field
from SSPS.
The
following changes have been made to these codes:
Ø The “9” code
designation was removed *; and
Ø The
limitations on the amount of visits has been removed;
*
If you are working on a plan of care that already has a flexible rate for other
services, and COPES skilled nursing is added, you will not be able to use a “9”
code on the 14/154/159. All other services except COPES skilled nursing still
require opening with a “9” code.
Nursing
services is reimbursed by using one service line on SSPS form 14/154/159 for
payment. The rate for COPES skilled nursing cannot be supplemented by
authorizing more than one service line for the same date of service. Providers
can only be paid for each actual visit of nursing service they perform.
Client
training under SSPS code 5247 is never used as payment for COPES skilled
nursing tasks.
Effective 12/01/01, you
will need to:
Ø Review and update all service plans that include COPES skilled nursing to determine whether they comply with this MB.
MB-AASA-HCS/AAA/RCS-01-
November
20, 2001
Page Five
Ø Review current 14-154/159’s using service code 5243. If the authorization extends beyond 01/31/02 you will need to terminate the service line effective 01/31/02. A review of the current nursing services will occur and a new service line can be opened beginning 02/01/02 on the same 14-159 as long as there is no change in providers.
Ø Fax requests using the new SSPS service code 5290 to HQ: Attn: COPES Program Manager (360) 438-8633 for review and/or approval. The CA and SP must be completed prior to faxing indicating the specific client circumstance and frequency of skilled nursing visits. When approved the authorization will be valid for the amount of time indicated. (Attachment C)
Ø Reauthorize the new rate for current COPES skilled nursing providers whose payment rates exceed the above-mentioned rate. If the current provider is unwilling to continue services using this new rate structure, there may be a change in providers.
Ø Any skilled nursing task, or training to provide skilled nursing tasks, must be provided under the codes 5243 or 5290. Any such service currently being paid, as COPES client training must be reauthorized under the skilled nursing code using these guidelines.
Ø AAA’s that do not currently have skilled nursing contracts must develop them and notify their Case Management, and HCS offices when they are effective.
For questions or comments
please contact:
|
Marrianne
Backous Aging and Disability Services Administration Home
and Community Services COPES
Program Manager 360-725-2535 Backomr@dshs.wa.gov |
Candace Goehring Aging and Disability Services
Administration State Unit on Aging Nursing Service Program
Manager 360-725-2562 goehrcS2@dshs.wa.gov |
___________________________
Penny Black, Director
Home and Community Services Division
Attachments