This page provides answers to frequently asked questions regarding tiered reimbursement rates that are being implemented for some Home- and Community-Based Services for members with an ID waiver.
1. What are tiered reimbursement rates?
Tiered reimbursement rates provide funding for services to members based on the severity of the member’s needs. Reimbursement is higher for members with more severe needs as documented by a valid, reliable assessment. Reimbursement is lower for members who present relatively less severe needs.
2. Why are tiered reimbursement rates being implemented?
Tiered reimbursement rates ensure that higher reimbursement is provided for services to members based on the severity of a member’s needs. The current system does not effectively target funding in this manner.
3. What HCBS ID waiver services will be reimbursed using a tiered rate methodology?
Daily Supported Community Living (SCL) (H2016 HI), full day Day Habilitation (T2020), full day Adult Day Care (S5102), and Residential-Based Supported Community Living (RBSCL) for children (H2016 U3). Full day and extended day Adult Day Care are combined into a full day rate.
4. What HCBS ID waiver services will not be reimbursed using a tiered rate methodology?
The tiered rate methodology applies to services paid on a daily rate listed above. The tiered rate methodology will not be used for HCBS ID waiver services paid in shorter time units such as: SCL 15-minutes (H2015), Day Habilitation 15-minutes (T2021), Adult Day Care 1/2 day (S5101), or Adult Day Care Hourly (S5100) services. Extended day Adult Day Care (S5105) is being eliminated as a service option.
5. How were individual provider transitional rates developed?
The historical reimbursement for members who received the affected services was used to determine individual provider tiered rates.
6. How will providers be informed of their transitional tiered rates?
A letter from the Iowa Medicaid Enterprise (IME) was sent to each provider that details the individual provider tiered rates.
7. Who will be impacted by tiered rates?
The tiered rate methodology will impact ID waiver members who utilize the following services:
• Daily SCL
• Full day Day Habilitation
• Full day Adult Day Care
• Residential Based SCL
8. Will the tiered reimbursement rate methodology only be used for services provided through the HCBS ID waiver?
Yes
9. How is a member’s tier assigned?
An member’s tier is assigned based upon the results of the member’s Supports Intensity Scale (SIS) assessment related to home living skills, community living activities, health and safety activities, social activities, and the identification of exceptional medical and behavioral support needs. Iowa Administrative Code rules for tier assignment will be promulgated in 441-79.1(29).
10. What if a member does not have a SIS assessment completed?
All members should have a full SIS assessment completed prior to December 1, 2017. If a provider identifies that a member does not have a full SIS completed to place them into a tier level, contact the member’s case manager (CM) or Community-Based Case Manager (CBCM) to get an assessment scheduled.
11. Will HCBS ID waiver services funded through the Consumer Choice Option (CCO) be funded using the tiered reimbursement rate methodology?
No. The existing CCO rate methodology for services will be used to create a CCO budget. If a member receives a service that will be affected by tiered rates (see question #3 above) outside of their CCO budget, the affected service will be reimbursed using tiered rates.
12. Will all the identified applicable HCBS ID services provided to all other members whose services are not funded by a CCO budget be paid through tiered reimbursement rates?
Yes. Any of the identified services in question #3 above that is not part of a CCO budget will be reimbursed by a tiered rate.
13. Will all providers of the identified HCBS ID waiver services be paid using the tiered reimbursement rate methodology?
Yes, all providers of the affected HCBS ID waiver services will be paid through the tiered rate reimbursement methodology for members enrolled in managed care and fee for service.
14. Will tiered rate reimbursement affect the payment to members receiving other HCBS services?
Funding for services provided to members accessing the Brain Injury Waiver or Habilitation program services will not change. Current payment methodology will remain the same.
15. Will all tiered rates be the same regardless of the member’s other supports and services?
All tiered reimbursement rates will be the same regardless of the member’s other supports and services except for Daily SCL. Daily SCL will have two sets of rates depending on whether or not the member is receiving “day services” outside of the Daily SCL setting. Daily SCL tiered reimbursement rates will be higher to serve members that are not receiving day services and lower for those who are receiving day services.
16. What services are included in day services?
Day services include, but are not limited to, enhanced job search, supported employment, prevocational services, adult day care, day habilitation, and employment outside of Medicaid reimbursable services. Any funding source paying for the services listed above would be included as a day service. Any day service authorized in a CCO budget will also be considered a day service listed above to determine the SCL rate “with” and “without” day services.
17. How will it be determined a member has “with day services” and “without day services” for determining what Daily SCL rate will be reimbursed?
“With day services” means the member’s service plan identifies an average of 40 hours or more per month of day services outside of Daily SCL.
“Without day services” means the member’s service plan identifies an average of less than 40 hours of day services per month outside of daily SCL.
18. How often can the daily SCL procedure code (H2016 or S5136) be updated in a service plan if a member has a change above/below the 40 hour monthly average of day service hours utilized per month?
The daily SCL service procedure code may change any time the amount of “with” or “without” day services change in a member’s service plan. The day services will be reviewed at least annually when the member’s service plan is reviewed. The daily SCL procedure code (H2016 or S5136) may change more frequently if the member’s CBCM agrees the amount of day services the member receives outside of daily SCL has been or needs to be modified. Any change to the amount of day services and the resulting change to the member’s daily SCL procedure code shall take place on the first day of the month following the month in which the service changes were identified as needed by the member
19. Can a SIS assessment be reconsidered if there is a change in member need or if it is believed it does not accurately reflect the member’s current needs?
The following SIS reconsideration processes can be used when members, families or providers believe that the current SIS assessment is not representative of the member’s current needs.
1. A formal request for reconsideration to an existing SIS assessment is made to the member’s case manager by the member, family, or a provider.
2. The CM or CBCM requests a SIS to be completed in an off year for a member.
3. An Emergency Needs Assessment (ENA) is conducted by a SIS assessment entity telephonically with the case manager to determine the necessity of a new SIS assessment. The following criteria is used:
a. Member has experienced significant health or safety changes in their condition.
b. Member has been in a nursing facility or hospital for over 30 days.
c. If it is identified during the Emergency Needs Assessment (ENA) process that there were changes in three of the five domains and the condition is expected to continue, a new assessment would be conducted.
ENA Domains:
1. Activities of daily living
2. Instrumental activities of daily living
3. Medical Condition or diagnosis
4. Cognitive function/memory
5. Behavior Concerns
20. How is the integrity of the SIS maintained?
SIS assessments are completed by a neutral entity trained in the SIS assessment review process. The SIS assessor follows a quality plan to ensure the SIS is administered and scored in a manner consistent with American Association of Intellectual and Developmental Disability (AAIDD) standards. SIS assessors complete multiple quality assurance activities to assure that all assessments are valid and reliable. This includes an Interviewer Reliability and Qualifications Review (IRQR) at a minimum of two times per year with an AAIDD certified assessor. Through the various internal Quality Assurance (QA) processes conducted on the assessors and the assessment process, the SIS assessment is considered reliable, which means the results obtained are consistent with the results obtained by the SIS authors, plus or minus an acceptable error rate.
21. Will providers have access to a member’s SIS assessment?
Yes, providers will have access to the SIS assessment from the Managed Care Organization (MCO) or from the CM for Fee-for-Service (FFS).
22. How are SIS assessments appealed?
There is no adverse action with the completion of a SIS assessment. As such, there are no appeal rights.
23. Will previously completed SIS assessments be made available in a paper format?
No, but the information will be available in an electronic format. The information will include a spreadsheet of the SIS scores, but not the actual SIS assessment.
24. How will current individual member SIS information be sent to providers?
Initial SIS scores will be sent to providers from the MCOs and from IME for the member they manage.
25. How will future SIS assessment information be shared with members, guardians and providers?
SIS data files will be shared with providers through each MCO and FFS case manager.
26. Will SCL providers continue to submit cost reports after the transition to the tiered rate methodology?
Yes, however, the cost report process is being modified/simplified as the purpose will change from reconciling costs to informing on the tiered rates. The SCL cost report will continue for those programs/services not being paid through the tiered rate methodology
27. Will the provider indirect administrative costs be limited to 20 percent?
The 20 percent indirect administrative costs were limited to services provided through the retrospectively limited prospective rate rules in 441— 79.1(15). The SCL ID waiver service has been removed from this rule and as such, the 20 percent indirect administrative costs do not apply.
28. Will Residential Care Facilities (RCF) rates be phased in?
Yes. RCF providers will be notified of the individual provider phase-in RCF rate.
29. How will changes in reimbursement rates be communicated to providers affected by the Daily SCL transitional rate phase in?
Providers affected by transitional tiered rates will be notified of the initial tiered rates assigned to the provider, as well as the progressive transitional rates (both increase and decrease) that will take effect on July 1, 2018. Full implementation of tiered rates for all providers will be effective July 1, 2019.
30. Will providers have input into the SIS assessment?
The provider is encouraged to participate in the SIS assessment process.
31. What are the options if a provider determines that it cannot serve a member at the assigned reimbursement rate?
Tiered reimbursement rates for each tier have been calculated based on historical costs for members that have similar acuity levels. Rates are designed to meet member needs, and provide sufficient funding to serve all members that a provider serves.
32. For Day Habilitation – Are the tiered rates going into place regardless of age (i.e., 16-18 year olds as well)?
Yes. Day Habilitation is available to members age 16 and older. If a 16+ year old is accessing Day Habilitation, they must have a SIS – A completed to determine the tier assignment. The SIS – A is available for use with members age 16 and older. If a member has a current SIS – C completed but is not scheduled for a full SIS assessment and is requesting Day Habilitation services, a full SIS – A must be completed to determine the tiered rate for Day Habilitation services
33. What is the scoring matrix for placement into a tier?
Access the document , "Scoring Matrix for Placement into the Home and Community Based Services (HCBS) Intellectual Disability (ID) Waiver Tiered Rates Fee Schedule".
34. Why does the code S5136 on my authorization list a description of Companion Care when the service is Supported Community Living?
The new service code S5136, is what Iowa Medicaid Enterprise assigned to SCL services "with" day services. This is a nationally recognized code and we are unable to change the standard code description.
35. What does the inclusion of HCBS Waiver transportation in the daily SCL tiered rate mean to SCL providers?
Tiered rate reimbursement for daily SCL includes the cost of all transportation unless paid through the Non-Emergency Medical Transportation (NEMT) state plan benefit or the local school system for members accessing RBSCL services. Transportation can no longer be billed separately for members receiving daily SCL.
36. Is the cost of HCBS Waiver transportation included in the tiered rates reimbursement for daily SCL?
Yes. When tiered rates were developed, the cost of all transportation of members accessing daily SCL was identified and incorporated into the final tiered rates. This includes approximately $3M that was included by providers as part of the $1570 funds in the daily SCL rates as well as approximately $10M in waiver transportation service costs associated with members receiving daily SCL services.
37. Can a provider charge a member for transportation costs associated with the provision of daily SCL?
Only HCBS Waiver transportation that is identified in the member's service plan is required to be paid by the provider. Transportation provided outside of what is identified in the member's service plan is not required for payment by Medicaid. Arrangements for transportation between the member and provider may occur.
38. How will the HCBS Waiver transportation provided by the SCL provider interfere with transportation provided by the employment provider?
Some HCBS Waiver services, like supported employment may include the cost of transportation in the service reimbursement rate. When transportation is provided through the SE service, the SCL provider would not be responsible for paying.
39. If a member uses paratransit for HCBS Waiver transportation, who pays?
If the member is accessing daily SCL services in the ID waiver, it is the responsibility of the SCL provider to pay for the cost of HCBS Waiver transportation directly to paratransit if it is identified in the member's service plan.
40. For providers who will not immediately go to tiered rates, but will be part of the phase in, what was the phase in rate based?
The percent up or down is based upon the historical revenues the provider has been paid for the provision of daily SCL services.
41. Were the most recent SIS assessments used for the initial tier assignment?
Yes, the most recent full SIS assessment has been used for initial member tier assignment.