fundamentals of plan of care development

• AFTER the client is assessed, the case

manager develops a Plan of Care and submits

it for approval.

• The CM revises the POC as the client’s

needs change (Section 12) .

• Only the CAP/DA services approved in the

POC may be provided.

NOTE:NOTE: Providers may begin services before the

POC is approved if they are willing to risk that Medicaid may not pay. If the client is not eligible for MID on the date of

service, the client is not approved for CAP/DA, or the service is not approved in the Plan, MID will not pay

for the service.

• Summarizes the assessment into how

needs are to be met / Outlines the goals

and objectives / Indicates the specific

services needed.

Initial PlanInitial Plan = No more than 5 days

after the appropriate parties sign AND

no later than 60 days after the

FL-2 approval date.

•CNRCNR = No more than 5 days after parties

sign AND no later than the 5th day of the month

following the CNR month.

•RevisionsRevisions = Should be approved before

the change is made BUT can be approved

retroactively for up to 30 days. No more than 5

days after the parties sign.

• Consult those involved in client’s care /

Formal and informal services must meet needs

identified by assessment / Must include CM

activities (assessment and ongoing), CAP

waiver services, regular Medicaid community

services, and other community care services.

• Initial New = Date the 1st service (other than the initial assessment) is to be provided. May be no earlier than the CAP effective date and no later than 60 days after the FL-2 approval date.

• Initial Returning = Date the first service is to be provided after completing the initial returning assessment.

CNR = No earlier than the first day of the CNR month and no later than the first day of the month following the CNR month.

When the1st service is effective AFTER the completion of the CNR assessment

If no changes to POC, use the 1st of the month following the CNR month

If changes to POC, use date of the change

•Revision = Date of the change. No earlier than 30 days prior to the local approval date.  

•Pen and Ink Changes = For cases with change in provider or cost.

Re-compute the cost summary; if the MID cost remains within the monthly limit, no local approval is required. Enter date when the Pen and

Ink change is effective.

**Don’t forget to select the LOC**

Reasons for revisionReasons for revision Select all that apply

Increase, decrease, new, delete in Waiver and regular Medicaid services

Change in rate and provider for Pen and Ink Changes

Change in payor

Transfer

Use “Other” when none of the other choices apply

• Minimum of one goal must be listed

• Usually involve maintaining

and /or improving the client’s

health, safety, functioning

and independence.

Examples of Goals:

• Maintain client’s health, safety, and well being at home.• Extend client’s socialization.• Maintain current level of independence as much as possible.• Prevent potential skin breakdown due to decreased mobility and occasional incontinence.• Maintain an optimal level of health.• Reduce caregiver stress.

• Individuals or organizations providing support.

• Phone numbers are optional.

• Give “approximate” age of individuals.

• For formal support, may list the agency name instead individual; age is not required.

Support CodesSupport Codes• 16 choices

• Choices 1-10 (relatives), indicate if a paid caregiver

TasksTasks•Select all specific tasks each support entry provides.

•May select “All”.

AvailabilityLives with client?

Client’s emergency contact?

ChoicesChoices • PRN – No times necessary

• Other – Lists days and times

• 24/7 – No further entry of days / times required

24 Hour Calendar

• Use when the assessment (Section P) indicates the client cannot be left alone.

• Shows who will provide coverage at what times.

• Must correlate to the formal and informal services previously listed.

• Divide the day into timeframes that flow one into another.

• Write the hours covered each day (24 hr. period), beginning at midnight and ending at midnight, and tell who is covering them.

Sunday12 –

10 amMay

B. Tall10 am – 12 pm IHA

12 – 5 pm

Goldie Locks

5 – 12 pm

May B. Tall

Monday12 – 8

amMay B.

Tall

8 am –

12 pmIHA

12 – 5 pm

May B. Tall

5 – 6 pm

B. Tall 6 – 10 pm

I. S.

Tall

10 pm – 12 am

May B. Tall

Tuesday12 – 7

amMay B.

Tall7 – 8

am IHA8 am

– 4 pm

ADH

4 – 10 pm

Gloria Highest

10 pm – 12

am

Bay B.

Tall

Wednesday Same As Monday

Thursday Same As Tuesday

Friday Same As Monday

Saturday Same As Sunday

Shows:Shows:

• CAP and other services

• How long they’ll be provided

• Who provides them

• Who pays for them

• What they cost

Where to get Where to get info:info:

• DMA fee schedules

• DME fee schedules

• Home Health Supply lists

ServicesServices:

• First line is always case management assessment (Total includes home visit, and time entering into AQUIP in the assessment section) divided by 12.

• Second line is always for monthly Case Management (estimate).

• Use a separate line for each of the other services.

CodeCode:• Procedure code for CAP services

• Revenue code for HH services

• Applicable codes for all other Medicaid services

Purchase / Rental Choice:Purchase / Rental Choice:

• Use for DME items

Provider Agency:Provider Agency:

• Agency that will provide and bill for the service.

• Must be enrolled with DMA.

CM assessment = Hours/YearMonthly CM = Hours/MonthIHA = Hours/WeekTelephone Alert = 1 Each Month Home Mob. Aids = 1 Each YearDME purchased = 1 Each Year DME rental = 1 Each MonthSkilled Nursing = Visits/Month (or Week)

QuantityAnticipated Quantity and Frequency

Therapies = Visits/Week (or Year)

Short term int. serv.= Days/Week (or Year)

Medical Supplies = Units/Month

Instit. Respite = Days/Year

In Home Respite = Hours/Year

Hospice = 1 Each Day

Waiver supplies = Units/Month *

Diabetic supplies = Units/Month *

*Waiver Supplies (based on the way it’s billed)

• For billing of Enteral Formulas, 100 calories = 1 unit.

• Units/Month: Take calories / can divided by 100 (calories) = units /100 calories.

• Then take units /100 calories x cans / month = Units/Month.

ExampleExample: MD orders 30 – 8oz cans of

Ensure Plus each month.

• Ensure Plus has 355 calories / can.

• 355 divided by 100 (calories) = 3.55.

• 3.55 x 30 cans/month = 106.5 units / month.

*Diabetic Testing Supplies: (Examples Handout):

• Based on 1 unit of lancets = 100/box.

• 1 unit of strips = 50/pkg.

Find the portion of those units for the

“Units / Month”

From Date / To Date:From Date / To Date:• Use for DME, Home Mobility Aids, and Short term intensive services.• Can also use for Institutional and In Home Respite.

 For Purchased DME and HMA:For Purchased DME and HMA:• Enter the first and last month / year of the pro-ration period.Example: 11/2003 – 10/2004• The first month is the month the item was provided.

For Rental DMEFor Rental DME• Enter the anticipated start and end dates of the rental (usually 15 months if the client has Medicare and Medicaid; usually 10 –12 months for MID only clients)

Example: 3/2006 to 5/2006

For Short-term Intensive ServicesFor Short-term Intensive Services• Enter the anticipated starting and ending dates of service

Example: 11/12/2003 to 12/12/2003

*Total number of day from the first to the last may not exceed 60 calendar

days

Unit RateUnit Rate• Rate that will be reimbursed by Medicaid in direct relationship to what is shown in the Quantity column.

Example: if frequency is in hours, show the cost /

hour.*The amount shown is either the amount

charged by the provider OR the maximum MID allowable charge,

whichever is LESS.

Nutritional Supplements Nutritional Supplements by Mouth by Mouth:

• Unit Rate: = Avg. monthly cost

divided by units/month.

• Our Ensure Plus example: $41.70 divided by 106.5 units/mo. = .39 (per 100 cal.).

(MID max = .53 per 100 cal.)

*Average Monthly Cost* • To convert weekly into monthly costs multiply by 4.3• CM assessment is pro-rated for 12 months (or otherwise) • Monthly CM is calculated “straight out”• Purchased DME and HMA are pro-rated (12 months or otherwise) carried over to revisions throughout the pro-ration period.

Examples: Bed rails purchased in 11/2003

Reimbursement = $157.82 divided by 12 months = $13.15/month. Stays on POC

from 11/2003 to 10/2004

 Short-term Intensive Services’Short-term Intensive Services’• Pro-rate the total cost for 12 months (or otherwise)

Example: PT is provided 2 x week

for 60 days, at $90.26 / visitTotal = $1444.16 divided by 12 = $120.35

NOTE: A POC revision just to delete the DME monthly pro-rated cost at the end of the pro-ration period in NOT necessary. Costs can be deleted

IN THE NEXT REVISION after the end of the period.

• Include in all revisions for the pro-ration period; delete in the 1st revision after that.

• Use a separate line each time a STIS is added.

Institutional Respite and In Home Respite are pro-rated

•Use a separate line each time a new round is added.

 Diabetic testing supplies:• Lancets:Lancets: Units / month x $12.06 (unit rate) = avg. monthly cost .• StripsStrips:: Units / month x $33.94 (unit rate) = avg. monthly cost.

• Medicare pays 80%, Medicaid pays 20%.(Only Medicaid

Pays For Insulin Syringes)

Waiver Supplies (Lead Agency Provided Services

handout)• Your cost (what you pay the supplier) + delivery charges + taxes + 10% overhead.

• Must not exceed the MID max. Reimbursement Rate.

• Cost on POC should match the invoice.

*Nutritional supplements by Mouth Sample Worksheet

Lead Agency Medical Supplies:• Your cost (What you pay the supplier + deliver charges + taxes + 10% overhead.

RestrictionRestriction: Must not exceed the MID max. on the HH Supply Schedule.

Example:Diapers cost $44.91/case (includes delivery charge; 80 diapers/case)

• $44.91 + $3.14 (7% tax) + 4.81 (10%) = $52.86

• $52.86 divided by 80 diapers = .66 each (MID max. reimb. = .90 each)

• Hospice (Must be paid for by Medicare) :

Unit rate x 31 days.

Example: $115.16 x 31 = $3569.96

(Under “Service” write Hospice and list the

services provided, ex. “Nursing, diapers,

underpads, hospital bed”.

Using the appropriate column:• Medicaid is the payor of last resort

• Services paid by a third party must be billed to that party first

• General rule: If Medicare is the primary funding source for DME, Medicare pays 80% of the Medicare allowable, and Medicaid will pay 20%.

Also keep in mind if Medicare or private

insurance pays LESS than

Medicaid’s reimbursement rate,

Medicaid can only be billed the difference

between the third party

payment and the

Medicaid maximum.

Example: An Agency Charges $125

for a DME Item

• The Medicaid max is $110 and Medicare only pays $100

• Only $10 may be billed to Medicaid (difference between the Medicare reimbursement and Medicaid max).

Other Costs/S (Source of PaymentOther Costs/S (Source of Payment)

• 10 choices• Title XX = Social Services Block Grant Program

• Title III = Aging

• Local funds = locally raised such as public funds, private agency funds, amounts obtained through community projects, and similar sources.

Use codes 9 and 10 if a source is not listed

If there are multiple sources, list the one that will pay the larger portion.

CAUTION: The client may not be listed as

the funding source for any service that is covered by

Medicaid. CAP/DA services, DME, and all Community Care Services are

Medicaid covered services

Signed by client or representative before initial or continuing participation may be approved.

• Certain POC revisions require client signature.• If client signature isn’t required, select that choice.• If client is unable to comprehend the statement, have it read by whomever is acting on client’s behalf.• If client is unable to sign, the representative can sign for him/her.

• If client signs by a mark, must be witnessed by someone OTHER THAN the CM. Preference is a family member or other individual chosen by the client.

Client’s Signature Indicates the Client:

• Has been given the option of nursing home placement.

• Has chosen CAP instead.

• Agrees to the POC.

• Has been informed of the right to appeal.

• CM signs ALL POCs.

• Optional - Signatures of parties providing informal support (primary caregiver) may be obtained after getting the client’s permission.

• One can’t sign a POC as both the case manager and the approval authority

• (DMA currently completes the local approval for 3 counties)

• Required Action on Changes.

• Change in the cost that exceeds the cost limit.

• If you add, reduce, increase, or delete service.

• Exceptions are temporary, one time changes.

• Remember to follow correct procedure for reductions, terminations, or denials of CAP services.

REVISING THE POC (CAP Manual Section 12)