Relative as Direct Support Employee (RDSE)

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2 Relative as Direct Support Employee (RDSE) Network Management

3 AGENDA The Policy NC Innovations Waiver Amendment Specific to RDSE New Employees Existing Employees Services Responsibilities Application: Verification of Relative/Legal Guardian as Direct Support Employee Q & A

4 THE POLICY: NC INNOVATIONS WAIVER RELATIVE AS PROVIDER POLICY The Relative as Provider Policy (RDSE) applies to members ages 18 and older. Members under the age of 18 may not receive services provided by a relative who is residing in their home. The Relative must be qualified to render Community Living and Support. The RDSE applies to Relatives who live in the home of the member and are employed by a waiver provider agency. Relatives are defined as individuals related to the member by blood or marriage. It is recommended that a Relative residing in the home of the member provide no more than 40 hours per week of services to the member.

5 NC INNOVATIONS WAIVER AMENDMENT SPECIFIC TO RDSE The NC Innovations Waiver Amendment became effective November 1, Relatives employed through the RDSE process, working 40 hours per week or less, must be reported to the LME- MCO, but do not require approval by the LME-MCO. If more than 40 hours per week are requested to be provided by the Relative residing in the member s home, then approval must be obtained by the LME-MCO.

6 NEW EMPLOYEES 40 hours or less Applications will not be submitted to Cardinal Innovations when requesting 40 hours or less per week. Providers will report all new employees working 40 hours or less per week to Cardinal Innovations. Reporting is available on Cardinal Innovations website via an electronic tool. Providers should report all new employees as soon as the hiring agreement is final and before services are rendered.

7 NEW EMPLOYEES 40 hours or less The following information will be required when reporting new employees: Provider Agency Name Relative First Name Relative Last Name Member First Name Member Last Name Member Date of Birth County in which Member s Medicaid originates Provider s address

8 NEW EMPLOYEES 40 hours or less Providers will be required to attest to the following statements: The Relative lives in the member s home. The Relative will work 40 hours or less per week. The prospective employee understands that the Provider Agency/Employer of Record will monitor the service that a Relative provides each month on-site, at a minimum of one time per month. The prospective employee understands that Cardinal Innovations Care Coordinator will monitor the Relative provision of services on-site, at a minimum of one time per month.

9 NEW EMPLOYEES 40 hours or less Providers will be required to attest to the following statements: The prospective employee will provide Community Living and Support. Payments are only made for services in the Individual Support Plan (ISP) authorized by the Cardinal Innovations Utilization Management Department. The Relative must meet the provider qualifications for the service. The provider certifies that there is documented training for the specific medical task by a professional appropriately qualified in the task or equipment and that the employee receives nursing supervision to carry out this function as specified by the NC Nursing Practice Act. The Provider will train all staff, including the Relative, providing medical tasks.

10 NEW EMPLOYEES Providers will receive a secure, electronic acknowledgement of receipt. Verify the address for accuracy and keep a copy for your records.

11 NEW EMPLOYEES 41 to 56 hours Complete the Application Verification of Relative as Direct Support Employee. The provider will receive a decision letter. Approvals are typically effective through the day before the member s date of birth (DOB) of the following year or the current year, depending on when the application is submitted. Per the NC Innovations Waiver Amendment, new employee requests will be capped at 56 hours per week.

12 EXISTING EMPLOYEES 40 hours or less Applications will not be submitted to Cardinal Innovations when requesting 40 hours or less per week, but must be reported via the electronic tool. Continued employment of Relatives requires annual recertification. To request annual recertification, providers will report all existing employees working 40 hours or less to Cardinal Innovations via the electronic tool, 45 days prior to the member s birth date. If the employee is not recertified before the expiration date, the Provider may be subject to a potential payback.

13 EXISTING EMPLOYEES 41 to 56 hours An application is required for annual recertification 45 days prior to the member s birthday. Complete the Verification of Relative/Legal Guardian as Direct Support Employee. The provider will receive a decision letter from Cardinal Innovations. Approvals are typically effective through the day before the member s next birthday. Per the NC Innovations Waiver Amendment, requests for an increase over 56 hours will not be approved.

14 EXISTING EMPLOYEES Existing employees approved and rendering 56 hours per week or more as of December 31, 2015 Relatives who were approved, and providing more than 56 hours of services on December 31, 2015 may be grandfathered to provide the amount of services that they were approved to provide as of December 31, 2015, as long as The member continues to choose the Relative as the staff member There are no health or safety issues The member is not isolated from his/her community. Requests for an increase over the previously approved grandfathered hours will not be approved.

15 EXISTING EMPLOYEES Existing employees approved and rendering 56 hours per week or more as of December 31, 2015 Reminder: Providers and employees are held to the same Health and Safety requirements regardless of number of hours worked. The RDSE Application Review process does not assess medical necessity nor influence the contents of the ISP.

16 AT-A-GLANCE HOURS PER WEEK Per Employee New Employee Application Required? 40 hours or less NO Existing Employee (already approved through the RDSE process for your agency) Annual recertification Application Required? NO Report via Electronic Tool Report via Electronic Tool 41 to 56 hours YES YES 57 hours and above Not allowed, per the NC Innovations Waiver Amendment YES Applicable only to those approved by 12/31/2015. IMPORTANT: Requests for increase in hours (above 56 hours) are not allowed per the NC Innovations Waiver Amendment.

17 COMMUNITY LIVING AND SUPPORT Per the NC Innovations Waiver Amendment effective November 1, 2016, Community Living and Support is the only service that Relatives can render through the RDSE process.

18 Relative as Direct Support Employee Responsibilities Electronic Tool Application Questions & Answers

19 RESPONSIBILITIES: CARDINAL INNOVATIONS Network Management Thoroughly review Timely correspondence

20 RESPONSIBILITIES: CARDINAL INNOVATIONS Utilization Management (UM) Monitoring Determines Medical Necessity for the service requested. UM does not approve the provider. Verifies Waiver Compliance to ensure that the Waiver is operated as intended. Conducts Utilization Reviews to ensure best practices/promising practices are being followed. The RDSE Application Review Process does not assess Medical Necessity nor influence the contents of the ISP.

21 RESPONSIBILITIES: CARDINAL INNOVATIONS Care Coordination Monitoring Monthly Face-to-Face Health & Safety of Member Compliance with the Waiver Examples: Member s needs met; Relative not burned out Member getting services per the ISP Agency back-up staff As needed, confer with Quality Management (QM) regarding qualifications Care Coordinator may link family to Community Navigator to assist with identifying natural/unpaid supports

22 RESPONSIBILITIES: CARDINAL INNOVATIONS QM Monitoring Assess Paybacks Non-compliance with the RDSE policy or process may place the provider agency at risk of a potential payback If a Relative provides services before they are approved through the RDSE process Annual Recertification not submitted Complaint Investigations Investigate Health & Safety issues when received Routine Monitoring (i.e., Provider Performance Profile)

23 RESPONSIBILITIES: PROVIDERS Provider Agency = Employer Anything that applies to your regular employees also applies to a Relative when you are employing them through the RDSE Process. Employment Law: It is the provider agency s responsibility to comply with Employment Law, which also applies to Relatives under the RDSE policy.

24 RESPONSIBILITIES: PROVIDERS Payments: Only for service authorized in the ISP Only for service rendered Report or complete the application and obtain original signatures The Relative does not complete the application The Care Coordinator does not complete the application

25 RDSE Application and Electronic Reporting Tool

26 APPLICATION and ELECTRONIC TOOL: LOCATION s/network-providers

27 APPLICATION & ELECTRONIC TOOL: LOCATION s/network-providers/relative-as-directsupport-employee

28 ELECTRONIC TOOL Applications will not be submitted to Cardinal Innovations when requesting 40 hours or less per week, but must be reported via the electronic tool. CLICK HERE TO VIEW THE ELECTRONIC FORM

29 APPLICATION: VERIFICATION OF RELATIVE/LEGAL GUARDIAN AS DIRECT SUPPORT EMPLOYEE If more than 40 hours are requested to be provided by Relatives residing in the member s home, then approval must be obtained by Cardinal Innovations. Employment-based justification must be provided as to why there is no other qualified provider to provide Community Living and Support. In exceptional situations, up to 56 hours per week may be approved. This is the total number of hours that one Relative may provide regardless of the number of members residing in the home.

30 APPLICATION: VERIFICATION OF RELATIVE/LEGAL GUARDIAN AS DIRECT SUPPORT EMPLOYEE Application (41-56 hours) Complete Type or Print Clearly Original (no faxes, no s) Only one relative per application Most current applications are on Cardinal Innovations website at:

31 APPLICATION: VERIFICATION OF RELATIVE/LEGAL GUARDIAN AS DIRECT SUPPORT EMPLOYEE - GENERAL Justification must be complete and be employmentbased. Examples: No personnel are available with the appropriate skills/training to provide the authorized service. No personnel are available during the hours when the service is needed.

32 Examples of Common Questions

33 COMMON QUESTIONS What is the definition of a relative as it relates specifically to RDSE? Per the NC Innovations Waiver Amendment: Relatives are defined as individuals related by blood or marriage to the member. The relative must live in the home of the member. Excluded from this policy are the following relatives: biological or adoptive parents of a minor child, stepparents of a minor child or the spouse of a member.

34 COMMON QUESTIONS If a current application is approved for more than 56 hours per week under the existing Waiver, and a future application requests additional hours (under the NC Innovations Waiver Amendment) will this be approved? No, this will not be approved.

35 COMMON QUESTIONS What if two parents in the same home are rendering services to the same member? Each parent can provide up to 56 hours each; however, the total number of hours may not exceed the number of hours approved in the member s ISP.

36 COMMON QUESTIONS What if one parent is rendering services to two or more members? Can the parent work 56 hours for each member? No. The parent can provide a total of 56 hours. If there are two members, then two parents, or one parent and an additional staff person must render the service.

37 COMMON QUESTIONS If a Relative was approved to render services for more than 56 hours per week as of 12/31/2015, and they change provider agencies, will they be grandfathered to continue to work the same amount of hours with the new provider agency? Yes, those hours may carry over to the new agency; however, the Provider Agency still has the discretion to make a business decision on whether it is appropriate for the Relative to continue working those same hours.

38 COMMON QUESTIONS Once a Relative is reported using the electronic tool or approved to render services under the RDSE policy, can another Relative pick up those hours if the approved Relative dies or otherwise can no longer render services to the member? No. Approved hours (including any grandfathered hours) are nontransferrable. The new employee could be approved to work a maximum of 56 hours per week if certain conditions are met. The new employee (includes those coming from another provider agency) has to be reported or receive approval before rendering services.

39 COMMON QUESTIONS What about Residential Supports? The RDSE policy applies to relatives providing services to members in the members homes. The RDSE policy does not apply to licensed and unlicensed facilities (group homes or AFLs), as these settings are provider-operated. If the member is receiving services in his/her own home, Residential Supports should not be billed. The only service that Relatives may render under RDSE is Community Living and Support. The RDSE policy does not impact members who have left their parent s home and now live with Relatives who are not their parents, step-parents, or adoptive parents. This living arrangement would be considered an Alternative Family Living setting (AFL).

40 HELPFUL TOOLS ON WEBSITE Electronic Tool (40 hours or less) Verification of Relative/Legal Guardian as Direct Support Employee Application (41-56 hours) RDSE Specific Communication Bulletins NC Innovations Waiver Tips

41 PLEASE REMEMBER Remember: Relay information to all staff who submit RDSE applications or are responsible for reporting QP Staff Provider Members/ Family

42 PLEASE REMEMBER Application: Complete and legible Most current application is on Cardinal Innovations website Timely submission (immediately upon new hire; recertification 45 days prior to DOB)

43 PLEASE REMEMBER Mail applications to: Cardinal Innovations Healthcare Attn: Network Management 550 South Caldwell Street Suite 1500 Charlotte, NC 28202

44 RDSE CONTACT Questions to: with the Subject Line: RDSE QUESTION