Provider Update

Provider Update

The APD emergency rate reduction to provider rates will end at midnight, April 15.Provider rates returned to their March 2011 levels effective Saturday, April 16.

Rates for services provided between April 1 and April 15 will remain at the reduced rate.

To keep from issuing over 150,000 new service authorizations,APDis updatingcurrent service authorizationsfor April 1 – June 30, 2011. These service authorizations will have an approved/authorized amount based on the reduced rate for services provided between April 1through April 15 and the original (higher) rate for services from April 16through theservice authorization end date.

Changed service plans will be available in ABC by close of business Monday,April 18, 2011.

Service authorization requests will be submitted to FMMIS the evening of April 18. Service authorizations are anticipated to be available Tuesday,April 19.

Billing is suspended until system changes are complete. APD anticipates that service authorizations will be available to Waiver Support Coordinators on Tuesday,April 19. The WSC must review and distribute these service authorizations. Once a provider has received a service authorization, they may begin billing for April services.

If you have any questions or problems with your service authorization, Area Office staff can answer questions and make corrections to service plans.

A.Rates

The rate shown on the service authorization will be the original (higher) rate. The approved/authorized amount on the service authorization may not be equal to the original (higher) rateshown on the service authorization multiplied by the number of units. The service authorization may show an amount slightly less than theoriginal rate multiplied by the number of units because of the reduced rate used for services provided betweenApril 1 and April 15, 2011.

When billing for April,please remember to reduce the amount billed for services provided between April 1 and April 15, 2011.

Because of the rate change, services (other than monthly) should be billed daily by date in April. Please do not “roll-up”service rates used after April 15 with services provided during the April 1 through April 15 period.

B.Service Scenarios

The sections below describe how reduced rate service authorizations will be handled to increase the rates.

Use at least three digits to the right of the decimal point when performing these calculations.

1.Service Plans with Approved Amountsless than or equal to $1.00 or Rate equal to $0.00:

Service Plans with Approved Amount less than or equal to $1.00 or Rate equal to $0.00 will not be updated by this process.

2.Monthly Services (One unit per month billed)

Services that are billed once per month must be prorated for the month of April. This means that a monthly rate must be a blend between the reduced rate (April 1-15) and the original (higher) rate (April 16-30).

The services below will be handled as follows:

For April,

The reduced rate will be multiplied by 50% (.5).

The original (higher) rate will be multiplied by 50% (.5).

These two rates will be added together to getthe blended rate for April

Each remaining month (May and June) will be billed at the original (higher) rate

New Service Authorization Amount is equal to the April blended rate plus the May and June rates

Example:

Reduced rate = $85, Original (higher) rate = $100, authorization period 4/1/2011-6/30/2011

For April,

$85 x .5 = $42.50

$100 x .5 = $50

$42.50 + $50 = $92.50 (blended amount for April)

92.50 (April) + 100 (May) + 100 (June) = $292.50 New Service Authorization Amount (April-June)

Monthly Services

Res Hab Basic – Standard - Monthly

Res Hab Ext 1 - Standard - Monthly

Res Hab Ext 2 - Standard - Monthly

Res Hab Min - Standard - Monthly

Res Hab Mod - Standard - Monthly

Support Coordination - Limited

Support Coordination - Full

Support Coordination – Transitional

Support Coordination CDC+ - Limited

Support Coordination CDC+ - Full

The following blended rates can be used for billing April monthly services.

Support Coordination and CDC Consultant (Non- Geographical, Geographical and Monroe)

Full$121.13

Limited$60.57

Trans.$293.13

Residential HabilitationStandard - Monthly (Non-Geographical)

Behavior Focused

Basic$1,058.67 N/A

Minimal$2,115.44 $2,243.05

Moderate$3,174.37 $3,349.73

Extensive Level 1$4,270.00 $4,526.84

Extensive Level 2$5,609.10 $5,947.02

Residential Habilitation Standard - Monthly (Geographical)

Behavior Focused

Basic$1,137.98 N/A

Minimal$2,274.08 $2,411.40

Moderate$3,412.60 $3,617.91

Extensive Level 1$4,590.24 $4,866.23

Extensive Level 2$6,030.38 $6,392.98

Residential Habilitation Standard - Monthly (Monroe County)

Behavior Focused

Basic$1,270.18 N/A

Minimal$2,538.74 $2,691.45

Moderate$3,809.19 $4,038.51

Extensive Level 1$5,123.88 $5,432.26

Extensive Level 2$6,731.30 $7,136.53

3.Unit Based Services

These services must use the reduced rate between 4/1 and 4/15, 2011. The higher rate will be usedfor these services between 4/16 and 4/30, 2011. All May and June services will be billed at the higher rate.

The services below will be handled as follows:

Calculate number of days between service authorization begin date and 4/15/2011 equal the Reduced rate days (DaysReduced)

Calculate the number of days between 4/16/2011 and service authorization end date equal the remaining days (DaysRemain)

DaysReduced plus DaysRemain equal theDays in the Service Authorization (DaysSA)

Service Authorization Approved Amountdivided by reduced rate is equal thenumber of units (Units)

Units divided by the DaysSA equal theunits per day (UnitsDay)

UnitsDay multiplied by DaysReduced multiplied by reduced rate is equal the4/1/2011-4/15/2011 amount (ReducedAmt)

UnitsDay multiplied by DaysRemain multiplied byoriginal (higher) rateequal the4/16/2011-end of Service Authorization Amount (RemainingAmount)

ReducedAmt plus the RemainingAmount equal theNew Service Authorization Amount

Example:

Reduced rate = $85, Original (higher) rate = $100, Period 4/1/2011-6/30/2011, Amount $8500

4/1/2011 – 4/15/2011 = 15 (DaysReduced)

4/16/2011 – 6/30/2011 = 76 (DaysRemain)

15 + 76 = 91 (DaysSA)

$8500 / $85 = 100 (Units)

100/91 = 1.0989 (UnitsDay)

1.0989 * 15 * $85 = $1401.0975 (ReducedAmt)

1.0989 * 76 * $100 = $8351.64 (RemainingAmount)

$1401.0975 + $8351.64 = $9752.7375 (New Service Authorization Amount)

Unit Based Services

In - Home Supports (Live-In Staff)

Res Hab Basic - Standard - Daily

Res Hab Ext 1 - Standard - Daily

Res Hab Ext 2 - Standard - Daily

Res Hab Min - Standard - Daily

Res Hab Mod - Standard - Daily

Residential Habilitation - (Live In Staff) - Daily

Respite Care - Day

Adult Day Training - Facility Based

Adult Day Training - Off Site

Behavior Analysis Level 1

Behavior Analysis Level 2

Behavior Analysis Level 3

Behavior Assistant Services

Companion

Dietitian Services

In - Home Supports (Awake Staff)

Occupational Therapy

Personal Care Assistance

Physical Therapy

Private Duty Nursing - LPN

Private Duty Nursing - RN

Residential Habilitation - (Quarter Hour)

Residential Nursing Services - LPN

Residential Nursing Services - RN

Respiratory Therapy

Respite Care - Quarter Hour

Skilled Nursing - LPN

Skilled Nursing - RN

Specialized Mental Health - Therapy

Speech Therapy

Supported Employment Group

Supported Employment - Individual Model

Supported Living Coaching

4.Services Reduced by a flat 15 percent

The services below will be handled as follows:

Calculate number of days between service authorization begin date and 4/15/2011 equal the Reduced rate days (DaysReduced)

Calculate the number of days between 4/16/2011 and service authorization end date equal the remaining days (DaysRemain)

DaysReduced plus DaysRemain equal the Days in the Service Authorization (DaysSA)

Service Authorization Approved Amount divided by reduced rate is equal the number of units (Units)

Units divided by the DaysSA equal the units per day (UnitsDay)

Reduced rate / .85 = original (higher) rate

UnitsDay multiplied by DaysReduced multiplied by reduced rate is equal the 4/1/2011-4/15/2011 amount (ReducedAmt)

UnitsDay multiplied by DaysRemain multiplied by original (higher) rate equal the 4/16/2011-end of Service Authorization Amount (RemainingAmount)

ReducedAmt plus the RemainingAmount equal the New Service Authorization Amount

Example:

Reduced rate = $85, Period 4/1/2011-6/30/2011, Amount $8500

4/1/2011 – 4/15/2011 = 15 (DaysReduced)

4/16/2011 – 6/30/2011 = 76 (DaysRemain)

15 + 76 = 91 (DaysSA)

$8500 / $85 = 100 (Units)

100/91 = 1.0989 (UnitsDay)

$85 / .85 = 100 (original (higher) rate)

1.0989 * 15 * $85 = $1401.0975 (ReducedAmt)

1.0989 * 76 * $100 = $8351.64 (RemainingAmount)

$1401.0975 + $8351.64 = $9752.7375 (New Service Authorization Amount)

Services Reduced by a flat 15 percent

CONSUMABLE MEDICAL SUPPLIES

IN HOME SUPPORTS MONTHLY - S.L.WAIVER

Personal Emergency Response - Service

Res Hab Basic - Behavior Focus

Residential Habilitation - (Day) Intensive Behavior in a Licensed Facility

Special Medical Home Care

Transportation - Mile

Transportation - Month

Transportation - Trip

5.One time or infrequent services

The services below will be handled as follows:

A list of these service authorizations is being provided to the Area Offices. Changes for these services will be handled manually by the Area Offices

Services

Adult Dental Services

Behavioral Analysis Services Assessment

Durable Medical Equipment

Environmental Accessibility Adaptations

Home Accessibility Assessment

Occupational Therapy Assessment

Personal Emergency Response - Installation

Physical Therapy - Assessment

Respiratory Therapy Assessment

Specialized Mental Health - Assessment

Speech Therapy - Assessment

6.Special Case for Res Hab Behavior Focus

The services listed below have the same procedure code of either "T2020U6" or "T2023U6" in the Rate table. However Res Hab Basic – Behavior Focus does not have assigned rates as this service comes under services with negotiated rates.Because this service is handled differently than the other services with the same procedure codes it is necessary to handle these services differently. The business rule being applied is:

a) Take the pre-April 1 ABC service plan original (higher) rateand compare it with all the rates available in the original (higher) rate table.

b) If a perfect rate match is found for theprocedure code and rate, the matched rate will be used in the current service plan. Otherwise the ABC original service plan rate will be used in the current service plan.

Services

Res Hab Basic - Behavior Focus - Monthly

Res Hab Ext 1 - Behavior Focus - Monthly

Res Hab Ext 2 - Behavior Focus - Monthly

Res Hab Min - Behavior Focus - Monthly

Res Hab Mod - Behavior Focus - Monthly

Res Hab Basic - Behavior Focus - Daily

Res Hab Ext 1 - Behavior Focus - Daily

Res Hab Ext 2 - Behavior Focus - Daily

Res Hab Min - Behavior Focus - Daily

Res Hab Mod - Behavior Focus - Daily

C.Things to Know

One time or infrequent services are being handled manually

Units may not be used on a daily basis so the calculated amount may not be correct

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