DIRECT PURCHASE OF SERVICE STANDARDS
Contract Guidelines & General Operating Standards
REVISED: DECEMBER 2015
Table of Contents
Overview of the Waiver Program and Care Management 5
Direct Service Purchase System 5
Funding Structure 6
Target Population 6
Provider Eligibility Standards 6
1. Eligible Organizations 6
2. Assurances 6
3. Standard/Universal Precautions 7
Application Process 7
1. Medicaid Subcontractor Enrollment Agreement 7
2. Service Information/Bid Agreement 7
3. Assurances 8
4. Business Associate Agreement (HIPAA/HITECH/OMNIBUS 2013) 8
Vendor Selection 8
Billing and Reporting 9
Billing Forms 9
1. Region 3B AAA’s Purchase of Service Monthly Participant Billing Form 9
2. Summary Report 9
3. Non-Service Delivery Form 10
I. GENERAL OPERATING STANDARDS FOR WAIVER AGENTS AND CONTRACTED 10
DIRECT SERVICE PROVIDERS 10
REQUIRED PROGRAM COMPONENTS 10
1. Contractual Agreement 10
2. Compliance with Service Definitions 10
3. Person-Centered Planning Process 10
4. Contributions 10
5. Confidentiality (HIPAA/HITECH/OMNIBUS & PHI Protections) 11
6. Insurance Coverage 11
7. Staffing - Provider Requirements 12
8. Staff Identification 12
9. Volunteers 12
10. Direct service workers (DSW) and/or VOLUNTEER Requirements 12
11. Identification/Valid Drivers’ License 12
12. Valid Auto Insurance/Transporting Participants 12
13. Reference Checks 12
14. Criminal Background Checks – Lifetime, Fifteen & Ten Year Bans 13
LIFETIME Ban: 13
FIFTEEN Years after completion of parole/probation: 13
TEN Years after completion of parole/probation: 13
(Misdemeanors) - TEN Years from the date of conviction: 13
15. Background & Reference Checks for Rehires 13
16. Background & Reference Checks for Adult Foster Care and Homes for Aged 14
17. TB Testing 14
18. Position/Job Descriptions 14
19. Record Retention 14
20. Dignity and Respect for Participants 14
21. Smoking Policy 14
22. Waiver Sponsored Training 15
23. Drug Free Workplace 15
24. Emergency/Weather Service Delivery Plans 15
25. Universal Precautions/OSHA Compliance 15
Policies and Procedures 15
1. Participant Complaint Resolution/Critical Incidents 15
2. Reporting Suspected Abuse, Neglect, and Exploitation 15
3. Participant Confidentiality 16
4. Appeals and Grievances 16
5. Participant Feedback/Evaluation 16
6. Participant’s Rights and Responsibilities 16
7. Emergencies in a Participant’s Home and/or During the Delivery of a Service 16
8. Administration of Medication (Prescription and OTC) 17
9. Personnel, recruitment, training, and supervision 17
10. Worker Service Records 17
11. Health and Welfare 18
Orientation and Training of ALL Provider Employees 18
1. New Hire Orientation 18
2. Annual Staff Development 18
3. Training Records 19
II. GENERAL OPERATING STANDARDS FOR DIRECT PURCHASE OF SERVICE AND 19
RESIDENTIAL SERVICE PROVIDERS 19
A. Home-Based Service Providers 19
1. Charging for MI-Choice / MAASA Services 19
2. Participant Assessments 19
3. Service Need Level 20
Grid of Service Need levels 20
4. Supervision of Direct-Care Workers 21
5. Participant Records 21
6. Notifying Participant of Rights 21
7. In-Service Training 22
8. Reference and Criminal History Screening Checks 22
9. Additional Conditions and Qualifications 22
B. Community-Based Service Providers 22
1. Adherence to Standards 22
2. Participant Records 23
3. Notifying Participant of Rights 23
4. Reference and Criminal History Checks 23
III. Specific Operating Standards for Providers - Services 23
DIRECT PURCHASE OF SERVICE GUIDELINES - OVERVIEW
Overview of the Waiver Program and Care Management
Region 3B Area Agency on Aging (R3BAAA) as a Pre-paid Ambulatory Health Care provider, is in contract with the Michigan Department of Health and Human Services (MDHHS), serves as a Medicaid administrative agent to provide the Home and Community Based Waiver Services for Elderly and Disabled (HCBS/ED) Waiver Program. This Medicaid program funds a variety of home and community based service to participants aged 18 years and older who, without such services, would require a nursing facility level of care. The waiver increases traditional Medicaid services so that people in need of nursing facility care can choose to remain in the community to receive their long-term care.
R3BAAA implements the waiver through its Care Management (CM) program. CM is a service that accesses and manages home and community based care for adults whose needs are at a level of complexity requiring a specialized resource management effort. CM identifies the needs of participants through a comprehensive assessment performed by nurse and social worker teams, specifying and managing waiver and personal care services. CM personnel access these services from community vendors, monitoring performance and participant’s condition and adjust services as necessary.
Direct Service Purchase System
R3BAAA purchases needed services for participants from a pool of competing community service providers, when other payment options are not available. The Direct Service Purchase (DSP) pool is established through formal agreements with providers who access the pool by entering per unit bids for each service they choose to provide. The amount of quality providers in the DSP pool will be regulated to insure an adequate amount of providers in each geographic location to allow the participants in the program a definite choice, while ensuring that providers who continue to maintain the necessary standards can assume that there is sufficient client base available to warrant the lengthy admissions process. R3BAAA's CM component is responsible for authorizing services delivered and establishes the frequency and duration of all services purchased. Services available for bid are:
Adult Day Health Non-Medical Transportation
Chore Services Personal Emergency Response System
Community Living Supports Nursing Services (Med Sets)
Counseling Services Private Duty Nursing
Financial Management Services Training Services
Home Delivered Meals Personal Care Services
In-Home Respite Care Homemaker Services
Out-of Home Respite Care Community Living Support in an Assisted
Living Setting
Additional Services available through the MI Choice Waiver Program
Fiscal Intermediary Services* Goods and Services* Nursing Facility Transition
Environmental Accessibility Adaptations Specialized Medical Equipment and Supplies
*Applies to participants enrolled in the self-determination program
Funding Structure
R3BAAA uses a unit cost reimbursement structure to purchase direct care services. The Bid Agreement form, submitted during the application process, is the formal agreement that establishes a fixed unit cost reimbursement rate for each unit of service delivered. Monthly reimbursement from R3BAAA is based on the number of service units provided and verified during the month. (NOTICE: A Bid Agreement is only completed by Adult Foster Care and Homes for the Aged residential service providers to provide base rates for the facility, as Community Living Supports units ordered are determined on a per participant basis.)
Target Population
Participant eligibility for all services is determined by R3BAAA’s CM staff; it is the responsibility of CM to determine appropriate service interventions. Participants who are medically eligible for nursing home placement, financially eligible for Medicaid under special expanded income guidelines, and require at least one waiver service are qualified to receive services within the waiver.
Provider Eligibility Standards
1. Eligible Organizations
Public, private non-profit or profit-making service organizations and political subdivisions of the state that offer services which meet R3BAAA's minimum standards are eligible to apply; providing that there are sufficient participants in the system to warrant an increase in providers. ** Notice: Obtaining a contract and being listed on our Provider Referral Listings does NOT guarantee referrals, as participants make the choice of providers under “person centered planning.”
2. Assurances
Providers are required to complete and sign Assurances upon initiation of a contract with R3BAAA and yearly, thereafter. Assurances relate to an agreement by any service provider who will receive funds from the waiver agent relating to their compliance”…with the Department Health and Human Services and the MI Aging and Adult Services Agency service definitions, unit definitions, and minimum service standards as prescribed” and all federal, state and local laws listed below:
· Civil Rights Compliance - Service providers must not discriminate against any employee or applicant for employment or assignment, or against any MI Choice applicant or participant, pursuant to Title VI of the Civil Rights Act of 1964, the Persons With Disabilities Civil Rights Act of 1976 (P.A. 220) (formerly Michigan Handicappers Civil Rights Act of 1976), the Elliot-Larsen Civil Rights Act (P.A. 453 of 1976), and Section 504 of the Federal Rehabilitation Act of 1973. Each service provider must complete an appropriate Federal Department of Health and Human Services form assuring compliance with the Civil Rights Act of 1964. Direct service providers must clearly post signs at agency offices and public locations where services are provided in English and other languages as appropriate, indicating non-discrimination in hiring, employment practices, and provision of services.
· Equal Employment - Service providers must comply with equal employment opportunity principles in keeping with Executive Order 1979-4 and Civil Rights Compliance in state and federal contracts.
· Debarment and Suspension – Service providers assure that they will comply with Federal Regulation, 2 CFR parts 180 & 215 and certifies to the best of its knowledge and belief that it, its employees, and its subcontractors:
Ø Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any federal department or contractor;
Ø Have not within a three-year period preceding this agreement been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction;
Ø Violation of federal or state antitrust statues or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property;
Ø Are not presently indicated or otherwise criminally or civilly charged by a government entity (federal, state or local) with commission of ay of the offenses enumerated in section 2, and;
Ø Have not within a three-year period preceding this agreement had one or more public transactions (federal, state or local) terminated for cause or default.
· Drug Free Workplace – Michigan Department of Health and Human Services (MDHHS) prohibits the unlawful manufacture, distribution, dispensing, possession, or use of controlled substances in all service provider workplaces. Each service provider must operate in compliance with the federal Drug-Free Workplace Act of 1988.
· Americans with Disabilities Act As Amended (ADAAA) - Each program must operate in compliance with the Americans with Disabilities Act As Amended (29 CFR 1630 - 2008, 2009, 2010, 2013)
3. Standard/Universal Precautions
Service providers must evaluate the occupational exposure of employees to blood or other potentially infectious materials that may result from the employee’s performance of duties. Service providers must establish appropriate standard precautions based upon the potential exposure to blood or infectious materials. Service providers with employees who may experience occupational exposure must also develop an exposure control plan which complies with the Federal regulations implementing the Occupational Safety and Health Act.
Application Process
Organizations proposing to participate in this system receive the Direct Purchase of Service Operational Guidelines, Minimum Service Standards for All Services (this DPOS manual), service specific minimum service standards, and the application which is structured in following parts - the Medicaid Subcontractor Enrollment Agreement, the Bid Agreement form, Assurance forms, and Business Associates Agreement.
1. Medicaid Subcontractor Enrollment Agreement
All providers must complete this form, regardless of current or past participation in Medicaid. Box numbers 1, 3, 4, 5, 6, 7, must be completed with signature and date at bottom of form.
2. Service Information/Bid Agreement
Allowable reimbursements and unit definitions as stated in the service specific minimum service standards must be adhered to. When establishing unit rates, providers are advised to consider all potential costs that may be incurred during service provision. Applicants complete this one page form as follows (after they are accepted as a provider):
a. Provider Information - complete all information requested including contact persons for ordering services and for billing inquiries.
b. Background - Provide a brief narrative regarding the background of the provider relevant to proposed services to be delivered.
c. Service and Bidding Information - for each service being applied for, provide information regarding the capacity or number of potential units available for purchase each week, cost per unit, and geographic area served. Also, obtain the appropriate authorizing signature and date of signing at the bottom of the form. (Ineligible costs to the program are bad debts, capital expenditures, construction, entertainment, severance pay, and penalties.)
3. Assurances
This includes the minimum service standards assurance, and statutory assurances, which govern service activities for recipients of federal and state funding awards. Please review all information, fill in the agency name and address where appropriate, secure authorizing signatures (Owner/Responsible Signatory) and indicate the date of signing.
· Minimum Standards Assurance - Minimum service standards and service definitions have been established for each service. Provider compliance is affirmed when signing the Minimum Standards Assurance form in the application, indicating that the provider has read the DPOS Minimum Service Manual and understands the responsibility for compliance under the contract for each service to be performed. This form also establishes a commitment from the provider to assure a priority for service delivery for other services offered (non-DSP) within the regulatory and capacity limits of other funding sources.
4. Business Associate Agreement (HIPAA/HITECH/OMNIBUS 2013)
This document is required by the Federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) and its amendments (HITECH/OMNIBUS) to facilitate compliance with the HIPAA Rules. In consideration for the compensation paid to direct service providers (Business Associates) to provide services relating to and on behalf of R3BAAA (Covered Entity), the parties agree to the terms set forth in this agreement. Confidentiality of all Personal Health Information (PHI) gathered, disseminated and stored by both the provider and R3BAAA on any and all participants served is protected through this agreement.
Vendor Selection
Supports Coordinators offer providers for participant choice on a case by case basis, utilizing the following criteria. Please note that providers must deliver services at levels specified in CM care plans, approved by the participant: