fw: If you don't agree with your tier..

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Wilbur Hawke wrote: Sent: Wednesday, September 03, 2008 5:03 PMTo: pen@...Subject: If you don't agree with your tier.. Due Process Rights And Tiers Questions, Concerns, Information? Go to Our Message Boards Want to dispute your tier? YOU ONLY HAVE TEN DAYS! That is, ten days from when you receive your tier notification. You need to be in contact with your support coordinator as soon as possible to make sure your services will

not be affected. The ARC Nature Coast gave us this helpful tip, "Save the envelope that your notification comes in, as verification of when you received your notice." From WaiverProvider.Com Reader: Please, please encourage WSCs, consumers and families to contact Dawn with The Advocacy Center. They have a team of attorneys that will be assisting consumers during the Tier implementation process. Dawn can be reached at 1(800)342-0823 X 218. Thanks for spreading the word! From Nangle- I spoke with Dawn , and she informed me that she has worked at the Advocacy Center for 13 years and they never change anyone. She said that once people get their tier letter, THEN they can contact the advocacy center for help in requesting a hearing. From The Agency For Persons With Disabilities: Due process rights on the tier assignments are fully described in thenotice of hearing rights included with the tier assignment notices.Federal guidelines do not require a fair hearing where benefit reductions are a result of a change of law applied to a group of recipients. Therefore, a client will not be entitled to a hearing if he alleges that the tier assignment will reduce his/her services. However, if a client alleges facts supporting an argument that APD erred in his/her tier assignment, the client will be entitled to a fair hearing. APD will try to resolve any factual disputes raised in a hearing request before the case proceeds to hearing.There is no alternative to a constitutional right to due process. However, there are alternatives to address the accuracy of a person's tier assignment. Clients are encouraged to ask questions about their tier assignments. Their waiver support coordinator and APD Area Offices

are available to answer any questions. The area Offices can review a client's tier assignment to confirm that the tier assignment is accurate. If a client believes that his/her circumstances have significantly changed recently, he may request a change in services through Prior Service Authorization process.APD does not categorize fair hearing decisions by an Administrative Law Judge as a "win" or "loss." The results of a fair hearing determine the waiver benefits a client should receive. If you consider that a ruling in favor of the client is a "win," then, yes, it is possible to "win" a fair hearing. This is possible where a hearing is granted, the client's allegations are supported by sufficient evidence presented at the hearing, and the Administrative Law Judge rules in the client's favor based on the evidence presented.Will QSI of ICG help at a hearing? There seems to be some confusion in the pubic perception of how

APD uses assessment tools, such as the ICG and QSI. In planning and developing support and cost plans, a valid assessment such as the ICG or QSI is required per rule, however, a client may also have several specialty assessments for a variety of issues. ICGs administered in 2006 will be used as the assessment tool in conjunction with other specialty assessments. Thereafter, the QSI will replace the ICG and will be administered in the same manner as the ICG was in the past. Interim support and cost plan reviews will be performed as in the past per APD policy and procedure. To the extent that a QSI or any other assessment tool may be used as evidence to prove a fact at issue in a hearing, it maybe considered to "help" at hearing. BedellAgency for Persons with Disabilities ADVERTISE With WaiverProvider.Com Still Not Getting Our Newsletter? Sign Up, It's Free USING MEDICARE TO EASE MED WAIVER BUDGET CUTS Written By Advantage Home Assisted Care Inc. Advantage Home Assisted Care, Inc. has been involved and committed to the Developmental Disabilities community for 18 years. We are one of the largest Medicaid Waiver Providers in Pinellas County, and with the many Med Waiver funding cuts,it concerns us how our consumers will receive the services that continue to be needed. Our Top Priority in the days and months ahead is to reach out and teach about the Medicare Home Health Benefits. Medicare is greatly underutilized in the Developmentally Disabled population, mainly because of

unawareness. Medicare Home Health can be implemented anywhere along the health care continuum. Preferably, it is best used before hospitalization is necessary. Keeping consumers out of the hospital is a main priority. It can be a very confusing and scary event for them. Usually most communication with health care providers is lost and they are at the mercy of the health care system. Most times they are then discharged without any follow up care or understanding of what transpired in the hospital.It is statistically proven that rehospitalization occurs more often 1-2 weeks after initial hospitalization. With Home Health Care, medical nursing personnel can monitor the consumer closely as well as teach consumers and caregivers signs and symptoms to be aware of, to prevent further hospitalization. Home Health can also replace long stays at rehabilitation centers after hospitalization as all therapies can be provided in the home or group

home, where the consumer feels more comfortable in their own surroundings. By being aware of signs and symptoms, that can trigger a Medicare episode, we can tremendously impact the level of care to our consumers, through a benefit that most already have, at no extra cost. Signs and Symptoms to watch for-- 1) Open Wounds- Cuts, Burns, Decubitus Ulcer 2) Change in Medications 3) Change or Decline in Mental status(I.e. confusion, increased behaviors, paranoia, depression, anxiety, etc.) 4) Change or Decline in Physical status 5) Fevers or Infections 6) Injections, Catheters and Tube Feedings 7) Difficulty Swallowing, Changes or Alterations in Eating Habits or Diet 8) Falls or Unstable Gait 9) Swelling of Feet 10) Upper Respiratory Infections, Difficulty Breathing 11) Increased or Change

in Seizure Activity 12) Discharge from Hospital Upon reporting any of these signs or symptoms our Nurse's will contact the consumer's Doctor and obtain a doctor's Order to treat the consumer. A Medicare Certification period is for 60 days. If the problem is resolved they can be discharged from Home Health. If the problem persists they can be recertified for an additional 60 days, or until the problem is resolved. Also, our Nurse's can call in referrals for any other problems they might notice, that could help the consumer(i.e. Physical Therapy, Speech Therapy, Occupational Therapy, Medical Social Worker, Home Health Aide. We have seen time after time how much Medicare can be the missing piece to help increase the level of care delivered to the consumer. Contact Jerry@... For More

Information From: Martha F. Barrera, Sr. AttorneyRE: Tier Implementation Meeting with APD August 28, 2008 On Thursday I attended a meeting with Bedell, APD Acting General Counsel, Director Jim DeBeaugrine and Matt McCoy regarding the issues raised by tier implementation relevant to fair hearings and their effect on the overall plan. AC intern, Funk accompanied me to the meeting. Due to our recent discussions through emails and teleconferences, I developed a list of issues for discussion with APD that were not expressed in my email to Ms. Bedell last week. By way of this memo, I am going to attempt to summarize the content of yesterday's meeting. At the meeting, the Director expressed his desire to work with us to make the process of tier implementation fair. He outlined the steps APD was taking to achieve that goal and

answered our questions as to specific issues. 1. Correcting assignment errors and information to support coordinators. The Director is cognizant of the concerns and issues resulting from the sharing of the lists of tier placements with support coordinators. They will be issuing a clarification on this process and of the process for requesting hearings. Support coordinators will be advised that the right to request a hearing applies to everyone. They will not be encouraged to advise their clients not to request a hearing as seems to be happening. 2. No one will be disenrolled from the waiver due to request for hearing. 3. Fair hearing process. APD is aware of the fact that there will be a lot of persons seeking a fair hearing. APD will be liberally interpreting letters requesting a hearing as stating a disputed issue of fact to afford individuals an opportunity to have their case heard. There won't be wholesale motions to dismiss or

wholesale denial of formal hearings. 4. Tier 4 limitation on services and fair hearings. In Tier 4 there are limited services under the statute and the waiver itself. One example is adult dental services are not provided in that tier. In these cases, if the fair hearing request contests only the lack of a service that is not provided under the tier 4 waiver, then APD will deny the request for formal hearing. The grounds for denial are that the service is not available because it is due to a change in law. This does not apply to persons challenging the tier placement on other grounds. We should monitor this situation to ensure that persons are not wrongfully denied the right to a formal hearing. 5. Adult dental. The Director believes that adult dental is an important service for persons with DD. He asked the Legislature during last session to include adult dental in tier 4 with no success. APD will be asking the Legislature again this next session.

In my opinion, this is an issue that the stakeholders should support. 6. Retroactivity of cost plans. The tiers are new programs. Placement in a tier begins a new cost plan. There is no retroactive application of a person's existing cost plan to the new tier's cost plan. The cost plan amounts are going to be prorated beginning October for the period through June 30th. Services received during fair hearing process are billed under the old cost plan not the one that begins with the tier placement. 7. Voluntary service reductions. APD is requesting that individuals submit new cost plans within the October 15 deadline. Those persons who request a hearing need to submit the new plans as well. The plans will not be implemented for persons whose hearings are pending and will not be used as evidence against the individual at the hearing. APD is looking at the voluntary service reduction plan as an application for a placement in a tier since this is

essentially a new program. The application, so to speak, will not be processed until the hearing process is concluded and only if the hearing is not successful. We should monitor this process to ensure the new voluntary cost plans are not used against persons at their hearings and/or that services are not reduced based on the new cost plan while the hearing process is pending. 8. Children in tier 4. The APD notices to parents of children living at home who are placed in tier 4 will state that the services are not being reduced only transferred to Medicaid state plan. These services, such as PCA, will not suffer interruptions. The new cost plans will not cause the state plan services to be reduced. 9. CDC+ Children in CDC+ may retain parents as PCA providers even under the transfer to state plan. The Director explained the mechanics of how that process will be accomplish and still meet Medicaid guidelines. It was a very technical explanation which,

surprisingly, I understood enough to be assured that this important issue will not be a problem. 10. Dates of Notices. Notices will be issued with the date the notice is mailed not last week's dates. 11. There will be two reviews of the tier placement: one prior to the Notice based on the list sent to support coordinators for those cases where a review is requested, the other is after the Notice is received and a hearing is requested. APD will review these cases to see if the tier placement was made in error and make the necessary changes without the necessity of going to trial. 12. The Director has instructed staff to establish a threshold amount where APD will review cost plans where the reduction in funding is large. For example a person who is placed in tier 3 whose current cost plan is $20,000 over the $35,000 will be reviewed to determine an error in the tier assignment. His opinion is that persons who have such a large

reduction in services belong in another tier. 13. The Director will write a response to Patty specifically on the 3 questions posed by the FCC in Pensacola. In the meantime, I believe most of them are addressed here. said that there was an issue with providers who submitted hearing requests without the signature of the client, his/her family or guardian is requesting the hearing. She has one set of hearing requests from one provider and will be returning those for the provider to get signatures and a statement from the individuals or their families. also said she would like to be informed of any problems, issues or questions. I believe I addressed the sum and substance of the meeting with APD. If you have questions, let me know. If you think that we should hold a telecom to discuss the meeting, please let me know and I will schedule one. Thank you for your assistance in this matter. Not Getting The Answers You Need? Try Our Message Boards Don't Forget, Every Thursday Night at 7PM we have a live discussion room. See The Delmarva Interview WaiverProvider.Com SupportCoordinators.Com WaiverInfo.Com This message was sent from Nangle to pen@.... It was sent from: Clear Choice Web Solutions Inc, P.O. Box 6842 , Spring Hill, FL 34611. You can modify/update your subscription via the link below. Manage your subscription View this message in the iContact Community: View message Comment on this message Receive as RSS Share this message with others: del.icio.us Digg reddit Facebook StumbleUpon