RHS Daily Service rate clarification

For the original publication, please click here. The following is a text version of the original publication.
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To: Bureau of Developmental Disabilities Services providers and stakeholders 
From: Cathy Robinson, Director, Bureau of Developmental Disabilities Services 
Re: RHS Daily Service rate clarification 
Date: September 3, 2015 

In response to the August 1, 2015, implementation of the Residential Habilitation Services (RHS) daily rate implementation, the Bureau of Developmental Disabilities Services (BDDS) has been asked to clarify the procedures utilized for RHS exceptions and Budget Review Questionnaires (BRQs). Therefore, the following guidance is being provided. 

In the most recent Centers for Medicare and Medicaid Services’ (CMS)-approved Community Intergration and Habilitation Wavier (CIH), effective July 1, 2015, individuals who choose RHS and meet all of the following criteria are eligible for and will utilize RHS Daily Services: 

• Individuals who have an algo score of 3, 4, or 5 on their Objective Based Allocation (OBA). 
  
• Individuals who are living with housemates and are utilizing a shared staffing model. 
  
• Individuals who are living outside of their family home. 
  

RHS Daily Service Definition: 
RHS Daily Services provide up to a full day (24-hour basis) of services and supports which are designed to ensure the health, safety and welfare of the participant. RHS Daily Services assist with the acquisition, improvement, and retention of skills necessary to support individuals to live successfully in their own homes; acquire and enhance natural supports; and become integrated and participate in their larger community. 

Services are designed to help individuals acquire and improve their self-help, socialization, and adaptive skills. Services should be directed toward increasing and maintaining natural supports, physical, intellectual, emotional, social functioning and full community participation. 

CIH Waiver Language for RHS Daily Service Exceptions & BRQ Description 
Following the CIH Waiver application submission, CMS requested formal responses from Indiana regarding possible instances where an exception or alternative would need to be identified for individuals being served by RHS Daily Service. The following BDDS response was accepted and incorporated into Indiana’s approved CIH Waiver: 

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The State will develop policies to allow for exceptions when participants desire to come out of the daily rate. The Budget Review Questionnaire (BRQ) process will allow a participant to opt out of the RHS Daily rate and to increase use of CHIO [Community Based Habilitation – Individual], especially when participants are aging and/or retired. 
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A BRQ may be submitted by a case manager in cases where an individual being supported through RHS Daily Service experiences a change in one of the following areas (460 IAC 13-4-1): 

1. The overall algo score, which is determined by the ICAP or addendum 
   
2. Age 
   
3. Employment 
   
4. Living arrangement 
   

As outlined above, if an individual experiences a change in their medical or behavioral status, resulting in a determination to change their overall algo score, this change would potentially result in an individual being removed from the daily rate (decreased algo below a three, or increased above a five). 

Likewise, if an individual is older or of retirement age and demonstrates a need to not attend day programming, they may also be considered for a change from RHS Daily Service to RHS hourly rate via a BRQ under the ‘Age’ category.

For individuals who have a relevant employment change, a BRQ may be appropriate, and may result in a change from RHS Daily Service to RHS 20.

In the event of a living arrangement change, resulting in an individual no longer living with housemates and a shared staffing model, a change to the living arrangement in Advocare would result in an individual no longer being eligible for RHS Daily Service. The update of the living arrangement in Advocare to a living arrangement reflecting no housemates and no shared staffing, would remove the individual from the RHS Daily Service and the BRQ could be utilized to review and assess any subsequent budgetary needs beyond what RHS 20 would be authorized to provide.

BRQ Submission for Personal Allocation Review (460 IAC 13-8-1) 
Once an Individualized Support Team (IST) determines or identifies a change exists in one of the above areas, they may request a Personal Allocation Review through the case manager via the BRQ. The BRQ is submitted to the local BDDS office and then to the PAR unit for review. 

BRQ Response and Next Steps 
The PAR Unit will notify the case manager of any change in algo or allocation based on the review by the PAR Unit. This change may result in an individual being transitioned to RHS 20 from RHS Daily Service due to no longer meeting the RHS Daily Service eligibility criteria. A BRQ without ALL of the pertinent, requested information will be returned to the case manager for more information. Please note the following situations as related to BRQs for individuals being supported via RHS Daily Service:

• BRQ submitted for individuals who are being supported via RHS Daily Service that do not clearly reflect an identified change in algo, age, employment, or living arrangement will not be considered by the PAR Unit. 
  
• BRQ requests that are filed under the correct, appropriate impact area (algo, age, employment, or living arrangement), but may be missing necessary information for the PAR Unit will be sent back to the case manager by the PAR Unit with a specific request for more information. 
  
• BRQ requests for individuals who are being supported via RHS Daily Service, that do not reflect adequate IST involvement, agreement, and team discussion via a team meeting will not be considered, regardless of the identified BRQ area under which the request is filed. For example, documentation reflecting an email discussion among the IST solely around a participant’s budget, with no indication or mention of the participant’s individualized needs or desires for his or her daily programming is not adequate to support the PAR Unit review of a BRQ. 
  
• BRQ requests that have been filed under one of the four BRQ areas (algo, age, employment, or living arrangement) and do not demonstrate an identified change in any of these areas and only requests to be removed from or included in RHS Daily Service will not be considered. 
  
• BRQ requests to allow a participant to opt out of the RHS Daily rate and to increase use of Community Habilitation Individual (CHIO), expressly when participants are aging and/or retired, should be filed under the ‘Age’ BRQ category.
  

 
BRQ Requests and Associated Timeline 
Effective September 1, 2015, the PAR Unit will no longer accept and review BRQs to support services that occurred prior to the date of the BRQ submission. Retroactive BRQs to address services that were rendered prior to submission of the BRQ by the case manager, without prior approval of the State, will not be supported.