Wellness Coordination, Service Definition

For the original publication, please click here. The following is a text version of the original publication. 
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WELLNESS COORDINATION 

Service Definition: 
Wellness Coordination services means the development, maintenance and routine monitoring of the waiver participant’s Wellness Coordination plan and the medical services required to manage his/her health care needs. 

Wellness Coordination services extend beyond those services provided through routine doctor/health care visits required under the Medicaid State Plan and are specifically designed for participants requiring assistance of an RN/LPN to properly coordinate their medical needs. 

1. Tier I: Health care needs require at least weekly* consultation/review with RN/LPN including face to face visits once a month
2. Tier II: Health care needs require at least weekly consultation/review with RN/LPN including face to face visits at least twice monthly.
3. Tier III: Health care needs require at least twice weekly consultation/review with RN/LPN including face to face visits once a week

*Weekly – a calendar week (Sunday – Saturday) 

Conditions and Requirements: Necessity for Wellness Coordination services will typically be reserved for participants assessed with health scores of 5 or higher through the State’s objective based allocation process. Participants assessed with health scores of 0-4 would not require assistance of an RN/LPN to coordinate medical needs. As medical events occur and/or a participant’s medical needs change, the Individualized Support Team is expected to obtain reassessment for potential revision to the health score and to ensure utilization of the appropriate tier of services. 

Service Standards: 
Reimbursement is available for Wellness Coordination Services when the following circumstances are present: 

1. The participant requires assistance in coordinating medical needs beyond what can be provided through routine doctor/health care visits.
2. WellnessCoordination Services are specifically included in the participant’s individualized support plan

Reimbursable Activities: 
Coordination of Wellness Services by the RN/LPN provider must include, but is not limited to the following:

1. Completion of the State’s Risk Assessment Tool
2. Development, oversight and maintenance of a Wellness Coordination plan
3. Development, oversight and maintenance of the Risk Plan which includes:
   1. Training of Direct Support Professionals to ensure implementation of Risk Plans
4. Consultation with the individual’s health care providers
5. Face to face consultations with the individual as described in the support plan
6. Consultation with the individual’s support team
7. Active involvement at all team meetings, reporting on the Wellness Coordination plan as it relates to the individual’s full array of services as listed in the ISP.

Limitations: 
Activities Not Allowed 
Reimbursement for Wellness Coordination services is not available under the following circumstances:

1. The individual does not require Wellness Coordination services
2. Wellness Coordination services are not specified in the Individualized Support Plan
3. Wellness Coordination services may not be provided by a provider of waiver funded Case Management services
4. Residential, vocational, and/or educational services otherwise provided under other Supported Living services cannot be billed as Wellness Coordination services
5. Services furnished to a minor by a parent(s), step-parent(s), or legal guardian
6. Services furnished to a participant by the participant’s spouse

Documentation Standards 
Wellness Coordination services must be documented in agency files

1. Weekly consultations/reviews
2. Face to face visits with the individual
3. Other activities, as appropriate
4. Services must address needs identified in the person centered planning process and be outlined in the Individualized Support Plan
5. The provider of Wellness Coordination will provide a written report to pertinent parties at least quarterly. “Pertinent parties” includes the individual, guardian, BDDS service coordinator, waiver case manager, all service providers, and other entities associated with the Individualized Support Team

Appendix C: Participant Services 
                         C-1/C-3: Provider Specifications for Service 

Wellness Coordination 
Provider Category 
DDRS will allow both “Agency” and “Individual” provider types 

Provider Type: 
       DDRS Approved Wellness Coordination Agencies and/or Individuals 

Provider Qualifications: 

Licensure: 
Be either a registered nurse (RN) or a licensed practical nurse (LPN) under IC 25-23-1 working under the supervision of an RN 

Certificate: 
n/a 

Other Standard: 
Must be enrolled as an active Medicaid provider 
Must be DDRS-approved 

Must comply with Indiana Administrative Code, 460 IAC 6 (noting that Wellness Coordination is referred to as Health Care Coordination within 460 IAC 6) 

Must comply with any applicable BDDS service standards, guidelines, policies and/or manuals, including DDRS Waiver Manual and DDRS BDDS Policy Manual 

Verification of Provider Qualifications 
    Entity Responsible for Verification: 
    Initially, BDDS. For Re-approval, BDDS or BQIS. 
    Frequency of Verification: 
    Up to 3 years.