APD > Waiver > Tiers

Procedures for Enrolling In the Tier Waivers

Purpose:This process defines uniform procedures for the notification of individuals regarding their tier waiver assignments, bringing cost plans into compliance with tier waiver limits, and processing tier change requests.

Background:In response to legislative changes in law, APD is implementing a 4-tiered waiver program.  APD staff reviewed cost plans for all individuals enrolled in the Developmental Disabilities and Family and Supported Living Waivers, and the Consumer Directed Care program.  The Agency assigned each individual to a tier waiver based on criteria specified in proposed Rules 65G-4.0021, 65G-4.0022, 65G-4.0023, 65G-4.0024, and 65G-4.0025.

For most people, enrolling in one of the new Tier Waivers will not impact services.  However, for some people, the state may not be able to pay as much for services under the new waiver system as it has in the past.  Three of the Tier Waivers have caps or limits on what can be spent annually for services.  If the person is being enrolled in a Tier Waiver that has a cap on spending that is lower than what the person is currently spending on services, the individual must work with his or her waiver support coordinator to plan for and prioritize services that are most important and fall within the annual cap for the new waiver.

• Tier 1 Waiver: The current Developmental Disabilities waiver with no annual spending cap
• Tier 2 Waiver: Annual spending cap of $55,000
• Tier 3 Waiver: Annual spending cap of $35,000
• Tier 4 Waiver: Currently the Family and Supported Living Waiver. Annual spending cap of $14,792

A. Consumer Notification of Tier Assignment

1. By September 2, 2008, APD Central Office will begin mailing notices to all individuals currently receiving waiver services to notify them of their tier assignment.  Individuals with guardians identified in the guardian field in ABC will have notices sent to the name listed in this field rather than directly to the individual receiving services.
2. Each notice stresses the importance of the individual, family or guardian immediately contacting the person's waiver support coordinator to review the person's cost plan and to make any necessary changes in services in order to bring the annual cost plan within the annual cap of the new waiver, if necessary.
3. The notice will also provide information on due process rights if a person feels that an error was made in their tier assignment and desires to file for a fair hearing.
4. The APD Central office will provide information to the Area staff on hearings requested and any action that needs to be taken on an individual's cost plan as a result.
5. By August 20, 2008, the APD Central Office will provide each Area office with a spreadsheet of individuals receiving waiver services in the Area, the Tier waiver to which the person is to be enrolled and the name of the person's waiver support coordinator.
6. No later than August 22, 2008, Area APD offices will distribute to Waiver Support Coordinators (WSCs) the spreadsheet information about people on their caseloads via Zixmail so that the WSCs are aware of the tier assignment for each person. The Area APD office will supply Waiver Support Coordinators with copies of the sample notification letters being received by individuals for their information and reference.
7. The WSC will be requested to immediately begin contacting people on their caseload to:
   
   1. inform people who will not be affected by their new tier waiver enrollment and to answer any questions that they may have about how services will continue, and
   2. establish appointments or contacts for those individuals whose plans will have to be altered, and begin assisting individuals in prioritizing their cost plans, as applicable. The WSC should contact individuals to discuss their Tier Waiver assignment regardless of whether the individual will be affected by a cost plan modification to assist people in understanding the new Tier Waiver enrollment.
8. All tier notification letters will have the Area APD office as the return address. If the Area APD office receives an undelivered letter from the post office, the Area will provide the letter to the Waiver Support Coordinator for hand delivery within 2 business days, or will directly contact the person and/or family/guardian. Notification must be timely in order to meet the deadlines associated with implementation of Tier Waiver enrollment.
9. The Area is requested to keep a spreadsheet on returned letters so that addresses can be corrected in the ABC system, and to provide a copy to the APD Central office for information and tracking.
10. If the Waiver Support Coordinator hand delivers the letter, the WSC must document the hand delivery in their case notes.
11. The Area APD office may also hand deliver the letter if an updated address is provided, and shall document the hand delivery. All address corrections must be input into the ABC system to improve the accuracy of the client demographic fields.
12. The Area may receive requests for information on the tiers from individuals and families, and inquiries as to whether the Tier assignment received is correct. In reviewing the Tier assignment for error, the appropriate Area staff are requested to contact either Deb Blizzard, Lorena Fulcher or Linda Mabile in the APD Central office to review the individual's Tier assignment information and to approve a Tier assignment change, if warranted. If there is a change in assignment as a result of the joint Area/Central office review, the individual will be informed and provided with a revised Tier assignment notice with the correct Tier waiver designation by the Area office. The individual's Waiver Support Coordinator will also be advised.
13. The Area may not change a Tier assignment independent of the Central office as Tier enrollment will be managed at the Central office level.
14. This informal review process does not take the place of a request for hearing if that is how the individual wishes to proceed.

B. Cost Plan Adjustments

1. Some individuals will not be required to adjust their cost plan because their existing cost plan is within the annual tier waiver spending limits of the tier to which they are enrolled.
2. Some individuals may have a cost plan total that exceeds the cap of the waiver to which they will be enrolled, but the person's spending history (annual expenditures) are traditionally below the cost plan and cap for the new waiver. Individuals with plans in this category will have to have their existing service plans adjusted in ABC, but will not need to close the existing cost plan, and can use their usual and customary spending patterns to come within the cap for the new waiver.
3. If an individual has a cost plan and expenditures that exceed annual spending limits for the new assigned tier, the Waiver Support Coordinator or CDC Consultant is requested to work with the individual to re-prioritize services to come within the tier waiver cap level. Expenditures can be evaluated to determine any areas of savings. The WSC should also refer to the APD document entitled “Tier Implementation Role of the Waiver Support Coordinator” for assistance in prioritizing services and maximizing funding limits.
4. For individuals whose cost plan needs to be revised to come within the tier limit, the Waiver Support Coordinator or CDC Consultant must submit information on the adjusted cost plan to the Area APD office using the Amendment Request Form no later than September 24, 2008. Information should be recorded on the Amendment Request Form in the tables for adding and removing services.
5. The Area APD office will adjust the cost plan in the ABC system to come within the spending limits of the assigned tier waiver by October 10, 2008. Service plans in ABC cannot be deleted, so if a service is being eliminated, the Area Office will need to enter a new ending date on the service plans and reduce the approved amount to equal the accumulated amount, if any services have been provided out of the plan prior to the elimination of that service. If no services have been provided (no billing is outstanding), the Area Office will end the plan and remove all dollars from the approved amount.
6. If the individual has a cost plan and expenditures that will exceed the annual spending limits for the assigned tier, the Area Office will end the existing cost plan and all associated service plans with an ending date of 10/14/08, and create a new cost plan and service plans beginning 10/15/08 and ending 6/30/09, making sure that the total of the service plans does not exceed 75% of the annual tier limit.
7. In determining the amount of services to be include in the 10/15/08-6/30/09 cost plan, factor all monthly services, i.e., Waiver Support Coordination, and Residential Habilitation (Monthly) at 9 months rather than 8.5 months. For services by the quarter hour or day, factor 17 days of the service(s) from 10/15/08-10/31/08. For the cost plans that ends 10/14/08, 14 days of service(s) should be included for daily and quarter hours services in October.
8. The Area APD office may directly approve the following cost plan modifications:
   
   
   • Any continuation services in the cost plan.
   • Reductions in previously approved services and service levels
   • Any changes to providers and provider rates that do not impact the intensity or frequency of a service.
   • Meaningful day options that do not exceed the 30 hour a week limit for supported employment, ADT 6-10 ratio services and/or companion, or a combination of these services. (Whether new or continuation requests.) Transportation to and from the service may also be approved, if necessary and appropriate.
   • For individuals newly enrolled in the Tier 4 waiver, substitution of services to meet needs on that Tier waiver may be approved. (For example, substituting in-home support service hours for prior approved Personal Care Assistance service hours on an individual's plan.) The hours for the service must be substituted on a one for one basis. Areas may not increase the frequency or intensity of a service without submitting to PSA.
9. The Area APD office may not approve new services or increase existing services during this exercise except for the examples listed in #8 above. Prior Service Authorization review is required for any new or increases in services.
10. After receiving the Amendment Request Form with the updated cost plan information, the Area APD office will review the information to ensure that the cost plan is within waiver spending limits for the Tier to which the person will be enrolled. The cost plan should be updated in the ABC system using the following procedures:
    
    
    • If the person is assigned to Tier 1, no changes need to be done in ABC. The existing 7/1/08 cost plan will remain in effect.
    • If the individual is assigned to Tier 2, 3 or 4 and has an existing cost plan that is under the annual spending limits of the assigned tier, and all services are allowable on the assigned tier, no changes need to be made to ABC and the existing 7/1/08 cost plan will remain in effect.
    • If the person is assigned to Tier 2, 3 or 4, and they are over the annual approved spending limit of the tier, or have been receiving a service that is not allowable on the assigned tier, the existing cost plan and associated service plans will need to be adjusted to reflect the service dollars approved for services prior to 10/15/08 and both the cost plan and all service plans closed in ABC effective 10/14/08. A new cost plan and associated service plans will need to be entered into the ABC system effective 10/15/08 and end 6/30/09. Since the cost plan is less than 1 year, the Area APD office must prorate the annual spending limit on service plans. As described in #7 above, for monthly services, i.e, Waiver Support Coordination and Residential Habilitation (Monthly), prorate the 10/15/08 cost plan for 9 months (rather than 8.5). For the cost plan ending 10/14/08, remove 1 month of any monthly services since they will be included in the 10/15/08 cost plan. For all other quarter hours and daily services, the cost plan ending 10/14/08 should include up to 14 days of the service for the month of October and the cost plan beginning 10/15/08 should include up to 17 days of the service for October.




EXAMPLE 1 - A COST PLAN WITH MONTHLY RESIDENTIAL HABILITATION AND WAIVER SUPPORT COORDINATION: The service plan for Residential Habilitation Monthly beginning 7/1/08 ending 10/14/08, will include 3 months of Residential Habilitation and 3 months of Waiver Support Coordination. The cost plan beginning 10/15/08 through 6/30/09 will include 9 months of these two services.

The service plan for a quarter hour or daily service for the same individual for the cost plan running 7/1/08 through 10/14/08 will include up to 106 days of the service. The service plan for the cost plan running 10/15/08 through 6/30/09 will include up to 259 days of the service.

EXAMPLE 2 - AN INDIVIDUAL MOVING INTO A TIER WHERE THEY HAVE ALREADY BEEN APPROVED FOR SERVICES IN EXCESS OF THE ANNUAL TIER AMOUNT:

An individual is assigned to Tier 4 beginning 10/15/08, but has already been approved for $10,000 of services between 7/1/08 through 10/14/08.This individual's cost plan that runs from 7/1/08-10/14/08 will include the amount of services for those 106 days that were previously approved. The new cost plan running 10/15/08-6/30/09 will have the cap of $14,792 prorated down to $11,094 for the 9-month period. Any daily and quarter hours individual services within this $11,094 must be prorated by the number of days in the month not to exceed 8.5 months.

• The Comments Section of the service plans need to indicate the frequency and intensity and level of service. Example: "Companion, 3x wk, 16 qtr.hrs/dy", or: "Standard Res Hab Minimal". Comments such as "2080 qtr.hrs" or "monthly res hab" are not acceptable.
• Check to make sure the correct rate is entered into the system and that the math is correct when calculating the prorated allocation.

11. For individuals who are moving to Tier 4, please note that only the following services are available:



• Adult Day Training
• Behavior Analysis
• Behavior Assistant
• Consumable Medical Supplies
• Durable Medical Equipment
• Environmental Accessibility Adaptations
• In Home Support Services
• Personal Emergency Response System
• Respite Care
• Supported Employment
• Supported Living Coaching
• Transportation
• Waiver Support Coordination




Waiver Support Coordinators will assist individuals assigned to the Tier 4 Waiver for the first time to locate services that will meet their needs. Many of the services on this Tier waiver have expanded definitions. For example, In-home support services can be used in the family home as an in-home support, may perform functions similar to a personal care assistant, and can also perform functions found in companion services. For CDC participants assigned to Tier 4, the cost plan will be based on the services above. However, in development of the CDC purchasing plan, CDC participants assigned to Tier 4 will be able to use the full range of CDC services as described in CDC procedures.

12. The APD Area office will notify the waiver support coordinator or CDC Consultant when ABC has been updated and cost plans approved no later than October 13, 2008. The WSC shall:
• Furnish a copy of the revised cost plan to the individual/family/guardian,
• Explain and review with the individual the changes and limits in the revised cost plan.
• Send updated service authorizations to all affected providers. WSCs must provide the prorated service authorization for the cost plan that ends 10/14/08, as well as the new service authorization that runs 10/15/08 through 6/30/09.
• Furnish the individual with a notice of his or her due process rights at the time that the cost plan is provided and reviewed.The waiver support coordinator must utilize the letter template and hearing rights attached to this procedure to provide the notice. The WSC must document delivery of the letter, notice of hearing rights and the revised cost plan in casenotes or by filing a copy of the letter in the individual's central record.



13. CDC Participants are included in the procedures above for notification and reprioritization of cost plans if the plan exceeds the amount of the Tier cap. Adjusted cost plans for CDC participants must be submitted to the Area office by September 24, 2008. Once approved the CDC Consultant will be notified of the approval and will begin work with the individual and family on the CDC Purchasing Plan per approved CDC procedures. This Purchasing Plan must be submitted no later than November 15, 2008 to the APD Central office for review and input into the CDC system. Changes to the Purchasing Plan will be effective December 1, 2008.

C. Area notification of people who will not meet waiver enrollment requirements for their new Tier Waiver.

1. Waiver Support Coordinators will be furnished with a spreadsheet listing Tier Waiver assignments for people on their caseloads and are requested to immediately make contact with people on their caseload about their assignment. WSCs should contact individuals to discuss their Tier Waiver assignment regardless of whether the individual will be affected by a cost plan modification or not. People who do not have to change their plans will want to be reassured of this information. People who will need to reprioritize their plan to come within the limits of their new Tier Waiver enrollment will need to begin work with the WSC to evaluate options. WSCs will submit information on adjusted cost plans to the Area APD office no later than September 24, 2008.
2. WSCs will notify their Area office immediately if it is determined that there are difficulties working with the individual, family or guardian in cost plan reprioritization, and that the cost plan modification will not meet the September 24 deadline for furnishing a revised cost plan to the Area office. The Area office will also be notified by the WSC if the WSC has been unable to contact the individual in order to meet the September 24, 2008 deadline.
3. Efforts to make contact with individuals on a WSC's caseload will be documented in case notes. The WSC is expected to make numerous attempts at contact to assure that individuals have adequate notice to make Tier cost plan changes.
4. The Area office will provide a report to the APD central office by September 11, 2008 of individuals who will not meet the deadline as identified in # 2 above. The report will be updated as additional information is received by the Area office. Report information should be submitted to Linda Mabile in the HCBS Bureau via email. Information in the spread sheet should include the individual's name, social security number, waiver support coordinator's name and a comment on why the cost plan modification date will not be met.

D. Approving services for people under 21 who receive personal care assistance services

Effective 7/1/08, funding responsibilities for Personal Care Assistance (PCA) services for individuals under the age of 21 shifted to Medicaid State Plan. While PCA services remain on the person's cost plan and services are billed through the waiver, payment for these services for people under 21 comes from Medicaid State Plan, not waiver funding.

PCA services for people under 21 will not be completely transitioned to Medicaid State Plan until approximately December 2008. Until the full transition to Medicaid State Plan occurs, Personal Care Assistance hours and costs for individuals under the age of 21 will continue to appear on the individual's cost plan, but the amount of the service will not be calculated as part of the annual tier expenditure cap. As funding for this service for people under the age of 21 is fully transferred to Medicaid State Plan, the service will be discontinued on the individual's cost plan and full payment will be picked up by Medicaid. (Individuals will be notified in advance that this is occurring.)

Individuals under age 21 will receive a notification letter of their assigned tier. Individuals under the age of 21, with their parent or guardian, will need to make immediate contact with their Waiver Support Coordinator to plan for any reprioritization of services on their cost plan, other than PCA.

The allocation of all services (except Personal Care Assistance) may not exceed the annual tier spending limit. The following is an example:

An individual under the age of 21 is newly assigned to Tier 4, but previously had $10,000 of approved Personal Care Assistance services and $20,000 of other services for a total cost plan of $30,000. The Tier 4 Waiver has a cap of $14,792. Normally this is the total amount that would be approved on the person's cost plan. Due to Medicaid State Plan assuming the cost for PCA services for this age group, the cost of the PCA services will not be included within the overall total amount of the tier cap. Therefore, the annual cost plan limit for this individual shall be the $14,792 for all service except PCA, but will reflect the $10,000 of PCA as well. The service plans must be pro-rated accordingly to accommodate a cost plan that is less than 12 months. This availability of the total plan amount of $24,792 will be in effect until PCA services are transferred to Medicaid State Plan for the individual.

APD Area offices will train Waiver Support Coordinators in how to handle PCA services and cost planning for individuals under 21.

E. Temporary Procedures for Submission of Tier Change Request

A tier change may occur for one of the following reasons:

• The individual experiences a significant change in condition or circumstance that affects their health, safety, and welfare
• The Area APD office or PSA Contractor determines that a service previously approved is not medically necessary or not provided within waiver coverage and limitation, or statute

1. The individual experiences a significant change in condition or circumstance that affects their health, safety, and welfare



1. APD will review an individual's tier assignment if the person experiences a significant change in circumstance or condition that affects their health and safety, and if the change meets rule criteria to move to a new tier. Please refer to the Agency for Persons with Disabilities Criteria for Tier Selection Operational Detail.
2. The Waiver Support Coordinator will notify the Area office using the Amendment Request Form that a significant change has occurred for the individual and will detail the requested service modifications necessary to support that significant change. The Area APD office will review the information submitted and, if in agreement that a significant change is present, will submit the service change information to the Prior Service Authorization contractor (PSA) for review and approval in accordance with routine PSA procedures.
3. If the Area APD office does not agree that the documentation supports that a significant change has occurred that warrants a change, the Area APD office will issue a Notice to Deny a Request for a Tier or Service Change. (Sample letter will be provided to the Area for use.) The letter will explain any due process rights that the individual will be afforded as a result of the denial.
4. If the Area APD office recommends that the individual meets the criteria for a tier change, the Area APD office will notify the APD Central designee of the tier change request, and that information to support the service change has been forwarded to the PSA contractor, if appropriate.
5. The PSA Contractor will review the service(s) to determine medical necessity, make a recommended determination, and send the information to the APD Central Office designee prior to issuing a final determination.
6. If the APD Central Office concurs with the service change and new tier, APD Central Office will update the ABC enrollment system with the appropriate tier assignment and notify the Area APD office via e-mail of the tier change. At the same time, the PSA Contractor will issue their determination on the PSA request.
7. If the APD Central Office does not concur with the service change and new tier assignment, (i.e. the service is not medically necessary or within waiver coverage, limitation or statute) the PSA Contractor will be notified to issue a Notice of Intent to Deny, Reduce or Terminate services in accordance with normal PSA procedures and follow the PSA Procedures leading up to a Final Notice.

Sometimes an individual will request services that would require placement into another tier, such as a request to move into another living setting. The Tier change request submittal process must be followed before the new service can be approved. If there is an emergency, the Area APD office may issue a temporary approval for the service not to exceed 30 days following the Operating Procedure for Emergency Approval. However, the approval for services must clearly specify the temporary nature of the emergency approval. A temporary emergency approval does not automatically guarantee that a tier change will be approved.

2. The Area APD office or PSA contractor determines that a service previously approved is not medically necessary or not provided within waiver coverage and limitation, or statute



1. If the PSA process results in the denial, termination, or a reduction of a service that affects a tier assignment, the PSA Contractor will notify the APD Central Office designee for approval of a new Tier enrollment. If a Tier change is approved by the central office, the Area APD office will be notified via e-mail of the tier change. This occurs after all due process or hearing proceedings are complete.
2. The PSA contractor will follow routine procedures for notifying the individual and waiver support coordinator of the denial, termination or reduction in services, and the enrollment in a new Tier Waiver resulting from these actions. As in current procedures, the individual will be notified of their due process rights.
3. The APD Central Office will update the ABC system with the tier change when appropriate.



3. Tier changes that do not require PSA review

In rare instances, a Tier Change resulting from a significant change in condition or circumstance will not require a PSA review. (for example: the individual moves from a group home back into the family home without adding additional services.) This includes situations where an individual changes tiers, but does not make changes to services, aside from meaningful day activities. When the Tier change request is submitted to the APD Central Office that does not require a PSA review, the Area APD office shall attach supporting documentation as justification of the new tier needed. Documentation required for specific services that trigger a tier change can be found on the PSA Documentation Requirements Checklist.

If approved, The APD Central Office will update the ABC system with the tier change and notify the Area APD office via e-mail.

4. Tier Assignments for New Enrollees

The process for assigning tiers to individuals newly enrolled on the waiver will be addressed in a separate operating procedure.

F. Communication Procedures

Area APD offices must schedule a face to face meeting with Waiver Support Coordinators to explain this tier implementation process no later than August 27 or 28, 2008. APD will disseminate information to the Family Care Councils and post information on the APD website regarding tier implementation. Every effort shall be made by Agency staff to answer questions and provide needed information about the new Tier Waiver System. Updated brochures and other information items will be provided to the Area offices by the APD Communications office.

Areas with questions or concerns about Tier Waiver implementation should contact Lorena Fulcher (Lorena_Fulcher@apd.com), Deb Blizzard (Deb_Blizzard@apd.com), or Linda Mabile ( Linda_Mabile@apd.com) at the APD Central office. Waiver Support Coordinators should direct their questions to the local Area APD offices.

Date ____________

Dear ___________________________
(Individual or Guardian)

Your approved cost plan for enrollment in a Tier Waiver is attached.

Your "Notice of Hearing Rights" is also attached.

If you need any further information or assistance please call me or your area office.

Sincerely,

Waiver Support Coordinator

Enclosures: Cost Plan
Notice of Hearing Rights

Your new cost plan is part of the implementation of the tier waiver system for all recipients of the Community and Home-Based waiver services This is part of a change in state law required by Section 393.0661, Florida Statutes (2007) and Agency Rules 65G-4.0021 through 65G-4.0025, Florida Administrative Code. Therefore, if the only issue you raise is the change to the State law requiring the tier waiver system, your request for a hearing will be denied as authorized by 42 CFR 431.220.

However, if you believe that the agency has made a factual error in your approved cost plan for 10/15/08 through 7/31/09, you may be entitled to an administrative hearing as provided in Sections 120.569 and 120.57, Florida Statutes (2007) and 42 CFR 431.220. A hearing will only be granted if your hearing request states facts that demonstrate there was an error in your cost plan. Mediation is not available in this proceeding

If the agency determines you have a right to hearing, you may represent yourself or use legal counsel, a relative, a friend, or other spokesperson in a hearing on this matter. If you are not representing yourself, proof of guardianship or other documentation of your representative’s authority to act on your behalf is required with the request for hearing.

Section 393.125(1)(c), Florida Statutes (2007), states that you must make your hearing request to the agency, in writing, within thirty (30) days of receiving this notice.

Additionally, your hearing request must include the following information:

1. The name, address, and telephone number of the party making the request and the name, address and telephone number of the party’s counsel or representative upon whom service of pleadings and papers must be made;
2. A statement that you are requesting an administrative hearing;
3. A list of any facts and circumstances on which you rely to assert an error in your cost plan,
4. A reference to, or copy of, the letter notifying you of your approved cost plan;
5. A statement indicating the date you received your approved cost plan, and
6. If someone is making the request for hearing on your behalf, a document, such as an Order Appointing Guardian or a written statement of authorization, establishing the representative’s authority to act on your behalf.

If you file your request within ten (10) days of receiving notice of your new cost plan, your services will continue at the existing level until the final decision on your request for hearing.

To request a hearing mail or fax your completed request to:
Agency Clerk, Agency for Persons with Disabilities
4030 Esplanade Way, Suite 380
Tallahassee, Florida 32399-0950
Facsimile – (850) 410-0665

You may contact your local APD office if you have questions or need assistance in completing a hearing request.