Provider Update
The APD emergency rate reduction to provider rates will end at midnight, April 15. Provider rates will return to their March 2011 levels effective Saturday, April 16.
Rates for services provided between April 1 and April 15 will remain at the reduced rate.
To keep from issuing over 150,000 new service authorizations, APD is changing current service authorizations (April 1 – June 30). These service authorizations will have an approved amount based on the reduced rate for services provided between April 1 through April 15 and the old (higher) rate from April 16 through the service authorization end date.
Changed service plans will be available in ABC by close of business Monday, April 18.
Service authorization requests will be submitted to FMMIS the evening of April 18. Service authorizations are anticipated to be available Tuesday, April 19.
Billing is suspended until system changes are complete. APD anticipates that service authorizations will be available to Waiver Support Coordinators on Tuesday, April 19. WSC must review and distribute these service authorizations. Once a provider has received a service authorization, they may begin billing for April services.
If you have any questions or problems with your service authorization, Area Office staff can answer questions and make corrections to service plans.
Rates
The rate shown on the service authorization will be the old (higher) rate. The approved amount on the service authorization may not be equal to the old rate shown on the service authorization multiplied by the number of units. The service authorization for April may show an amount slightly less than the original rate multiplied by the number of units because of the reduced rate used from April 1 through April 15.
When billing for April, please remember to reduce the amount billed for services provided before April 16.
Because of the rate change, services (other than monthly) should be billed daily by date in April. Please do not “roll-up” service rates used after April 15 with services provided during the April 1 through April 15 period.
Service Scenarios
The sections below describe how reduced rate service authorizations will be handled to increase the rates.
Service Plans with Approved Amount <= $1.00 or Rate = $0.00 :
Service Plans with Approved Amount <= $1.00 or Rate = $0.00 will not be updated by this process.
Monthly Services (One unit per month billed)
The services below will be handled as follows:
For April,
The reduced rate will be multiplied by 50% (.5).
The old rate will be multiplied by 50% (.5).
These two amounts will be added together to get the blended amount for April
Each remaining month (May and June) will be billed at the old rate ($100.00)
New Service Authorization Amount (April-June) 92.50 + 100 + 100 = $292.50
Example:
Reduced rate = $85, Old rate = $100, 4/1/2011-6/30/2011
For April,
$85 x .5 = $42.50
$100 x .5 = $50
$42.50 + $50 = $92.50 (blended amount for April)
92.50 + 100 + 100 = $292.50 New Service Authorization Amount (April-June)
Monthly Services
Res Hab Basic - Standard
Res Hab Ext 1 - Behavior Focus
Res Hab Ext 1 - Standard
Res Hab Ext 2 - Behavior Focus
Res Hab Ext 2 - Standard
Res Hab Min - Behavior Focus
Res Hab Min - Standard
Res Hab Mod - Behavior Focus
Res Hab Mod - Standard
Support Coordination - Limited
Support Coordination - Full
Support Coordination – Transitional
Support Coordination CDC+ - Limited
Support Coordination CDC+ - Full
Unit Based Services
The services below will be handled as follows
Calculate number of days between begin date and 4/15/2011 = Reduced rate days (DaysReduced)
Calculate the number of days between 4/16/2011 and service authorization end date = remaining days (DaysRemain)
DaysReduced + DaysRemain = DaysSA
Approved amount / reduced rate = number of units (Units)
Units / DaysSA = units per day (UnitsDay)
UnitsDay * DaysReduced * reduced rate = 4/1/2011-4/15/2011 amount (ReducedAmt)
UnitsDay * DaysRemain * old rate = 4/16/2011-end of service authorization amount (RemainingAmount)
ReducedAmt + RemainingAmount = New Service Authorization Amount
Example:
Reduced rate = $85, Old rate = $100, Period 4/1/2011-6/30/2011, Amount $8500
4/1/2011 – 4/15/2011 = 15 (DaysReduced)
4/16/2011 – 6/30/2011 = 76 (DaysRemain)
15 + 76 = 91 (DaysSA)
$8500 / $85 = 100 (Units)
100/91 = 1.0989 (UnitsDay)
1.0989 * 15 * $85 = $1401.0975 (ReducedAmt)
1.0989 * 76 * $100 = $8351.64 (RemainingAmount)
$1401.0975 + $8351.64 = $9752.7375 (New Service Authorization Amount)
Unit Based Services
In - Home Supports (Live-In Staff)
Res Hab Basic - Standard - Daily
Res Hab Ext 1 - Standard - Daily
Res Hab Ext 2 - Standard - Daily
Res Hab Min - Standard - Daily
Res Hab Mod - Standard - Daily
Residential Habilitation - (Live In Staff) - Daily
Respite Care - Day
Adult Day Training - Facility Based
Adult Day Training - Off Site
Behavior Analysis Level 1
Behavior Analysis Level 2
Behavior Analysis Level 3
Behavior Assistant Services
Companion
Dietitian Services
In - Home Supports (Awake Staff)
Occupational Therapy
Personal Care Assistance
Physical Therapy
Private Duty Nursing - LPN
Private Duty Nursing - RN
Residential Habilitation - (Quarter Hour)
Residential Nursing Services - LPN
Residential Nursing Services - RN
Respiratory Therapy
Respite Care - Quarter Hour
Skilled Nursing - LPN
Skilled Nursing - RN
Specialized Mental Health - Therapy
Speech Therapy
Supported Employment Group
Supported Employment - Individual Model
Supported Living Coaching
Services Reduced by a flat 15 percent
The services below will be handled as follows
Calculate number of days between begin date and 4/15/2011 = Reduced rate days (DaysReduced)
Calculate the number of days between 4/16/2011 and service authorization end date = remaining days (DaysRemain)
DaysReduced + DaysRemain = DaysSA
Approved amount / reduced rate = number of units (Units)
Units / DaysSA = units per day (UnitsDay)
Reduced rate / .85 = old rate
UnitsDay * DaysReduced * reduced rate = amount prior to 4/16/2011 (amount 1)
UnitsDay * DaysRemain * old rate = amount after 4/15/2011 (amount 2)
Amount 1 + amount 2 = New Service Authorization Amount
Example:
Reduced rate = $85, Period 4/1/2011-6/30/2011, Amount $8500
4/1/2011 – 4/15/2011 = 15 (DaysReduced)
4/16/2011 – 6/30/2011 = 76 (DaysRemain)
15 + 76 = 91 (DaysSA)
$8500 / $85 = 100 (Units)
100/91 = 1.0989 (UnitsDay)
$85 / .85 = 100 (old rate)
1.0989 * 15 * $85 = $1401.0975 (ReducedAmt)
1.0989 * 76 * $100 = $8351.64 (RemainingAmount)
$1401.0975 + $8351.64 = $9752.7375 (New Service Authorization Amount)
Services Reduced by a flat 15 percent
CONSUMABLE MEDICAL SUPPLIES
IN HOME SUPPORTS MONTHLY - S.L.WAIVER
Personal Emergency Response - Service
Res Hab Basic - Behavior Focus
Residential Habilitation - (Day) Intensive Behavior in a Licensed Facility
Special Medical Home Care
Transportation - Mile
Transportation - Month
Transportation - Trip
One time or infrequent services
The services below will be handled as follows:
A list of these service authorizations is being provided to the Area Offices. Changes for these services will be handled manually by the Area Offices
Services
Adult Dental Services
Behavioral Analysis Services Assessment
Durable Medical Equipment
Environmental Accessibility Adaptations
Home Accessibility Assessment
Occupational Therapy Assessment
Personal Emergency Response - Installation
Physical Therapy - Assessment
Respiratory Therapy Assessment
Specialized Mental Health - Assessment
Speech Therapy - Assessment
Special Case for Res Hab Behavior Focus
The services listed below have the same procedure code of either "T2020U6" or "T2023U6" in the Rate table. However Res Hab Basic does not have any given rates as this service comes under services with negotiated rates. The business rule being applied is:
a) Take the pre-April 1 ABC service plan rate (old) and compare it with all the rates available in the old rate table.
b) If a perfect rate match is found for the procedure code and rate, the matched rate will be used in the current service plan. Otherwise the ABC old service plan rate will be used in the current service plan.
Services
Res Hab Basic - Behavior Focus
Res Hab Min - Behavior Focus
Res Hab Mod - Behavior Focus
Res Hab Ext 2 - Behavior Focus
Res Hab Ext 1 - Behavior Focus - Daily
Res Hab Ext 2 - Behavior Focus - Daily
Res Hab Min - Behavior Focus - Daily
Res Hab Mod - Behavior Focus - Daily
Problems That Might Occur
One time or infrequent services are being handled manually
Units may not be used on a daily basis so the calculated amount is not correct