Effective 28 Aug 2013

208.895. Referral for services, department duties — assessments and care plans, requirements — definitions — report. — 1. Upon the receipt of a properly completed referral for service for MO HealthNet-funded home- and community-based care or a physician's order, the department of health and senior services shall:

(1) Process, review and approve or deny the referral within fifteen business days;

(2) For approved referrals, arrange for the provision of services by a home- and community-based provider;

(3) Notify the referring entity or individual within five business days of receiving the referral if a different physical address is required to schedule the assessment. The referring entity has five days to provide a current physical address if requested by the department. If a different physical address is needed, the fifteen-day limit included in subdivision (1) of this subsection is suspended until the information is received by the department;

(4) Inform the applicant of:

(a) The full range of available MO HealthNet home- and community-based services, including, but not limited to, adult day care services, home-delivered meals, and the benefits of self-direction and agency model services;

(b) The choice of home- and community-based service providers in the applicant's area, and that some providers conduct their own assessments, but that choosing a provider who does not conduct assessments will not delay delivery of services; and

(c) The option to choose more than one home- and community-based service provider to deliver or facilitate the services the applicant is qualified to receive;

(5) Prioritize the referrals received, giving the highest priority to referrals for high-risk individuals, followed by individuals who are alleged to be victims of abuse or neglect as a result of an investigation initiated from the elder abuse and neglect hotline, and then followed by individuals who have not selected a provider or who have selected a provider that does not conduct assessments; and

(6) Notify the referring entity and the applicant within ten business days of receiving the referral if it has not scheduled the assessment.

2. If the department of health and senior services has not complied with subdivision (1) of subsection 1 of this section, a provider has the option of completing an assessment and care plan recommendation. At such time that the department approves or modifies the assessment and care plan, the care plan shall become effective; such approval or modification shall occur within five business days after receipt of the assessment and care plan from the provider. If such approval, modification, or denial by the department does not occur within five business days, the provider's care plan shall be approved and payment shall begin to the provider based on the assessment and care plan recommendation submitted by the provider.

3. At such time that the department approves or modifies the assessment and care plan, the latest approved care plan shall become effective. If the department assessment determines the client does not meet the level of care, the state shall not be responsible for the cost of services claimed prior to the department's written notification to the provider of such denial.

4. The department shall implement subsections 2 and 3 of this section unless the Centers for Medicare and Medicaid Services disapproves any necessary state plan amendments or waivers to implement the provisions in subsections 2 and 3 of this section allowing providers to perform assessments.

5. The department's auditing of home- and community-based service providers shall include a review of the client plan of care and provider assessments, and choice and communication of home- and community-based service provider service options to individuals seeking MO HealthNet services. Such auditing shall be conducted utilizing a statistically valid sample. The department shall also make publicly available a review of its process for informing participants of service options within MO HealthNet home- and community-based service provider services and information on referrals.

6. For purposes of this section:

(1) "Assessment" means a face-to-face determination that a MO HealthNet participant is eligible for home- and community-based services and:

(a) Is conducted by an assessor trained to perform home- and community-based care assessments;

(b) Uses forms provided by the department;

(c) Includes unbiased descriptions of each available service within home- and community-based services with a clear person-centered explanation of the benefits of each home- and community-based service, whether the applicant qualifies for more than one service and ability to choose more than one provider to deliver or facilitate services; and

(d) Informs the applicant, either by the department or the provider conducting the assessment, that choosing a provider or multiple providers that do not conduct their own assessments will in no way affect the quality of service or the timeliness of the applicant's assessment and authorization process;

(2) A "properly completed referral" shall contain basic information adequate for the department to contact the client or person needing service. At a minimum, the referral shall contain:

(a) The stated need for MO HealthNet home- and community-based services;

(b) The name, date of birth, and Social Security number of the client or person needing service, or the client's or person's MO HealthNet number; and

(c) The current physical address and phone number of the client or person needing services.

­­Additional information which may assist the department including contact information of a responsible party shall also be submitted.

7. The department shall:

(1) Develop an automated electronic assessment care plan tool to be used by providers; and

(2) Make recommendations to the general assembly by January 1, 2014, for the implementation of the automated electronic assessment care plan tool.

8. No later than December 31, 2014, the department of health and senior services shall submit a report to the general assembly that reviews the following:

(1) How well the department is doing on meeting the fifteen-day requirement;

(2) The process the department used to approve the assessors;

(3) Financial data on the cost of the program prior to and after enactment of this section;

(4) Any audit information available on assessments performed outside the department; and

(5) The department's staffing policies implemented to meet the fifteen-day assessment requirement.

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(L. 2009 H.B. 395 § 1, A.L. 2010 S.B. 842, et al. merged with S.B. 1007, A.L. 2013 S.B. 127)