Administrative Entity Operating Agreement
This Agreement is effective as of July 1, 2013, for the purposes of ______________
________________________________________, hereinafter referred to as the
“Administrative Entity (AE)”, conducting the administrative functions of the Consolidated
(CMS # PA.0147) and Person/Family Directed Support (P/FDS)(CMS # PA.0354)
Waivers for individuals and Waiver Participants with intellectual disabilities.
WITNESSETH:
WHEREAS, the Department retains the authority and responsibility to implement,
administer and oversee the Consolidated and P/FDS Waivers, hereinafter referred
collectively to as the “Waivers”, except where otherwise specifically named.
WHEREAS, the AE is responsible for the Waiver administrative functions as defined in
Appendix A to this Agreement.
WHEREAS, authorization has been given for the Waivers as a result of federal approval
under Section 1915 (c) of the Social Security Act.
WHEREAS, federal approval was conditioned on assurances that the expenditure of
Waiver funds be governed by the Waivers, including the criteria set forth in Appendix A
to this Agreement.
WHEREAS, the Pennsylvania Mental Health and Intellectual Disability Act of 1966
creates a dynamic relationship in administrative oversight in the delivery of publicly
funded community behavioral health and intellectual disabilities services.
WHEREAS, the Department has offered the county program the right of first opportunity
to provide certain administrative services for the Waivers, in order to better coordinate
care with other publicly funded community human services.
NOW THEREFORE, the AE intending to be legally bound to perform AE administrative
functions agrees as follows:
1. That the allocation of administrative funding is conditional upon the AE’S
compliance with the Waivers and Agreement conditions.
2. That this Agreement shall remain in full force and effect until it is:
a. Altered by a change in law,
b. Altered by an approved Waiver amendment or Waiver,
c. Superseded by another agreement or amendment to this Agreement,
or
d. Terminated as outlined in Sections and Subsections 9.0 through
9.3.2.1 of this Agreement.
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Signature of Person with legal authority to bind the Department to the terms of this
Agreement:
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Typed or Printed Name
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Signature
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Date
Signature(s) of persons with legal authority to bind the AE to the terms of this
Agreement:
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Typed or Printed Name
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Signature
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Date
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Typed or Printed Name
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Signature
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Date
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Typed or Printed Name
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Signature
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Date
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Typed or Printed Name
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Signature
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Date
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Typed or Printed Name
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Signature
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Typed or Printed Name
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Typed or Printed Name
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Signature
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Table of Contents
Section
Section Title
Page
Table of Contents
3
Operating Agreement Terms and Conditions
Definition of Terms
General Scope of the Operating Agreement
Sovereign Immunities
Authority of the Department
Authority of the Administrative Entity (AE)
Indemnification
Administrative Functions
Delegated or Purchased Administrative Functions
Authorization to Delegate or Purchase Administrative
Functions
Monitoring of Delegated or Purchased Administrative
Functions
Financial Administration Requirements
Financial Liability for the Waiver Program
Administrative Payments to the AE
Ineligible Waiver Expenditures
Financial Liability of Waiver Participants
Financial Audits
Desk Review
Claim Resolution Support
Waiver Records
Waiver Participant Records
Other Waiver Records
Safeguarding Waiver Records
Access to Waiver Records
Waiver Capacity Management
Waiver Capacity Commitment
Waiver Residential Vacancy Management
Reserved Capacity Due to Hospital or Rehabilitation
Care
Unanticipated Emergencies
Meeting the Needs of Waiver Participants
Prioritization of Urgency of Need for Services (PUNS)
Service Delivery Preference
Eligibility and Enrollment for Waiver Services
Level of Care
MFP Consent
Financial Eligibility
5
5
13
13
13
13
13
14
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Appendix A:
1.0
2.0
2.1
2.1.1
2.1.2
2.2
3.0
3.1
3.1.1
3.1.1.1
3.2
3.2.1
3.2.2
3.2.3
3.2.4
3.2.5
3.2.6
3.2.7
3.3
3.3.1
3.3.2
3.3.3
3.3.4
3.4
3.4.1
3.4.2
3.4.3
3.4.4
4.0
4.1
4.2
4.3
4.3.1
4.3.2
4.3.3
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18
19
19
19
20
21
21
21
21
21
22
22
23
23
24
24
25
25
26
26
26
27
27
27
28
28
3
4.3.4
4.3.5
4.3.6
4.4
4.5
4.6
4.7
4.7.1
4.8
4.8.1
4.8.2
4.8.2.1
4.8.3
4.8.4
4.9
4.9.1
4.9.2
5.0
5.1
5.2
5.3
6.0
6.1
6.2
6.3
6.4
7.0
7.1
7.1.1
7.1.2
7.2
7.3
8.0
8.1
8.2
9.0
9.1
9.2
9.2.1
9.3
9.3.1
9.3.2
9.3.2.1
Consolidated Waiver Enrollment
Person/Family Directed Support (P/FDS) Waiver
Enrollment
Waiver Transfers
Offering Free Choice of Willing and Qualified Providers
Financial Management Services (FMS)
Service Initiation upon Waiver Enrollment
Statewide Needs Assessment
Statewide Needs Assessment Contractor
Individual Support Plans (ISPs)
Review, Approval and Authorization of Individual Support
Plans (ISPs) and Waiver Services
Additional Prerequisites for Service Authorization
Residential Services
Implementation of Individual Support Plans (ISPs)
Service Requests
Fair Hearing and Appeal
Notice of Fair Hearing Rights
Continuation of Waiver Services
Waiver Providers
Provider Recruitment and Enrollment
Qualification of Waiver Providers
Ineligible Waiver Providers
Monitoring Waiver Requirements
Monitoring of Waiver Providers
Correction of Issues and Non-Compliance
Administrative Review
Implementation of Department Decisions and Findings
Quality Management (QM)
Quality Management (QM) Plan
Utilizing Department Information to Enhance Quality
Functions of the AE’s QM Point Person(s)
Incident Management
Independent Monitoring for Quality (IM4Q)
Training and Technical Assistance
Participation in Training
Technical Assistance
Operating Agreement Remedies and Termination
Agreement Remedies
Agreement Termination
Enforcement
Transition Plan and Closeout Procedures for
Agreement Termination
Transition Plan for Agreement Termination
Closeout Procedures for Agreement Termination
Enforcement
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30
30
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31
32
33
34
34
35
35
36
36
36
36
37
37
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Appendix A
Operating Agreement Terms and Condition
1.0
Definition of Terms
The following capitalized terms as used in this Agreement are defined as set forth
below:
Administrative Entity: County/AE (AE) – A county/joinder or non-governmental entity
that enters into and maintains a signed current agreement with the Department to
perform administrative functions delegated by the Department, as the Department’s
designee, in compliance with the Department’s approved Consolidated and P/FDS
Waivers, Written Policies and Procedures and Departmental Decisions.
AE Oversight Monitoring (AE OM) Process – A process including ODP’s continuous
review of specific indicators with a formal onsite review of the AE conducted annually
aimed at assessing the AE’s ability to conduct Waiver operational and administrative
functions and a subsequent development of a Findings Report summarizing the onsite
review.
Agency With Choice (AWC) – A type of Financial Management Services (FMS)
Provider acting as the Common-Law Employer which provides an administrative service
that supports a Participant or Participant’s Surrogate acting as the Managing Employer
in the management of the Participant’s Support Service Workers (SSW’s) and supports
and services authorized in the Participant’s Individual Support Plan (ISP).
Annual Review Update – The category field in the Home and Community Services
Information System (HCSIS) used to document the results of an ISP annual review
meeting. The annual review update date is the end date of the current ISP.
Approved Program Capacity – The individual capacity established by the Department
for each Waiver-funded residential service location licensed under 55 Pa. Code
Chapters 6400 (relating to Community Homes for Individuals With Mental Retardation).
Assessed Needs – Needs of Waiver Participants identified through the Statewide
Needs Assessment or other valid assessments that have been conducted based on the
Participant’s unique circumstances, documented in writing including frequency and
duration, when applicable prescribed by a licensed medical professional, and identified
as a required need by the Participant’s team responsible for developing the ISP.
Bi-annual Review – The category field in HCSIS used to document the results of the
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six month review for certain class members and waiver participants receiving a
service(s) that requires a six month review.
Bureau of Hearings and Appeals (BHA) – The Departmental entity charged with
conducting administrative hearings and timely adjudication of appeals which are filed in
accordance with state and federal regulations.
Centers for Medicare & Medicaid Services (CMS) – The agency in the federal
Department of Health and Human Services that is responsible for federal administration
for Medicaid, Medicare, and State Children’s Health Insurance programs.
Claim – A bill for a service(s) or a line item of service within a bill for a service(s)
provided to a Waiver Participant that is submitted through the Provider Reimbursement
and Operations Management Information System in electronic format (PROMISe™)
Common-Law Employer – The individual or Provider that is the legal employer, also
known as “employer of record” of the staff hired to support the Participant.
Corrective Action Plan (CAP) – A plan to address issues of noncompliance or a
Health and Welfare risk of a Participant.
Cost Report – An annual report of revenue and expenses required of Providers
rendering specified services to Waiver Participants which is then used by the
Department to develop prospective rates for those Waiver services.
County Assistance Office (CAO) – The county offices of the Department that
administer public assistance benefits including determining and maintaining recipient
Medicaid Waiver eligibility.
County/Joinder Mental Health/Intellectual Disabilities (MH/ID) Board – The board
established by a county, joinder or city of the first class as per Section 302 of the Mental
Health and Intellectual Disability Act of 1966, 50 P.S. §§ 4101-4704.
Critical Revision – The category field in HCSIS used to add, delete or modify the level
of a service in a current ISP based on the Participant’s Assessed Needs which requires
approval and re-authorization of the service in the ISP.
Department – The Pennsylvania Department of Public Welfare (DPW) and the state
program offices under the heading of this Department, including ODP, except where
some other subdivision is specifically named.
Departmental Decisions – Written determinations made by the Department including
but not limited to: service review findings, Provider dispute resolution findings, BHA
decisions, reconsiderations made by the Secretary of DPW, decisions made by the
Deputy Secretary of ODP, Provider qualification and disqualification actions, licensing
actions, interpretations of policy, findings resulting from an investigation completed by
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an ODP regional certified investigator, Findings Reports related to AE performance and
responses to a CAP or Directed Corrective Action Plan (DCAP).
Desk Review – The review designed to identify errors in a Cost Report and to
determine whether or not a Cost Report has been completed in accordance with the
Cost Report instructions.
Directed Corrective Action Plan (DCAP) – A document developed or approved by the
Department or the Department’s designee to resolve noncompliance.
Factoring – The act of an individual, service Provider or organization such as a
collection agency or service bureau, which advances money to a Provider for accounts
receivable that the Provider has assigned, sold or transferred to the individual or
organization for an added fee or deduction of a portion of the accounts receivable.
Factoring does not apply to a business agent, such as a billing service or an accounting
firm that furnishes statements and receives payments in the name of the Provider, if the
organization’s compensation for this service is:
1. Related to the cost of processing the billing.
2. Not related on a percentage or other basis to the amount that is billed or
collected.
3. Not dependent upon the collection of the payment.
Financial Management Services (FMS) – A type of Provider (either AWC or Vendor
Fiscal/Employer Agent (VF/EA) that provides administrative support to a Waiver
Participant who self-directs all or some of their HCBS services and fulfills specific
employer or employer agent responsibilities for that Participant.
Findings Report – A report detailing issues identified through the monitoring of each
AE conducted by the Department during the AEOM Process to ensure compliance with
this Agreement, Written Policies and Procedures and Departmental Decisions.
Fiscal Year (FY) – The period of time extending from July 1 of one calendar year
through June 30 of the next calendar year.
Fiscal Year Renewal – The category field in HCSIS used to create a renewal of the ISP
for the next FY with a begin date of July 1 and an end date of June 30.
General Update – The category field in HCSIS used to update content in an ISP that
does not impact services or funding.
Health and Welfare – Health and Welfare relates to the assurances outlined in the
federal code of regulations at 42 CFR 441.302, through applicable state and federal
laws and Written Policies and Procedures.
Home and Community Services Information System (HCSIS) – The secure internet
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information system serving the DPW state program offices that oversee Medicaid
Waivers.
Independent Monitoring for Quality (IM4Q) – A survey and interview instrument
focusing on the quality of services and supports for individuals and Participants with
intellectual disabilities which provides a source of data to support ODP quality initiatives.
Individual Support Plan (ISP) – The comprehensive decisions agreed upon by the
Participant’s team and documented on the form designated by the Department which
identifies outcomes and needed services and supports provided to an individual.
Ineligible Provider – A Provider identified on one of the following lists or databases:
Excluded Parties List System (EPLS) – This system includes information
regarding entities debarred, suspended, proposed for debarment, excluded or
disqualified under the non-procurement common rule or otherwise declared
ineligible from receiving federal contracts, certain subcontracts and certain
federal assistance and benefits.
List of Excluded Individuals/Entities (Maintained currently in the System for
Award Management or SAM) – A database maintained by the Office of Inspector
General for use by the public, health care providers, patients and others which
provides information relating to parties excluded from participation in Medicare,
Medicaid and all federal health care programs.
Medicheck – A list identifying providers, individuals and other entities precluded
from participation in the Commonwealth of Pennsylvania Medical Assistance
Program.
In addition, a Provider that expresses interest in delivering Waiver services that has not
completed the Department’s Provider qualification process is also considered an
Ineligible Provider of Waiver services until such time the Provider meets the qualification
criteria, completes the qualification process and is determined by the Department to be
a Qualified Provider.
Jurisdiction of the Administrative Entity – The geographic area and/or specific
Participants the AE is responsible for when providing Waiver functions as identified in
Appendix A to this Agreement and the approved Waivers.
Managing Employer – The Participant or Surrogate who agrees to enter into a jointemployer arrangement with the AWC FMS.
Medicaid or Medical Assistance (MA) – The program authorized under Title XIX of
the federal Social Security Act, 42 U.S.C. 1396 et seq., and regulations promulgated
thereunder.
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Office of Developmental Programs (ODP) – The Pennsylvania state program office
within DPW that oversees ODP Waivers, sets policy, provides funds and administers
services for individuals with intellectual disabilities and autism.
Organized Health Care Delivery System (OHCDS) – The arrangement in which a
Provider that renders at least one direct Waiver service also chooses to offer vender
services by subcontracting with a Vendor in order to facilitate the delivery of vendor
services. The OHCDS Provider enrolls, qualifies and monitors that the subcontracted
Vendor is in compliance with all state and federal laws and regulations, the current
Provider Agreement, Written Policies and Procedures and Departmental Decisions.
Participant – An individual determined to meet eligibility criteria and who is enrolled in
either the Consolidated or P/FDS Waiver.
Person/Family Directed Support (P/FDS) Cap – The per Participant limitation for
Waiver services funded through the P/FDS Waiver during a state FY, excluding costs
for supports coordination services.
Plan Creation – The category field in HCSIS used for the initial creation of an ISP or to
create an ISP for a Participant without a current ISP in HCSIS.
Prioritization of Urgency of Need for Services (PUNS) – The strategic planning tool
and current process used to categorize an applicant’s need for services prior to
enrollment in one of the Waivers which is then reviewed at least annually thereafter.
Provider – An entity or individual that enters into and maintains a signed Provider
Agreement with the Department to render a Waiver service(s), which meets the
definitions of both a Willing Provider and a Qualified Provider.
Provider Agreement for Participation in Pennsylvania’s Consolidated and
Person/Family Directed Support Waivers (Waiver Provider Agreement) – The ODP
agreement signed by a Waiver service Provider as per 42 CFR 431.107, under which
the Provider agrees to furnish services to Medicaid Waiver Participants in compliance
with state and federal requirements, including Waiver requirements approved by CMS.
Provider Reimbursement and Operations Management Information System in
electronic format (PROMISe™) – A secure internet tool that allows Providers,
managed care organizations and drug labelers or manufacturers to submit a Claim,
check a Claim’s status, access real time eligibility verification information, access webbased training courses, review and download user manuals and Claim forms.
Qualified Intellectual Disability Professional – A person who meets and maintains
acceptable professional standards, has at least one year of experience working directly
with individuals with intellectual disabilities or other developmental disability and holds a
valid certification, licensure or degree in an applicable field of study as identified in 42
CFR 483.430 (a)(2)(i)(ii) and 483.430 (b)(5)(i)-(ix), as well as any related academic
AE Operating Agreement Effective July 1, 2013
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disciplines associated with the study of: human behavior (e.g., psychology, sociology,
speech communication, gerontology, etc.), human skill development (e.g., education,
counseling, human development), humans and their cultural behavior (e.g.,
anthropology), or any other study of services related to basic human care needs (e.g.,
rehabilitation counseling) or the human condition (e.g., literature, the arts).
Qualified Provider – A Provider qualified to render a specific Waiver service that meets
state and federal laws and as per Written Policies and Procedures and Departmental
Decisions relating to qualification, requalification and disqualification of Waiver
Providers.
Quality Management (QM) Plan – A written plan describing how the AE will measure,
remediate and improve its performance in a manner consistent with the Department’s
QM Strategy to ensure sustained compliance with Waiver assurances and to contribute
towards achieving the Department’s identified priorities for improvement.
Quality Management (QM) Strategy – The structure, process, roles, responsibilities
and methods the Department uses to manage its performance to achieve quality results
including continuous cycles of performance measurement (discovery), correction of
individual problems (remediation) and implementation of system-wide change as
needed (improvement).
Reserved Capacity – The portion of the approved waivers that are reserved for the
enrollment of specified groups or targeted purposes.
Statewide Needs Assessment – The assessment designated by the Department to be
used during the ISP process to determine the individual’s or Participant’s needed
services.
Substantial Failure – A repeated pattern of noncompliance with the AE’s
responsibilities outlined in this Agreement, non-adherence with Written Policies and
Procedures and Departmental Decisions, inability to develop and /or implement an
approved CAP or DCAP to remedy noncompliance areas, and/or an egregious
noncompliance issue that jeopardizes Participant Health and Welfare and/or overall
state compliance with federal Waiver requirements approved by CMS.
Support Service Worker (SSW) – A person hired by a Waiver Participant or
Participant’s Surrogate who is managing services through one of the self-directing
options.
Supports Coordination Organization (SCO) – A type of Waiver Provider with the
primary responsibilities of locating, coordinating and monitoring needed services and
supports for Waiver Participants.
Supports Coordinator (SC) – An employee of a SCO with the primary responsibilities
of locating, coordinating and monitoring needed services and supports for Waiver
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Participants.
Surrogate – A person identified under state law to make decisions for a Participant who
is incompetent or incapacitated. A surrogate can have various legal titles, but for the
purposes of this Agreement, this person will be referred to a Surrogate. A Surrogate
includes one of the following:
•
•
•
•
•
•
A parent of a child under 18 years of age under the common law and 35
P.S. § 10101.
Legal custodian of a minor as provided in 42 Pa. C.S. § 6357.
A health care agent and representative for an adult as provided in 20 Pa.
C. S. Ch. 54.
A guardian of various kinds as provided in 20 Pa. C. S. Ch. 55 (as limited
by 20 Pa. C.S. § 5521 (f)).
A holder of powers of attorney of various kinds as provided in 20 Pa. C.S.
Ch. 56.
A guardian of a person by operation of law in 50 P.S. § 4417 (c)
Any of these would be considered a legal representative under applicable law.
For a surrogate performing the function of Common-Law Employer or Managing
Employer in one of the FMS options, additional persons can be designated as a
Surrogate by a Participant 18 years of age and older.
Unanticipated Emergency – An occurrence when an individual or P/FDS Waiver
Participant has an imminent risk of: institutionalization within twenty-four (24) hours,
substantial self-harm or substantial harm to others; if the individual does not
immediately receive services and this imminent risk is precipitated by at least one of the
following situations:
•
•
•
The illness or death of a caretaker.
The sudden loss of the individual’s home (for example, due to fire or
natural disaster).
The loss of the care of a relative or caregiver, without advance warning or
planning.
To be considered by the Department to be an Unanticipated Emergency, the AE and
the County Program must have no other resources available to address the individual’s
immediate Health and Welfare needs.
Vendor – An entity that provides general goods or services and possesses the following
distinguishing characteristics: goods/services are provided within normal business
operations, similar goods/services are provided to many different purchasers, and the
Vendor operates in a competitive environment providing goods/services to the general
public.
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Vendor Fiscal/Employer Agent (VF/EA) – A type of FMS Provider acting as the fiscal
agent which provides an administrative service that supports a Participant or
Participant’s Surrogate acting as the Common-Law Employer to hire and manage
SSWs. Under the VF/EA FMS model, the Participant or Surrogate retains full and legal
responsibility for all aspects of being the Common-Law Employer, with the exception of
processing payroll for the SSWs, withholding and reporting taxes, obtaining and
processing workers’ compensation and insurance payments and processing payment of
all invoices.
Waivers – The current approved Consolidated and P/FDS Waivers, except where
otherwise specifically named herein.
Waiver Administration Allocation – The administrative funds allocated to oversee and
provide Waiver administrative functions as per this Agreement, Written Policies and
Procedures and Departmental Decisions.
Waiver Capacity Commitment – The number of Participants the AE may enroll in a
specified Waiver at any given point in time during a FY, as approved by the Department.
Waiver Capacity Commitment Notification – A notification that designates the
Department’s current approved maximum number of Participants within the Jurisdiction
of the AE that may be enrolled in each Waiver at any given point in time during a FY.
There are two numbers designated in the Waiver Capacity Commitment Notification.
One reflects the number of Participants that may be enrolled in the Consolidated Waiver
and one reflects the number of Participants that may be enrolled in the P/FDS Waiver
during a FY.
Waiver Capacity Management – The overall process of properly maintaining the AE’s
Waiver Capacity Commitment which includes following Department-approved policies
and procedures relating to Waiver Capacity Commitment, Maintaining Reserved
Capacity (including the tracking of individuals due to hospitalization or rehabilitation
care), Waiver Residential Vacancy Management and management of Unanticipated
Emergencies.
Waiver Residential Vacancy Management – The process of identifying and managing
a vacancy in a service location licensed under 55 Pa. Code Chapter 6400 (relating to
Community Homes for Individuals with Mental Retardation) within the service location’s
Approved Program Capacity.
Willing Provider – A provider that agrees to serve Waiver Participants, to accept the
Department’s payment as payment in full for rendering a Waiver service and to abide by
all of the Medicaid Waiver Provider requirement, including entering into and maintaining
a signed current Waiver Provider Agreement with the Department.
Written Policies and Procedures – CMS-approved Waivers, Waiver amendments,
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rules, regulations, policies, policy clarification, bulletins, directives, procedures and any
Department-approved revisions specific to Medicaid Waivers that are developed and
overseen by the Department. This includes written correspondence signed by the
Secretary of DPW or the Deputy Secretary of ODP.
2.0
General Scope of the Operating Agreement
2.1
Sovereign Immunities
Nothing herein is intended to limit, modify, alter or impair, directly or indirectly,
the sovereign immunities of the Commonwealth, the Department or AE
respectively, including but not limited to such immunities as applicable to
dealings with third parties.
2.1.1 Authority of the Department
The Department retains the authority to exercise discretion in the
administration and supervision of all Waiver-related matters including the
terms and conditions of this Agreement and to issue Departmental
Decisions and Written Policies and Procedures related to the Waivers. An
AE does not have the authority to change or disapprove any
administrative Departmental Decisions or otherwise substitute its
judgment for that of the Department with respect to the application and
implementation of Written Policies and Procedures and Departmental
Decisions.
2.1.2 Authority of the Administrative Entity (AE)
The authorities of the AE are as set forth herein and shall include the
authority to enter into and maintain subcontracts with other entities, as
reverenced in Section 3.1 and Subsection 3.1.1 of this Agreement, for the
administrative functions hereunder and the other authorities of the AE as
set forth herein.
2.2
Indemnification
Without waiving any immunity conferred by statute or common law, the AE shall
hold the Commonwealth of Pennsylvania and by extension, the Department and
ODP, harmless from and indemnify the Commonwealth of Pennsylvania, the
Department and ODP against any and all claims, demands and actions based
upon or arising out of any activities performed under this Agreement or
nonperformance under this Agreement by the AE, any agent of the AE, any
subcontractor or anyone directly or indirectly employed by the AE or an agent or
subcontractor of the AE and shall, at the request of the Commonwealth,
Department or ODP, defend any and all actions brought against the
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Commonwealth, Department or ODP based upon any such claims, demands and
actions.
3.0
Administrative Functions
All Waiver services and administrative functions must be provided in compliance with
federal and state statutes and regulations that apply to the Waiver Programs and waiver
Participants, the conditions of this Agreement, litigation affecting waiver enrollment or
waiver Participants, Written Policies and Procedures and Departmental Decisions.
3.1
Delegated or Purchased Administrative Functions
The AE may delegate or purchase administrative functions in accordance with
applicable provisions of Pennsylvania statute and regulation. Please see
Subsection 3.1.1 of this Agreement for a list of AE functions that may and may
not be delegated or purchased. The AE shall continue to retain responsibility for
compliance with this Agreement, Written Policies and Procedures and
Departmental Decisions when it delegates to or purchases administrative
functions from an entity.
The AE shall ensure that any delegated or purchased administrative functions
are established in writing pursuant to a subcontract or agreement. If
administrative functions identified in this Agreement are delegated to or
purchased from an entity, the AE shall ensure Pursuant to a subcontract or
agreement with that entity, the administrator or director of that entity shall also be
responsible for the terms and conditions attached to those administrative
functions as per this Agreement, Written Policies and Procedures and
Departmental Decisions.
All subcontracts and agreements for delegated or purchased administrative
functions must comply with 42 CFR 434.6 and 42 CFR 434.10 and must allow for
periodic inspections by the Department, the Commonwealth of Pennsylvania, the
United States Comptroller General, the United States Department of Health and
Human Services and the authorized representatives of any of the agencies listed
in this Section, to validate the quality, appropriateness and timeliness of services
performed as part of the subcontract or agreement.
The Department retains the authority to provide the AE with direction that must
be followed related to the selection of an entity performing delegated or
purchased administrative functions. Subsection 3.1.1, further addresses
delegated or purchased functions.
For all administrative functions performed by or subcontracted to an entity, the
AE shall submit to the appropriate regional ODP on an annual basis, by April 1
for the upcoming fiscal year:
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1. A list of the administrative functions the AE will continue or begin to
delegate or purchase from an entity during the next FY.
2. A brief statement describing each specific administrative function the AE
will delegate to or purchase from an entity or proposes to delegate or
purchase during the next FY and the current entity or proposed entity that
will provide those administrative functions for the AE during the next FY.
3. Procedures the AE has or will put in place to monitor the completion of
those delegated or purchased administrative functions during the next FY.
4. A list of related subcontracts or agreements to be effective during the next
FY.
This shall include a description of the tasks/functions delegated, specific work
requirements for each delegated function, reporting requirements and process to
address any performance issues. The AE may submit the written subcontract or
agreement that it has with the entity as an alternative when it includes this
information. The monitoring protocols must include:
•
•
Frequency of AE review and the staff (positions/titles) responsible for
monitoring.
A description of the method to be used. This must address all
requirements of the delegated function.
If the AE does intend to subcontract or delegate administrative functions in
accordance with the conditions referenced in Subsection 3.1.1, the AE shall
submit the information outlined in #1-4 above with this signed Agreement.
If the AE proposes to make a change to its delegated or purchased
administrative functions, the AE shall notify the appropriate regional ODP in
writing at least thirty (30) calendar days prior to initiating the change and in
compliance with the additional conditions referenced in Subsection 3.1.1 of this
Agreement.
If the AE proposes to begin delegating or purchasing a new administrative
function to a current subcontracted entity or new entity after the submission of
the information outlined in #1-4 above with this signed Agreement or after the
annual re-submission of delegated or purchased administrative functions
information as outlined in #1-4 above, the AE shall submit the information
outlined in #1-4 above in relation to the new proposal to the appropriate regional
ODP prior to entering into a new subcontract or agreement and in compliance
with the additional conditions referenced in Subsection 3.1.1 of this Agreement.
3.1.1 Authorization to Delegate or Purchase Administrative
Functions
The AE shall notify the Department prior to delegating or purchasing
administrative functions from an entity. Upon notification to the
AE Operating Agreement Effective July 1, 2013
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Department, the purchase or delegation of administrative functions
referenced in “List A” of this Subsection is not subject to Department
approval, except relating to the Department retaining authority to provide
direction regarding selection of the subcontracted entity. However, the AE
shall remain responsible for the conditions referenced in Section 3.1
including the responsibility of prior notification to the appropriate regional
ODP and retaining its responsibilities and authorities as set forth herein.
List A – Once prior notification is given to the appropriate regional ODP,
the administrative functions which have been designated as AE
responsibilities within the following Sections and Subsections, may be
delegated to or purchased from an entity:
1. Section 4.2, Service Delivery Preference.
2. Subsection 4.3.1, Level of Care; related to the certification by
the Qualified Intellectual Disability Professional.
3. Subsection 4.3.3 , Financial Eligibility.
4. Section 4.7, Statewide Needs Assessment.
5. Subsection 4.9.1, Notice of Fair Hearing Rights; however, the
AE must conduct the issuance of adverse actions.
6. Section 5.1, Provider Recruitment and Enrollment; however, if
delegated to or purchased from an entity, the AE remains
responsible to notify the contracted entity of service gaps due to
absence of choice of Providers.
7. Section 6.4, Implementation of Departmental Decisions and
Findings; however, the AE is responsible for review, approval
and authorization of Waiver services and Departmental
Decisions directly related to the AE.
8. Section 8.2, Technical Assistance; unless directly related to an
activity required to be conducted by the AE.
Prior approval must be obtained from the Department when the AE wants
to delegate or purchase one or more of the responsibilities referenced in
“List B” of this Subsection. However, the AE shall remain responsible for
the conditions referenced in Section 3.1 including the responsibility for
prior notification to the appropriate regional ODP and retaining its
responsibilities and authorities as set forth herein. Prior approval requests
shall be submitted in writing to the appropriate regional ODP to delegate
or purchase any of the following responsibilities.
List B – Once prior approval to delegate or purchase the administrative
functions to an entity has been obtained from the Department, the
administrative functions which have been designated as AE
responsibilities within the following Sections and Subsections may be
delegated to or purchased from and entity:
AE Operating Agreement Effective July 1, 2013
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1. Subsection 3.2.6, Desk Review.
2. Subsection 3.2.7, Claim Resolution Support.
3. Subsection 3.3.1, Waiver Participant Records.
4. Subsection 3.3.2, Other Waiver Records.
5. Subsection 3.3.3, Safeguarding Waiver Records.
6. Subsection 3.3.4, Access to Waiver Records.
7. Section 3.4, Waiver Capacity Management.
8. Subsection 3.4.1, Waiver Capacity Commitment.
9. Subsection 3.4.2, Waiver Residential Vacancy Management.
10. Subsection 3.4.3, Reserved Capacity Due to Hospital or
Rehabilitative Care.
11. Subsection 3.4.4, Unanticipated Emergencies.
12. Section 4.1, Prioritization of Urgency of Need for Services
(PUNS).
13. Subsection 4.3.1, Level of Care, related to the determination by
the AE.
14. Subsection 4.3.4, Consolidated Waiver Enrollment; however,
the AE must make the final decision regarding an individual’s
enrollment.
15. Subsection 4.3.5, Person/Family Directed Support (P/FDS)
Waiver Enrollment; however, the AE must make the final
decision regarding an individual’s enrollment.
16. Subsection 4.3.6, Waiver Transfers; however the AE must make
the final decision regarding the transfer.
17. Section 4.4, Offering Free Choice of Qualified and Willing
Providers.
18. Section 4.5, Financial Management Services (FMS), however,
the AE must conduct the review, approval and authorization of
Waiver services.
19. Section 4.6, Service Initiation upon Waiver Enrollment.
20. Subsection 4.7.1, Statewide Needs Assessment Contractor.
21. Section 4.8, Individual Support Plans (ISPs); however the AE
must conduct the review, approval and authorization of Waiver
services.
22. Subsection 4.8.1, Review, Approval and Authorization of
Individual Support Plans (ISPs) and Waiver Services; however,
the AE must conduct the review, approval and authorization of
Waiver services.
23. Subsection 4.8.2, Additional Prerequisites for Service
Authorization; however, the AE must conduct the review,
approval and authorization; however, the AE must conduct the
review, approval and authorization of Waiver services.
24. Subsection 4.8.2.1, Residential Services; however, the AE must
conduct the review, approval and authorization of Waiver
services.
25. Section 4.8.3, Implementation of Individual Support Plans
AE Operating Agreement Effective July 1, 2013
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(ISPs).
26. Section 4.8.4, Service Requests.
27. Section 4.9, Fair Hearing and Appeal
28. Subsection 4.9.2, Continuation of Waiver Services.
29. Section 5.2; Qualification of Waiver Providers; however the AE
must make the qualification recommendation to the appropriate
regional ODP.
30. Section 6.0, Monitoring Waiver Requirements.
31. Section 6.1, Monitoring of Waiver Providers; however, the AE
must approve and issue the monitoring findings.
32. Section 6.2, Correction of Issues Identified During AEOMP,
External Reviews, Provider Monitoring, Targeted Reviews and
Audits; however, the AE remains responsible to develop, submit
and implement a CAP directly related to an AE issue.
33. Section 6.3, Administrative Review.
34. Section 7.1, Quality Management (QM) Plan; however the AE
must sign-off on the QM Plan.
35. Section 7.2, Incident Management
36. Section 7.3, Independent Monitoring for Quality (IM3Q).
There are AE responsibilities referenced throughout Appendix A
which the AE may never delegate to or purchase from and entity.
If an administrative function in this Agreement is not included in List
A or B above, or has an identified restriction in List A or B above,
the AE shall not delegate or purchase those administrative
functions from an entity.
3.1.1.1 Monitoring of Delegated or Purchased
Administrative Functions
Monitoring of delegated or purchased administrative
functions as referenced in this Agreement is a separate and
discrete function from the AE monitoring of provider
requirements as referenced in Sections 6.0 and 6.1 of this
Agreement.
If the AE delegates or purchases an administrative function
that has been designated as a responsibility of the AE to an
entity, the AE shall monitor that delegated or purchased
administrative function to ensure compliance with written
Policies and Procedures, Departmental Decisions, state and
federal laws and the terms and conditions of this Agreement.
The AE shall use the form issued by the Department to
record and report the monitoring findings. The AE shall be
held responsible for the quality, compliance and completion
of an administrative function which has been delegated to it
AE Operating Agreement Effective July 1, 2013
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by the Department, even when the AE delegates or
purchases that administrative function to an entity through a
subcontract or agreement.
The Department will utilize a variety of means to ensure
compliance with Agreement requirements, Written Policies
and Procedures and Departmental Decisions, when the AE
demonstrates a Substantial Failure to monitor and ensure
delegated or purchased administrative functions are
conducted in compliance with the terms and conditions of
this Agreement. The Department will pursue remedial
actions as needed to resolve any outstanding performance
concerns and violations with the Agreement. The application
of remedies shall be a matter of public record once an
acceptable CAP has been developed by the AE.
AE noncompliance will be addressed through remedial
efforts as referenced in Section 9.1 of this Agreement. While
remedies will generally follow a progressive path, the
Department reserves the right to deviate from this path for
significant issues of noncompliance as determined by the
Department.
In the event that the Department finds there has been
Substantial Failure of the AE to ensure adherence and
compliance, through the monitoring of delegated and
purchased administrative functions, with the responsibilities
and functions outlined in this Agreement or Substantial
Failure of the AE to monitor Waiver services, for compliance
with the terms and conditions of this Agreement, when
provided to Participants in the Pennsylvania ODP service
system through the delegation or purchasing of an
administrative function to an entity, the Department may
provide notice of termination as referenced in Section and
Subsections 9.2 through 9.3.2.1 of this Agreement.
3.2
Financial Administration Requirements
3.2.1 Financial Liability for the Waiver Program
The ultimate financial liability to meet the needs of Waiver Participants
rests with the Department, within the scope of the approved Waivers, and
to exceed the limits of the state appropriation.
3.2.2 Administrative Payments to the AE
AE Operating Agreement Effective July 1, 2013
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Contingent of state budget approval, the Department shall make advance
quarterly payments of Waiver administration funds necessary to comply
with the requirements outlined in this Agreement to the county or
county/joinder. The first quarterly installment shall be for the quarter of the
FY beginning July 1 and ending September 30. The second installment
shall be for the quarter October 1 ending December 31. The third
installment shall be for the quarter beginning January 1 and ending March
31. The fourth installment shall be for the quarter beginning April 1 and
ending June 30. The Department will provide the final allocation no later
than September 30.
The Department reserves the right to review advance installments against
actual expenditures at any time, and to make appropriate adjustments in
subsequent advances. If an overpayment cannot be recovered through
an adjustment, the Department shall request a refund from the AE.
The Department will evaluate increases and decreases in the AE’s
workload and reserves the right to adjust the allocation to the AE via an
updated notice indicating its Waiver Administration Allocation. This will
occur up to the state appropriation.
The Department will evaluate the Waiver Administration Allocation against
the terms of the Agreement to assure there are sufficient allocations to
perform all terms. If the state appropriation is not sufficient to allow all
terms of the Agreement to be completed, the Department will prioritize the
terms of the Agreement and notify the AE regarding this prioritization.
To the extent that the AE requests additional funds for inclusion in its
Waiver Administration Allocation, the Department shall notify the AE of its
decision in writing within thirty (30) calendar days of receipt of a request.
3.2.3 Ineligible Waiver Expenditures
The AE shall ensure that the following are not authorized as Waiver
services:
1. The purchase of Waiver ineligible service(s).
2. Service(s) or benefit(s) to an individual who is ineligible for Waiver
service(s) or benefit(s)
3. The purchase of a Waiver service(s) rendered by a Provider that is
restricted or sanctioned by the Department.
4. The purchase of a Waiver service(s) rendered by a Provider that is not
qualified to render a Waiver service(s).
5. The purchase of a Waiver service(s) rendered by an Ineligible
Provider.
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3.2.4 Financial Liability of Waiver Participants
The AE may not require a Participant to pay a cost share or co-pay for
Waiver-eligible service(s), unless otherwise specified in the approved
Waivers.
3.2.5 Financial Audits
The AE shall comply with all applicable federal audit requirements,
including the Single Audit Act, as amended; the revised Office of
Management and Budget Circular A-133, titled: Audits of Stated, Local
Governments and Non-Profit Organizations; 45 CFR 74.26 and any other
applicable law or regulation promulgated by the federal government.
The AE shall assist the Department as requested with the review and
follow up of Provider audits.
3.2.6 Desk Review
The AE shall collect data to support rate setting activities for Waiver
service(s) when requested and in accordance with instructions issued by
the Department.
The AE shall conduct a Desk Review of the Provider Cost Reports as per
instructions issued by the Department.
3.2.7 Claim Resolution Support
The AE shall use the Claim resolution support process issued by the
Department to assist Providers in the timely resolution of a denied Claim
resulting from issues with ISPs and /or discrepancies between HCSIS and
information maintained by the Department’s CAO.
The AE shall designate staff to serve as the point of contact for Claim
resolution support issues and shall advise the appropriate regional ODP
and Waiver Providers of this staff designation.
3.3
Waiver Records
The AE shall preserve Waiver records and documents until the expiration of five
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(5) years after the Waiver Participant’s case has been permanently closed or the
Waiver-funded service was furnished. Records that relate to litigation, audit
exceptions or the settlement of a Claim related to performance or expenditures
under this Agreement shall be retained by the AE until such litigation, exception
or Claim has reached final disposition.
3.3.1 Waiver Participant Records
The AE shall maintain the following Waiver service and financial records
that separately identify Waiver Participants, funds and Waiver services:
1. Documentation of initial level of care determinations, including
all supporting documentation necessary to certify level of care.
2. Documentation of the choice between institutional and home
and community-based services.
3. Documentation of the initial financial eligibility determination
made by the County Assistance Office, such as the initial PA162 form.
4. Documentation of level of care re-determinations, including all
supporting documentation necessary to recertify level of care.
5. OVR referral and response letters, if applicable.
6. Service review findings letter(s) issued by the Department.
7. Requests for fair hearings, including supporting documentation.
8. Documentation of meetings related to service disputes.
9. Service requests and responses.
10. Requests for extensions to service limitations and responses.
11. Requests for services requiring prior authorization and the ODP
response related to such requests.
12. ISP Review Checklist(s)
13. Correspondence/documentation related to the transfer of a
waiver participant to the AE.
14. Required documentation related to incidents and incident
investigation.
15. Money Follows the Person (MFP) consents.
3.3.2 Other Waiver Records
The AE shall maintain the following other Waiver Records:
1. Subcontracts or agreements with entities paid with
administrative funds (i.e., entities providing delegated or
purchased administrative functions, Health Care Quality Unit
(HCQU), IM4Q contracts, etc.).
2. Records of AE monitoring of delegated or purchased
administrative functions, including any associated Corrective
Action Plans and verification of remediation.
AE Operating Agreement Effective July 1, 2013
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3. Records to substantiate waiver administrative costs and
methodology.
4. Invoices and billing records for administrative functions.
5. Any documentation related to Cost Report Desk Reviews
completed by the AE.
6. Provider audits, for time periods prior to July 1, 2009, or as
specified by the Department.
7. Documentation relating to monitoring of Waiver Providers.
8. Correspondence and documentation relating to an AE
developed CAP or DCAP.
9. Correspondence and documentation relating to the
development, modification or remediation of an approved CAP
or DCAP for Waiver Providers.
10. Documentation of the verification of Provider qualification
standards, including any supporting information.
11. Provider disputes, for actions which took place prior to July 1,
2009, or as specified by the Department, including supporting
documentation.
12. Correspondence and/or documentation of issues identified and
resolved through Waiver service monitoring.
13. AE QM Plans and associated reports.
3.3.3 Safeguarding Waiver Records
The AE shall develop and implement a written protocol relating to
safeguarding Waiver records and shall include the restriction or
disclosure of information concerning Waiver applicants and Waiver
Participants that is consistent with 42 CFR 431, subpart F.
3.3.4 Access to Waiver Records
The AE shall develop and implement a written protocol relating to
full and free access to all records pertaining to Waiver applicants,
Participants, services and payments for services; thereby allowing
for the evaluation, through inspection or other means of the quality,
appropriateness and timeliness of services performed under this
Agreement. Said access shall be granted to the following:
1.
2.
3.
4.
The Department.
The Commonwealth of Pennsylvania.
The United States Comptroller General.
The United States Department of Health and Human
Services.
5. The Authorized representatives of any of the agencies
listed in this Section.
AE Operating Agreement Effective July 1, 2013
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3.4
Waiver Capacity Management
The AE shall comply with the Waiver Capacity Management process as
approved by the Department which includes the policies and procedures relating
to Waiver Capacity Commitment (including management of reserved capacity),
Waiver Residential Vacancy Management in settings licensed under 55 Pa. Code
Chapter 6400 and management of Unanticipated Emergencies.
The AE shall cooperate with filling a vacancy as per Department-established
policies and procedures, including remaining within the Provider’s Approved
Program Capacity. For a residential service location licensed under 55 Pa. Code
Chapter 6400 that receives Waiver funding, the Department shall establish an
Approved Program Capacity. Once established, the Approved Program Capacity
is the maximum number of individuals who may receive services at that service
location of any given day throughout the FY, regardless of the service type or
funding used to pay for that service.
The total number of Participants in the Consolidated or P/FDS Waiver during a
FY may not exceed the approved number of Waiver Participants in the AE’s
current Waiver Capacity Commitment. The AE shall be notified in writing if its
Waiver Capacity Commitment is increased or decreased.
3.4.1 Waiver Capacity Commitment
The AE shall provide administrative functions to ensure that Waiver
services are provided to Waiver Participants, while not exceeding the
maximum number of Participants identified in the AE’s current Waiver
Capacity Commitment, subject to the requirements outlined in Sections
and Subsections 3.4 through 3.4.4 of this Agreement.
For example, if the AE’s Waiver Capacity Commitment for the
Consolidated Waiver is thirty (30), the AE may only have thirty (30)
Participants enrolled in the Consolidated Waiver at any point in time
during the FY.
The Department will designate the number of new participants the
Department expects the AE to enroll in one of the Waivers as part of the
waiting list initiative or other reserved capacity category, if applicable. The
AE shall identify those individuals using the designation made and
instructions given by the Department. The waiting list and/or other
reserved capacity categories will be identified separately from the Waiver
Capacity Commitment.
The Department reserves the right to adjust the number of Participants in
the AE’s Waiver Capacity Commitment in either Waiver based on
budgetary, utilization or other considerations.
AE Operating Agreement Effective July 1, 2013
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The AE shall only enroll an individual with an emergency need as defined
in PUNS into one of the Waivers, except for individuals designated in a
reserved capacity category. If the AE is unable to provide services to the
number of Waiver Participants identified in its Waiver Capacity
Commitment Notification by filling the capacity with an individual in
emergency PUNS, it shall notify the appropriate regional ODP per
established procedures and notify the appropriate regional ODP per
established procedures and instructions.
If the AE has enrolled or fails to enroll all individuals within the Jurisdiction
of the AE with an emergency PUNS into one of the Waivers, the
Department retains the authority to release the capacity for use by an
individual within the Commonwealth who does have an emergency PUNS.
If the AE needs to increase the number of Participants it serves over its
current Waiver Capacity Commitment for either Waiver due to an
Unanticipated Emergency, a written request to increase the Waiver
Capacity Commitment must be submitted to the appropriate regional ODP.
The AE may not enroll Participants in excess of its current Waiver
Capacity Commitment.
3.4.2 Waiver Residential Vacancy Management
The AE shall develop and maintain an implementation protocol in
accordance with the Department’s Waiver Residential Vacancy
Management established policies and procedures. The AE shall assign a
staff point-person to implement the Waiver Residential Vacancy
Management activities identified in the AE’s protocol and in accordance
with the Department’s established policies and procedures.
Providers of Waiver-funded residential habilitation settings licensed under
55 Pa. Code Chapter 6400 may only render services to participants up to
the Approved Program Capacity of the service location. Therefore, the AE
shall only approve and authorize Waiver services for Participants in
residential settings licensed under 55 Pa. Code Chapter 6400 that are
within the service location’s Approved Program Capacity except as
approved by ODP. The AE shall also ensure it remains within its
approved current Waiver Capacity Commitment.
3.4.3 Reserved Capacity Due to Hospital or Rehabilitation Care
The AE shall develop and implement a written protocol to monitor the
status of former waiver Participants whose enrollment in the waiver is
being reserved because of a short-term stay in a hospital or rehabilitation
care facility.
AE Operating Agreement Effective July 1, 2013
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When a Participant is in reserved capacity status due to a hospital or
rehabilitation care stay extending more than 30 consecutive days, the AE
shall review team recommendations regarding the participants return to
the community on at least a monthly basis. This may include
recommendations from medical providers about the Participant’s progress,
the possibility of a return to the former residence, changes in level of
support, any adaptations required, and whether natural, family and
community supports can assist the Participant in returning to the
community.
3.4.4 Unanticipated Emergencies
An individual in need of services may be unknown to an AE; an individual
may not be identified correctly through the PUNS process; or the
individual’s PUNS does not yet accurately reflect an unanticipated change
in circumstances. All of these factors may lead to the occurrence of an
Unanticipated Emergency as defined in Section 1.0.
The AE shall develop and implement a protocol to manage Unanticipated
Emergencies efficiently and in the best interest of the individual in need of
services. This protocol shall include activities to be implemented in the
event that the individual is not enrolled in one of the Waivers. The AE
shall work cooperatively with the County Program to address the
individual’s needs. The AE shall develop and implement the protocol as
directed in established policies and procedures and as approved by the
Department.
4.0
Meeting the Needs of Waiver Participants
All needs of Waiver Participants shall be provided in compliance with this Agreement,
Written Policies and Procedures and Departmental Decisions
4.1
Prioritization of Urgency of Need for Services (PUNS)
The AE shall assign at least one (1) point person for PUNS. The PUNS point
person is responsible for PUNS related activities and ongoing local training of the
AE staff, SCOs and intake/registration workers.
The AE shall develop and implement a written protocol consistent with the
current PUNS bulletin and manual to include the following:
1. The initial completion of the PUNS in consultation with the Waiver
applicant and/or applicant’s Surrogate and obtaining signature of such
participation.
2. The Waiver applicant is placed in the appropriate category of need in
AE Operating Agreement Effective July 1, 2013
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the PUNS.
3. The PUNS is reviewed and updated at least annually.
4. The PUNS is updated within thirty (30) calendar days of an identified
change in need.
5. The PUNS in entered in HCSIS.
If the AE identifies performance issues of a SCO through the PUNS review, the
AE shall notify the SCO of the issues. The AE shall request the submission of a
CAP from the SCO to address the AE’s findings. If after consultation with the
SCO, the AE finds that the SCO’s CAP is unsatisfactory, the AE shall notify the
appropriate regional ODP.
Except as provided through the designation in reserved capacity status, the AE
shall ensure that all Waiver applicants most in need with an emergency need
identified in PUNS, within the Jurisdiction of the AE, are enrolled in one of the
Waivers prior to investigating the enrollment of an applicant with a different
PUNS assessed category. The AE shall only enroll an applicant who is
assessed as having an emergency need, as defined in PUNS, into one of the
Waivers, and as referenced in Section 4.3 and corresponding Subsections.
If the AE cannot identify an individual in emergency need within the Jurisdiction
of the AE, the AE shall notify the regional Waiver Capacity Manager related to
the AE’s capacity.
The AE may not admit a Waiver applicant into a Waiver based on financial
contributions or other types of enrollment fees paid by the applicant, a
representative of the applicant or on behalf of the applicant to the AE, Waiver
Providers or any other entity.
4.2
Service Delivery Preference
The AE shall monitor compliance with the service delivery preference process
established by ODP in Written Policies and Procedures and Departmental
Decisions relating to service delivery preference.
4.3
Eligibility and Enrollment for Waiver Services
4.3.1 Level of Care
The AE shall complete the determination and re-determination of level of
care as specified in the approved Waivers. The AE shall maintain a
complete record of level of care determinations and re-determinations as
per Section and Subsections 3.3 through 3.3.4 of this Agreement. The AE
shall apply the process and instruments described in Written Policies and
Procedures and Departmental Decisions relating to individual eligibility for
Medicaid Waiver services.
AE Operating Agreement Effective July 1, 2013
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4.3.2 MFP Consent
The AE is responsible to ensure that MFP eligible participants are
provided with “Informed Consent for Participation in the Money Follows
the Person Rebalancing Initiative” upon enrollment. The AE shall notify
the CAO if consent is obtained and shall maintain MFP records.
4.3.3 Financial Eligibility
The AE shall cooperate with the Department’s CAO in determining an
individual’s initial and continuing financial eligibility for Waver services in
accordance with procedures established by the Department in Written
Policies and Procedures and Departmental Decisions relating to individual
eligibility for Medicaid Waiver services.
4.3.4 Consolidated Waiver Enrollment
As part of its continuous responsibility for safeguarding the Health and
Welfare of Waiver Participants, the AE shall ensure, as identified through
the approval, authorization and implementation of Waiver service outlined
in Section and Subsections 4.8 through 4.8.3 of this Agreement, that the
Assessed Needs and Health and Welfare of existing Consolidated Waiver
Participants are fully addressed. Needs may be addressed through
Waiver services, generic resources, community opportunities and family
and natural supports. The AE will also ensure that it remains within its
approved current Waiver Capacity Commitment for the Consolidated
Waiver.
4.3.5 Person/Family Directed Support (P/FDS) Waiver Enrollment
As identified through the approval, authorization and implementation of
Waiver services outlined in Section and Subsections 4.8 through 4.8.3 of
this Agreement, the AE shall ensure that the Assessed Needs and Health
and Welfare of existing P/FDS Waiver Participants are addressed within
the P/FDS Cap prior to enrolling a new applicant into the P/FDS Waiver.
Needs may be addressed through Waiver services, generic resources,
community opportunities and family and natural supports. The AE will
also ensure that it remains within its approved current Waiver Capacity
Commitment for the P/FDS Waiver.
The AE shall only enroll a new applicant into the P/FDS Waiver it the
following apply:
1. Assessed Needs identified through the planning process can be
addressed within the P/FDS Cap.
AE Operating Agreement Effective July 1, 2013
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2. An unaddressed need(s) does not relate to Health and Welfare
and the applicant agrees to receive only those needed services
that can be provided within the P/FDS Cap.
3. A need(s) not addressed within the P/FDS Cap will be
addressed using non-Waiver funded resources and /or
supports.
When a P/FDS Waiver Participant experiences a change that results in an
emergency need for services which will cause the Participant to go over
the P/FDS Cap, the AE shall:
1. Explore alternative, more cost-effective ways to provide
services, including the use of less-costly Providers and generic,
community-based resources.
2. Determine if failure to provide the additional service(s) presents
a Health and Welfare issue. If the Participant’s Health and
Welfare will be at jeopardy without the additional service(s), the
AE shall, in the following order:
a. Authorize non-Waiver funds, as available, to address the
outstanding needs.
b. Evaluate whether the Participant should be enrolled in
the Consolidated Waiver. If the AE does not have
available Waiver Capacity to enroll a Participant into the
Consolidated Waiver, it shall request an increase to its
current Waiver Capacity Commitment as per Subsection
3.4.1 of this Agreement.
4.3.6 Waiver Transfers
In the event of a transfer request, there are two circumstances that may
occur as specified in AE letter #6 and any subsequent revision. The
sending AE shall provide the receiving AE with participate records. The
receiving AE shall accept the transfer within 60 days of the date of the
relocation or discovery unless there are concerns regarding the current
eligibility of the participant based on the documents submitted. The
determination made by ODP will be implemented. Upon acceptance of the
transfer by the receiving AE, capacity will be increased by one. The
sending AEs waiver capacity will be reduced by one.
4.4
Offering Free Choice of Willing and Qualified Providers
The AE shall validate that applicants are offered free choice of Willing and
Qualified Providers for each service or support the AE approves and authorizes
on an ISP, including the free choice of all SCO’s willing to provide services in the
geographic area by ensuring that the SCO Directory, maintained by ODP, is
AE Operating Agreement Effective July 1, 2013
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shared.
The AE shall initiate recruitment of Provider activities as referenced in Section
5.1, when there is an absence of choice of Willing and Qualified Providers.
4.5
Financial Management Services (FMS)
The Department shall maintain an administrative contract with a VF/EA FMS.
The AE shall make information on FMS and Participant direction available to
Waiver applicants at Waiver enrollment. The AE shall ensure adherence to the
requirements outlined in Written Policies and Procedures and Departmental
Decisions relating to AWC FMS. When aware or notified of concerns regarding
the performance of a common law employer, the AE shall try to resolve the issue
and provide technical assistance to avoid any recurrence. If these efforts are
unsuccessful, the AE shall notify the regional office of ODP.
4.6
Service Initiation Upon Waiver Enrollment
The AE shall develop and implement a written protocol to monitor that Waiver
services are initiated within forty-five (45) calendar days after the effective date of
Waiver enrollment for a Waiver Participant. Upon identification of delays in
service initiation, the AE shall submit a written request for an extension to the
appropriate regional ODP. The written request must include the reason for the
delay and the AE’s efforts to resolve the issues, including evidence of offering the
choice of other Willing and Qualified Providers. The extension request must
include documentation of the AE’s efforts to resolve service delays, including the
barriers to service initiation.
4.7
Statewide Needs Assessment
The Department is responsible for implementing a Statewide Needs Assessment
ensuring the assessment of all current Waiver Participants as per the
Department’s Written Policies and Procedures.
The AE shall complete its required functions related to completion of the
Statewide Needs Assessment in accordance with Written Policies and
Procedures and Departmental Decisions relating to the Statewide Needs
Assessment. When an individual is identified for enrollment in a waiver, the AE
shall initiate an urgent request to have the Statewide Needs Assessment
conducted in accordance with Departmental instructions so the SIS can be
completed prior to the receipt of waiver services. If a SIS cannot be completed
prior to enrollment in the waiver because an individual requires the immediate
initiation of waiver services to ensure their health and safety, the regional office
must be notified for approval to request that the SIS be completed within 30 days
after the start date of waiver enrollment.
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4.7.1 Statewide Needs Assessment Contractor
The AE shall notify the appropriate regional ODP of any concerns
regarding the performance of the Statewide Needs Assessment
contractor. Such concerns may include, but are not limited to timeliness of
assessments, conduct of assessors and scheduling. Concerns shall be
submitted in writing to the appropriate ODP regional program manager.
4.8
Individual Support Plans (ISPs)
The AE shall initially review, approve and authorize a written ISP prior to each
Participant’s receipt of Waiver service(s)), and at least annually thereafter. A
subsequent Critical Revision must also receive the AE’s review, approval and
authorization, within the Department’s approved timelines. The AE shall approve
and authorize Fiscal Year Renewal ISPs prior to July 1 of each year.
When an objection is raised in regards to the content of the ISP, the Department
has the final responsibility for the content of ISPs, including directing the content
of the services and supports in an ISP.
4.8.1 Review, Approval and Authorization of Individual Support
plans (ISPs) and Waiver Services
The AE shall have a written protocol to ensure that the review, approval
and authorization of services in ISPs are conducted as per Written
Policies and Procedures, Departmental Decisions and this Agreement.
Prior to authorizing a service in an ISP, the AE shall validate that:
1. Any required prior authorization or ODP approval of an
exception to service limits was obtained through the established
prior authorization or exceptions process.
2. All Assessed Needs as identified through the Statewide Needs
Assessment instrument, other assessments as appropriate and
the planning process are included in the ISP.
3. The outcomes listed in the ISP relate to an identified need.
4. The outcomes listed in the ISP relate to an identified preference.
5. Services are identified to support outcomes.
6. Services paid for through the Waivers must be identified to
support outcomes based on Assessed Needs, which are
required by the Participant.
7. The ISP reflects the full range of a Waiver Participant’s needs
and therefore must include all Medicaid and non-Medicaid
services, including informal, family and natural supports and
supports paid by other service systems to address those needs.
8. The ISP includes the type of services to be provided; the
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amount, duration and frequency of each Waiver-eligible service
and the Provider to furnish each service.
9. Services are consistent with the approved Waivers and current
Waiver service definitions.
10. The ISP is documented on the Department-approved format in
HCSIS.
11. Providers are identified for each Waiver service.
12. The identified Providers are Willing and Qualified
13. The ISP checklist is completed, when and as required.
The AE shall authorize supported employment, vocational
(including prevocational Services and transitional work services)
and education support services as per federal and state
requirements, Written Policies and Procedures, Departmental
Decisions and only when the local district OVR has documented
that OVR funding is not available. The required documentation
must be obtained prior to the initial authorization of supported
employment, vocational and education support services.
The AE may only authorize therapy and nursing services through
the Waivers if there is documentation that the service is medically
necessary and not covered through the Medical Assistance State
Plan, which includes Early Periodic, Screening, Diagnosis and
Treatment (EPSDT), Medicare and /or private insurance. Therapy
and nursing must be provided under the State Plan (which includes
EPSDT), Medicare and/or private insurance plans until the plan
limitations have been reached and documentation is secured by the
Supports Coordinator.
The AE shall ensure that the authorization of a Waiver service in an
ISP is continuously updated to reflect changes in a Participant’s
Assessed Needs.
If an update to an ISP includes a Waiver service or a Waiverfunding change, it will require review, approval and authorization by
the AE.
4.8.2 Additional Prerequisites for Service Authorization
The AE shall ensure that Waiver service authorization is not effective until
the Participant’s Waiver effective start date and after all of the following
state assurances are met:
1. The Department’s CAO has provided notice of the Waiver
Participant’s eligibility for services. The AE also may access the
eligibility information using PROMISe™, as long as the eligibility
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2.
3.
4.
5.
6.
7.
confirmation is printed and maintained in the Participant’s record
maintained by the AE.
The Waiver Participant has exercised freedom of choice of
Willing and Qualified Providers in accordance with federal law
and Department established policy.
All ISPs must be written in accordance with Waiver
requirements, including those referenced in Section and
Subsections 4.8 through 4.8.3.
The AE has authorized Waiver-funded services as necessary to
address documented and current Assessed Needs.
The AE shall ensure that Waiver-funded services furnished to a
Waiver Participant are not authorized if the services are
rendered through a Factoring arrangement, either a direct
arrangement or through a power of attorney.
Waiver Providers, including Providers of Vendor services and
vendors contracted through an OHCDS, are appropriately
qualified to render waiver services as referenced in Section 5.2
of the Agreement and as per Written Policies and Procedures
and Departmental Decisions relating to qualification and
disqualification of Waiver Providers.
The standardized statewide needs assessment has been
completed or, when the person’s health and safety requires,
approval has been obtained from the Department to proceed
with enrollment.
A Provider of vendor services includes a provider who is acting in
accordance with OHCDS requirements and a VF/EA (fiscal agent) to offer
and pay vendor services. For Vendor services, the AE is responsible to
verify and document that the Vendor rate entered by the SC on the ISP
does not exceed the rate charged to the general public plus any allowable
administration fee, prior to authorizing the Vendor service in the ISP. The
AE is also responsible to verify that the administrative charge is an
allowable administrative charge and does not exceed the ODP established
rate as per Written Policies and Procedures related to the provision of
Vendor services. The AE shall verify that services, including Vendor
services are added and authorized in an ISP in accordance with directions
issued by the Department related to the provision of Vendor services.
4.8.2.1
Residential Services
The AE shall only approve and authorize a service to be provided in
a licensed or unlicensed residential service setting that is agencyowned, leased, rented or operated, if the residential service setting
is located throughout the community in noncontiguous and noncampus settings. Locations that share one common party wall are
not considered contiguous.
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The AE shall review requests for clearance of new residential
service settings to ensure the proposed location meets waiver
standards and applicable guidelines for program capacity and
provide ODP with the findings and a recommendation. The AE
shall provide a recommendation to the regional ODP regarding
requests to change approved program capacity of homes licensed
under Chapter 6400.
4.8.3 Implementation of Individual Support Plans (ISPs)
The AE shall ensure that ISPs are reviewed and approved, that Waiverfunded services are authorized prior to implementation and that those
Waiver-funded services are furnished in accordance with the approved
and authorized ISP, Written Policies and Procedures, Departmental
Decisions and the terms and conditions of this Agreement. The AE shall
implement immediate corrective action if a Participant’s Health and
Welfare is at risk. This requirement also applies to situations when a
Provider is unavailable or unable to deliver authorized services. If the AE
is unable to resolve delays in implementing an ISP by the service start
date, the AE shall immediately notify the appropriate regional ODP.
4.8.4 Service Requests
Upon receipt from a SCO of a request to initiate or alter service(s) in an
ISP, the AE shall use information resulting from documentation,
assessment or reassessment evaluations to determine whether the
identified service(s) is necessary to address a current Assessed Need(s).
If the AE determines the identified service(s) is not needed or not Waiver
eligible, the AE shall provide written denial of the service(s) to the
Participant, along with notice of the Participant’s fair hearing rights within
thirty (30) calendar days of the receipt of the service request. If the AE
determines the service(s) is necessary, the AE shall consistent with the
Waivers and this Agreement:
1. Notify the SCO of the approval of the service request,
instruct the SCO to update the ISP as necessary and
submit for approval and authorization to the AE.
2. Approve and authorize the updated ISP within thirty (30)
calendar days of receipt of the service request. This
function must be conducted by the AE.
3. Notify the involved Provider(s) and ensure that the
service(s) is implemented as written and by the service
start date in the ISP.
If there are delays in implementing service(s), the AE shall immediately
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notify the appropriate regional ODP. The AE shall implement immediate
corrective action if the Participant’s Health and Welfare is at risk.
4.9
Fair Hearing and Appeal
The AE is responsible to ensure that fair hearing and appeal activities are
conducted in compliance with this Agreement, Written Policies and Procedures
and Departmental Decisions. The AE shall cooperate with the Department as
requested, regarding the Department’s service review of formal fair hearing
requests to ensure compliance.
Once the Department distributes its findings of the service review to the Waiver
Participant and/or Participant’s Surrogate, AE, and SCO, the AE shall ensure that
the findings and all Departmental Decisions are implemented as written.
The AE shall notify the appropriate regional ODP if it is unable to resolve issues
that cause the implementation of Departmental Decisions and findings to be
delayed. The Department will review requests for extensions should an AE
experience difficulty in implementing Departmental Decisions and findings. The
Department shall approve or deny such requests within ten (10) days of receipt
of the request. ODP reserves the right to approve or deny such requests.
4.9.1 Notice of Fair Hearing Rights
The AE shall have a written protocol to validate Waiver applicants are
provided with fair hearing rights and appeal information as per Written
Policies and Procedures and Departmental Decisions relating to due
process, fair hearing rights and appeals for Waiver applicants and
Participants.
The AE shall develop and implement a written protocol to validate Waiver
applicants receive the assistance needed to complete and file and appeal
as per Written Policies and Procedures and Departmental Decisions
relating to appeals. For appealable and non-appealable circumstances
refer to Written Policies and Procedures relating to appeals.
When the AE makes a determination to deny, suspend, terminate or
reduce a Waiver service or Waiver service request, the AE shall provide
the required written notice to the Waiver Participant and/or the
Participant’s Surrogate.
The AE shall participate in fair hearings and appeals that involve Waiver
applicants, Participants and/or services. If the fair hearing and appeal is
regarding a service that required prior authorization or exception approval
by the Department, as defined in the approved Waiver service definitions,
ODP may directly participate at the hearing. The Department and ODP
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retain the authority to attend any and all fair hearings and appeals
involving Waiver applicants, Participants and/or services.
4.9.2 Continuation of Waiver Services
In the event a fair hearing request is filed within 10 calendar days of the
mailing date of the written notification from the AE, the AE shall ensure
that current approved and authorized services remain in the ISP and the
authorization of services provides for continuation of those Waiver
services pending a final administrative action on such a request in
accordance with Written Policies and Procedures and Departmental
Decisions relating to due process, fair hearing and appeals.
5.0
Waiver Providers
5.1
Provider Recruitment and Enrollment
The AE shall support the development of a network of Waiver Providers through
recruitment and other capacity building efforts. The AE shall initiate recruitment
of Providers when there is the absence of Provider choice.
The AE shall provide ongoing technical support to Providers utilizing ODP’s
Provider Handbook on enrollment, qualification and HCSIS and PROMISe™
processes. This support includes, but is not limited to:
1. The provision of information regarding the Provider application,
enrollment, and qualification processes. The information must be
developed or approved by ODP.
2. The provision of “hands-on” technical support or referral to the
appropriate entity for enrollment support.
3. Communication to the appropriate regional ODP regarding issues
related to Provider recruitment and enrollment processes.
4. Oversight of transition planning in the event of provider closure or
notification that a provider is no longer willing to provide supports to a
Participant. This shall include actions to ensure that any affected
waiver Participant(s) is afforded choice of provider.
5. The provision of information regarding ODP required provider
orientation and training.
6. Orientation or training of providers, when approved or requested by the
Department.
5.2
Qualification of Waiver Providers
This Section applies to all Waiver Providers, with the exception of SCO’s and the
statewide VF/EA FMS. The AE shall complete the Waiver Provider Qualification
process as instructed by ODP and as outlined in Written Policies and Procedures
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and Departmental Decisions relating to qualification, requalification and
disqualification of Waiver Providers.
If a vendor is contracted through an OHCDS, the AE shall monitor that the
Provider acting as the OHCDS and subcontracted vendor are qualified per
Written Policies and Procedures, and Departmental Decisions.
The AE may not impose any additional requirements beyond these established
by the Department relating to qualification and disqualification of Waiver
Providers.
If an AE identifies that a Qualified Provider may meet the criteria for
disqualification or restriction included in Written Policies and Procedures and
Departmental Decisions relating to qualification, requalification and
disqualification of Waiver Providers, the AE shall immediately notify the
appropriate regional ODP of its recommendation to disqualify or restrict the
Provider.
The AE shall not authorize Waiver services to be delivered by a non-qualified
Provider.
5.3
Ineligible Waiver Providers
The AE shall not authorize services to be provided by an Ineligible Provider.
Upon receipt of notification of such terminations and exclusions by the
Department, the AE may not approve or authorize said ineligible Provider to
render a Waiver service.
As directed and instructed by the Department, the AE may not authorize or shall
terminate the provision of Waiver services by an Ineligible Provider or a Provider
suspected of fraud or willful misrepresentation.
In the event that Provider terminations or exclusions effect the provision of
service(s) in an ISP, the AE shall immediately notify the appropriate SCO and in
collaboration with the SCO, shall make revisions to the ISP accordingly.
6.0
Monitoring Waiver Requirements
The AE shall conduct provider monitoring of the cost based and fee schedule waiver
Providers and providers of vendor services selected by ODP for on-site review during
the annual review cycle. This shall exclude SCOs.
The AE shall provide support and technical assistance to SCOs to help assure
adherence with waiver requirements, 55 Pa. Code 51, written Policies and Procedures
and Departmental decisions.
AE Operating Agreement Effective July 1, 2013
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6.1
Monitoring of Waiver Providers
The AE shall conduct monitoring using the Department’s standardized monitoring
tool and process in order to ensure ongoing adherence to the approved Waiver
qualification standards, ongoing compliance with the provisions of 55 Pa. Code,
Chapter 51, the terms and conditions of this Agreement, any amendments to this
Agreement, Written Policies and Procedures and Departmental Decisions.
When a provider renders services in multiple AEs, the on-site audit is conducted
by the lead AE, along with Reviewing AEs conducting on-site audits for those
waiver Participants in the sample registered with them. The Lead AE is
designated by ODP based on the AE with which the most individuals served by
the provider are registered. ODP shall reassess the designation of the Lead AE
or reviewing AEs at the beginning of each monitoring cycle.
Lead and Reviewing AEs shall conduct on-site audits of all providers designated
by ODP on an annual basis. Reviewing AEs will submit the provider monitoring
results electronically to the lead AE. The lead AE shall consolidate the reviewing
AEs’ provider monitoring results into one AE audit report.
The AE shall request a CAP from the Provider within 15 days of notification to
address issues identified during the Provider monitoring. If the CAP submitted by
the Provider does not appropriately address the identified issues, the AE shall
initiate remediation efforts and notify the appropriate regional ODP. The AE shall
notify the appropriate regional ODP if initial remediation efforts are unsuccessful
relating to the following:
1. Failure to meet Waiver qualification standards.
2. Failure to comply with the provisions in the Waiver Provider
Agreement.
3. In a significant number or proportion of cases:
a. The Provider has furnished Waiver services at a frequency or
amount not consistent with authorized ISPs.
b. The Provider has furnished Waiver services of a quality that
does not meet professionally recognized standards of health
care, as defined in 42 CFR 1001.2.
c. The Provider has failed to comply with Departmental Written
Policies and Procedures.
d. Commission of a violation as listed in 55 Pa. Code 1101.75 and
1101.77 (related to provider prohibited acts)
e. Failure to complete provider qualification status within the
required timeframes.
f. Submission of false information for qualification
g. Conviction of illegal business activities
The Department shall, in collaboration with the AE, follow up on remediation
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efforts, issue a DCAP which must be implemented as directed, and/or initiate
sanctions.
6.2
Correction of Issues and Non-Compliance
The AE is responsible to complete and submit a CAP to address issues resulting
from external reviews, monitoring and audits. Unless otherwise specified, the
completed CAP must be submitted within 15 days of notification of the issue(s).
The AE shall validate and document all actions taken to fix the identified issues.
For AEOMP, the AE must document that how each instance of non-compliance
has been fixed/remediated using the AEOMP database. For situations involving
imminent Health and Welfare issues, the AE shall implement immediate
corrective action to address the issues and notify appropriate regional ODP.
If the Department submits questions or concerns to the AE in response to a
submitted CAP, the AE shall respond to those questions or concerns within the
specified time frame provided. For issues related to non-compliance with Waiver
requirements, the Department reserves the right to provide a Directed CAP to the
AE, if the AE’s follow-up submissions and/or response to questions or concerns
do not fully address the issues or noncompliance areas. The AE is responsible
for implementation of the CAP upon the approval from the Department or upon
receipt of a DCAP from the Department, as referenced in Section 6.4 of this
Agreement.
In the event a non-compliance issue(s) identified through the monitoring of
Waiver requirements involves issues related to the performance of a Provider,
including a SCO, the AE shall request the CAP be completed within 15 days
unless a shorter deadline is necessary to allow the AE to submit its CAP to the
Department. If after consultation with the Provider, the AE finds that the
Provider’s CAP is unsatisfactory, the AE shall notify the appropriate regional
ODP. The Department will, in collaboration with the AE, address an
unsatisfactory Provider CAP.
If the AE identifies Provider performance issues through its validation efforts, the
AE shall make efforts to resolve the issues and shall notify the appropriate
regional ODP. Notification to the regional ODP must include documentation of
the remediation efforts. The Department will assist the AE in addressing
Provider performance issues as needed.
Remediation actions, whether requiring action by the AE or a provider, should be
completed within 30 days but no later than 90 days from the date of notification of
the issue. The AE shall validate and document all corrective actions.
6.3
Administrative Review
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When directed by the Department, the AE shall conduct an administrative review
of the services provided using the monitoring procedures outlined in ODP’s AE
OM Process, with the exception of the sample size and interviews with Waiver
Participants. The review shall include an analysis of the data collected and the
implementation of procedures that assure Waiver compliance. The review shall
include a minimum sample of five (5) percent of Waiver Participants under the
Jurisdiction of the AE, but shall include not less than a minimum number of five
(5) records and a maximum of thirty (30) records per Waiver. In addition,
selection of the sample must be proportionally represented by each SCO
providing services to Participants under the Jurisdiction of the AE. If the SCO
provides services to five (5) or less Participants under the Jurisdiction of the AE,
every record shall be reviewed.
The AE shall conduct all monitoring of Participants as specified in the current AE
OM Process. In the conduct of the administrative review, the Department
reserves the right to require that the AE conduct face-to-face interviews.
Upon completion of the administrative review, the AE shall promptly forward the
summary results and analysis of the administrative review no later than thirty (30)
calendar days after the completion of the review. The AE shall also submit any
necessary CAP(s) no later than fifteen (15) calendar days after the completion of
the review to the appropriate regional ODP.
6.4
Implementation of Departmental Decisions and Findings
The AE shall implement Departmental Decisions and findings. If the AE
determines it has been unable to resolve its questions or concerns related to
Department Decisions and findings through routine and standard
communications, the AE shall direct its questions, concerns and issues related to
Department Decisions and findings in writing to the appropriate Department staff
(DPW-ODP Regional Program Manager) with copies to the DPW-ODP Director
of the Bureau of Supports for People with Intellectual Disabilities, the DPW-ODP
Deputy Secretary and the DPW Secretary. A written response from the
Department will be issued within fifteen (15) calendar days. At the direction of
the Department, the AE shall continue to implement Departmental Decisions and
findings until the Department’s response is provided to the AE.
If the findings or Departmental Decisions involve issues related to the
performance of a Provider including AWC FMS providers, providers of vendor
services, Providers acting as OHCDS Providers for the delivery of vendor
services, and SCOs, the AE shall notify the Provider of the findings or
Departmental Decisions. The AE shall monitor the Provider to ensure the
implementation of an ODP-approved CAP to address the findings or
Departmental Decisions. If monitoring of the Provider reveals unsatisfactory
performance, the AE shall notify the appropriate regional ODP. ODP will assist
the AE in addressing Provider performance issues as further provided herein
AE Operating Agreement Effective July 1, 2013
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Sections 6.1 and 6.2 of this Agreement.
The Department reserves the right to issue a DCAP which must be implemented
as directed.
For all findings and/or Departmental Decisions requiring the provision of a
service, such service shall be provided within thirty (30) calendar days of the
finding/decision notification or as directed by the Department when related to a
risk to a Participant’s Health and Welfare. When implementing services related
to fair hearing decisions, the AE shall provide services as per Written Policies
and Procedures and Departmental Decisions relating to due process, fair hearing
and appeals. The AE shall approve and authorize the service and monitor
service implementation.
The AE shall notify the appropriate regional ODP when:
1. There is a delay in the implementation of authorized services or
2. There is a need for an extension of time to implement the
Departmental Decisions and findings
The AE shall work with the responsible Provider or Provider of Vendor services
to ensure the provision of the authorized service, document the interaction with
the Provider and notify the appropriate regional ODP.
The AE may make a written request for an extension and ODP will review
requests for extensions should an AE experience difficulty in implementing
Departmental Decisions and findings. ODP will notify the AE of its decision
within five (5) calendar days of receipt of said request.
7.0
Quality Management (QM)
7.1
Quality Management (QM) Plan
The AE shall have a written QM Plan that implements the Department’s QM
Strategy related to the methodology, accountability, responsibility and ongoing
review of QM activities. The AE shall review and analyze data and performance
over time, direction from the Department regarding priorities and any feedback
received from the Department to improve internal QM processes and build or
refine objectives for the next QM plan year. AEs shall maintain documentation of
the process used to select these opportunities for improvement.
The AE’s QM Plan shall be developed to extend for two years from July 1
through June 30.
The QM Plan shall contain:
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1.
2.
3.
4.
Measurable objectives that relate to the identified goals and outcomes.
Performance measures that support each objective.
The data source for each performance measure.
The person or persons responsible for QM Plan improvement.
The AE shall provide evidence of implementation of its QM Plan.
7.1.1 Utilizing Department Information to Enhance Quality
The Department shall provide information to the AE to enhance the quality
of the AE’s administrative functions. Information will include, but not be
limited to: AE Letters, alerts, informational memos and packets, summary
reports, data reports, policy and procedure clarifications and general
information. The AE shall utilize the information to support its
administrative functions outlined in this Agreement.
7.1.2 Functions of the AE’s QM Point Person(s)
The person(s) filling the AE QM personnel position shall be responsible to
ensure that the conditions identified in Section 7.1 are met and to fulfill
requirements as defined by the Department.
7.2
Incident Management
The AE shall conduct incident management activities in accordance with ODP
requirements.
7.3
Independent Monitoring for Quality (IM4Q)
The AE shall comply with the responsibilities outlined in the current IM4Q
Protocol and Guidelines. The AE shall assign at least one (1) AE representative
to serve as the coordinator or point person for activities related to IM4Q. The AE
shall have a written procedure for implementing the IM4Q “closing the loop”
process.
8.0
Training and Technical Assistance
8.1
Participation in Training
In order to ensure consistent application of Waiver requirements, Written Policies
and Procedures and Departmental Decisions, the AE shall attend and participate
in the ODP Academy and any other training session determined by the
Department as a mandatory training. At a minimum, the AE shall ensure that the
management position(s) designated by ODP attend, participate and complete the
ODP Academy and training deemed mandatory for attendance by the AE.
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The Department retains the authority to designate a specific training session as
mandatory and designate specific AE functional lead(s) and staff that must
attend.
8.2
Technical Assistance
The AE shall request support, training and technical assistance as needed.
Upon such request, the Department shall provide support, training and technical
assistance as determined necessary by the Department to ensure compliance
with this Agreement, Written policies and Procedures and Departmental
Decisions. The Department shall contact the AE within thirty (30) calendar days
to respond to the AE’s request to provide support, training or technical
assistance.
9.0
Operating Agreement Remedies and Termination
9.1
Agreement Remedies
The Department will utilize a variety of means to ensure compliance with
Agreement requirements, Written Policies and Procedures and Departmental
Decisions. The Department will pursue remedial actions as needed to resolve
any outstanding performance concerns and violations with the Agreement. The
application of remedies shall be a matter of public record once an acceptable
CAP has been developed by the AE.
AE noncompliance with the Agreement will be addressed through the following
remedies. While remedies will generally follow a progressive path, the
Department reserves the right to deviate from this path for significant issues of
noncompliance as determined by the Department. The Department may utilize
the following actions:
1. Notify the AE in writing of the Agreement violation and conditions with
copies to the County Mental Health/Intellectual Disabilities administrator
and executives, administrator of the County/Joinder, County
Commissioners/County Council/Executive Directors and/or Boards of
Directors of the AE and the County/Joinder MH/MR Advisory Board.
2. Require a CAP including a detailed work plan outlining specific corrective
activities. Specified status reports will be required for continuance of the
Agreement.
3. The AE shall be required to conduct at least one administrative review of
the services provided using the monitoring procedures outlined in ODP’s
AEOM Process, with the exception of the sample size and interviews with
Waiver Participants. The review shall include an analysis of the data
collected and the implementation of procedures that assure Waiver
compliance.
4. Revise the AE’s Waiver Capacity Commitment.
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5. Provide a DCAP to the AE, including specific required training and/or
technical assistance activities.
6. Require attendance and participation of the AE in directed-technical
assistance and required trainings.
7. Validate corrective actions and intensity monitoring of the performance of
the AE, which may include onsite performance monitoring and a
requirement for regular written and/or oral status updates.
8. Adjust the Waiver Administration Allocation commensurate with nondelivered functions and failure to perform the terms and conditions of this
Agreement, Written Policies and Procedures and Departmental Decisions.
9. Termination of the Agreement.
The Department reserves the right to make adjustments to the AE’s Waiver
Capacity Commitment or Waiver Administration Allocation. The implementation
of remedial actions does not require an amendment to the Agreement. The
remediation notice to the AE is sufficient authority according to this provision.
The following are examples of compliance or performance problems for which
remedial actions can be applied to address areas of non-compliance. This listing
is not meant to be exhaustive, but only representative:
1. Failure to document efforts to address Waiver Participant Health and
Welfare.
2. Failure to be responsive to the concerns of Waiver Participants.
3. Failure to conduct the review, approval and authorization of Waiver
services in ISPs as per Written Policies and Procedures, Departmental
Decisions and this Agreement.
4. Failure to properly manage administrative funds.
5. Failure to perform efficiently and effectively.
6. Failure to comply with the Waiver Capacity Commitment approved by the
Department.
7. Failure to make appropriate and timely level of care determinations and
re-determinations.
8. Failure to make correct or timely service determinations.
9. Failure to demonstrate the ability to meet the responsibilities outlined in
this Agreement
10. Failure to comply with Department requirements related to Claim
resolution.
11. Failure to comply with Written Policies and Procedures.
12. Failure to implement Departmental Decisions.
13. Submission of inaccurate, incomplete or late reports.
In the event that the Department finds there has been Substantial Failure of the
AE to adhere to the responsibilities and functions outlined in this Agreement
including applicable Written Policies and Procedures and Departmental
Decisions or Substantial Failure to perform or provide services to Participants in
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the Pennsylvania ODP service system, the Department may provide notice of
termination as referenced in Section and Subsections 9.2 through 9.3.2.1 of this
Agreement.
9.2
Agreement Termination
Either party may terminate this Agreement without cause with at least one
hundred twenty (120) calendar day prior written notice given to the other party
and the relevant county/joinder Commissioners. The parties may terminate this
Agreement without cause with less than one hundred twenty (120) calendar day
notice, only if an agreement to do so is in writing and signed by both parties.
The Department may terminate this Agreement for material cause with no less
than one hundred twenty (120) calendar day prior written notice.
9.2.1
Enforcement
Failure of either party to provide the prior written notice required by
Section 9.2 shall permit the other party to seek specific performance in a
court of competent jurisdiction for up to one hundred twenty (120)
calendar days following any notice of failure to perform.
9.3
Transition Plan and Closeout Procedures for Agreement Termination
9.3.1
Transition Plan for Agreement Termination
In the event that this Agreement is terminated as per Section and
Subsections 9.2 through 9.3.2.1 of this Agreement, the Department and
the current AE shall cooperate to develop a plan for transitioning
administrative activities related to Waiver Participants to the successor
AE. The transition plan must be developed within thirty (30) calendar days
of written notice of termination and will span the remainder of the one
hundred twenty (120) calendar days. The current AE shall cooperate with
the Department to implement the plan. The Department shall have the
sole authority to approve the adequacy of the transition plan, including
providing for the financing of said plan. The current AE shall ensure
continuity of care for all Participants being served under this Agreement
until all Waiver Participants are being served under the Jurisdiction of the
AE selected by the Department. The current AE will cooperate with the
Department in developing a transition plan for the maintenance of
Participant eligibility and the provision of services during the transition
period, including the systematic transfer of each Waiver Participant and
Participant’s record from the responsibility of the current AE to the
Successor AE. The transition period may be extended at the
Department’s discretion. The current AE will cooperate with the successor
AE regarding the transfer of records and services.
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9.3.2
Close out Procedures for Agreement Termination
If this Agreement is terminated, the following shall take effect:
1. Within thirty (30) calendar days following the notification of
termination of this Agreement, or as otherwise approved in
writing by the Department, the AE shall provide to the
Department all financial, performance and other reports required
by this Agreement.
2. Within thirty (30) calendar days following the notification of
termination of this Agreement or as otherwise approved in
writing by the Department, the current AE will supply to the
Department and/or the successor AE all material necessary for
continued operation of payment and related systems, including:
a.
b.
c.
d.
e.
Computer programs.
Data files
User and operation manuals.
System and program documentation
Training programs of Waiver functions for responsible
staff, staff agents or designees, related to the operation
and maintenance of the payment system.
If the AE possesses the proprietary rights to such materials, the
AE shall permit the Department to purchase the materials or
purchase the use of the materials through leasing or other
means.
3. The portion of all funds accumulated by the AE that are
comprised of Waiver administrative funds and related interest
must be refunded to the Department within thirty (30) calendar
days after the notification of termination of this Agreement, less
amounts needed to cover an outstanding Claim or liability,
unless otherwise directed in writing by the Department.
4. All financial, administrative and clinical records under the AE’s
responsibility must be retained by the current AE for a period of
five (5) years from the termination of this Agreement. The
current AE shall provide copies of all necessary records to the
successor AE as part of a transition plan.
5. The records required to be retained and provided, as per
Section and Subsections 3.3 through 3.3.4 shall continue to be
retained and provided by the current AE for a period of five (5)
years from the termination of this Agreement. The current AE
shall provide copies of all necessary records to the successor
AE as part of the transition plan.
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The transition plan will include financing arrangements with the successor AE,
which may utilize remaining Waiver-related funds held by the previous AE
and owed to the Department.
Should additional statistical or management information be required by the
Department after this Agreement has been terminated, the AE will be given at
least forty-five (45) calendar days’ notice to provide the required information.
9.3.2.1
Enforcement
The obligations in Subsections 9.3.1 or 9.3.2 shall be enforceable
through an action for specific performance in a court of competent
jurisdiction.
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