What's the difference?

What’s the difference?

Differences between Mi Via and Centennial Care Self-Directed Community Benefit

Though they are both Medicaid funded self-directed programs, Mi Via and the Centennial Care Self- Directed Community Benefit are very different. AAA Participant Direction provides support to Mi Via Participants and Self-Directed Community Benefit members to self-direct Medicaid long-term care services.

Mi Via

Centennial Care Self-Directed Community Benefit (SDCB)

What we call recipients of Mi Via Services:
Participants
What we call recipients of SDCB services:
Members
Mi Via participants get Mi Via Consultant Services from AAA Participant DirectionSDCB members get Support Broker services from AAA Participant Direction
The Mi Via program is managed by the Department of Health (DOH)/Developmental Disabilities Support Division (DDSD). AAAPD has a service agreement with DDSD to provide Mi Via Consultant services. We are considered a Mi Via Consultant Agency.The SDCB program is managed by Centennial Care Managed Care Organizations (MCO) under contract with the Human Services Department (HSD)/Medical Assistance Division (MAD). AAAPD has a contract with Western Sky to provide SDCB Support Broker services to their members. We are considered a Support Broker Agency.
Participant registers on the waiting list for the Developmental Disabilities Waiver (DDW ) or the Medically Fragile Waiver (MFW). They must have an intellectual/ developmental disability or be medically fragile.The member’s MCO Care Coordinator (CC) completes a Comprehensive Needs Assessment (CNA) to determine member’s eligibility for the Community Benefit (long-term care). Members will have a physical disability, brain injury, chronic health condition or be elderly.
When a waiver slot becomes available, the participant receives an allocation letter to the Developmental Disabilities Waiver (DDW) or the Medically Fragile Waiver (MFW). They select Mi Via at this time, instead of the DDW or MFW.If eligible for the Community Benefit, the member receives Agency-Base Community Benefit (ABCB) services for 120 days. At any time during these 120 days, the member may request to be transferred to Self-Directed Community Benefit (SDCB) program but won’t be able to start the SDCB program until after the 120 days.
Participant gets a list of Mi Via Consultant Agencies from DDSD and selects one using the Primary Freedom of Choice Form (PFOC). DDSD sends the PFOC to AAAPD. That is how the participant selects AAAPD.The MCO Care Coordinator gives member a list of Support Broker Agencies to choose from and a selection form. The member selects AAA Participant Direction and the Care Coordinator sends us the selection form. This is how they select AAAPD.
Participant completes the financial eligibility process through the Income Support Division (ISD)/HSD.Member has already completed the financial eligibility process with ISD when they come to us for Support Broker services.
Participant completes medical eligibility by submitting the Abstract and History & Physical (H&P) forms completed with their doctor and completing an in-home assessment. This information goes to the Third Party Assessor (TPA), which is Qualis. Qualis decides if participant is medically eligible. This is also referred to as Level of Care (LOC).Member was already deemed to be medically eligible through the Comprehensive Needs Assessment process, along with the Nursing Facility Level of Care evaluation (NFLOC). This is done by the MCO Care Coordinator.
Upon receiving LOC approval, the participant receives an Individual Budget Allocation (IBA) as per a rate schedule based on age. This is the budget amount they have to use to purchase their supports, goods, and services.The SDCB member receives a budget amount that is determined by the Comprehensive Needs Assessment. This becomes the budget amount the member has to use to purchase their SDCB services.
Participant meets with their Mi Via Consultant for enrollment with AAAPD and orientation to Mi Via.Member meets with their SDCB Support Broker for enrollment with AAAPD and orientation to SDCB.
Participant decides who will be the Employer of Record (EOR). It is usually the participant. A participant that has a guardian cannot be the EOR. Consultant helps participant complete an Employer of Record (EOR) Request Form and sign all necessary forms.MCO Care Coordinator completes a Self-Direction Self-Assessment Form with the member to determine if the member can be the EOR. If the member has a guardian, they cannot be the EOR. The Support Broker helps member complete an Employer of Record (EOR) Request Form and sign all necessary forms.
Participant completes a Mi Via Services & Support Plan (SSP) using person-centered planning. The consultant enters the SSP into FOCOSonline.The member engages in person-centered planning with their Support Broker.
Participant and consultant, using information from the SSP and following the description of Mi Via services and the range of rates for services, develop the Plan/Budget. The consultant enters the Plan/Budget into FOCOS. Once the participant approves of the SSP and Plan/Budget as the consultant entered it, the consultant submits it to Qualis, the TPA, for approval.With their Support Broker, the member develops a Plan/Budget for SDCB services, using person-centered planning and following the description of SDCB services and the range of rates for services. The Support Broker enters the Plan/Budget into working plan status in FOCOSonline and lets the MCO Care Coordinator know that the Plan/Budget is ready for the Care Coordinator to review and submit. The Care Coordinator reviews the Plan/Budget for errors and to make sure everything meets the criteria for approval and service descriptions. The Care Coordinator then submits the Plan/Budget to the MCO’s Utilization Team for approval.
The participant completes an Emergency/Back-up Plan which is part of their SSP. They initial the Emergency/Back-up Acknowledgement Form and keep a copy.The member completes a SDCB back-up plan. The plan is embedded in the applicable SDCB budget goals in FOCOSonline.
The participant can submit a Plan/Budget that exceeds their IBA. However, the participant must meet the criteria for additional funding to get the increase in their budget. They have to get professional health care providers to document how the participant’s needs cannot be met within their IBA.The member is not allowed to request SDCB services that would exceed their SDCB budget amount. The only way a member can get an increase in their budget is for the Care Coordinator to complete another CNA and NFLOC that demonstrates a change in the member’s condition.
Qualis approves or denies each service, support or good that the participant has requested. They can also issue a Request for Additional Information (RFI) before they decide to approve or deny an item. The consultant helps the participant respond to the RFI from Qualis. After Qualis receives and reviews the RFI information, they will approve or deny the item. Qualis sends out an approval/partial approval letter to the participant and the consultant.The MCO’s Utilization Management Team approves or denies each service, support or good that the member has requested. They can also issue a Request for Additional Information (RFI) before they decide to approve or deny an item. The Support Broker helps the member respond to Utilization’s RFI. After Utilization receives and reviews the RFI information, they will approve or deny the item.

The participant has options if they don’t feel that the TPA should deny an item:

  • Provide additional information for why the denied item is necessary for reconsideration;
  • Request a Medicaid Fair Hearing to determine if the denial will hold or be overturned;
  • Prior to the Medicaid Fair Hearing, the participant can have an Agency Conference with all parties to understand the TPA’s decision and maybe come to a resolution.

The member has options if they don’t feel that the MCO should deny an item:

  • Provide additional information for why the denied item is necessary for reconsideration;
  • The member has to request an Appeal through the MCO before they can request a Medicaid Fair Hearing;
  • If the MCO upholds the denial on Appeal, the member can request a Medicaid Fair Hearing to determine if the denial will hold or be overturned.
The consultant contacts the participant monthly and visits the participant quarterly to track how the implementation of the SSP/Plan is going.

The Support Broker contacts the member monthly and visits the member quarterly to track how the implementation of the SSP/Plan is going

Depending on the member’s assigned level of care coordination, Level II or Level III, the CC will contact the member monthly and visit semi-annually (Level II) or visit quarterly (Level III)

If the participant wants to make a change in their Mi Via budget, the consultant helps them do a revision. The revision is submitted to Qualis for approval.If the member wants to make a change in their SDCB budget, the Support Broker helps them do a revision. The revision is entered into working plan status in FOCOSonline and the Care Coordinator is asked to review and submit it to Utilization. The Care Coordinator then submits it to the MCO’s utilization process for approval.
Annually, the consultant helps the participant complete the LOC process with Qualis and the financial eligibility process with ISD. The consultant helps the participant develop their annual SSP/Plan and submits it to Qualis for approval.Annually, the Support Broker helps the member complete the financial eligibility process. The MCO Care Coordinator completes the annual CNA and NFLOC assessments. The Support Broker helps the member complete their annual SDCB budget goals and passes this on to the Care Coordinator who reviews and submits to the MCO’s Utilization Team.

At this point, the process of implementing the Mi Via budget and the SDCB budget is the same.

Once the SSP/Plan is approved, the participant/EOR implements the SSP/Plan with the support of the Financial Management Agency (FMA), which is Conduent. The participant will complete Employee Enrollment Packets and Vendor Enrollment Packets and submit to Conduent. To get employees paid, the participant/EOR submits timesheets and Payment Request Forms (PRF) to Conduent for payment. The consultant educates, guides and assists the participant to implement their SSP/Plan.Once the SDCB budget is approved, the member/EOR implements the budget with the support of the Financial Management Agency (FMA), which is Conduent. The member will complete Employee Enrollment Packets and Vendor Enrollment Packets and submit to Conduent. To get employees paid, the member/EOR submits timesheets and Payment Request Forms (PRF) to Conduent for payment. The Support Broker educates, guides and assists the participant to implement their SDCB budget.