Att 8 UCA Specific Program Assessment Process Flows.docx

ATTACHMENT 8: UCA SPECIFIC PROGRAM ASSESSMENT PROCESS FLOWS

PACE and Certain Home and Community-Based (HCBS) Waiver Program UCA Assessment Processes Individuals may seek clinical eligibility determinations for PACE and certain HCBS Waiver programs in two scenarios:

1. If the individual already knows they want to go through the clinical eligibility determination process for PACE or certain HBCS Waiver programs at the time of their initial UCA assessment.

2. After receiving a PACE or HCBS Waiver program referral as an Output of the assessment process described in RFR Section 1.5.2.3. In this scenario, the individual would go through the UCA assessment process again, with the purpose of receiving a clinical eligibility determination for PACE or the desired Waiver program. To minimize assessment fatigue, the Assessor would leverage the information already collected in the initial assessment when appropriate.

In Scenario 1, in which the individual seeks a determination for PACE or certain HCBS Waiver programs at the time of their initial assessment, the PACE or Waiver Assessor does the UCA assessment and includes review of additional clinical eligibility criteria specific to those programs. The Outputs will include a determination of PACE or Waiver clinical eligibility, which is not a standard Output that results when System Logic is run to determine Outputs for other services and programs (described in the high-level process flow in RFR Section 1.5.2.3). The process described below reflects the steps that would occur in Scenario 2 after an initial assessment that results in a referral Output for PACE or certain HCBS Waiver programs.

Program of All-Inclusive Care for the Elderly (PACE). Assessments for individuals seeking enrollment in a PACE program would be conducted using the UCA Tool and the e-CAS to inform the clinical eligibility determination and notification process for initial enrollment and periodic reassessments.

Anticipated High-Level Assessment Process for PACE Program (May be revised during requirements gathering and as needed.)

1. Intake: The Assessor will initiate the intake process described further in RFR Section 1.4.1.1.3:

a. The Assessor completes the screening questions on the e-CAS.

· The e-CAS will determine that the individual has had a recent assessment and will require the Assessor to provide justification for a new assessment.

· The Assessor will answer in the e-CAS that the individual is seeking clinical eligibility for the PACE program.

b. The Assessor initiates requests for required documents (e.g., Primary Care Provider (PCP) referral) and/or uploads the required documents on the e-CAS, if needed. Documentation that supports additional clinical eligibility criteria specific to PACE will be included.

c. The e-CAS checks to confirm required documents have been uploaded/submitted.

2. Assessment Completion: Assessor completes the UCA Tool with the individual by entering responses to questions in the e-CAS.

3. Preliminary System Logic Output: Based on the individual’s responses to UCA Tool questions, the e-CAS will generate a report with the preliminary clinical eligibility for PACE.

4. Quality Review and Final Output:

a. The e-CAS will notify an EOHHS nurse reviewer to review the individual’s assessment.

· The EOHHS nurse will review the e-CAS preliminary Output report, assessment question responses and other required documentation.

b. The EOHHS nurse signs off on the final Output for PACE clinical eligibility in the e-CAS.

5. Notification and Data Sharing:

a. The e-CAS will send the final Output for PACE clinical eligibility to the appropriate MassHealth system(s).

· In addition, the e-CAS will generate a notice to the individual and electronic notification to the PACE program with the final Output for clinical eligibility.

· The notice may be mailed by the Selected Bidder or MMIS, as determined by EOHHS.

Following completion of the PACE enrollment process, the e-CAS will receive data from MMIS to inform the calculation of the assessment expiration date, which determines the date when a Member’s periodic reassessment must be completed. See Attachment 6 EOHHS Requirements for further details on expiration dates.

6. Other Steps, Depending on Output/Programs: Additional steps may occur, depending on the final clinical eligibility determination for PACE provided to the individual and the individual’s decisions regarding that determination. These can include activities supported by the e-CAS including Options Counseling, Appeals and reassessment support.

Certain Home and Community-Based (HCBS) Waiver Programs. For certain HCBS Waiver programs, Assessors from University of Massachusetts Medical School’s Commonwealth Medicine Waiver Unit (CWM) would use the UCA Tool and the e-CAS to provide a preliminary clinical eligibility Output considered along with additional required screening tools, if applicable. For the HCBS Waiver programs with CWM Assessors, e-CAS workflows would support review by a CWM supervisor and consultation with a clinical review team, including agency staff from MRC or DDS, if the initial supervisor review does not confirm clinical eligibility. Following manual entry of the final Output for the HCBS Waiver clinical eligibility into the e-CAS by the Assessor, the information would be paired with the financial eligibility determination completed in the MA-21 System by MassHealth for a final determination of eligibility to enroll in the HCBS Waiver program. The UCA Tool would also be used for required annual clinical eligibility redeterminations.

Anticipated High-Level Assessment Process for Certain HCBS Waiver Programs (CWM Assessors) (May be revised during requirements gathering and as needed.)

1. Intake: The Assessor will initiate the intake process described further in Section 1.4.1.1.3:

a. The CWM Assessor will complete the screening questions on the e-CAS.

· The e-CAS will determine that the individual has had a recent assessment and will require the Assessor to provide justification for a new assessment.

· The CWM Assessor will answer in the e-CAS that the individual is seeking clinical eligibility for a specific HCBS Waiver program.

b. The CWM Assessor will initiate requests for required documents (e.g., PCP referral) and uploads the required documents on the e-CAS, if needed.

c. The e-CAS will check to confirm required documents are uploaded/submitted. Documentation that supports additional clinical eligibility criteria specific to the Waiver program will be included.

2. Assessment Completion:

a. The CWM Assessor completes the UCA Tool with the individual by entering responses to questions in the e-CAS.

b. The CWM Assessor will conduct other required clinical screenings (outside of the e-CAS), if needed, and upload completed documentation in the e-CAS.

c. The CWM Assessor will support the individual with submitting financial eligibility information to MassHealth, if necessary (outside of the e-CAS).

3. Preliminary System Logic Outputs: Based on the individual’s responses to UCA Tool questions, the e-CAS will generate a report with the preliminary System Logic Output of clinical eligibility for the HCBS Waiver program.

a. The CWM Assessor will review the UCA Tool preliminary System Logic clinical eligibility Output and consider it along with other clinical assessment information to make a recommendation on clinical eligibility.

b. The CWM Assessor will enter the recommendation of clinical eligibility or no clinical eligibility into the e-CAS.

c. The CWM Assessor will request supervisor review in the e-CAS.

4. Quality Review and Final Output:

a. The e-CAS will send electronic notification to the supervisor to review the case.

b. The supervisor will review the recommendation and assessment documents on the e-CAS.

c. If the supervisor confirms clinical eligibility, the supervisor enters the final clinical eligibility determination into the e-CAS.

· The e-CAS sends the final clinical eligibility decision to the Assessor who will sign the assessment as complete.

· The process then moves to step 5.

d. If the supervisor is unable to confirm clinical eligibility, the supervisor will use the e-CAS to initiate a request for review by the MRC or DDS clinical review team, as appropriate.

· The clinical review team will enter a final clinical eligibility determination in the e-CAS after team consultation, if applicable.

· The e-CAS sends the final clinical eligibility decision to the Assessor who will sign the assessment as complete.

· The process then moves to step 5.

5. Data Sharing and Notification:

a. The e-CAS will send the final clinical eligibility decision for the HCBS Waiver program to the appropriate MassHealth system(s) (e.g., MassHealth Electronic Data Management Center).

b. The e-CAS will send written notification about clinical eligibility to the individual and electronic notification to the Assessor and other authorized users (e.g., MRC or DDS case managers), if applicable.

· The notice may be mailed by the Selected Bidder or MMIS, as determined by EOHHS.

6. Other Steps, Depending on Output/Programs: Additional steps may occur, depending on the final HCBS Waiver clinical eligibility decision provided to the individual and their decisions regarding that determination. These can include activities supported by the e-CAS including options counseling, Appeals and reassessment support.

Final approval for HCBS Waiver enrollment depends on the financial eligibility determination process outside the e-CAS. Once MassHealth completes the final HCBS Waiver eligibility determination, MassHealth will send the relevant waiver eligibility information to the e-CAS for the periodic reassessment process, which requires an annual redetermination.

Senior Care Options and One Care In addition to the use of the UCA Tool for determining clinical eligibility or referral to other services and programs, the UCA Tool may also be used to determine the level of payment or risk adjustment for certain MassHealth Health Plans, including Senior Care Options (SCO) and One Care.

Anticipated High-Level Assessment Process for SCO or One Care Payment Level (May be revised during requirements gathering and as needed.)

1. Intake for SCO or One Care Payment Levels: A Member is referred for a UCA assessment upon enrollment in a SCO or One Care plan.

· The Assessor completes the screening questions on e-CAS and indicates the assessment is for determining the payment level for the Member.

· The Assessor uploads required documents, if needed.

2. Assessment Completion: Assessor completes the UCA Tool with the Member by entering responses to questions in the e-CAS .

3. Preliminary System Logic Output: Based on the Member’s responses to UCA Tool questions, the e-CAS will generate a report with the preliminary payment level determination.

4. Quality Review and Final Output:

· If needed, the e-CAS will notify the EOHHS nurse reviewer to review the Member’s assessment.

· The EOHHS nurse will review the e-CAS report and assessment responses and will enter the final payment level determination in the e-CAS.

5. Notification and Data Sharing:

· The e-CAS will send the payment level information to MMIS for SCO or One Care payment for the Member.

· The Member does not receive a notification of payment level or other e-CAS Outputs.

6. Other Steps, Depending on Output/Programs: When a Member is referred for assessment specifically for the purposes of determining a SCO or One Care payment level, reassessment support is the only additional step anticipated to require the e-CAS .

· Reassessment support: Payment level reassessments may be conducted using the e-CAS for the following reasons:

· Periodic reassessments at required intervals based on program requirements (e.g., at least annually for One Care and semi-annually for SCO);

· Payment level reassessments when a Member has a status change that could lead to a new payment level; and

· Reassessments when a Members transfers from a One Care or SCO plan to another One Care or SCO plan.

Attachment 8, UCA Specific Program Assessment Process Flows 1