CHC Waiver services

CHC Waiver services

PHW Waiver services

Participant Handbook

During each visit the participant should be offered a copy and/or access to the PHW Participant Handbook. The SC should review the handbook with the participant and in the last section of the PCSP will check off that each highlighted portion of the handbook has been covered with the participant or responsible party.

Home Modifications/Repairs process/DME/SME

Home Modifications 

Home modifications are defined as environmental interventions aiming to support activity performance in the home. More specifically, home modifications often are changes made to the home environment to help people with functional disability or impairment to be more independent and safe in their own homes and reduce any risk of injury to themselves or their caregivers. 

Examples of Home Modifications include: Grab bars, stair glide, walk-in shower, ramp, VPL, door widening, handrails, railings. 

Process: 

  1. When the Service Coordinator receives a request from the participant (“ptp”), they are then  responsible for explaining the process and assisting the ptp with obtaining Proof of Home Ownership (POHO) and having the Letter of Consent (LOC) signed by the home owner(s)/landlord. If the participant is the sole homeowner, the LOC is not required to be filled out however POHO is required. If the participant rents (i.e apartment), POHO is not required however LOC is required. Types of valid POHO include:
    • Mortgage Statements, Annual Property Tax Statements, or Warranty Deeds.
  2. The Letter of Consent (LOC) must be signed by all homeowners, dated, and all checkboxes must be checked off or else the LOC will be considered invalid. 
  3. If there is more than one home owner, they both must be listed on the document or it will be considered invalid and a task will be received from PHW. 
  4. The SC is required to follow-up with the participant consistently until documents have been received.
  5. When the documents are received, the Service Coordinator will complete the Comprehensive Needs Assessment and ensure the need and request for the Home Mod is put in appropriately.
  • InterRAI “Home Environment” section must be completed accurately to reflect the need for Home Mod.
    • i.e. participant requests a stair glide but “IADL’s” section of InterRAI shows participant needs limited assistance climbing stairs, and “Home Environment” section does not indicate that the participant does not need assistance maneuvering through rooms, then the request will be denied. 
    • i.e. participant requests an outside railing and “IADL’s” section of InterRAI reflects that participant needs assistance climbing stairs outside of the home to go shopping, but “Outside Environment” section does not indicate that the participant does not need assistance with access to the grocery store.
  • Signed PCSP with the Home Modification request in the Service Plan.
    • If the participant is requesting a specific item the PCSP and SRT must match with the request. I.e: “Home adaptations evaluation is needed for a stair glide.”;
    • If the participant states they are having difficulty with ingress/egress then the SC can list that as the need, goal, and service details of the service pan. (ie. Home adaptation evaluation is needed, the participant is having difficulty with ingress/egress.)
      • This will allow the evaluator to determine if it is safer to have railings, stair glide, or other modifications in that specific  home/situation. 
    • Amount – 1 unit
    • Provider – TBD 
  1. Complete Service Request Tool (SRT)
    • SRT should match the request on the PCSP. 
    • Date of request on the SRT should be the date the assessments were completed
  2. Upload POHO to Envolve under document upload
    • Document Category: Long Term Services and Supports
    • Document Type: POHO
    • File Name: POHO_Ptp last name_Ptp first initial_Ptp ID#_mmddyyyy
    • Send POHO to Home_Adaptations@pahealthwellness.com
    • Please Note: if the POHO is not received within 14 days of plan submission, the modification request will be denied. This is why it is advised not to submit the request prior to receiving the POHO.
  3. In the event that a modification has been added to the care plan prior to homeowner approval and/or POHO, the turnaround time for these documents is 30 days. 

NOTE: If an HA request is denied due to a lack of information and then the information is received after the denial letter was sent the SC should consider this to be a NEW REQUEST and submit a NEW SRT indicating the NEW DATE the request is being submitted.

NOTE: Building new rooms is EXCLUDED as well as improvements to the home of general maintenance. 

Home Modification Repairs

If the SC has been informed from the participant that they need a repair of any kind to a previously installed modification: 

  • The SC should confirm with the participant who the provider was. 
  • The SC should reach out to the provider to confirm if the installation is still under warranty.
    • If the installation is under warranty, the provider should be notified of the repair that is needed so they can schedule to go to the participants home and evaluate.
  • If the installation is no longer under warranty, the SC is required to confirm the make and model number of the modification. 
  • The SC can add this service to the PCSP, including the make and model number.
  • SRT is required.

Durable & Specialized Medical Equipment 

Examples of DME: (Reusable) wheelchair, walker, recliner, hoyer lift, scooter, hospital bed, cane, commode, etc. 

Examples of SME: (Disposable) wet wipes, barrier cream, gloves, incontinence supplies such as: diapers, pads, and liners.

NOTE: PA Health and Wellness does not differentiate between DME & SME.

Process: 

If the Participant is requesting SME or DME: 

  1. SC receives the request and assists the participant with asking the Primary Care Physician (PCP) to send a script to their chosen provider
    1. If the PCP sends the script directly to the SC instead, the SC may utilize the Vendor form to send the request with the script to the chosen provider.
      1. It is recommended that the SC inquire if the item being requested is covered by the chosen provider prior to sending the documents.
      2. For items that require a script, try to obtain that from the PCSP DURING the visit and submit it with everything else. Otherwise get it ASAP.
  2. Simple DMEs and SMEs do NOT go onto the PCSP until AFTER they are approved/covered by insurance or Authorization is made (unless it is an Exceptional DME, see below)
    1. The PCSP should state: “This item is covered under Medicare (or other insurance)”.
    2. SRT is NOT REQUIRED for any SME or DME unless specified below. 
  3. If the item is denied by insurance and an authorization is needed, the provider will submit a prior auth and it will be reviewed.
    1. If the item is denied by insurance and an authorization is not needed, the provider should be able to supply the item. 
  4. If the Participant is requesting custom items:
    1. Any item that is custom to the participant (i.e. it cannot be used straight out of the box) and the cost is equal to or greater than $5,000 is considered Exceptional DME (EDME) and is required to be added to the PCSP and an SRT must be completed.
    2. The following items would be Exceptional DMEs and therefore should be listed on the PCSP and have an SRT completed:
  • Manual wheelchairs – no script is needed if ptp is requesting for purchase, PHW does not do rentals
  • Power wheelchairs – no script is needed
  • Power scooters – no script is needed
  • Lift Chair/Recliners- *script needed
  • Shower chairs with tilt/rolling shower chairs with commode – *script is needed
  • Tub transfer system (not the typical transfer bench) – *script is needed
  • Speech Generating devices – *script is needed
  • Repairs to any of the above items – no script is needed
  1. If the item being requested is specific (EDME), visit is required and must be listed on the PCSP service details as such.
  2. If there is a chosen provider from the participant, they should also be listed on the PCSP. If not, state TBD for Provider

NOTE: There may be exceptions to this process depending on the item being requested. PHW will send task on how to proceed in these circumstances

Regarding Recliners:

  1. Consider Recliners as EDME.
  2. Dual Eligible participants are required by Medicare to have a face to face visit with their ordering physician and the physician should be initiating that request, by writing a script for the item and sending it to either PHW or SC.
    1. Two scripts may be required:
      1. Chair Portion of a lift chair
      2. Mechanical portion of a seat lift
  3. If a script, InterRAI, PCSP, and SRT is provided to PHW for a dual eligible participant with the request, they will send the request to a provider for Medicare processing. 
  4. If a script, InterRAI, PCSP, and SRT is provided to PHW for a non-dual eligible participant, they will send the script to a provider for a quote.
  5. The Service Coordinator has the ability and it is preferred that they send the script, demographics, primary insurance info to a provider directly. A current PCSP, SRT, and InterRAI must be on file.
  6. If Medicare denies the request, PHW will need a new SRT on file within 48 hours of receiving a quote when Medicare denies.

Keep in Mind the Following: 

  • Diagnoses:
    • Items will require a specific diagnosis 
    • Participants may not always be eligible for what they are requesting.
      • i.e. If your participant is requesting diapers, but your InterRAI reflects that they are not incontinent and they do not have any incontinent diagnosis, then they will not be qualified to receive diapers. 
    • This goes for insurance AND waiver coverage. 
  • Order of Mobility with DME items:
    • A participant who is requesting a walker and a wheelchair will need to decide which is more pertinent to their needs.
      • i.e. If the participant already has a wheelchair, they cannot receive a walker, if they have a walker already, they cannot receive a cane. If they start with a cane then they ARE allowed to receive a walker, and then a wheelchair but this cannot go in reverse order.

Home Adaptations

Other PHW Benefit Resources

Pennsylvania Long-Term Care Insurance Benefits | PA Health & Wellness (pahealthwellness.com)

https://wellcare.pahealthwellness.com/

Affordable Health Insurance in Pennsylvania | Ambetter from PA Health & Wellness (pahealthwellness.com)

Employment Services

Employment Services

As you know in the PCSP there is a section that is specifically about employment/volunteering and we are responsible for ensuring that we are discussing services that are available to assist any participant with attaining or maintaining employment or volunteering.  

We need to ensure that we are discussing available resources related to employment and documenting in our notes as well as in the PCSP what resources we have offered.  

There are currently four types of employment services offered through CHC:

  1. Benefits counseling
  2. Job coaching
  3. Employment skills development
  4. Career assessment

Prior to requesting employment services through CHC, referrals must be done the Office of Vocational Rehabilitation (OVR) and Work Incentives Planning and Assistance (WIPA) to determine if they are able to provide the needed services.  If OVR and WIPA are unable to begin services for the participant (ie. ptp is put on a wait list) then employment services can be requested through CHC.

Example if ptp who does NOT want assistance with employment: No NEED, GOAL, or OUTCOME needed for Employment.

Example if ptp wants assistance with employment : Must have NEED, GOAL and OUTCOME.  Must also have Services listed in Service plan

EXAMPLE IF PTP IS WORKING AND WANTS TO CONTINUE WORKING: Must have NEED, GOAL and OUTCOME.  Must also have Services listed in Service plan

Providers outside of CHC:

  1. WIPA Hotline1-866-968-7842
  2. OVR (Office of Vocational Rehabilitation)
    1. PHILADELPHIA
      1. Vocational Rehabilitation Services
        1. 801 Market Street Suite 6034 Philadelphia, PA 19107
        2. 215-560-1900 Voice 
        3. 800-442-6381* Voice 
    2. PITTSBURGH
      1. Vocational Rehabilitation Services
        1. 531 Penn Avenue Pittsburgh, PA 15222
        2. 412-392-4950 Voice
        3. 412-392-5921 TTY
        4. 800-442-6371* Voice
        5. 888-870-4474* TTY

Providers in Network

  1. Community Integrated Services, 215-238 7411
  2. If unsure of the provider the ptp would like to use TBD can be used

Additional Information:

What is OVR?

The Office of Vocational Rehabilitation (OVR) serves people who have disabilities that present a substantial impediment to employment. Services are provided to individuals to prepare for, secure, retain, advance in or regain employment. OVR has 21 District Offices located around the state. Our counselors work every year with thousands of persons who have physical, mental or emotional disabilities.

https://www.dli.pa.gov/Individuals/Disability-Services/ovr/Pages/Rehabilitation-Services-Handbook.aspx

Directory:

  1. https://www.dli.pa.gov/Individuals/Disability-Services/ovr/Pages/OVR-Office-Directory.aspx

OVR Employment Service:

  1. https://www.dli.pa.gov/Individuals/Disability-Services/ovr/Pages/Individualized-Employment-Services.aspx
  2. Vocational Rehabilitation Home (pa.gov)

What is WIPA?

To amend the Social Security Act to expand the availability of health care coverage for working individuals with disabilities, to establish a Ticket to Work and Self-Sufficiency Program in the Social Security Administration to provide such individuals with meaningful opportunities to work, and for other purposes. 

  • provide in-depth counseling about benefits and the effect of work on those benefits;
  • conduct outreach efforts to beneficiaries of SSI and SSDI (and their families) who are potentially eligible to participate in federal or state Work Incentives programs; and
  • work in cooperation with federal, state and private agencies and nonprofit organizations that serve SSI and SSDI beneficiaries with disabilities.

WIPA Hotline1-866-968-7842 Monday through Friday from 8 a.m. – 8 p.m. ET.

  1. https://www.ssa.gov/work/WIPA.html
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