IRIS Policy Manual: Work Instructions

1 Department of Health Services Division of Medicaid Services P-00708A (10/2021) IRIS Policy Manual: Work Instructions State of Wisconsin Page 1 of 133 IRIS Policy Manual: Work Instructions Table of Contents Chapter 2: Eligibility .. 9 Medicaid Cost Share Payments .. 9 Business Rules .. 9 Cost Share Payments .. 9 Monitoring .. 10 Supplemental Security Income Exceptional (SSI-E) .. 11 Business Rules .. 11 Supplemental Security Income Exceptional (SSI-E) .. 12 Monitoring .. 13 Chapter 3: Referral, Welcome, Orientation and Enrollment .. 14 IRIS Consultant Biography Page .. 14 Business Rules .. 14 Education .. 15 Completion of IRIS Consultant Biography (F-01486) .. 15 Data Collection, Reporting, and Monitoring .. 15 Transfers between IRIS Consultant Agency Providers .. 16 Business Rules .. 16 Transferring IRIS Consultant Agency (ICA) Providers .. 18 Monitoring .. 19 Youth in Transition Referral Special Considerations .. 20 Business Rules.

2 20 Youth in Transition Referral .. 20 Department of Health Services Division of Medicaid Services P-00708A (10/2021) IRIS Policy Manual: Work Instructions State of Wisconsin Return to TOC Page 2 of 133 Denial of Enrollment .. 22 Business Rules .. 22 Denial of Enrollment Process .. 23 Data Collection, Reporting, and Monitoring .. 24 Withdrawal from Referral Process .. 25 Business Rules .. 25 Agency-Initiated Referral Withdrawal Process .. 25 Participant-Initiated Referral Withdrawal Process .. 26 Monitoring .. 26 Participant Handbook and Participant Education Manual .. 27 Business Rules .. 27 Requesting Printed Copies of Handbook and Manual .. 27 Initial Enrollment and Review of Participant Education Manual .. 27 Annual Review of Participant Education Manual .. 28 Record Review Remediation of Participant Education Manual Chapter(s) .. 29 Chapter 4: Health and Welfare .. 30 40-Hour Health and Safety Assurance .. 30 Business Rules .. 30 Plan Development.

3 30 Payments .. 31 Exceptions .. 32 Self-Directed Personal Care (SDPC) and Exceptions .. 33 Continuous and Ongoing Exception Criteria .. 34 Short-Term Planned or Unplanned Exception Criteria .. 34 Education .. 36 Incorporating the 40-hour Health and Safety Assurance into the Planning Process .. 36 Submitting Timesheets .. 36 How FEAs will apply the 40-hour Health and Safety Assurance to Timesheets Exceeding the 40-Hour Limit .. 36 Requesting Additional Hours .. 37 Data Collection, Reporting, and Monitoring .. 37 Assessing Risk .. 38 Department of Health Services Division of Medicaid Services P-00708A (10/2021) IRIS Policy Manual: Work Instructions State of Wisconsin Return to TOC Page 3 of 133 Business Rules .. 38 Identifying Risk .. 39 Addressing Risk in the ISSP .. 40 Allowing for Informed Decision-Making about Risk .. 40 Monitoring .. 41 Restrictive Measures .. 42 Business Rules .. 42 Development of Restrictive Measures Application .. 44 Restrictive Measures Application Approval Process.

4 45 Communication of Review Panel s Decision and Implementation of Restrictive Measures .. 45 ICA Monitoring of Restrictive Measures .. 46 DHS Monitoring of Restrictive Measures Processes .. 46 Critical Incident Reporting .. 48 Business Rules .. 48 Incident Reporting and Follow-Up Process: .. 49 Referrals to Adult Protective Services (APS) .. 50 Referrals to Division of Quality Assurance (DQA) .. 51 Referrals to 1-2 Bed AFH Certifying Unit at LSS .. 52 CIR SharePoint Review Process .. 52 Remediation Assurance (RAP) Process .. 53 Data Analysis and Reporting .. 54 Monitoring .. 54 Emergency Backup Plan .. 56 Business Rules .. 56 Education .. 57 Completing the Emergency Backup Plan .. 57 Changing the Emergency Backup Plan .. 57 Completing the Annual Emergency Backup Plan Review .. 58 Data Collection, Reporting, and Monitoring .. 58 Chapter 5: Person-Centered Planning .. 59 Meaningful Individual Support and Service Plan Development .. 59 Department of Health Services Division of Medicaid Services P-00708A (10/2021) IRIS Policy Manual: Work Instructions State of Wisconsin Return to TOC Page 4 of 133 Business Rules.

5 59 Identifying Long-Term Care Outcomes .. 60 Support/Services/Goods Prioritization .. 61 WISITS .. 61 Monitoring .. 62 Budget Amendment Process .. 62 Business Rules .. 62 Identifying the Need for a Budget Amendment .. 67 Budget Amendment Submission 67 Pre-Review 68 DHS Review .. 68 Budget Amendment Annual Verification .. 69 Independent Review Process (Does not apply to BAAVs) .. 69 Appeals Process .. 70 Monitoring Process .. 71 Data and Quality Management Process .. 71 One-Time Expense Requests .. 71 Business Rules .. 71 Identifying Needs for One-Time Expense .. 74 One-Time Expense Submission Process .. 74 Pre-Review 75 DHS Review .. 76 Independent Review Process .. 77 Appeals Process .. 78 Monitoring Process .. 78 Data and Quality Management Process .. 78 Project SEARCH .. 80 Business Rules .. 80 Identification, Outreach & Assessment .. 80 Applying for Project SEARCH .. 81 Paying for Project SEARCH .. 82 Department of Health Services Division of Medicaid Services P-00708A (10/2021) IRIS Policy Manual: Work Instructions State of Wisconsin Return to TOC Page 5 of 133 After Completion of Project SEARCH Program.

6 83 Chapter 6: Participant Choice of Qualified Providers .. 84 Participant Employer and Participant-Hired Worker Setup Packets .. 84 Business Rules .. 84 FEA Set-up of Participant Employer and PHWs .. 85 Monitoring .. 86 Participant-Hired Worker Background Checks .. 87 Business Rules .. 87 Identification of Applicant and Completion of Paperwork .. 89 Completion of Background Checks for New Hires .. 89 Completion of Scheduled Background Checks for Ongoing Participant-Hired Workers .. 90 Completion of Ad-Hoc Background Checks for Ongoing Participant-Hired Workers .. 90 DHS Appeal Process for Participant-Hired Workers .. 91 Monitoring .. 92 APPENDIX .. 93 Transferring/Changing Fiscal Employer Agent Providers .. 96 Business Rules .. 96 Chapter 7: Disenrollments .. 97 Involuntary Disenrollments .. 97 Business Rules .. 97 Education .. 100 Requesting DHS Approval for Involuntary disenrollment for Reasons Unrelated to Cost Share or Eligibility .. 100 Involuntary disenrollment : Loss of Financial Eligibility.

7 100 Involuntary disenrollment : Loss of Functional Eligibility .. 101 Involuntary disenrollment : Failure to Pay Cost Share .. 101 Data Collection, Reporting, and Monitoring .. 101 Chapter 10: Program Integrity .. 103 Fraud Allegation Review and Assessment (FARA).. 103 Business Rules .. 103 Identifying and Reporting Process .. 106 Fraud Allegation Review and Assessment Process .. 107 Department of Health Services Division of Medicaid Services P-00708A (10/2021) IRIS Policy Manual: Work Instructions State of Wisconsin Return to TOC Page 6 of 133 Mitigation of Fraud/Abuse .. 107 Referral to the Department of Health Services .. 108 Referral to the Office of the Inspector General/Department of Justice .. 109 Referral to Department of Justice .. 109 Pursuing Recoupment .. 110 Monitoring .. 110 Data/Narrative Reporting .. 111 Conflict of Interest Participant .. 112 Business Rules .. 112 Identification and Reporting of a Conflict of Interest .. 112 Investigation 113 Resolution Process.

8 113 Implementation Process .. 113 Monitoring .. 113 Conflict of Interest Provider .. 115 Business Rules .. 115 Completion of the Conflict of Interest Disclosure 116 Conflict of Interest Mitigation Process .. 116 Monitoring .. 116 IRIS Self-Directed Personal Care Disclosure Statement .. 116 Business Rules .. 116 Form Implementation .. 117 Monitoring .. 117 Record Review Process .. 117 Business Rules .. 117 Record Review Sample .. 119 Record Review Process .. 119 Remediation Process .. 119 Remediation Validation .. 119 DHS IRIS Record Review SharePoint Case Closure .. 120 Data Collection, Reporting, and Monitoring .. 120 Department of Health Services Division of Medicaid Services P-00708A (10/2021) IRIS Policy Manual: Work Instructions State of Wisconsin Return to TOC Page 7 of 133 Quality Management Plans .. 121 Business Rules .. 121 Quality Management Plan Development .. 121 Monitoring Process .. 121 Modifying/Adding/Discontinuing Quality Management Strategies.

9 122 Chapter 11: Appeals and Grievances .. 123 Appeals .. 123 Business Rules .. 123 Notice of Action .. 123 Notification of Appeal .. 124 Concurrent Review .. 124 DHS and ICA Negotiations .. 125 Hearing Process .. 125 Post-Hearing Activities .. 126 Appeals Process .. 126 Monitoring Process .. 126 Data and Quality Management Process .. 126 Record Requests .. 127 Business Rules .. 127 Making the Request for Records .. 128 When Records are Requested from the DHS Office of IRIS Management (OIM) .. 128 When Records are Requested from the ICA, FEA, or IRIS SDPC Oversight Agency .. 128 Chapter 13: IRIS Self-Directed Personal Care (SDPC) .. 129 IRIS SDPC Forms and Documentation .. 129 Business Rules .. 129 Education .. 130 Completion of Forms .. 130 Completion of Case Notes .. 130 Data Collection, Reporting, and Monitoring .. 131 IRIS SDPC: Oversight Home Visits .. 132 Business Rules .. 132 Department of Health Services Division of Medicaid Services P-00708A (10/2021) IRIS Policy Manual: Work Instructions State of Wisconsin Return to TOC Page 8 of 133 Education.

10 132 Requesting and Obtaining Fewer IRIS SDPC Nurse Oversight Visits .. 132 Data Collection, Reporting, and Monitoring .. 133 Department of Health Services Division of Medicaid Services P-00708A (10/2021) IRIS Policy Manual: Work Instructions State of Wisconsin Return to TOC Page 9 of 133 Chapter 2: Eligibility Medicaid Cost Share Payments Business Rules 1. Medicaid financial eligibility is one of the requirements that must be met to be considered eligible for IRIS. 2. Cost share is the amount of a participant s income which must be paid, each month, to maintain Medicaid financial eligibility. 3. An Income Maintenance worker calculates the cost share amount as part of initial and ongoing Medicaid financial eligibility. 4. Medicaid rules require participants to report financial status changes to the County Income Maintenance Unit within ten (10) calendar days. Changes in a person s financial status may result in a new monthly cost share amount.