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Individual Budgets, SIS Scores, and Services

Cardinal Innovations Healthcare — octubre 2, 2018 — 4 min de lectura

Making sense of the system and recent updates from the state.

1. Who has an individual budget?
  • Members receiving services through the NC Innovations Waiver.
2. What is the goal of the Individual Budgeting Tool (IBT)?
  • Statewide planning tool designed and implemented by DHHS in November 2016.
  • Used to help members make decisions about the services and supports they need to achieve their life goals.
  • Offers flexible ways to change services as needed, depending on life changes.
  • Creates some equality in service funding throughout the state.
3. How are services determined?
  • Members unique needs and goals come first.
  • Services are considered and developed one person at a time.
  • Your care coordinator helps you develop your care plan and consider the services and supports that could be the most helpful to you.
  • You are entitled to receive all services that are medically necessary and included in the NC Innovations Waiver, regardless of your individual budget.
  • Utilization Management receives the Individual Support Plan (ISP) developed by you and your team and reviews it to be sure there are no concerns with your health and safety, and to be sure it does not go against any NC Innovations Waiver rules.
  • Utilization Management also reviews other clinical documentation that you or your team may provide and uses that to determine what services you are authorized to receive, and how often. The SIS® is just one tool that may inform your individual plan.
  • Utilization Management also uses and often requests tools such as behavioral logs, medical records and other assessments to help them understand your unique needs.
  • Medical Necessity is the most important determination of service need.
4. When I need more than my individual budget, what do I do?
  • If you believe you need services over what has been originally approved, or if your needs have changed, contact your care coordinator, who can help you submit a request. You can request new services at any time, or appeal a decision if any services you request are denied.
  • Your care coordinator will provide information and education regarding waiver requirements as well as items that could potentially help the UM reviewer reach a decision. However, they will ultimately submit whatever service array you decide, regardless of the amount of your individual budget.
  • You do not have to request an Intensive Review in order to obtain services over your budget. We may contact you for more information to better understand your needs.
  • Your ISP is valid for one year. Your care coordinator will help you develop a new plan each year, prior to the expiration of your current plan.
  • If Cardinal Innovations decides to change your services during your plan year without you requesting the change, you can appeal and continue the services you had during the appeal process until a final decision is reached.
5. Why is the state sending out letters about IBT?
  • DHHS and Cardinal Innovations want you to know your rights.
  • The annual planning and budgeting process can be confusing, and the letter is written to be sure you understand how IBT should be used.
  • We want to ensure your ability to receive the services and supports you need to live independently in your community.
  • We want you to have choice and flexibility in the services you receive, based on your current needs and goals.
6. Where can I learn more?
  • Cardinal Innovations will collaborate with you, your family and your provider to ensure that you have the services you need.
  • You care coordinator is your planning partner. Call him/her if your individual needs change. You can also contact your Community Navigator for help in finding additional community resources.
  • In addition to contacting your care coordinator, you can call the Cardinal Innovations 24/7 Access line at 1-800-939-5911 or DHHS/Medicaid at 1-919-855-4290.
  • Visit http://bit.ly/2y2NdUH to find additional information and resources to help you and your family.
 

What does Medical Necessity mean?

"Medically Necessary” means that a service or support is absolutely required in order for there to be improvement to a condition or skill, or to prevent a condition or skill from getting worse. It is not based on preference, but is based on what is absolutely needed to ensure the best possible health for the member.

 

What is the Supports Intensity Scale (SIS®)?

  • A standardized assessment tool designed to measure your support needs.
  • The SIS® includes questions about extra support you may require for medical and/or behavioral reasons, as well as supports you may require in your home and community, to allow you to live the life of your choice.
 

What is Intensive Review?

Intensive Review is conducted by a group of IDD professionals who look at the supporting clinical information submitted by the planning team. This review helps us determine if your needs can or cannot be met within your assigned IBT Category. You are not required to request Intensive Review to receive services above your IBT level.

Utilization Management uses Intensive Review when new or additional services are requested to determine what supports you may need and make additional recommendations that help support you in the community.


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