South East Needs Your Cooperation with Eligibility and Funding Requirements

Hello Everyone,  This is Jerry Peters from the South East Consortium and this blog hopefully will be a new and effective way to communicate with our families.  I hope to share with you some of the exciting things we're doing and solicit your suggestions on were we need to go.  I want to start with our biggest concern and try to clear up confusion surrounding OPWDD non-waiver eligibility, Medicaid Waiver and our relationships with Medicaid Service Cordinators.

As you know New York State converted our funding about 5 years ago to included Medicaid.  They also tightened regulations on reimbursement for non-waiver people.  With that came a hurricane of paperwork and compliance issues, most of which we are still learning about.  This entire process of how to successfully help with making people eligible for services so we can request reimbursement for services has been essentially self-taught and "hit and miss."  The eligibility process and subsequent Front Door process is extremely slow and can be confusing, but I feel we now have a handle on it.  A good example is our summer camp program this past summer.  We enrolled 10 kids who did not have eligibility under the assumption a determination could be made within 3-4 months.  This was also done because we didn't want 10 kids sitting at home during the summer with nothing to do.  Not only did we not get this kids through the process by the end of camp, for many reasons, most of them are still "not determined".  Consequently South East was not able to "bill" New York State for providing the services.

In regards to Medicaid Waiver.  The Office of the Medicaid General (OMIG) requires certainly documentation/authorization be complete and in our files in order to properly "bill" Medicaid for services provided.  If its not there it is considered fraud.  Most of this we did not know until very recently so we have been scrambling to get the paperwork up-to-date.  This is critical because if Medicaid performs an audit on South East (and they will) we stand to receive incredibly harsh penalties which would threaten our very existence.  When Medicaid performs an audit if it finds one error with one person there is an assumption that the entire sampling is wrong.  There's a cute word called "extrapolation" and you throw that into the mix it's a real problem.

So that's why we need the help from families to work with Medicaid Service Coordinators to get this paperwork to us.  Most MSC's are very cooperative and great to work with.  Some not!  Sometimes in the past we have requested information and had no response.  Sometimes we are just ignored.  That can't be tolerated and that's why I made the decision that parents need to help us get what we need or we will temporarily "block" registration.  I cannot place this agency at risk because we do not have copies of paperwork that should be readily available.

That said, we look to the future and the possibility of being of service to you.

An Important Message to our Families and Participants Residing at Home

For the past several months South East has been attempting to better understand and properly implement procedural regulations and related paperwork to obtain reimbursement from New York State and Medicaid. South East is deemed by New York State and Medicaid as a “Respite Service Provider” and this designation has thrown South East into a complex bureaucratic environment. Consequently, South East has encountered problems and concerns it has never experienced before.

Six years ago, New York State converted OPWDD’s financial support to include Medicaid. No one envisioned that this would alter our agency infrastructure and critically strain our limited resources, but it has. These new structures pose real threats. Program staff are consumed with enormous amounts of paperwork which takes away from providing programs and services; various obstacles regarding billing for reimbursement could result in denial of claims which would result in non-payment; there is always the disturbing possibility that harsh penalties could be levied if procedural applications are either misinterpreted or done improperly and, lastly, New York State has a “cap” on its fund allocation to South East which will affect any program expansion and increase in new enrollments.

While South East appreciates the governmental financial support it receives from New York State, we have found this new way of doing business to be stressful, overwhelming and confusing for everyone. In many cases South East provides valuable services to individuals in need, but regulations either delay any reimbursement or deny it altogether. Some would perceive this as New York State realizing a goal of saving money; South East sadly perceives this as denying services because there is no way to pay for them.

So, as we move forward, South East has imposed the following conditions related to enrollment effective this fall:

• If you have not initiated the OPWDD eligibility process to determine eligibility status you will not be permitted to enroll. It’s a tedious, but necessary process and we can help you. 
• If you are recognized as pursuing OPWDD eligibility or Medicaid Waiver (or Self Direction) you may enroll as a Transitional Participant. 
• If you are recognized as being confirmed for OPWDD eligibility and completed the “Front Door” process you must provide South East with all related paperwork before being dropped from Transitional Participant status. 
• If you are recognized as ineligible for OPWDD services meaning South East cannot claim reimbursement from New York State then you may enroll as a Direct Cost Participant if you reside in the South East Consortium catchment area. 
• If you are on Medicaid Waiver or pursuing Medicaid Waiver (also Self-Direction) you will not be permitted to enroll in South East programs until South East is properly listed as a service provider on your ISP and all related documentation is completed. It is the responsibility of parents to ensure your Medicaid Service Coordinator properly lists South East as a service provider and ensures South East receives a copy of the ISP semi-annually. 

Although these conditions may seem drastic and somewhat punitive, they are necessary for South East to stabilize itself to move forward. Be assured our most valued partners are our participants and their families. We will continue to do our best to support you. Please contact our office at (914) 698-5232 for assistance. Kathleen Peters-Durrigan, our Program Eligibility Coordinator, is on staff to help guide you through this process.

Jerry Peters