Guide to Estimate Waiver Revenues

May 21, 2016

As we still anticipate that the redesign of the three ID/D Waivers will be approved by CMS and we will be able to implement in early to mid-July, providers are becoming increasingly concerned that they do not have to tools to estimate revenue for the services to be reimbursed based on the SIS Level/Tier system.

The key services using this method to calculate the rate which will begin this summer are Group Home Residential, Group Day (currently center-based day) and Community Engagement (currently community-based day). Sponsored Residential is not affected until January 2017.

Some information has been shared about the service definitions and requirements, and provider qualifications; it has been a challenge for providers to gather the information needed to calculate the potential revenue for budgeting purposes.

DBHDS has responded to our request for some information (see memo from DBHDS), it is probably more efficient for providers to gather their own data and do their own calculations. DMAS is also working with us to add the assigned “Tier” for each individual to the Eligibility File on the Web-portal and may be able to produce a report for each provider with the necessary information.

We do know that the Group Home Residential procedure code will be “modified” to reflect the licensed capacity of the home and that the individual’s level of need (Reimbursement Tier) will be entered into the vaMMIS system to serve as an “edit” to set the rate.

Contents:
 Memo from DBHDS to CSB ID Directors
 DBHDS Slide with “formula” to calculate the SIS Level (without the Tier indicated)
 Final Rates – March 22, 2016
 Sample SIS Report for “John Allen” – selected pages
 Sample Tier Calculation Form (using data from John Allen)
 Worksheets that can be adapted for provider use!

The Guide is available here and is on the Member’s Waiver Redesign page from future reference by VNPP Members