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Scott Chad D
Hill Sharon K; Maggie Klein; Bowlin Royce A; SWEET Elaine; Knight Kelly C
CORBIN Nicole; ROSS Donald; Daniels Jason H; Forsman Lea; MITCHELL MICK J; Oyster Michael W; Busek
Rhonda J
FW: Understand that recently KePRO issued 300 denials to clients that no longer qualified for adult residential
services - Who is triaging and planning these clients" transition to other settings?
Thursday, October 26, 2017 3:42:00 PM
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Thank you for the good questions Sharon, some answers below as well as an
opportunity to consider the connection between the residential rate work and the
Kepro determinations.
Q: Who is triaging and planning for these clients' transition to other settings?
For 1915(i) HCBS eligible members and OHA funded members, Kepro, as the IQA for
OHA conducts a needs assessment and develops a person centered plan in
accordance with CMS guidelines for each person determined ready to transition to a
lower level of care. That plan is provided to the entity contractually responsible for
coordinating that person’s care. OHA has intergovernmental agreements (IGA) and
financial assistance agreements (CFAA) with each Community Mental Health
Program and contracts with “Choice model” providers to provide transition
management and planning for residential members determined to no longer need
services in a licensed setting. CMHP’s, providers of service and Choice providers are
engaged in the work Kepro is performing on behalf of OHA. In addition, Kepro is
contracted to provide conflict free case management to monitor implementation of
each person center pan.
OHA has not yet pursued development or implemented an adequate home and
community based service delivery system. As a result, members may not have
access to all community based transition options that can be made available to them
and the services and associated outcomes OHA is purchasing from Kepro, the
CMHP’s and the Choice contractors may not be fully supported because of this.
Q: Who is working with counties for these transitions?
OHA, via our contracts with Choice model providers (CMHP, CCO, MHO) provides
funding and support to the work required by each CMHP through statute and contract.
Kepro is also a resource for CMHP and Choice contractors.
Q: Is OHA Communications involved since this action may risk a client
decompensating from disruption of residential services?
When you consider the following, that’s a strong assumption and not likely something
OHA would put forth into a communication outside of established Medicaid member
and provider notice requirements. The outcomes Kepro is achieving are the result of
years of planning by OHA based on Miranda B / Olmstead policy, CMS HCBS
requirements and agreement with the USDOJ during development of the Oregon
Performance Plan.
• OHA has contracted with a URAC accredited EQRO/IQA. Kepro utilizes
McKesson / InterQual criteria to support medical appropriateness
determinations and perform care planning and complex care management.
InterQual is the industry standard for evidence-based clinical decision support
and was selected to provide assurance Kepro makes accurate decisions about
our members care.
• Each member receives a notice of action and has Medicaid appellate rights to

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 ensure health, safety, appropriateness and legality of decisions made by OHA
or its designee.
• OHA is following CMS approved HCBS eligibility criteria and assuring service
and support decisions are made by an agent that is independent, qualified and
free of conflict.
• Per requirement in state plan, Oregon administrative rule and contractual
requirements with CMHP, Choice and Kepro contractors, each member
receives a needs assessment, person centered plan and conflict free case
management to ensure each person receives the services and supports
necessary to treat their condition in the setting of their choice.
OHA has issued notices of action to several hundred members indicating they are
able to transition to a lower level of care. All notices have been sent as of Wednesday
of this week and included notices to the CMHP, provider and member. In addition,
OHA will be providing the Choice contractors with information on each member
determined ready to transition based on Choice contractor assignment. This will go
out by Monday.
As our contractors and partners work with our members on transition, OHA should be
prepared to respond to other questions that may be posed by the community as it
may become apparent the OHA fee-for-service Medicaid behavioral health system
has not kept pace with the IQA and Choice contracts and outcomes. Some likely
questions OHA communications may want to be prepared to answer are;
• Why is OHA continuing to remain focused on a financing licensed residential
treatment for the non-rehabilitative needs of this member population given the
EQRO determinations.
• Why is OHA not pursuing Medicaid fee-for-service payment policy and planning
that aligns with member choice, USDOJ requirements, CMS HCBS rules and
evidence based practices.
• What is the reason OHA isn’t pursing an operational plan to develop financing
and rate strategies for the HCBS services allowed by 1915(i) HCBS.
• Why is OHA allocating resources to ensure individuals receive services in the
most integrated community setting at the same time OHA fee-for-service is not
operationalizing or funding integrated community settings.
Q: Who in other programs needs to be advised of these clients and the denial
of services (e.g. Contracts).
The provider clinical support unit responsible for management of the behavioral
health fee for service benefit and the Kepro contract has been working in tandem with
the adult behavioral health services unit, OHA behavioral health financing, the OHA
licensing and certification unit, OHA hearings and appeals unit, the Oregon state
hospital and DHS APD and ODDS divisions. All programs areas have been fully
engaged in this process, meet regularly and each have a role in management of our
fee for service behavioral health benefit and the work being performed to achieve the
Oregon performance plan outcomes.
Q: From the Adult Residential Rate Standardization project perspective, we are
examining the processes in place and those needing to be created for clients
as we incentivize transition to the most integrated setting.
Can you share your transition and triage planning?
Related to our work with the residential rate standardization, I think these pending

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 transitions highlight some of the continued misalignment between OHA Medicaid
policy and the outcomes required of Oregon by the USDOJ and CMS.
The IQA portion of the Kepro contract represents the third time an OHA contracted
EQRO has made determination that a majority of individuals receiving services in
OHA licensed settings do not need the level or care provided or the services offered
in a licensed setting. Despite these independent determinations, OHA continues to
pursue regressive policy to ensure provider fiscal requests are responded to over
progressive policy in consideration of administering a Medicaid benefit based on the
assessed needs of our members and their right to receive services in the most
integrated community setting possible.
Previous policy work resulted in a draft 1915(i) HCBS SPA and a benefit and code set
appropriate to support the member’s transitions currently being facilitated. I’m
including the service description and code set below as an example of the types of
services OHA could be directing efforts toward developing in place of the current rate
goals.

Services:
Habilitation Services
Habilitation: Habilitation services are medically appropriate
health services and devices provided to individuals or groups of
individuals that help a person keep, learn, or improve skills and
functioning for daily living. Habilitation Services include;
Facility Based Habilitation (FBH): Services provided in an OHAlicensed setting that support a person’s ability to learn
and/or maintain activities skills to manage activities of daily
living (ADL), instrumental activities of daily living (IADL)
and psychosocial skills. Examples include skills training and
support to independently manage medication, budget, plan and
prepare meals, manage health conditions, maintain personal
hygiene, clean and maintain a residence, maintain compliance
with court or legal requirements, plan and participate in
social, recreational or community activities. Provider approved
to provide facility based habilitation include OHA licensed
Secure Residential Treatment Homes or Facilities, Residential
Treatment Homes or Facilities.
H0018 Behavioral Health; long term residential (non-medical, nonacute care in a residential treatment program), without room and
board, per diem.
Home Based Habilitation (HBH): Services provided in the persons
home, residence or other non-licensed community setting
including supportive and supported housing programs that
support a person’s ability to learn or maintain activities of
daily living (ADL) and instrumental activities of daily living
(IADL) skills. Examples include, support to independently
manage medications, budget, plan and prepare meals, manage
health conditions, maintain personal hygiene, clean and
maintain a residence, maintain compliance with court or legal
requirements and plan and participate in social, recreational
or community activities. Approved providers for HBH include OHA
certified or independently licensed QMHP, QMHA, Peer Support

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 Specialist, Habilitation Specialist, Supported Housing Program,
Supportive Housing Program, Mental Health Student Intern.
S5135 Companion Care, adult (e.g ADl/IADL); per 15 minutes
S5136 Companion Care, adult (e.g ADl/IADL); per diem
H0043 Supported Housing Per-diem
H0044 Supported Housing Per-Month
Day Habilitation (DH): Services provided to a person or group
of people in an outpatient or community program setting that
support a person to develop or maintain community survival and
inclusion skills. Examples of services include; volunteer
activities, social skills training, communication skills
development, functional living activities, symptom and behavior
management. Approved providers of DH include OHA certified
Adult Habilitation Day Treatment Program.
H2012 Behavioral Health Day Treatment; per hour
Live-in Habilitation Provider payments: Payments made to a
provider meeting the requirements for habilitation specialist
will be provided for services provided to eligible recipients
to support a live-in habilitation specialist when such an
arrangements is indicated as necessary to meet the service and
support objectives identified in the person centered assessment
and included in the person centered plan. Live in habilitation
services are available in home and community based settings
that are not licensed or considered supported housing or
supportive housing.
S5123 Attendant Care Services; per diem
Home Based Respite Habilitation Provider: Payments made to a
provider meeting the requirements for habilitation specialist
will be provided for service provided to eligible recipients
receiving live-in habilitation services for a respite, relief
or an additional habilitation specialist as needed and
recommended by the EQRO in accordance with the person centered
plan. Home based respite habilitation providers are available
in home and community based settings that are not licensed or
considered supported housing or supportive housing.
S5150 Unskilled respite care, not hospice, per 15 minutes
S5151 Unskilled respite care, not hospice, per diem
Psychosocial Rehabilitation
Psychosocial Rehabilitation Services: Psychosocial Rehabilitation
services are clinical and psychosocial services that are
collaborative, person directed, individualized and evidence based
which focus on helping individuals to develop skills to increase
their capacity to be successful and satisfied in the living,
working, learning and social environments of their choice.
Psychosocial Rehabilitation (PSR): Examples of services
include; services to support the individual to independently
manage symptoms that pose a risk to self or others, symptoms
related to impulse control, symptoms that result in
disorganized and delusional thoughts, symptoms of emotional
excess, communication deficits, support to manage co-occurring

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 or co-morbid conditions, clinic services directed at reducing
the functional deficits experience by a person as a result of
having a behavioral health condition. Approved providers for
PSR include OHA certified or independently licensed QMHP, QMHA,
Peer Support Specialist, Mental Health Student Intern, Secure
Residential Treatment Home or Facility and Residential
Treatment Home or Facility.
H2017 Psychosocial Rehabilitation 15-minutes
H2018 Psychosocial Rehabilitation Per-diem
Home and Community Based Support Services
Home and Community Based Support Services (HCBSS): Services
designed and provided to assist a person to maintain and remain in
non-licensed home and community based settings and reduce the risk
or eliminate the need to move to a less independent setting.
Home and Community Based Support Services include;
HCBS Adult Foster Care: Adult Foster Care provides a time
limited period of care in a home licensed by OHA that provides
supervision for adults assessed as needing up to 24-hour
assistance with; daily personal care; daily recreational or
vocational activities; transportation to medical appointments,
shopping, preparing and serving meals; dispensing medications
and providing social interaction. Approved providers of HCBS
Adult Foster Care include OHA and DHS licensed Adult Foster
Care Homes.
S5140 Adult Foster Care Per-diem
S5141 Adult Foster Care Per-Month
HCBS Home Health Aide: Services provided by a provider meeting
the requirements of habilitation specialist that are directed
at supporting co-morbid conditions that put a person at risk of
moving to a less independent level of care. Home Health Aide
services must be assessed and recommended by the EQRO.
T1021 Home Health Aide or certified nurse assistant, per visit.
HCBS Home Delivered Meals: A service of having meals delivered
to a person up to three times daily to support that person to
maintain health and reduce risk of moving to a less independent
setting. Home Delivered Meal services must be assessed and
recommended by the EQRO.
S5170 Home Delivered Meals, including preparation; per meal
Medication Reminder: A service provided to a person to remind
them to take prescribed medications as ordered.
S5185 Medication Reminder Service, non-face to face, per month
HCBS Minor Home Modifications: Services or funding that provide
minor one time modifications to a home for the purpose of
supporting a person to maintain residence in a non-licensed
home and community based setting. Home Modification Services
must be assessed and recommended by the EQRO.
S5165 Home Modifications; per service
HCBS Transportation Services (non-duplicative of state plan
medical transportation): Services to transport a person to nonmedical appointments to support that person to maintain

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 residence in the most integrated community setting that is not
licensed.
T2003 Non –emergency transportation; encounter/trip
Health Club Membership: Payment to maintain an annual health
club membership for the purpose of maintaining health, managing
symptoms and reduce risk of moving to a less independent
setting.
S9970 Health Club Membership, annual
Laundry Services
S5175 Laundry service, external, professional; per order
Provider Escort: Service to support a provider to visit a high
risk area or high risk situation for the purpose of
facilitating services and supports to the recipient.
S9381 Delivery of Service to high risk areas requiring escort or
extra protection; per visit.
*Not included in SPA, but to be amended and included on fee
schedule.
Secure Residential Treatment
Provided in a licensed secure residential treatment facility.
Revenue code 1001 BH/RES TRTMT/PSYCHIATRIC
From: Hill Sharon K
Sent: Monday, October 23, 2017 4:41 PM
To: Scott Chad D ; Maggie Klein ; Bowlin Royce A ; SWEET Elaine ; Knight Kelly C
Cc: CORBIN Nicole ; ROSS Donald ; Daniels Jason H ; Forsman Lea ; MITCHELL MICK J
Subject: Understand that recently KePRO issued 300 denials to clients that no longer qualified for
adult residential services - Who is triaging and planning these clients' transition to other settings?
HelloUnderstand that recently KePRO issued 300 denials to clients that no longer qualify for adult
residential services, with 40 associated with PSRB that Elaine is addressing..
• Who is triaging and planning for these clients' transition to other settings?
• Who is working with counties for these transitions?
• Is OHA Communications involved since this action may risk a client decompensating from
disruption of residential services?
• Who in other programs needs to be advised of these clients and the denial of services (e.g.
Contracts)
From the Adult Residential Rate Standardization project perspective, we are examining the
processes in place and those needing to be created for clients as we incentivize transition to the
most integrated setting.
• Can you share your transition and triage planning?
Thank you
-Sharon
Sharon K Hill, MPA-HA; OPMA
Project Manager
OREGON HEALTH AUTHORITY
Health Systems Division
Portfolio and Business Office
Sharon.K.Hill@state.or.us

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 Desk: 503-945-6957
http://www.oregon.gov/OHA

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