QUEST Integration – Long-Term Services and Supports (LTSS)

Original Effective Date:

01/01/2015

Current Effective Date:

01/01/2015

HMSA QUEST Integration covers the following services to members who meet appropriate level of care. Long-term services and supports (LTSS) are divided into two categories:

Home and Community Based Services (HCBS)

• Adult day care
  • Regular supportive care provided to four or more disabled adult participants.
  • Includes include observation and supervision by center staff, coordination of behavioral, medical and social plans, and implementation of the instructions in the member’s service plan.
  • Therapeutic, social, educational, recreational, and other activities are also provided.
• Adult day health
  • An organized day program of therapeutic, social, and health services for adults with physical or mental impairments, or both.
  • Purpose is to restore or maintain a person’s capacity for remaining in the community.
  • Other services include emergency care, dietetic services, occupational therapy, physical therapy, physician services pharmaceutical services, psychiatric or psychological services, recreational and social activities, social services, speech-language pathology, and transportation.
• Assisted living services
  • Personal care and supportive care services (homemaker, chore, personal care services, meal preparation) that are furnished to members who reside in an assisted living facility.
  • Members must be receiving community care management agency (CMMA) services.
• Community care management agency (CCMA) services
  • Provided to members living in Community Care Foster Family Homes (CCFFH), Expanded Adult Residential Care Homes (E-ARCHs), assisted living facilities (ALFs), and other community settings.
  • Includes continuous and ongoing nurse delegation to the caregiver, including interaction with the caregiver on adverse effects and/or changes in member condition, and being accessible to the caregiver 24 hours a day, 7 days a week.
  • CCMAs conduct initial and ongoing assessments for recommendations for services, supplies, and equipment needs of the member, development of service plan in coordination with the member/member representative, ongoing face-to-face monitoring and implementation of the service plan
  • CCMAs communicate with the member’s physician(s) regarding member’s needs, changes in medication and treatment orders.
  • CCMAs work with families regarding services needs of the member and serve as an advocate for the member.
• Counseling and training
  • Includes member care training for members, family, and caregivers regarding the nature of the disease and the disease process
  • Provided to members, families/caregivers, and professional and paraprofessional caregivers on behalf of the member, individually or in groups, by a qualified health professional, at the member’s residence or alternate site.
• Environmental accessibility adaptations
  • Physical adaptations to the member’s home which ensure the health, welfare and safety of the individual or which enable the individual to function independently in the home rather than be institutionalized.
  • May include ramps, grab bars, modifications to bathroom facilities and doorways, special electric or plumbing systems for medical equipment, window air conditioners when necessary for the health and safety of the member.
  • Excludes modifications of general utility rather than direct medical or remedial benefit to the member, such as carpeting, roof repair, central air conditioning, adaptations that add to the square footage of the home
• Home delivered meals
  • Nutritionally sound meals delivered to the member’s residence (excludes residential or institutional settings) to members who cannot prepare nutritionally sound meals without assistance and who would otherwise be institutionalized
• Home maintenance
  • Services to maintain a safe, clean and sanitary environment for a member who cannot perform cleaning and minor repairs without assistance, and who would otherwise be institutionalized.
  • Includes heavy duty cleaning to bring a home up to acceptable standards of cleanliness at the inception of service to a member.
  • Minor repairs to stoves, refrigerators and water heaters
  • Fumigation or extermination services
• Moving assistance
  • Provided for members who must relocate due to deterioration of a home, eviction, loss of affordability, inability of the home to accommodate mobility needs or support medical equipment.
  • Use of family, landlord, community and third party resources that can provide this service without charge will be utilized whenever possible.
• Non-medical transportation
  • Enables member to gain access to community services, activities, and resources specified by the service plan when not included in the HCBS service being accessed.
  • Use of family, neighbors, friends, or community agencies which can provide this service at no cost will be utilized whenever possible.
  • Not covered for persons living in a residential care setting or a Community Care Foster Family Home (CCFFH).
• Personal assistance services – Level I and Level II
  • Provided in a person’s home to help with Instrumental Activities of Daily Living (IADLs) and Activities of Daily Living (ADLs).
  • Level I provided to persons needing assistance with IADLs in order to prevent a decline in health status and remain safely in their home, to persons not living with their family who would perform these duties as part of natural support.
    • Limited to 10 hours per week
    • May be self-directed to include companion services and homemaker/chore services.
  • Level II provided to persons requiring assistance with moderate/substantial to total assistance to perform ADLs and health maintenance activities.
    • Provided by a home health aide (HHA), personal care aide (PCA), certified nurse aide (CNA), or nurse aide (NA) with applicable skills competency.
    • May be self-directed
  • Companion services to assist or supervise with such tasks as meal preparation, laundry and shopping/errands are covered with service coordinator authorization.
  • Homemaker/chore services are covered with authorization from the service coordinator when the person who normally performs the services is temporarily not able to.
• Personal emergency response system (PERS)
  • 24-hour emergency assistance service for immediate assistance in the event of an emotional, physical, or environmental emergency
  • Individually designed to meet a member’s needs and capabilities
  • Limited to those who live alone or who are alone for significant parts of the day, have no regular caregiver, and who would otherwise require extensive routine supervision.
  • May be provided to those living in a non-licensed setting, except for ALF
• Residential care including E-ARCH and CCFFH
  • Personal care, nursing, homemaker, chore, and companion services and medication oversight provided in a certified private home by a care provider who lives in the home.
  • Member must have his/her own bedroom unless consents to sharing a room with another resident.
  • Member must be receiving ongoing CCMA services
• Respite care
  • Provided to persons unable to care for themselves and furnished on a short-term basis because of the absence of or need for relief for those persons normally providing the care.
  • May be provided at three different levels:hourly, daily, and overnight in the following locations:
    • Individual’s home or place of residence
    • CCFFH
    • E-ARCH
    • Medicaid certified NF
    • Licensed respite day care facility
    • Other community care residential facility approved by the state.
  • Must be authorized by the Primary Care Provider (PCP) as part of the service plan.
• Skilled (or private duty) nursing
  • Provided to persons requiring ongoing nursing care (in contrast to Home Health or part time, intermittent skilled nursing services ) listed in the service plan.
  • Services must be within the scope of state law
• Specialized medical equipment and supplies
  • Includes purchase, rental, lease, warranty costs, assessment costs, installation, repairs and removal of devices, controls or appliances, specified in the service plan.
  • Also includes items necessary for life support, ancillary supplies and equipment necessary to the proper functioning of such items, and durable and non-durable medical equipment not available under the Medicaid State plan.

Institutional Services

• Acute waitlisted ICF/SNF – provided in an acute hospital in an acute care hospital bed.
• Nursing facility (NF), skilled nursing facility (SNF), or intermediate care facility (ICF)
  • Provided to members needing 24-hour a day assistance with ADLs and IADLs and need care by licensed nursing personnel and paramedical personnel on a regular, long-term basis
  • Provided in a free-standing or a distinct part of a facility licensed and certified as meeting the requirements of providing skilled nursing, health-related care and rehabilitative services on a regular basis in an inpatient facility
  • Includes independent and group activities, meals and snacks, housekeeping and laundry services, nursing and social work services, nutritional monitoring and counseling, pharmaceutical services and rehabilitative services
• Subacute facility
  • Provided in either a licensed nursing facility or a licensed and certified hospital in accordance with Hawaii Administrative Rules.
  • Provides services that meet a level of care that is needed by the member not requiring acute care, but who needs more intensive skilled nursing care than is provided to the majority of members in a skilled nursing facility.
• Note: A patient assessment for level of care is necessary on the DHS Form 1147 only when Medicaid is the primary payer for the service. If a member has other insurance that is primary to QUEST covering the services, we will follow the appropriate coordination of benefits rules, and an approved 1147 form would not be required.

Services for “At Risk” Members

Persons are considered “at risk” when they don’t meet the criteria for nursing facility level of care but are at risk of deteriorating to the institutional level of care if certain long term services and supports (LTSS) are not provided..

“At risk” persons:

• Must reside in his/her home (or with family, guardian, or friend)
• Must not be residing in a care home, foster home, hospital, nursing facility, hospice facility, or intermediate care facility for persons with intellectual disabilities (ICF/ID)
• Need not be homebound
• May reside in a community shelter (i.e. YMCA, IHS, etc.)
• May receive services appropriate for their living environment (i.e. services included in the living environment, such as meals or room cleaning, are not provided by the health plan).

The following home and community based services may be provided when approved on the DHS Form 1147.

• Home-delivered meals (unless meals are included as part of their residence or if the person is receiving Personal Assistance Level I for meal preparation)
• Personal emergency response system (PERS)
• Personal assistance Level I and Level II\
• Adult day care
• Adult day health
• Skilled nursing services:

Revision History