From the Arc of North Carolina 5-10-17

Regarding people getting their budget letter and it showing a budget cut, I have a few helpful hints that I have used to help with planning and even with reconsideration reviews, mediations & appeals.

The Care Coordinator [now it’s your Tailored Care Manager] will almost always say to a family, “ask for what you need, even if it exceeds the budget guidelines”. They almost never add in “just be sure to submit enough information to justify ALL of the needs”.

Especially when asking for services that exceed the assigned budget guidelines, many of these things can be done right along with planning, to hopefully give the plan reviewer/Utilization Management (UM – the department that reviews and approves plans) enough information to clearly justify needs and approve the plan at first review. Even if they are not done during planning time, these things can be done to help prepare for the reconsideration review, mediation or appeal.

Although each situation is different and no one strategy can be applied in all situations, here are a few things that have been generally helpful:
1. Keep in mind that the only things UM knows about the individual is what is included in the plan and attachments to the plan
2. Have the planning team think about:
· What the person needs
· Why they need it
· What has happened in the past when the person didn’t get what they needed or what is likely to happen if they don’t get it
· Put all of this information in a letter or letters to be submitted with the plan, even if the information is already in the plan
3. Get letters of medical necessity from doctors that explain why the individual needs the support being requested. Hint – the doctor does not know anything about the Innovations rules. Consider writing up something for the doctor to review and revise as s/he sees fit. The letter will need to be on the physician’s letterhead.
4. Make sure that data is gathered throughout the year to document the individual’s unique issues that leads to them requiring care beyond what is described in their assigned individual budget level. This could be behavioral issues, seizures, lack of sleep, etc. Cardinal has provided templates that can be used to gather this data.
5. Also focus on the number of hours of support and why the individual needs them instead of the dollars that are associated with the needed supports
6. Look at the budget level assigned to the individual and then think about the individual and what information specific to the individual is not included in the description.
For example – Individual lives at home, one parent recently passed away, there are no family members who live close by to provide assistance and there is only 1 natural support in their life and this is why they would be considered an “outlier” in their budget level and need more support than the typical person in their budget level.
7. Some families have chosen to write a personal, heartfelt letter to UM stating why the individual needs the support requested and asking them to please not take away the support their family member needs to ensure her/his health and safety and ability to continue to live in the community.
8. UM may request to see the new short range goals for the new plan year, so before the plan is submitted for approval, it is a good idea to have the short range goal meetings with the provider agencies so that you don’t have to scramble at the last minute to get them completed and submitted.
9. UM may ask to see Preference Assessments and Functional Assessments from the provider agencies, so it is a good idea to request that the provider agencies have these done prior to the plan being submitted.
10. If services are denied or reduced and you to request a reconsideration review, mediation, appeal, always submit additional information, even if you think that it’s already been covered. The information might have been accidentally overlooked the first time or it is seen in a new light when presented again.