HCBS and LTSS Providers

• Your Provider Representatives for HCBS/LTSS: Long-Term Support Services (LTSS) / Home & Community Based Services (HCBS) PR Reps

Persons must have a medical need for the special care. There must be an open space in the HCBS program, and the individual must be determined eligible for Medicaid. The resource limit is $2,000 for a single person, and there are special resource provisions for those individuals who have a spouse.

People on HCBS may also share in the cost of care. Persons with income more than $2,382 a month help pay for their care.

There are seven HCBS waivers. Each waiver offers services for a specific group.

• Frail Elderly - Serves individuals age 65 and older who want community-based services as an alternative to nursing home care.
• Physical Disability - Serves individuals age 16-64 who are physically disabled and need assistance with activities of daily living.
• Intellectual/Developmental Disability - Serves individuals age 5 and up who meet the definition of intellectual or developmental disability.
• Serious Emotional Disturbance - Serves individuals age 4-18 at risk of being removed from their homes or hospitalized due to severe emotional and behavioral difficulties. (There are exemptions for children younger than 4 and extension of services up to the age of 22.)
• Autism - Serves children from time of diagnosis through 5 years of age.
• Technology Assisted - Serves children under 21 who are dependent upon mechanical ventilators or intravenous administration of nutritional substances or drugs. 
• Brain Injury - Serves individuals from birth through age 64 who have a traumatically acquired brain injury. (There are exceptions for individuals that are on the waiver when they turn 65.)

HCBS waivers are KanCare (Kansas Medicaid) programs that provide services to a person in their community instead of an institution, such as a nursing home or state hospital. In Kansas, the Kansas Department for Aging and Disability Services (KDADS) oversees the HCBS waivers. The services you receive will vary depending on the waiver you qualify for and your individual needs.

HCBS services do not pay for living expenses or room and board.

An individual must have KanCare Medicaid insurance to qualify for HCBS Waivers. They also must meet the definition of disability under the Social Security Act. They must meet the requirements of the specific waiver.

Providers are required to keep the documentation required for billing each HCBS service as outlined within the KMAP HCBS manuals and approved HCBS waivers. Providers are not required to submit this documentation unless requested by Sunflower.

• DRC Kansas - More information from Disability Rights Services Kansas.
• How to Complete Background Checks (PDF)

Long Term Services and Supports (LTSS) Resources

• Some Sunflower members are eligible for LTSS. To qualify for LTSS, you must meet the state’s criteria for needing an institutional level of care and meet certain financial requirements. A member does not need to reside in a nursing facility or some other institutional facility to get LTSS. Services can be provided in the home or in a variety of community-based settings.
• Care Managers. Sunflower Health Plan members who are eligible for LTSS are assigned a care manager. Members will receive service coordination services for as long as they stay on the LTSS program. Care managers will work with the member, the member representative or guardian (if applicable), and providers to help decide which services will best meet the members' needs. To contact our care managers, please review our territory map.

Nursing Facility Resources

• Nursing facilities have two additional times a year where their rates can be adjusted based on member acuity. This occurs when the nursing facility submits to the state MDS data on each resident in the facility on the first day of each calendar quarter with the completed and submitted assessments. The facilities are assigned a RUG-III 34 group, which equates to a CMI. Related to case mix indices, the more complex the higher the CMI is. This is determined four times a year and the rates will be adjusted for case mix twice annually using case mix data from the two quarters preceding the rate effective date. 
• Emergency Admissions. Kansas Administrative Regulation (KAR 30-10-7) allows a NF that admits a KMAP-eligible individual on an emergency basis to be reimbursed up to 13 days when the preadmission assessment determines the individual to be inappropriate for NF-level of care. Should this situation occur, the NF will need to contact the NF Program Reimbursement Manager at 785-296-4986 for further instructions on how to submit a claim for reimbursement for the emergency admission allowed by the regulation.
• Cost report with SNFs are able to capture their costs: All cost reports, historical or projected, must be for a period of 12 consecutive months, except as provided in KAR 129-10-17 (e) (1). Providers who filed a projected cost report must file a historical report for the projection period and a historical report for the first calendar year following the end of the projection period.
• Transportation. The cost of transporting a current NF resident for nonemergent services (either by ambulance or commercial non-ambulance medical transportation) is a responsibility of the NF. This includes new admissions to the NF. The home receives full payment for the date of admission; therefore, reimbursement for transportation is to be built into the facility’s per diem rate. The cost of transporting residents and new admissions to the NF is a cost NFs will incur. These expenditures should be included in the provider’s cost report.
• Please review the Nursing/Intermediate Care Facility, Intermediate Care Facility, Intellectual Disability and Mental Health Nursing Facility Fee-for-Service Provider Manual found on the KMAP website.

More nursing facility information:

• Skilled Nursing Facility: Covered Services for KanCare Members
• SHPBN-2017-030 Valid Level of Care Required for Long Term Care Services
• SHPBN-2017-021 Nursing Facility Prior Authorization Changes