TO: Residential Habilitation Agencies, Targeted Service Coordinators, and Developmental Disability Agencies
FROM: Leslie Clement, Acting Deputy Administrator
SUBJECT: 1. RESIDENTIAL HABILITATION SUPPORTED LIVING BILLING INSTRUCTIONS FOR DD AND ISSH WAIVER PARTICIPANTS ATTENDING PUBLIC SCHOOL
2. BILLING AND ADDENDUM PROCESS CLARIFICATIONS FOR MEDICAID INFORMATION RELEASE MA04-50
1. Supported Living Daily Rate for DD and ISSH Waiver Participants Attending Public School
As a result of some provider concerns about hourly billing for participants who meet the High or Intense Support criteria and attend public school, Medicaid has developed an adjusted daily rate for these participants. Providers can submit plan addendums for these participants to request a change to daily rate reimbursement for dates of service on or after 1/1/05. Two billing codes have been designated for use in billing the daily supported living rates. Procedure code H2016 can accommodate multiple reimbursement rates. For this procedure code, the prior authorization will contain a narrative description in the comment field that reflects the prior authorized service, number of approved days, and reimbursement rate. Procedure code H2022 is reserved for billing the daily rate for participants who require High Support.
For participants receiving High Support and attending public school, bill the following:
School Days Procedure Code - H2016 $175/day
Non-School Days Procedure Code - H2022 $221.12/day
For participants receiving Intense Support and attending public school, bill the following:
School Days Procedure Code - H2016 $208.50/day
Non-school Days Procedure Code - H2016 $263.36/day
These rates are based on an annualized prior authorization amount for the number of school days at the reduced rate and the number of non-school days at the full rate. The school rate must be billed for all days the participant is in school for 3 hours or more. Additional non-school days will be prior authorized to accommodate minor fluctuations in attendance based on historical absenteeism and related data for each participant. Significant changes in school attendance that impacts the hours needed for supported living will be addressed through the addendum process.
It is the responsibility of the school district to provide the services necessary to allow a participant to access educational opportunities. However, if a provider receives communication from the school that a participant cannot attend without being accompanied by supported living personnel, please notify Mary Wells, Bureau of Medicaid Policy, by email at: wellsm@idhw.state.id.us , or by phone at: (208) 364-1955.
2. Clarifications to Medicaid Information Release MA04-50 Supported Living Acuity Based Levels of Support
There has been some confusion regarding plans for 24 hours of supported living services. Plans for 24 hours of supported living services are only available for those participants who meet the High or Intense Support criteria. The process for billing 24 hour supported living is established through daily rates. All other supported living may be billed using the hourly billing process. Plans developed for these participants will identify natural supports, alone time, and other Medicaid services. Supported living providers may bill for a portion of the plan but not for the entire 24 hour period.
Some supported living providers have asked for clarification about when they could addend plans to reflect Intense Support needs. If a participant’s plan contained “community wrap around services” prior to 10/1/04, the plan can be addended to add Intense Support if the participant meets the Intense Support criteria. Addendums for Intense Support may only be requested between 10/1/04 and 12/31/04. Approved addendums received within this time frame can be authorized retroactively back to 10/1/04 as long as there is documentation that the participant has been receiving 1:1 support since that time. In order to receive the higher reimbursement rate for this service during the retroactive period, claims billed using procedure code H2022 at $221.12/day must be voided and new claims must be submitted using procedure code H2016 at $263.36. After 12/31/04, participants must wait until their annual plan date in 2005 to add Intense Support. If you are uncertain what type of documentation is necessary to validate the need for Intense Support, please contact your regional Independent Assessment Provider.
We are continuing to review our billing procedures related to community supported employment for providers that bill supported living daily rates. There are no changes at this time to the current practice.
If you have any questions concerning the information contained in this release, please contact Jean Christensen, Manager, Behavioral Health, Bureau of Care Management at (208) 364-1828.
Thank you for your continued participation in the Idaho Medicaid Program.
IDAHO MEDICAID PROVIDER HANDBOOK:
This information release does not replace information in your Idaho Medicaid Provider Handbook.
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