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MEDICAID INFORMATION RELEASE MA06-28
posted on March 02, 2009 12:18
July 1, 2006
MEDICAID INFORMATION RELEASE MA06-28
Mental Health Clinics, Psychosocial Rehabilitation (PSR) Agencies, Primary Care Physicians (PCP)
Leslie M. Clement, Administrator
SUBJECT: TRANSITION OF PARTICIPANTS FROM BASIC TO ENHANCED MEDICAID MENTAL HEALTH SERVICES
The purpose of this Information Release is to inform providers of :
·- the procedure for identifying whether or not a participant requires enrollment in the Medicaid Enhanced Plan based on health needs,
·- the provider’s role in determining that a participant’s mental health needs are best served by the Medicaid Enhanced Plan,
·- communication with the Department when a provider identifies a participant who should be assigned to the Medicaid Enhanced Plan, and
·- reimbursement process requirements.
All participants who are enrolled in the Medicaid Basic Plan who require enhanced mental health services must first obtain a comprehensive assessment, code H0031, to establish medical necessity for the Medicaid Enhanced Plan.
Role of the
Medicaid participants must obtain a Healthy Connections referral to obtain mental health services of any kind. There are basically two types of referrals the PCP may make:
·- If the medical situation warrants it, the PCP may make the referral to a Mental Health Clinic or a PSR agency for an immediate comprehensive assessment to establish the medical necessity for Enhanced Plan mental health services such as psychotherapy services up to 45 hours per year or psychosocial rehabilitation or partial care.
·- The PCP may choose to refer the participant to a Mental Health Clinic for any of the general Basic Plan mental health services such as psychotherapy, psychological testing, psychopharmacology or any combination of those services or other services and defer the decision about whether or not the participant needs an immediate comprehensive assessment to the Clinic professionals who will then take sufficient time to work with the participant to determine if Basic Plan services are adequate to meet the participant’s mental health needs.
Once a participant has obtained a referral from his PCP and is engaged in treatment at a Mental Health Clinic another PCP referral for obtaining a comprehensive assessment or obtaining further treatment in the Enhanced Plan is not necessary unless the participant switches mental health providers.
Criteria for Enhanced Plan Placement
Medical necessity for Enhanced Plan placement for child participants is established by the child meeting the criteria for severe emotional disturbance (SED) as presently described at IDAPA 16.03.09.450.01. Medical necessity for Enhanced Plan placement for adult participants is established by the adult meeting the criteria for severe and persistent mental illness (SPMI) as presently described at IDAPA 16.03.09.450.02. New IDAPA rules publishing August 2, 2006 will describe the same eligibility requirements at 16.03.10. 111.
Prior to a participant’s annual Medicaid renewal date the Department will review the participant’s utilization of mental health services in the current year. If the participant has a current (within the past twelve (12) months) comprehensive assessment that indicates the SED or SPMI criteria has been met the participant will be placed in the Medicaid Enhanced Plan. If there is no evidence of the criteria having been met but the participant has been a high utilizer of mental health services the Department will refer the participant for a comprehensive assessment to determine appropriate plan placement based on health needs.
Professional staff in Mental Health Clinics and Psychosocial Rehabilitation agencies must perform comprehensive assessments to determine whether participants need enhanced mental health services. The comprehensive assessment benefit is covered in Medicaid Basic Plan and counts toward the 26 service limitation and is also part of the 12 hour diagnosis and evaluation benefit (see IR # MA 2006-15). Comprehensive assessments must meet the requirements presently described in IDAPA 16.03.09.453.01. New IDAPA rules publishing August 2, 2006 will describe the requirements at 16.03.10. 112. Comprehensive assessments must not be a duplication of social histories which are still required to be a part of all medical records as a part of the intake process in Mental Health Clinics as presently described in IDAPA 16.03.09.468.01.
In addition to requirements described at 453.01, comprehensive assessments must include a statement describing whether the criteria for enhanced services have been met or not. Additionally, the comprehensive assessment must include either (a) or (b):
(a) Specific treatment recommendations, if clinically appropriate, for any or all of the following services if eligibility for enhanced services is met:
·- Partial Care
·- Psychosocial Rehabilitation
(b) Specific treatment recommendations for the participant who does not meet criteria and will remain in the Medicaid Basic Plan.
Comprehensive assessments and treatment plans do not require prior authorization, effective July 1, 2006.
New Form and Process Effective
July 1, 2006
The Clinic or PSR agency that has determined that a participant is eligible for enhanced mental health services as a result of the comprehensive assessment is responsible for notifying the Department that the participant’s Medicaid Plan placement should change. This provider must complete IDHW form H0002 and submit it via fax or electronically to the Family Medicaid Unit. Upon receipt of form H0002 the Family Medicaid Unit will change the eligibility classification of the participant so that providers’ claims for enhanced services will be reimbursed. The change in eligibility classification will occur within seventy-two (72) hours of receipt of form H0002 which will expedite the claims reimbursement process. The assessment provider must keep the original signed copy of form H0002 in the participant’s medical record.
The assessment provider must notify the participant (or the participant’s guardian as appropriate) of the outcomes of the comprehensive assessment including plan placement and treatment recommendations. The participant must select a mental health treatment provider who is qualified to provide the recommended treatment. The assessment provider and the treatment provider may be the same provider.
The assessment provider is responsible for providing a copy of the assessment to the chosen treatment provider(s) once one or more are identified if different from the assessment provider. Release of the participant’s personal health information must comply with all HIPAA requirements.
Treatment Plans and Multiple Providers
Mental health clinics and PSR providers must develop a treatment plan based on the comprehensive assessment. Only one treatment plan is allowed per participant per benefit period.
Mental Health Clinics
When participants choose more than one provider for clinic services during the same time period, the second provider must coordinate with the first provider by obtaining copies of the comprehensive assessment and treatment plan and addending the treatment plan with appropriate goals and objectives. The second provider is responsible for supplying the first provider with a copy of the addended treatment plan and all updates (120-day reviews). Updates to the treatment plan occur on the schedule of the original treatment plan. Duplication of services is not allowed.
If the participant chooses multiple PSR providers during the same time period, the second provider may submit a request for prior authorization to the Mental Health Authority for approval of additional treatment plan goals and objectives to complement the existing treatment plan. Providers, who are one of two that have been selected by participants who received treatment recommendations for clinic and PSR services, must coordinate the development of a single treatment plan between themselves to deliver the appropriate services. The second provider is responsible for supplying the first provider with a copy of the addended treatment plan and all updates (120-day reviews). Updates to the treatment plan occur on the schedule of the original treatment plan. Duplication of services is not allowed.
The comprehensive assessment is code H0031 and is limited to 24 units/yr and is reimbursed to Clinics and PSR providers at $11.35 per fifteen (15) minute unit.
The treatment plan is code H0032 which is limited to 8 units/yr per agency and is reimbursed to Clinics and PSR providers at $11.35 per fifteen (15) minute unit. All PSR services with the exception of H0031 and H0032 still require prior authorization by the Mental Health Authority. Incomplete assessments and treatment plans are subject to recoupment.
Psychiatric Hospitalization Access Remains Unchanged
While psychiatric hospitalization benefits for participants are limited to ten (10) days in the Medicaid Basic Plan the pathway for the participant to access psychiatric hospital services at any point, no matter how much of this benefit has already been used, remains the same as it was prior to Medicaid Modernization. Medicaid staff will be monitoring use of this benefit among participants and will adjust plan placements when medically necessary so that providers’ claims will be reimbursed as appropriate.
If you have any questions concerning the information contained in this release, please contact Pat Guidry at (208) 364-1813
Thank you for your continued participation in the Idaho Medicaid Program.
Directions: Please fill in all blanks, print and sign the form, submit to Family Medicaid by fax at
. Maintain original in participant’s records
You may choose to submit the form electronically to:
Name of Participant:________________________ Medicaid ID#:___________________
Name of Provider Certifying Medicaid Enhanced Plan: ____________________________________
Name of Agency and Agency provider#:__________________________________________
RATIONALE FOR ENHANCED
(Provider: please check the appropriate box as indication of the justification for this participant needing Medicaid Enhanced Plan)
Participant needs the following services:
o Additional Psychotherapy o Service Coordination
o Partial Care o Developmental Disabilities
o Psychosocial Rehabilitation o Inpatient Psychiatric Hospitalization
I have assessed ______________________on _____________and certify that this
(Name of participant)_____________________________ (date)
participant meets the requirements in IDAPA 16.03.10 for receiving the above indicated
services in the Medicaid Enhanced Plan.
Signature of Provider Certifying Participant’s Eligibility Date
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