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DMAS Office of Behavioral Health www.dmas.virginia.gov 1 Department of Medical Assistance Services Group Homes Levels A (H2022) and B (H2020) 2013.

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Presentation on theme: "DMAS Office of Behavioral Health www.dmas.virginia.gov 1 Department of Medical Assistance Services Group Homes Levels A (H2022) and B (H2020) 2013."— Presentation transcript:

1 DMAS Office of Behavioral Health 1 Department of Medical Assistance Services Group Homes Levels A (H2022) and B (H2020) 2013

2 2 Disclaimer These slides contain only highlights of the Virginia Medicaid Community Mental Health Rehabilitative Services Manual (CHMRS) and are not meant to substitute for the comprehensive information available in the manual or state and federal regulations. *Please refer to the manual, available on the DMAS website portal, for in-depth information on Community Mental Health Rehabilitative Services criteria. Providers are responsible for adhering to related state and federal regulations. 2 Department of Medical Assistance Services

3 3 Training Objectives To define the criteria needed to establish a Level A or B Group Home and licensing requirements; To identify staff qualifications; To identify required activities; To clarify eligibility criteria; To review the Medicaid Required Documentation for CSA and Non-CSA Admissions and Plans of Care; To review limitations of the service; and To review service authorization requirements. 3 Department of Medical Assistance Services

4 4 Service Definition – Level A Community-Based Residential Services for Children and Adolescents under 21 are a combination of therapeutic services rendered in a residential setting. This residential service provides structure for daily activities, psycho-education, therapeutic supervision and activities, and mental health care to ensure the attainment of therapeutic mental health goals as identified in the plan of care. The child/adolescent must also receive psychotherapy services in addition to the therapeutic residential services. This service does not include interventions and activities designed only to meet the supportive non-mental health special needs, including but not limited to personal care, habilitation, or academic-educational needs of the individual. 4 Department of Medical Assistance Services

5 5 Service Definition – Level B Therapeutic Behavioral Services for Children and Adolescents under 21 are a combination of therapeutic services rendered in a residential setting. This service will provide structure for daily activities, psycho-education, therapeutic supervision and activities, and mental health care to ensure the attainment of therapeutic mental health goals as identified in the treatment plan. The child/adolescent must also receive psychotherapy services in addition to the therapeutic residential services. This service does not include interventions and activities designed only to meet the supportive non-mental health special needs, including but not limited to personal care, habilitation, or the academic educational needs of the member. 5 Department of Medical Assistance Services

6 6 6 Department of Medical Assistance Services Licensing

7 7 Licensing Requirements – Level A Community-based residential services Level A shall be licensed by the Department of Social Services (DSS), Department of Juvenile Justice (DJJ), or Department of Education (DOE). 7 Department of Medical Assistance Services

8 8 Licensing Requirements – Level B Therapeutic Behavioral Services Level B residential services shall be licensed by the Department of Behavioral Health and Developmental Services. 8 Department of Medical Assistance Services

9 9 9 Department of Medical Assistance Services Staff Qualifications

10 10 Staff Qualifications – Level A At least 50% of the direct care staff must meet DMAS paraprofessional staff criteria Services provided by qualified paraprofessionals require supervision by a Qualified Mental Health Professional (QMHP) Paraprofessionals who do not meet the experience requirements may provide services for Medicaid reimbursement if they are working directly with a qualified paraprofessional on-site and being supervised by a QMHP. Supervision must include on-site observation of services, face-to-face consultation with the paraprofessional, a review of the progress notes, the individual’s progress towards achieving ISP goals and objectives, and recommendations for change based on the individual’s status. Supervision must occur and be documented monthly in the clinical record. The program director supervising the program/group home must be, at a minimum, a qualified mental health professional (QMHP) with a bachelor’s degree and have at least one year of direct work with mental health clients. The program director must be employed full time Department of Medical Assistance Services

11 11 Staff Qualifications – Level B The clinical director must be a licensed mental health professional (LMHP); and At least 50% of the direct care staff must meet DMAS paraprofessional staff criteria. Services provided by qualified paraprofessionals require supervision by a QMHP. Supervision is demonstrated by the QMHP by a review of progress notes, the member’s progress towards achieving ISP goals and objectives, and recommendations for change based on the member’s status. Supervision must occur and be documented monthly in the clinical record. Paraprofessionals who do not meet the experience may provide services for Medicaid reimbursement if they are working directly with a qualified paraprofessional on-site and being supervised by a QMHP. Supervision must include on-site observation of services, face-to-face consultation with the paraprofessional, a review of the progress notes, the individual’s progress towards achieving ISP goals and objectives, and recommendations for change based on the individual’s status. Supervision must occur and be documented monthly in the clinical record. The program director must be full time and be a QMHP with a bachelor’s degree and at least one year’s clinical experience. If any services are subcontracted, the subcontracted provider must meet all of the same qualifications as listed in the CMHRS Manual and related regulations for program operation and provider qualifications Department of Medical Assistance Services

12 12 Department of Medical Assistance Services Required Activities

13 13 Required Activities for level A & B Required Activities: There must be daily documentation of the provision of individualized supervision and structure designed to minimize the occurrence of behavioral issues indicated in the individual’s Initial Plan of Care (IPOC) and the Comprehensive Individual Plan of Care (CIPOC). Psycho-educational programming, which is part of the residential program, must include, but is not limited to, development or maintenance of daily living skills, anger management, social skills, family living skills, communication skills, and stress management. The individual must participate in seven (7) psycho-educational activities per week. Program activities must be documented at the time the service is rendered and must include the dated signatures of qualified staff rendering the service Department of Medical Assistance Services

14 14 Required Activities for level A & B Required Activities: In addition to the residential services, the individual must receive at least weekly individual psychotherapy provided by an LMHP. Family psychotherapy may also to be provided if there is continued family involvement. Therapy sessions are limited to no more than three (3) sessions in a seven-day period, including individual, family and group psychotherapy. If provided by a Medicaid-enrolled provider, the psychotherapy services may be billed separately as outpatient psychiatric services and must follow the service authorization process if necessary. If the weekly psychotherapy is missed due to the individual’s illness or refusal, justification must be documented in the clinical record. More than two (2) missed sessions per quarter will be considered excessive. Reasonable attempts should be made to make up a missed session. The facility/group home must coordinate services with other providers Department of Medical Assistance Services

15 15 Required Activities for level A & B Required Activities: The service provider must notify or document the attempts to notify the primary care provider or pediatrician of the individual’s receipt of this community mental health rehabilitative service. The facility/group home must coordinate services with other providers. To assist in assuring individual’s safety, the agency must provide adequate supervision of individuals at all times, including off campus activities Department of Medical Assistance Services

16 16 Required Activities for level A & B Required Activities: If an individual has co-occurring mental health and substance abuse disorders, integrated treatment for both disorders is allowed within Community-Based Residential Treatment Services as long as the treatment for the substance abuse condition is intended to positively impact the mental health condition. The impact of the substance abuse condition on the mental health condition must be documented in the treatment plan and the progress notes. If an individual receiving group home Services is also receiving case management services, the provider must collaborate with the case manager by notifying the case manager of the provision of group home services and send monthly updates on the individual’s progress. A discharge summary must be sent when the service is discontinued Department of Medical Assistance Services

17 17 Required Activities – Level A Required Activities Level A only: The staff ratio must be at least 1 to 6 during the day and at least 1 to 10 while the children/adolescents are scheduled to be asleep Department of Medical Assistance Services

18 18 Required Activities – Level B Required Activities Level B only: Individuals receiving Therapeutic Behavioral Services (Level B) must also receive group psychotherapy that is provided as part of the program. If provided by a Medicaid enrolled LMHP, group psychotherapy may be billed separately and must follow the service authorization process if necessary. The staff ratio must be at least 1 staff to 4 children during the day and at least 1 staff to 8 children while the children/adolescents are scheduled to be asleep. To assist in assuring client safety, the agency must provide adequate supervision of residents at all times, including off campus activities Department of Medical Assistance Services

19 19 Department of Medical Assistance Services Eligibility Criteria

20 20 Eligibility Individuals qualifying for this service must demonstrate medical necessity for the service arising from a condition due to mental, behavioral, or emotional illness, which results in significant functional impairments in major life activities in the home, school, at work, or in the community. The service must reasonably be expected to improve the individual’s condition or prevent regression so that the services will no longer be needed Department of Medical Assistance Services

21 21 Eligibility The individual is eligible for this service when all of the following are met: The individual is medically stable, but needs intervention to comply with mental health treatment; and The individual’s needs cannot be met with a less intense service; and An assessment which demonstrates at least two areas of moderate impairment in major life activities. A moderate impairment is defined as a major or persistent disruption in major life activities. The state uniform assessment tool (CAN) must be completed by the locality for Comprehensive Services Act (CSA) children/adolescents and must be current to within 30 days of placement Department of Medical Assistance Services

22 22 Eligibility For non-CSA individuals, a service specific provider assessment must be made by the independent referring clinician noting at least two moderate impairments within the past 30 days. A moderate impairment is evidenced by, but not limited to: Frequent conflict in the family setting such as credible threats of physical harm. Frequent is defined as more than expected for the individual’s age and developmental level. Frequent inability to accept age-appropriate direction and supervision from caretakers, family individuals, at school, or in the home or community. Severely limited involvement in social support, which means significant avoidance of appropriate social interaction, deterioration of existing relationships, or refusal to participate in therapeutic interventions. Impaired ability to form a trusting relationship with at least one caretaker in the home, school, or community. Limited ability to consider the effect of one’s inappropriate conduct on others and interactions consistently involving conflict, which may include impulsive or abusive behaviors Department of Medical Assistance Services

23 Department of Medical Assistance Services CSA or Non-CSA?

24 24 CSA or Non-CSA? The following slides describe the required documentation for CSA and Non-CSA admissions; All documentation must be complete, timely and include all required dated signatures; Sample forms are available in the manual; 24 Department of Medical Assistance Services

25 25 CSA or Non-CSA? If the case is an Adoption Subsidy case, it is NON-CSA –The education payment source is not considered; If the education is paid for by the Dept. of Education/CSA funded, it is a CSA case; If a child has been receiving CSA funding for other services, it is a CSA case; If the child is in foster care and receiving services through pooled funds, it is a CSA case Department of Medical Assistance Services

26 Department of Medical Assistance Services Units and Reimbursement

27 27 Reimbursement Rate Level A Reimbursement Rate: $ per unit (daily) Level B Reimbursement Rate: $ per unit (daily) Service Units and Maximum Service Limitations The service is limited to one unit daily. The rate includes payment for therapeutic services rendered to the individual. Room and board costs are not included in the rate Department of Medical Assistance Services

28 Department of Medical Assistance Services Certificate of Need (CON)

29 29 Certification of Need (CON) CSA Cases: CON must be completed by both the physician and at least 3 members of the FAPT; Must include dated signatures of the physician and FAPT; Authorization can begin no earlier than the date of the latest signature; Must be available in the medical record Department of Medical Assistance Services

30 30 Certification of Need (CON) Certification of Need (Independent Team Certification) NON-CSA Cases: –The CSB is responsible for completing the Independent Team Certification; and –The CSB completes the DMH224 and must include a physician’s dated signature, as well as the screener’s dated signature. (The CSB may use the sample CON in the manual in place of the DMH224) 30 Department of Medical Assistance Services

31 31 Certification of Need (CON) For both CSA and NON-CSA: The CON should reflect the child’s current condition and must be completed within 30 days of admission; The CON is required to be completed prior to admission with all necessary dated signatures; If the child is discharged and readmitted, a new CON is required; and If the child transfers to an acute psychiatric facility, the acute care team can do the new CON Department of Medical Assistance Services

32 Department of Medical Assistance Services Required Uniform Assessment (UAI) / CANS

33 33 Required Uniform Assessment (UAI) - CANS The State Uniform Assessment Instrument (CANS) is required for CSA Cases CSA Cases Only: –The CANS is the only uniform assessment instrument that is currently accepted. –For admission, the CANS should reflect the requested level of care and must be current. –It must be in the medical record. –It should be updated by the fiscally responsible locality when the child’s level of impairment changes significantly. –Completion information must be submitted to KePRO for SA. –Scoring notes the level of impairment that supports the need for the level of care Department of Medical Assistance Services

34 34 Required Uniform Assessment (UAI) - CANS At a minimum: The CANS summary sheet should indicate the child’s behavioral and emotional needs, and risk behaviors; and The CANS must also be available in the medical record Department of Medical Assistance Services

35 Department of Medical Assistance Services Initial Plan of Care (IPOC)

36 36 IPOC IPOC MUST: Be completed at admission; Include diagnoses, symptoms, complaints, and complications indicating need for admission; Include a description of the functional level of the individual; Include treatment objectives (short-term and long-term goals); Include ANY orders for medications, treatments, restorative and rehabilitative services, activities, therapies, social services, diet, and special procedures (health & safety recommendations); Include plans for continuing care, including review and modification to the plan of care; and Include plans for discharge 36 Department of Medical Assistance Services

37 Department of Medical Assistance Services Comprehensive Individual Plan of Care (CIPOC)

38 38 CIPOC CIPOC MUST: Be completed within 30 days after authorization for Medicaid reimbursement; Level A must be completed by at least a QMHP and signed and dated by the program director; Level B must be completed (to include signature and date) by an LMHP; Be based on a diagnostic evaluation that includes examination of the medical, psychological, social, behavioral, and developmental aspects of the recipient's situation and must reflect the need for inpatient psychiatric care; Both levels must be based on input from school, home, other healthcare providers, the child and family (legal guardian); 38 Department of Medical Assistance Services

39 39 CIPOC – cont’d CIPOC MUST: State treatment objectives that must include measurable short-term and long-term goals and objectives, with target dates for achievement; Prescribe an integrated program of therapies, activities, and experiences designed to meet the treatment objectives related to the diagnosis; Describe comprehensive discharge plans with related community services to ensure continuity of care upon discharge with the individual's family, school, and community Department of Medical Assistance Services

40 40 Reviews of CIPOC The CIPOC MUST: Be reviewed, signed and dated every 30 days by the QMHP (Level A) and LMHP (Level B) ; The response to services provided; Recommend changes in the plan as indicated by the individual’s overall response to the plan of care interventions; Determinations regarding whether the services being provided continue to be required; and Updates must be signed and dated by the service provider Department of Medical Assistance Services

41 41 Department of Medical Assistance Services Limitations

42 42 Limitations DMAS will reimburse only for services provided in facilities or programs with no more than 16 beds. The total number of beds will be determined by including all treatment beds located within the program/facility and on any adjoining or nearby campus or site. Treatment beds are all beds in the facility regardless of whether or not the services are billed to Medicaid. If a provider operates separate residences that are 16 beds or less and are in distinctly different areas of a locality (for example, greater than one mile apart), the bed count will only apply to each residence. Each residence that is 16 beds or less will be eligible for Medicaid reimbursement. DMAS does not pay for programs/facilities that only provide independent living services. Level B only: The caseload of the clinical director must not exceed a total of 16 clients including all sites for which the clinical director is responsible Department of Medical Assistance Services

43 43 Department of Medical Assistance Services Service Authorization (SA)

44 44 Service Authorization Contractor KePRO is the DMAS contractor for Service Authorization (SA). For questions go to the SA website: DMAS.KePRO.org and click on Virginia Medicaid Phone: VAPAUTH or Fax: OKBYFAX or Web: 44 Department of Medical Assistance Services

45 45 Service Authorization Contractor Submitting a request The preferred method is through the Atrezzo® web-based program Registration is required Information on Atrezzo is available on the KePRO website, or call or (804) or mail to: »KePro »2810 North Parham Rd, Suite 305 »Henrico, Virginia Department of Medical Assistance Services

46 46 Service Authorization Contractor Submitting a request continued… Continued Stay Requests: Continued Stay Requests may be faxed or submitted through Atrezzo and questions #1-#16 AND questions #20-#26 MUST be completed. If utilizing the Atrezzo Service Authorization Checklist complete the Continued Stay Request Service Authorization sheet. Retro Requests: For a Retro-authorization request, complete ALL questions Department of Medical Assistance Services

47 47 Service Authorization Contractor Submitting a request continued… For a CSA case, there must be 4 signatures on the CON including the physician and 3 FAPT members. For Non CSA cases, the CON must be completed by the CSB and signed by a physician and the CSB screener. All signatures must be individually dated and the last signature date is the date of completion. The CANS must be completed and current within 30 days prior to the start date being requested. The Initial Plan of Care must be signed within 24 hours of admission Department of Medical Assistance Services

48 48 Reminders When documenting that the failed placements were unsuccessful, provide information regarding why the placements were not successful. Treatment failures refers to the lack of improvement of a member’s symptoms and behaviors in previous treatment. Documentation should reflect that the behaviors have been present for at least 6 months and that they will persist for longer than 1 year without treatment. Documentation should support that the member would be unable to be treated safely at a less intensive level of care. Documentation should reflect the members inability or unwillingness to follow instructions, perform ADL’s or maintain behavioral control. Information should be submitted as it relates to the member’s formal and informal support systems Department of Medical Assistance Services

49 49 Contacts Helpful Resources: 12VAC Emergency Regulations for Community Mental Health Services Virginia Medicaid Web Portal link DMAS Office of Behavioral Health: – Address DMAS Helpline: Richmond Area All other 49 Department of Medical Assistance Services


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