Individual Care Grant Program Training March 3 - PowerPoint PPT Presentation

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Individual Care Grant Program Training March 3

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Quarterly and Annual Eligibility Reviews under Rule 135 ... visit of the youth's residential facility twice yearly if in-state or adjacent ... – PowerPoint PPT presentation

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Title: Individual Care Grant Program Training March 3


1
Individual Care Grant Program Training March 3
5, 2009 Chicago Springfield
  • Seth Harkins, EdD, Director ICG Program
  • Bill White, LCSW, Clinical Director, Illinois
    Mental Health Collaborative for Access and Choice

2
Goals for the Training
  • To review the application of Rule 135
  • To facilitate an understanding of Rule 132 and
    application to the ICG program
  • To facilitate an understanding of the role of the
    Illinois Mental Health Collaborative for Access
    and Choice (the Collaborative)
  • To facilitate an understanding of Rule 135
    clinical eligibility criteria and Rule 132
    medical necessity
  • To facilitate an understanding of the
    authorization of ICG Services
  • To facilitate an understanding of the role of the
    Collaborative clinical care manager (CCM).
  • To facilitate an understanding of the new billing
    process.

3
DHS/DMH Objectives for the Changes in ICG Services
  • Enhancement of recovery and resilience focus
  • Increase family participation
  • Focus on least restrictive environment
  • Outcomes
  • Enhanced clinical care management
  • Fee for service reimbursement
  • Resume Medicaid billing

4
Whats the Same?
  • ICG application process and requirements
  • ICG eligibility criteria and determination
    process
  • Quarterly and Annual Eligibility Reviews under
    Rule 135
  • Rates for services, except for application
    assistance and care coordination
  • Retrospective billing and payment for
    community-based services and residential claims

5
Whats the Same?
  • Rates for services except for application
    assistance and care coordination
  • Retrospective billing and payment for community
    services and residential per diems
  • Payments to providers will be made by DHS/DMH

6
Whats the Same?
  • Payments will be made to providers by DHS/DMH
  • Active parent and family role in treatment
    planning
  • Providers required to assist with Medicaid
    applications
  • Consumer registrations must be submitted to the
    Collaborative system.

7
Whats Different?
  • Claims submitted to the Collaborative for dates
    of service after 4/1/09
  • Services will be billed using the DMH Service
    Matrix and the old ICG codes are no longer valid
  • Residential nights of care will require
    authorization for claim payment

8
Whats Different?
  • Consumer registrations into DHS/DMH ROCS system
    not required for consumers receiving services
    on/after 4/1/09
  • Collaborative Clinical Care Manager role in
    placement decisions and treatment planning
  • HCD field offices aware of ICG program and
    exclusion of family income for Medicaid
    eligibility at 90th day of residential stay

9
Whats Different?
  • Behavior management and child support services
    annual limits of 1570 (72M) and 3500 (97M)
    respectively. Medical necessity reviews for
    additional services
  • All providers and sites required to be certified
    for Rule 132 services

10
Roles and Cooperation
  • The cooperation between the parent/guardian,
    ICG/SASS worker, and the Collaborative clinical
    care manager is vital to the ICG model.
  • ICG/SASS workers continue to provide case
    management and care coordination to all ICG
    youths.
  • Collaborative care managers will be a resource
    during placement decision meetings to assist with
    the factors that should be considered in
    determining the most appropriate treatment for
    youths eligible for ICG services. Collaborative
    CCMs will also participate in treatment planning
    meetings for youths placed in residential
    settings to assist with whether or how the
    treatment plan might need to change to assure
    progress toward treatment goals.

11
ICG/SASS Worker Responsibilities
  • ICG/SASS workers will provide the following case
    management services for ICG youth and families.
  • Application Assistance Activities
  • Assist families in determining whether to apply
    for ICG.
  • Assist families with compiling the documentation
    necessary to apply for the ICG
  • Assist families with submitting a completed ICG
    application.

12
ICG/SASS Worker Responsibilities
  • Case management services (Cont.)
  • Provide resource information regarding
    residential facilities available to families
  • Compile application packets for families seeking
    residential services, and assist with
    distribution to facilities
  • Maintain ongoing relationships with families,
    schools and the youths community in order to
    support the treatment plan. This includes
    participation in IEP meetings.

13
ICG/SASS Worker Responsibilities
  • Participate in quarterly staffings for treatment
    plan revision.
  • Submit Quarterly progress report.
  • Provide case management assistance to the
    parent/guardian to enroll the ICG youth in
    Medicaid by the 90th day of residential treatment.

14
ICG/SASS Worker Responsibilities
  • Meet with the family and the residential case
    manager at least once every 90 days by phone or
    in person.
  • Conduct on-site visit of the youths residential
    facility twice yearly if in-state or adjacent
    state, once yearly to another state. Participate
    in treatment plan revision meeting during the
    visit to advocate for the youth and family.
  • Provide case management to facilitate transition
    to intensive community-based services, when
    indicated.
  • Assist parents/guardians with completing forms
    and documentation necessary to support the ICG
    recipient (e.g. Annual Eligibility Review
    documentation)

15
ICG/SASS Worker Responsibilities
  • Maintain communication with the family,
    residential facility, Collaborative CCM, and
    DHS/DMH program staff.
  • Provide staff to attend DHS/DMH ICG training or
    meetings specific to residential care.
  • Assist with transition planning when an ICG
    recipient transitions out of the ICG residential
    program to community-based services or to adult
    services.
  • Maintain documentation of the support services
    rendered and provide that documentation to
    DHS/DMH ICG program staff upon request.

16
The Role of the Collaborative
17
Registration of ICG Eligible Consumers
  • All consumers who are eligible for ICG providers
    must be registered with the Collaborative prior
    to submitting any claims for services after April
    1, 2009.

18
Registration of ICG Eligible Consumers
  • Registrations must be completed through data
    entry at ProviderConnect.
  • For providers who have their own software, the
    Collaborative can accept batch registrations.
  • Requirements for consumer registrations can be
    found on the Illinois Mental Health Collaborative
    for Access and Choice website at the following
    link http//www.illinoismentalhealthcollaborative
    .com/provider/prv_information.htm

19
Collaborative Clinical Care Managers
  • Collaborative CCMs are Licensed Practitioners of
    the Healing Arts (LPHA) with child/adolescent
    experience consistent with the requirements of
    Rule 135.
  • Clinical Care Managers will continue to review
    ICG eligibility packets
  • for completeness
  • to make eligibility determinations

20
Enhanced Role of the Collaborative
  • The Collaborative CCM will be linked into the
    placement decision- making process once a youth
    is determined to be eligible for an ICG.
  • The Collaborative CCM will initiate a meeting
    between the parent/guardian and the ICG/SASS
    worker regarding the initial decision to select a
    community-based ICG or a residential ICG.

21
Enhanced Role of the Collaborative (Cont.)
  • The Collaborative CCM will join the
    parent/guardian and ICG/SASS worker for quarterly
    staffings, discharge staffings, and other
    staffings that affect the care and treatment of
    the client.
  • The Collaborative CCM will provide authorization
    for residential services.
  • Initial 120 day authorization
  • 90 day Concurrent authorizations

22
Clinical Care Managers Responsibilities
  • Authorizes residential nights of care based on
    the authorization request submitted by the
    provider
  • Authorizes child support and behavioral
    management services above the annual limits based
    on authorization requests from the providers. 97M
    threshold is 3500 and 782M is 1570.
  • Conducts reviews of Quarterly and Annual
    Eligibility Reports for continued eligibility,
    assists with transition to community services or
    a planful discharge from ICG funded services.

23
Quarterly Review Questionnaire Items
  • 1. Briefly describe the reason for admission.
  • 2. Describe the treatment goals you hope to
    accomplish with this client so that he/she can be
    discharged. How has the client progressed toward
    these goals during this quarter.
  • 3. Describe the current efforts you are making
    to prepare the client for discharge. Please give
    a tentative discharge date. If that is not
    possible tell why, describe why you feel
    continued residential treatment is necessary and
    list the barriers to discharge.

24
Quarterly Review Questionnaire Items
  • 4. List the discharge criteria that need to be
    met before discharge can occur.
  • 5. List the current diagnoses. Include a CGAS
    score with the diagnoses. Be sure to include
    scores from the Ohio Scales and the Columbia
    Impairment Scale List the current medications
    as well as the symptoms, behavior, etc. they are
    targeting.
  • 6. Is individual therapy occurring and, if so,
    with a frequency of at least once a week? If not,
    give a clinical justification.
  • 7. Is family therapy occurring and, if so, with
    a frequency of at least once a month? If not,
    give a clinical justification.

25
Quarterly Review Questionnaire Items
  • 8. Is there a need for any specialized therapy
    (e.g. treatment for clients who are sexual
    offenders)? If so briefly describe the need for
    specialized therapy and the type of therapy
    offered. If indicated, but not offered or
    ongoing, give a clinical justification.
  • 9. Is the family involved in the clients
    treatment? Describe the nature of their
    involvement and state whether or not it is
    sufficient to the clients needs. If the family
    is not sufficiently involved describe what
    efforts your facility is making to improve their
    involvement.
  • 10. (Optional) Include anything else you may wish
    to tell us about this client or your treatment
    plan for him/her.

26
Annual Eligibility Review
  • The Annual Eligibility Review determines whether
    the youth continues to meet Rule 135 eligibility
    criteria (continuing medical necessity).
  • The Annual Eligibility Review can result in
    continuation of services, step-down to
    community-based ICG services or termination.

27
Annual Eligibility Review
  • Parents/guardians are to be given six weeks
    notice of grant termination to allow sufficient
    time for transition to DMH funded community
    services, or, if the child will remain in a
    residential setting, for the payment
    responsibilities to be transitioned to another
    payer.

28
Quarterly Reports and Annual Eligibility Reviews
  • Send Quarterly Reports and Annual Eligibility
    Review information to Illinois Mental Health
    Collaborative for Access and Choice, P.O. Box
    06559, Chicago, IL 60606

29
Medicaid Application
  • Most ICG clients are eligible for Medicaid
    benefits after 90 days in a residential treatment
    facility. According to 94R this is considered
    away from home and the parent/guardians income
    does not apply to the youth and therefore the
    client becomes eligible for Medicaid during
    residential treatment.
  • Human Capital Development Offices will have a
    DHS/DMH memorandum indicating Medicaid
    eligibility for residential ICG clients.

30
Medicaid Application
  • Residential providers, ICG/SASS workers, and
    parents/guardians must cooperate to secure
    Medicaid enrollment.
  • Residential providers make the application on
    behalf of the youth.
  • It behooves the residential provider to establish
    a good working relationship with their local DHS
    office.

31
Medicaid Application
  • The date of the application for Medicaid and the
    consumers Medicaid eligibility status will be
    required in order to obtain authorization for
    residential nights of care.

32
Provider Certification
  • All providers, including residential providers
    and out-of-state providers will be required to be
    certified in accordance with the requirements of
    Section 132 either by the DHS Bureau of
    Accreditation, Licensing, and Certification
    (BALC) or by DCFS.
  • Each site that serves ICG youth will be required
    to be certified for the Applicable Rule 132
    services for community or residential services.

33
Provider Certification
  • Questions about certification can be directed to
  • DCFS if the provider is certified by DCFS
  • Cathy Cumpston at BALC (217-557-9282) for all
    other providers.

34
Services
  • The same types of services will generally be
    billable after 4/1/09 and the array of services
    is expanding in some areas to include other
    activities such as vocational services. The
    service descriptions and documentation
    requirements are changing for many services.

35
Services
  • The rates for most services are not changing, and
    residential rates will continue to be established
    by the Illinois Purchase Care Review Board
    (IPCRB).
  • However, application assistance (the old 51M) and
    case coordination (the old 50M) will now be
    reimbursed based case management on 15 minute
    units instead of a flat event rate of a flat
    monthly rate.

36
SERVICE CROSSWALK
37
SERVICE CROSSWALK
38
SERVICE CROSSWALK
39
Authorization Requirements
  • Residential ICG
  • An authorization request form and the required
    documentation must be submitted to the
    Collaborative within 72 hours of residential
    admission.
  • The initial authorization will typically be for
    120 days to allow the initial treatment plan to
    be complete before the next authorization is
    required.
  • CCMs authorize nights of stay approximately every
    90 days.

40
Authorization Requirements
  • Concurrent authorization
  • The authorization request form and all required
    documentation must be submitted 7 - 14 days prior
    to the expiration of the current authorization
    and Section B should be completed.
  • Concurrent authorization will typically be for 90
    days, unless the transition to community services
    or the termination of the grant appears imminent.

41
Authorization Requirements
  • Authorizations will be reviewed by LPHAs with
    child/adolescent experience.
  • If authorization is denied, the denial may be
    appealed.

42
Authorization Requirements
  • Community-based ICG services
  • Child Support Services (old 72 M) requires
    authorization for services after a 1,570
    threshold has been reached.
  • Behavior Intervention Management (old 97M)
    requires authorization for services once a 3,500
    threshold has been reached.
  • CBICG will require Quarterly Reports beginning
    4/1/09. The Quarterly Reports will replace the
    current 6 month reports.

43
Authorization Requirements
  • Therapeutic Stabilization is provided through
    Community Support Individual. There is no
    authorization required for this service.
  • Community Support Individual will be tracked on a
    case-by-case basis through post payment reviews.

44
Authorization Phase-in for Existing Youth in
Residential Settings
  • ICG youth who are in residential placements as of
    4/1/09 will not require authorizations prior to
    that date.
  • DHS/DMH will phase in authorizations for these
    clients between 4/15 and 7/15/09.

45
Authorization Phase-in for Existing Youth in
Residential Settings
  • The phase-in procedures are as follows
  • The Collaborative is in the process of compiling
    a list of ICG youth and their placements with the
    assistance of ICG/SASS workers and residential
    providers and expects to have a comprehensive
    census by April 1.
  • The Collaborative will build a transition
    authorization for each client from 4/1/09-
    4/15/09.

46
Authorization Phase-in for Existing Youth in
Residential Settings
  • If the first Quarterly or Annual Eligibility
    Review falls between 4/1 - 4/15, the client will
    be given an authorization through the same date
    in July. However, the extended transition
    authorization does not extend the due date for
    any Quarterly or Annual Eligibility Reviews that
    fall between 4/1 0 and 4/15.

47
Authorization Phase-in for Existing Youth in
Residential Settings
  • Transition authorization example
  • If the review date is 2/1/09, and the youth was
    admitted to residential care on 3/15/09, the
    transition authorization will expire 5/1/09 and
    the provider authorization request would be due 7
    - 10 days before that.

48
Authorization Phase-in for Existing Youth in
Residential Settings
  • The Collaborative will notify each provider in
    writing of authorization expiration dates for
    each client by March 31, 2009.
  • If a provider is serving an ICG youth that is not
    included on the list of authorization expiration
    dates, the residential provider is responsible
    for contacting the Collaborative by phone of the
    omission no later than April 10, 2009.

49
Differentiation of Quarterly/Annual Eligibility
Reviews and Authorizations
  • Quarterly and Annual Eligibility reviews are
    required by Rule 135 and relate to the youths
    continued eligibility for ICG funding.
  • Authorizations for residential nights of care
    relate to meeting medical necessity criteria for
    a residential level of care and are required for
    payment of residential per diem claims.

50
Billing for Services
  • Before billing for an ICG consumer, the ICG
    provider (for residential or community services)
    should assure that the consumer is registered to
    the provider under the appropriate ICG funding
    code (ICG for residential services and ICGC for
    community services).

51
Billing for Services
  • Residential providers are required to submit two
    types of claims - 1) per diem claims and 2)
    treatment encounters.

52
Billing for Services
  • Treatment service encounters represent the amount
    of treatment services provided during the
    residential day. No payment will be issued for
    these encounters, but providers will be expected
    to submit encounters equal to 40 of their per
    diem rate for the balance of FY2009. These
    encounters will be eligible for Medicaid
    reimbursement if the youth is Medicaid eligible
    and the service is allowable for Medicaid.

53
Billing for Services
  • For the balance of FY2009, providers will be paid
    their per diem rate, and payments will not be
    increased or decreased based on encounter levels.
    Encounter levels will be monitored against the
    40 target and payment adjustments may occur in
    the future if encounters are below target levels.

54
Billing Bed Holds
  • The Services Matrix contains new billing codes
    for bed holds and for special units and those
    codes apply as follows
  • Bed holds - Different billing codes are required
    to bill any day that a bed is being held for a
    youth that has been hospitalized or is otherwise
    not present at the facility. The requirements to
    approve bed holds above 59 days per year per
    client remain in place, but the bed hold codes
    should be used for any day that a youth is not
    present regardless of whether approval is
    required. Different code are required for group
    home and residential providers, S9986W017B and
    S9986W019B, respectively.

55
Billing Special Units
  • There are a small number of providers who have
    two residential units with different IPCRB rates
    at the same address, and one provider with three
    units at the same address. The special unit codes
    must be billed for youths placed into the special
    units and the authorization will also be tied to
    the special units to assure proper claims
    processing and payment. The special unit codes
    are S9986W020B, S9986W020M, S9986W021B and
    S9986W021M.

56
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