Appropriate Assessment and Identification of Persons Who Require an ICFMR Level of Care

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Appropriate Assessment and Identification of
Persons Who Require an ICF/MR Level of Care

• August 17, 2009
• Psychological Consultation and Assessment, Inc.
• Richard L. Workman, MA
• Linda O. Workman, MA

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Introduction

• Richard L. Workman, MA
• Educational Background
• Masters Degree Marshall University -1976
• Licensed Psychologist -1981
• Licensed School Psychologist - 1992
• Experiential Background
• Walter Reed Hospital 1971-1973
• Guthrie Center 1973-1974
• Kanawha County Schools 1976-1979
• Psychological Consultation and Assessment -1979
  to present

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Introduction

• Bureau for Medical Services 1983 to present
• On-site reviews annually
• Colin Anderson Center
• Greenbrier Center
• Green Acres
• Potomac Center
• ICF/MR Group Homes
• Eligibility Determinations
• ICF/MR
• MR/DD Title 19 Waiver
• CDCSP
• PASRR Coordination

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Introduction

• Linda O. Workman, MA
• Educational Background
• Masters Degree Marshall University 1975
• Licensed Psychologist 1981
• Licensed School Psychologist 1992
• Experiential Background
• Kanawha County Schools 1975-1980
• Psychological Consultation and Assessment 1981

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Introduction

• Bureau for Medical Services 1984 to present
• On-site reviews
• Colin Anderson Center
• Greenbrier Center
• Green Acres
• Potomac Center
• ICF/MR Group Homes
• Eligibility Determinations 2001 to present
• ICF/MR
• MR/DD Title 19 Waiver
• CDCSP
• Other
• PASRR Coordination
• On-site review for Day Treatment Programs
• Prior Authorization for Psychological Services
  Private Sector

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Training Outline

• Federal Perspective
• State Perspective
• PCA Perspective
• Historic Perspective
• Process Perspective
• More Information

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The Federal Perspective

• Congress established the Medicaid Program under
  Title XIX of the Social Security Act of 1965.
• Title XIX created the Medicaid Program to provide
  access to health care for certain low-income
  individuals and families.
• Medicaid is funded and administered through a
  cooperative state-federal partnership.

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The Federal Perspective

• Centers for Medicare Medicaid Services (CMS)
• Provide federal financial assistance to the
  states.
• Establish minimal program requirements.
• Provide regulatory oversight.

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The Federal Perspective

• Medicaid Program Requirements
• Broad federal requirements
• States have a wide degree of flexibility to
  design and administer their programs within
  federal guidelines
• Code of Federal Regulations

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The Federal Perspective

• Code of Federal Regulations (CFR)
• Codification of the general and permanent rules
• Published by the executive departments and
  agencies of the Federal Government
• It is divided into 50 titles that represent broad
  areas subject to Federal regulation.
• Each volume of the CFR is updated annually.
• Title 42, Sub-part C are the regulations
  pertaining to ICF/MR institutional level of care.

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The State Perspective

• Bureau for Medical Services
• (BMS)
• Administered pursuant to regulations promulgated
  under Title XIX of the Social Security Act, as
  amended.
• State administrative authority for the Medicaid
  Program is provided pursuant to Chapter 9 of the
  West Virginia Code.
• The Bureau for Medical Services (BMS) in the
  Department of Health and Human Resources (DHHR)
  is the single state agency responsible for
  administering the Medicaid Program in WV.

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The State Perspective

• The Bureau for Medical Services
• Establishes eligibility standards for Medicaid
  providers
• Determines benefits, sets payment rates, and
  reimburses providers.
• Coordinates and contracts with other entities to
  develop and implement Medicaid-related programs
  and services.
• Monitors and tracks program information related
  to member eligibility, service utilization,
  program expenditures, fraud and abuse, and
  financial management.

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The State Perspective

• Psychological Consultation and Assessment,
  Inc. (PCA) determines medical eligibility for
  the following services covered by the WV Medicaid
  Program
• Intermediate Care Facility Services for the
  Mentally Retarded (ICF/MR)
• Mentally Retarded/Developmentally Disabled Home
  and Community Based Waiver Services (MR/DD)
• Children with Disabilities Community Service
  Program (CDCSP)

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PCA Perspective
Initial Determination and Annual Redetermination
of Medical Eligibility
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Historic Perspective

• Institutions 1973
• Guthrie Center
• Huntington State Hospital
• Lakin State Hospital
• Weston State Hospital
• Colin Anderson Center
• Spencer State Hospital

• Institutions 2009
• Potomac Center
• ICF/MR Group Homes
• Waiver Group Homes

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Historic Perspective

• Deinstitutionalization in WV
• 1983-First on-site review of Individuals
  certified for an ICF/MR level of care.
• 1984-Began making eligibility determinations for
  small ICF/MR group homes and MR/DD Waiver.
• 1984-Annual on-site reviews of individuals
  requiring an ICF/MR level of care.
• 1985- First ICF/MR Waiver Manual, and eligibility
  determinations.

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The Process Perspective

• Determining Eligibility

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Step 1-Eligible Diagnosis

• A. Moderate Mental Retardation (MR) or below
• (or)
• B. Related Condition
• (and)
• C. Manifested prior to age 22

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Step 1 Eligible Diagnosis

• Related Conditions Any condition, other
  than mental illness, found to be closely related
  to mental retardation because this condition
  results in impairment of general intellectual
  functioning or adaptive behavior similar to that
  of mentally retarded persons, and requires
  services similar to those required for persons
  with mental retardation. Must be severe and
  chronic.
• May include
• Autism
• Traumatic Brain Injury
• Cerebral Palsy
• Spina Bifida
• Tuberous Sclerosis

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Step 1-Eligible Diagnosis

• If A or B is YES and C is Yes
• PROCEED!
• If No
• Eligibility for this applicant would be denied
  and the person would not require an ICF/MR
  institutional level of care.

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Step 2-Substantial Limitations

• Does the person have substantial limitations in
  three (3) of the six (6) major life areas?
• Self-Care
• Receptive or expressive language
• Learning
• Mobility
• Self-direction
• Capacity for independent living
• And manifested prior to age 22.

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Step 2-Substantial Limitations

• If substantial delays are present through
  adaptive behavior scores and behavioral
  descriptors, and manifested prior to age 22.
• PROCEED!
• If No
• Medical eligibility would be denied, and
  this person would not require an ICF/MR
  institutional level of care.

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Step 3-Active Treatment

• A. Does the person require aggressive,
  consistent implementation of a program of
  specialized and generic training, treatment, and
  health services?
• B. Does the person primarily require personal
  care services?
• C. Does the person primarily require verbal
  prompts?

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Step 3-Active Treatment

• If A is YES
• PROCEED!
• IF YES to B or C
• Medical eligibility for this person would be
  denied, and this person would not require an
  ICF/MR institutional level of care.

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Step 4-ICF/MR Level of Care

• Does the person require the equivalent of an
  ICF/MR institutional level of care?
• If YES
• Physician and independent psychologist must
  indicate that the person requires an ICF/MR level
  of care and packet developed to be submitted for
  determination of medical eligibility.

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The Process Perspective

• Certification

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Certification Process

• Does the physician certify and document the need
  for ICF/MR Level of Care?
• Does the physician indicate conditions that
  require special care?
• If YES proceed.

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Certification Process

• Has the Psychologist
• Addressed intelligence
• Provided adequate history to reflect
  developmental delay
• Provided a measure of adaptive behavior
• Indicated severity level for related condition
• If YES proceed.

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Certification Process

• Has the Psychologist (continued)
• Provided adequate diagnosis
• Indicated an ICF/MR level of care is required
• Confirmed substantial delays in 3 or more of the
  6 major life areas
• Provided diagnoses which are supported by
  appropriate assessment tools, background,
  history, and functional status
• If YES proceed.

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Certification Process

• Has the Social Worker
• Documented condition present during developmental
  period
• Reviewed family history
• Education History
• Employment History
• Recommended an ICF/MR level of care?
• If YES proceed.

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Certification Process

• Does the IPP document that the individual
  requires the level of support and training
  equivalent to an ICF/MR Level of Care?
• Are the IEP and educational needs consistent with
  the application packet?
• If YES proceed.

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Certification
Certification Process

• The individual would likely require an ICF/MR
  level of care if supported by required
  documentation.

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Summary

• Group exercise to demonstrate understanding of
  eligibility requirements.

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If Denied

• Right to Request for Fair Hearing
• 13 Days if terminated
• 90 Days if initial application
• Request for pre-hearing conference
• Provide additional documentation up to 5 days
  prior to hearing
• Present documentation and witnesses to support
  eligibility

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More information

• Questions
• Code of Federal Regulation
• Chapter 9 of the WV Code