Transcript Rule 132 Medicaid Community Mental Health Service Program

Rule 132 Medicaid Community Mental
Health Service Program
Seth Harkins, Ed.D.
Director, ICG Program
Department of Human Services
Division of Mental Health
Lee Ann Reinert, LCSW
Clinical Policy Manager
Department of Human Services
Division of Mental Health
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Application to the
Individual Care Grant
Program
Presented March 31, 2009
Agenda
Understand the purpose and vision of Rule
132
 Understand the requirements of Rule 132
 Understand the Individual Care Grant
(ICG) services covered by Rule 132
 Questions
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Presented March 31, 2009
Illinois Rule 132
As the state mental health authority, the
Department of Human Services, Division of
Mental Health (DHS/DMH) uses Rule 132 to
govern optional mental health Medicaid
benefits in Illinois.
http://www.ilga.gov/commission/jcar/admincode
/059/05900132sections.html
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Presented March 31, 2009
Underlying Vision of Recovery and
Resilience
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Recovery refers to the process in which
persons are able to live, work, learn, and
participate fully in their communities.
For some individuals, recovery is the ability
to live a fulfilling and productive life despite a
disability.
For others, recovery implies the reduction or
complete remission of symptoms.
Science has shown that having hope plays
an integral role in an individual’s recovery.
Presented March 31, 2009
Underlying Vision of Recovery and
Resilience (cont)
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Resilience means the personal and
community qualities that enable us to
rebound from adversity, trauma, tragedy,
threats, or other stresses – and to go on with
life with a sense of mastery, competence,
and hope.
Presented March 31, 2009
Underlying Vision of Recovery and
Resilience (cont)
We now understand from research that
resilience is fostered by a positive
childhood and includes positive
individual traits, such as optimism,
good problem-solving skills, and
treatments.
 Closely-knit communities and
neighborhoods are also resilient,
providing supports for their members.
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Presented March 31, 2009
Rule 132 Requirements
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Certification Process
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In order to bill for Rule 132, providers must be
certified by the DHS Bureau of Accreditation,
Licensure and Certification
Covered in previous trainings
Call Cathy Cumpston at 217-557-9282 for
certification questions
Recertification
Presented March 31, 2009
Rule 132 Requirements
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Role Definitions and Supervision
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Licensed Practitioner of the Healing Arts (LPHA)
Qualified Mental Health Professional (QMHP)
Mental Health Professional (MHP)
Rehabilitative Services Associate (RSA)
Clinical Record
Utilization Review
Post Payment Review
Presented March 31, 2009
ICG services billable under Rule 132
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Group A – Evaluation and Planning
Group B – Mental Health Services
Group C – Non-Medicaid Services
State of Illinois
Community Mental Health Services
Service Definition and Reimbursement Guide
http://www.hfs.illinois.gov/assets/070107_cmph
_guide.pdf
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Presented March 31, 2009
Group A Services
Evaluation and
Planning
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Presented March 31, 2009
Mental Health Assessment
A formal process of gathering information
 Results in treatment recommendations
 Diagnosis of mental illness not required
prior to beginning process
 Completed within 30 days of start of
treatment
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Presented March 31, 2009
Mental Health Assessment (Cont)
MHP may participate
 Requires at least one face to face contact
with QMHP and signature
 Requires review and signature by LPHA
 Required elements listed within the Rule
 Updated annually by QMHP who has at
least one face to face contact
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Presented March 31, 2009
Treatment plan development, review
and modification
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Services Crosswalk: 50M Care Coordination
For treatment provider
Presented March 31, 2009
Treatment plan development, review
and modification
Process resulting in a written Individual
Treatment Plan
 Developed with active participation by
individual being served and
parent/guardian
 Based on MHA and any additional
evaluations
 Prescribes treatment recommended
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Presented March 31, 2009
Treatment plan development, review,
and modification
Completed within 45 days of completion of
MHA
 MHP may participate, QMHP responsible
for process and must sign plan
 LPHA must review
 Date of LPHA’s signature is considered
effective date of the ITP
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Presented March 31, 2009
Treatment plan development, review,
and modification
Required elements are listed in the Rule
 Must include definitive 5-axis diagnosis.
Record must document plan for any
diagnostic questions remaining at the time
of ITP development.
 Must be reviewed no less than every 6
months
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Presented March 31, 2009
Treatment plan development, review,
and modification
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Shall include
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Signatures
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Continuity of care planning with parent/guardian,
Estimated transition/discharge date
Goals for continuing care
Under 12: parent or guardian
Over 12, under 18: Individual served and parent/guardian
Over 18/emancipated minor: individual served
Over 18, adjudicated legally incapable: individual served
and legal guardian
Presented March 31, 2009
Psychological evaluation
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Must be medically necessary
Must be conducted within 90 days of the ITP
Must utilize nationally standardized
psychological assessment instruments
Must result in written report including
formulation of problems, tentative diagnosis,
recommendations for treatment/services
Presented March 31, 2009
Group B Services
Mental Health
Services
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Presented March 31, 2009
Mental Health Services
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Following MHA (or Admission Note in certain
circumstances)
Consistent with ITP (or Admission Note in
certain circumstances)
Face to face, video conference, telephone
contact
Presented March 31, 2009
Mental Health Services (cont)
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Provided to:
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Individuals
Families of individuals
Groups of individual consumers
For the primary benefit and well-being of the
individual
Related to an assessed need and goal on the
ITP
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Presented March 31, 2009
Mental Health Services (cont)
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Services may be provided on-site or off-site,
as indicated by the specific service
Presented March 31, 2009
Crisis Intervention Services
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Activities to stabilize an individual in
psychiatric crisis
Goal of immediate symptom reduction,
stabilization, and restoration to a previous
level of role functioning
May be provided by MHP with immediate
access to QMHP
Presented March 31, 2009
Crisis Intervention Services
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Services Crosswalk – 87M Therapeutic
Stabilization
One of an array of Rule 132 services
Service must be provided and documented in
accordance with definition and rule
requirements
Presented March 31, 2009
Psychotropic Medication Services
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Psychotropic Medication Administration
Psychotropic Medication Monitoring
Psychotropic Medication Training
Presented March 31, 2009
Psychotropic Medication Services
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Psychotropic medication administration
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Time spent preparing the individual and the
medication for administration
Administering psychotropic medication
Observing the client for possible adverse
reactions
Returning medication to proper storage
Minimum staff: LPN under RN supervision
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Presented March 31, 2009
Psychotropic Medication Services
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Psychotropic medication monitoring
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Monitoring and evaluating target symptom
response
Monitoring for adverse effects, including tardive
dyskinesia screening
Monitoring for new target symptoms or medication
Staff must be designated in writing by a
physician or advanced practice nurse
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Presented March 31, 2009
Psychotropic Medication Services
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Psychotropic medication training
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Training the individual or the individual’s
family/guardian to
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Administer the individual’s medication
Monitor levels and dosage
Watch for side effects
Staff must be designated in writing by a
physician or advanced practice nurse
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Presented March 31, 2009
Therapy/Counseling
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May be provided to
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Individual
Group of 2 or more individuals
A family
Minimum Staff: MHP
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Presented March 31, 2009
Therapy/Counseling (cont)
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Examples
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Cognitive behavioral therapy
Functional family therapy
Motivational enhancement therapy
Trauma counseling
Anger management
Sexual offender treatment
Presented March 31, 2009
Community Support
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Community Support – Individual (CSI)
Community Support – Group (CSG)
Community Support – Residential (CSR)
Minimum staff: RSA
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Presented March 31, 2009
Community Support
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Location of service
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CSI and CSG – at least 60% must be provided in
natural settings
CSR – must be billed as on-site
For CSG, group size must not exceed 15
individuals
Presented March 31, 2009
Community Support
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Services and supports necessary to assist
individuals in achieving rehabilitative,
resiliency and recovery goals
These services facilitate:
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Illness self-management
Skill building
Identification and use of natural supports
Use of community resources
Presented March 31, 2009
Community Support – Individual/Group
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Services Crosswalk – 87M Therapeutic
Stabilization
One of an array of Rule 132 services
Service must be provided and documented in
accordance with definition and rule
requirements
Presented March 31, 2009
Examples of Community Support
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Coordination and assistance with
identification of individual strengths,
resources, preferences and choices
Assistance with the identification of existing
natural supports for development of a natural
support team, and in building such a team
Assistance with the identification of risk
factors related to relapse and development of
relapse prevention plans and strategies
Presented March 31, 2009
Examples of Community Support
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Support and promotion of self-advocacy and
participation in decision making, treatment
and treatment planning
Support and consultation with
individual/support system directed primarily
to the well-being and benefit of the individual
Presented March 31, 2009
Examples of Community Support
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Skill building in order to assist in
development of functional, interpersonal,
family, coping, and community living skills
that are negatively impacted by the
individual’s mental illness
Presented March 31, 2009
Community Support Is NOT:
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Supervised Meals
“Book-end Billing”
General Milieu Time
Presented March 31, 2009
Case Management Services
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Case management vs. Community support:
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Case management does for the client
Community support teaches the client how to do
for self
Presented March 31, 2009
Case Management Services
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Mental Health Case Management
Client Centered Consultation
Transition Linkage and Aftercare
Presented March 31, 2009
Case Management – Mental Health
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Assessment, planning, coordination and
advocacy
For individuals who
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Need multiple services
Require assistance in gaining access and using
services
Identification and Investigation of available
resources
Presented March 31, 2009
Case Management – Mental Health
(cont)
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Explaining options to the individual
Linking the individual with appropriate
resources
Minimum staff: RSA
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Presented March 31, 2009
Case Management – Mental Health
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Services Crosswalk – 51M
Application assistance for youth currently
receiving DMH funded services with a
Recipient Identification Number (RIN)
Presented March 31, 2009
Examples of Case Management –
Mental Health
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Helping individual access appropriate mental
health services, including the ICG program
Applying for public entitlements
Locating housing
Obtaining medical and dental care
Obtaining other social, educational,
vocational or recreational services
Presented March 31, 2009
Examples of Case Management –
Mental Health
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Assessing the need for service
Identifying and investigating available
resources
Explaining options
Assisting in application process
Presented March 31, 2009
Client Centered Consultation
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An individual client-focused professional
communication
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Between provider staff
With staff of other agencies
With other professionals or systems who are
involved with providing services to a client
Must be provided in conjunction with one or
more Group B mental health services
Minimum Staff: RSA
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Presented March 31, 2009
Client Centered Consultation
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Services Crosswalk: 50M Care Coordination
For ICG/SASS worker – during youth’s
residential stay (not at transition times)
Presented March 31, 2009
Examples of Client Centered
Consultation
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Face to face or telephone contacts (including
scheduled meetings or conferences)
between provider staff, staff of other
agencies, and child-caring systems
concerning the individual’s status
Contacts with educational, legal or medical
system
Staffing with school personnel or other
professionals involved in treatment
Presented March 31, 2009
Transition Linkage and Aftercare
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Services are provided to assist in an effective
transition in living arrangement consistent
with the individual’s welfare and development
Minimum staff: MHP
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Presented March 31, 2009
Transition Linkage and Aftercare
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Services Crosswalk – 50M Care
Coordination
For ICG/SASS worker, during transitional
phases of residential placement
Presented March 31, 2009
Examples of Transition Linkage and
Aftercare
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Services provided to individuals being
discharged from inpatient psychiatric care,
transitioning to adult services, moving into or out
of one placement to another placement or
parent’s home
Time spent planning with staff of current living
arrangement or the receiving living arrangement
Time spent locating client-specific placement
resources, such as meetings and phone calls
Presented March 31, 2009
Psychosocial Rehabilitation
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Facility-based rehabilitative skill-building
services
Individuals 18 or older
Available at least 25 hours/week at least 4
days/week
Adjunct service to community support
Presented March 31, 2009
Psychosocial Rehabilitation (cont.)
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Program director must be at least QMHP
Delivered by at least an RSA
Staff to client ratio shall not exceed 1 to 15
Document each session of service
Only billable for ICG-Community, age 18 and
older
Presented March 31, 2009
Group C
Non-Medicaid
Services
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Presented March 31, 2009
Group C – Non-Medicaid
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Oral interpretation and sign language
Vocational Services – age 14 or older only
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Vocational Engagement
Vocational Assessment
Job finding supports
Job retention supports
Job leaving/termination supports
Presented March 31, 2009
Oral Interpretation and Sign Language
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Service necessary to ensure provision of
mental health services to individuals whose
primary language is not English, or who have
hearing impairment
Need must be indicated on MHA
Must be performed in conjunction with
another medically necessary, billable service
Presented March 31, 2009
Vocational Engagement
Activities for a specific client to engage that
client in making a decision to actively seek
competitive employment or formal
credit/certificate bearing education
 Goal for employment or preparation for
employment must be on ITP
Minimum staff: RSA
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Presented March 31, 2009
Vocational Engagement Caveats
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Does not include provider-based prevocational programs or educational programs
that do not result in credentials recognized
by an employer
Activities related to employment that may be
viewed in terms of the client’s broader
rehabilitative or social functioning skills & are
not job specific should be expressed in those
terms and billed as Medicaid-covered
Presented March 31, 2009
services
Vocational Assessment
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Developing a vocational profile to guide
individual choices in seeking and maintaining
competitive employment
Minimum staff: RSA
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Presented March 31, 2009
Vocational Assessment
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Vocational profile typically includes:
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Work history
Interests
Skills
Strengths
Education
Impact of symptoms on ability to use strengths
Job preferences
Presented March 31, 2009
Vocational Assessment
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Client’s vocational goals should be integrated
in the treatment plan
Does not include pre-vocational work
experiences or simulated/situational work
experiences at the provider’s site
Presented March 31, 2009
Job Finding/Retention Supports
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Activities for a specific individual, directed
toward helping to find and procure a job/keep
the job
Provided under the following conditions:
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Placement based on consumer job preferences
Competitive employment in integrated work
settings
Ongoing supports as needed
Integration of supported employment services
with other mental health services
Presented March 31, 2009
Job Finding/Retention Supports
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At least 40% delivered in natural settings
This does not include general job
development
Minimum staff: RSA
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Presented March 31, 2009
Job Finding/Retention Supports
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Interventions must be specific to work and
the job
Therapeutic supports to help individuals
manage symptoms as they work toward
achieving recovery goals should be
distinguished from this service
Presented March 31, 2009
Job Leaving/Termination Supports
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Activities for a specific individual, who is
employed, directed toward helping them
leave a job in good standing.
May also be provided to help client see
unplanned job loss as transitional, and a
learning experience that will help with the
next job.
Presented March 31, 2009
Job Leaving/Termination Supports
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Provided to ensure that job loss is not seen
as a reason to discontinue participation in
supported employment
Minimum staff: RSA
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Presented March 31, 2009
Other ICG Billable Services
Overview of Material
Covered in Previous
Training
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Presented March 31, 2009
Other ICG billable services
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51M Application Assistance
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72M Child Support Services
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S9986 / W051M – Pseudo RIN Application
Assistance
For youth who are new to DMH system and do
not have RINs
S9986 / W072M – ICG Child Support Services
Will require authorization over $1575 per youth
Presented March 31, 2009
Other ICG billable services
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97M Behavior Management
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17M Group Home
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S9986 / W097M – ICG Behavior Management
Will require authorization over $3500 per youth
S9986 / W017M – ICG Services Group Home
(Consumer Present)
S9986 / W017B – ICG Services Group Home
(Bed Hold)
Presented March 31, 2009
Other ICG billable services
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19M Residential
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S9986 / W019M – ICG Services Residential
(Consumer Present)
S9986 / W019B – ICG Services Residential (Bed
Hold)
S9986 / W020M or W021M – Residential special
unit #1 or #2 (Consumer Present)
S9986 / W020B or W021B – Residential special
unit #1 or #2 (Bed Hold)
Presented March 31, 2009
Questions
Seth Harkins, Ed.D.
Director, ICG Program
Department of Human Services
Division of Mental Health
Lee Ann Reinert, LCSW
Clinical Policy Manager
Department of Human Services
Division of Mental Health
Cathy Cumpston, Chief
Bureau of Accreditation, Licensure and Certification
Department of Human Services
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Presented March 31, 2009