Transcript Individual Care Grant Program Training, March 3 & 5, 2009
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
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.
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
What’s 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
What’s 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
What’s 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.
What’s 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Services will be billed using the DMH Service Matrix and the old ICG codes are no longer valid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
What’s 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
What’s 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
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.
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.
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 youth’s community in order to support the treatment plan. This includes participation in IEP meetings.
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 90 th day of residential treatment.
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 youth’s 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)
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.
The Role of the Collaborative
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.
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
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
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.
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
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.
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.
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.
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 client’s treatment?
Describe the nature of their involvement and state whether or not it is sufficient to the client’s 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.
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.
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.
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
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/guardian’s 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.
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.
Medicaid Application
The date of the application for Medicaid and the consumer’s Medicaid eligibility status will be required in order to obtain authorization for residential nights of care.
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.
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.
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.
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.
SERVICE CROSSWALK
50M Care Coordination 50M Care Coordination 51M Application Assistance 51M Application Assistance 72M Child Support Services 87M Therapeutic Stabilization 97M
Old
Behavior Management
New
Community Services
H0032 Treatment plan development For treatment provider T1016 Client centered consultation
Comments
For ICG/SASS worker T1016 Case management mental health S9986 W051M Psuedo RIN Application assistance For youths currently receiving DMH funded services with a RIN For youths who are new to the DMH system and do not have RINs S9986 W072M ICG child support services H2015 Community support individual and group H2011 Crisis intervention S9986 W097M ICG behavior management Will require authorization if total expenses exceed $1,570 per youth per year Therapeutic stabilization will now be comprised of an array of Rule 132 services and the service billed must be provided and documented in accordance with the definition and requirements in the Rule.
Will require authorization if total expenses exceed $3,000 per youth per year
SERVICE CROSSWALK
51M Application Assistance 51M Application Assistance 72M Child Support Services 87M Therapeutic Stabilization T1016 Case management mental health S9986|W051M Psuedo RIN Application assistance S9986|W072M ICG child support services H2015 Community support individual and group H2011 Crisis intervention For youth currently receiving DMH funded services with a Recipient Identification Number (RIN) For youth who are new to the DMH system and do not have RINs Will require authorization if total expenses exceed $1,570 per youth per year Therapeutic stabilization will now be comprised of an array of Rule 132 services and the service billed must be provided and documented in accordance with the definition and requirements in the Rule.
97M Behavior Management S9986|W097M ICG behavior management Will require authorization if total expenses exceed $3,000 per youth per year
Additional community services are billable for ICG youth, such as assessments, counseling and vocational services. See the Services Matrix for a comprehensive listing of services billable under the ICGC Program code.
SERVICE CROSSWALK
17M Group Home 19M Residential 19 M Residential
Residential Services (per diem bills)
S9986|W017M ICG services group home Consumer present S9986|W017B ICG services group home Bed hold—should be billed for any overnight that the consumer is not present S9986|W019M ICG services residential S9986|W019B ICG residential Consumer present Bed hold—should be billed for any overnight that the consumer is not present S9986 W020M or W021M Residential special unit #1 or #2—consumer present S9986|W020B or W021B Only applies to residential providers who have more than one unit and IPCRB rate at a single address Residential special unit #1 or #2—bed hold
Residential Treatment Services (encounters)
Services provided during the residential day are billable as encounters and additional instructions are provided under the Residential Billing section below.
Refer to the Services Matrix for the services listed under the ICG program code for the services that can be submitted as residential encounters.
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.
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.
Authorization Requirements
Authorizations will be reviewed by LPHAs with child/adolescent experience.
If authorization is denied, the denial may be appealed.
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.
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.
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.
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.
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.
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.
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.
Differentiation of Quarterly/Annual Eligibility Reviews and Authorizations
Quarterly and Annual Eligibility reviews are required by Rule 135 and relate to the youth’s 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
.
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).
Billing for Services
Residential providers are required to submit two types of claims - 1) per diem claims and 2) treatment encounters.
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.
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.
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, S9986|W017B and S9986|W019B, respectively.
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 S9986|W020B, S9986|W020M, S9986|W021B and S9986|W021M.