Transcript Document 7542016

Magellan Training: Medicaid Rehabilitation Option
MRO
Initial Auth
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What information do I need when I call?
 Current diagnosis (onset)
 Rehabilitation Assessment
Functional Limitations
 Rehab Plan
 Licensed clinician contact
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MRO Re-Auth Form
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Client Name and SS#
Agency Name and Contact Person
Auth End Date
Medications and Number of Face to Face
Current Dx
Program Type or Service
Medicaid ID# and Service Location
MRO Re-Auth Form
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Rehabilitation Need
Measureable Goal
Progress on Goal
Crisis Plan (include something other than ER or 911)
Discharge Plan and ELOS
Hospitalizations or ER visits in report period
Psychiatrically Stable (if not a brief description)
Specific Functional Limitations R/T Major Mental Health Diagnosis
Specific Functional Limitations
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Must be the result of long term mental illness
Must be present for one year
Must be pervasive across life skills areas
Must require life skills training to improve client’s quality of life
MRO
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Medicaid Chapter 35
PRR, ACT, DR, CS
Active Life skill training
Assessment based
Client centered
Realistic goals
Crisis plan
Medicaid Rehab Option Guidelines
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Must meet SPMI status
Must have functional limitations
May have other diagnosis as secondary
SPMI Guidelines
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At risk of institutionalization if services not provided
Seriously interferes with functioning
Has had one year or will have
Results in functional deficits in two of three life skills areas.
SPMI Con’t
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Not primary substance abuse
Not primary developmental disabilities
Major Life Skills Areas
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Voc/Educational
Social Skills
Activities of Daily Living
Vocational/Educational
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Inability to be employed
Inability to pursue education
Inability to carry out home management tasks (meals, laundry,
budgeting, child care)
Social Skills
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Inappropriate
Inadequate
Participates only with extensive support
History of dangerousness
Activities of Daily Living
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Inability to consistently perform
 Hygiene, grooming, meals
 Personal business
 Transportation, care of residence
 Medical, legal, housing
 Avoidance of common dangers
MRO Authorization Considerations
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Careful examination of functional limitations.
Focus on where the limitations can best be addressed (home or club
house).
Compensatory training not cure.
Not a life time service (except ACT)
Without assessment and diagnosis we cannot authorize these services.
Authorization Considerations
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A major mental illness alone is not sufficient for SPMI
Presence of symptoms is not sufficient
Provider must link functional deficits to Axis I disorder
NOS not acceptable
Considerations con’t
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Brain injury
Typically developmentally delayed have not met milestones
Axis I typically have met milestones
Considerations con’t
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Across settings
Long term
Requires support/intervention
Medication
Our case notes/hx of care
Compensation not cure
Considerations con’t
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Long term sub abuse and homelessness often look like SPMI,
because many SPMI have both.
TBI often look like SPMI
Psychiatric Residential Rehab
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SPMI
These deficits require 24 hour psychiatric residential setting
The need is 24 behavioral monitoring
Day Rehab
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Day Rehab
 The need: Day structure to work on socialization/self care/pre-voc
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Community Support
 The need: Case management
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In home work on self care
Household/ADL tasks
Community Support
 The need: Case management and
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In home work on self care
Household/ADL tasks
Authorization Considerations
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PRR and DR are authed together for those who have both needs
CS and DR are authed together for those who have high social needs
plus in home needs.
CS is not authed with PRR (except 30 days in/out)
ACT
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Two in Omaha
One in Lincoln
One in Hastings
ACT Guidelines
 The need: SPMI plus high utilization of emergency/hospital
services
 Poor response to lower levels of care
 24 hour available intervention
 Poor response to other treatment
General MRO Admission
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Meets Admit guidelines
Does not require a higher LOC
A lower LOC is not indicated
Likelihood of benefit from service
Is making progress
General MRO Continuing Stay
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Meets Admission guidelines
Does not require a higher LOC
A less intensive LOC is not appropriate
Reasonable likelihood of benefit
Is making some progress in rehabilitation goals
General MRO Exclusion
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Not SPMI
Primary substance abuse or DD
Does not have functional deficits in two or three areas
Resides in a Nursing Home or PRR
Needs a higher LOC
General MRO Discharge
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Maximum benefit
Sustainability plan in place
Supports in place
Crisis relapse plan in place
Or the individual requests discharge
Q&A