Children’s Mental Health Waiver(CMH Waiver)

Prospective Provider

Informational Meeting

August 2005

Presented by:

Your Regional HCBS Specialist

What is a Medicaid Waiver?• A person eligible for a Medicaid waiver

“waives” his(her) entitlement to receive services in an institution.

• Approximately 2/3 of the cost of waiver services is covered by the Federal govt. and 1/3 of the cost of waiver services is covered by the county or the state.

I choose waiver

What is HCBS?• HCBS is the acronym for Home and Community Based

Services.• HCBS is the title for the Medicaid waiver program in the

state of Iowa.• There are currently six Medicaid HCBS waivers in the

State of Iowa. The CMH Waiver will be added as the seventh with a planned implementation date of October 1, 2005.

• Current HCBS waivers are AIDS/HIV, Brain Injury, Elderly, Ill and Handicapped, Mental Retardation and Physical Disability

• Differences among all waivers include the following:– Eligibility requirements– Availability statewide– Target populations– Level of care requirements– Caps on dollar amounts available– Menu of services available

The Concept• Waivers are:

– Supports in an individual’s home and/or community

– Designed for the individual needs of the specific person

– An array of services to meet the support needs of the population serviced by the specific waiver

– Supported by a team process with the individual as the focus and the main source of information

– Paid through Title XIX funding– Consumer-driven

Waivers Will Not:

• Pay room and board costs

• Replace responsibility of parents

• Replace natural supports

• Teach basic academics

• Provide a Cadillac service

• Become an emergency service for placements

CMH Waiver• The Children’s Mental Health Waiver provides funding

and individualized supports to eligible children in their homes and community.

• To be eligible, a child must meet the following:– Be diagnosed with a serious emotional disturbance– Be eligible for Medicaid under specific coverage groups– Be certified in need of hospital level of care– Be under age 18– Choose HCBS waiver services– Be a recipient of targeted case management services or be

eligible for targeted case management following approval.– Receive one billable unit of a CMH Waiver service per

calendar quarter– Have a service plan developed by an interdisciplinary team,

approved by the department, and completed, at least, annually

The Goal of CMH Waiver• The goal of the CMH Waiver is to:

– Maintain a child with severe emotional problems in the family home and circumvent the need for out of home placement

Or

– Reunification of a child placed outside of the family home because of severe emotional problems

TeamworkThe Interdisciplinary Team

(IDT)

• Team work is an integral part of providing quality services • An interdisciplinary team is established for each person• The ultimate goals of the CMH Waiver are to enhance the

individual’s abilities to:– Exercise choice– Take risks– Make decisions– Fully participate in their life, their communities and in society

• Team Member’s Roles and Responsibilities– Individual– Targeted Medicaid Case Manager– Service Providers– Significant Others

The Individual’s and the Family’s Role

• Exercise control

• Learn and understand rights and responsibilities

• Actively participate in CMH Waiver services

• Maintain active communication with the targeted case manager.

The Provider’s Role

• Develop and carry out service provision based on the service plan developed by the individual and the IDT.

• Develop and carry out service provision based on the philosophy of rights and dignity for the individual and his/her family.

• Maintain active communication with the targeted case manager.

The Case Manager’s Role

• Help individuals meet their needs in an effort to promote their independence, becoming part of society and making own decisions on matters affecting them

• Act as Advocate• Facilitate the individual’s access to the service system• Promote self-determination• Emphasize and promote individualism• Coordinate services with other providers• Ongoing communication• Request for information• Help providers • Monitor service utilization

CMH Waiver ServicesCHMW offers the following services:

– Environmental Modifications, Adaptive Devices and Therapeutic Resources

– Family and Community Support Services

– In-Home Family Therapy

– Respite

Determining Which CMH Waiver Services Will Be

Provided• The interdisciplinary team meets to decide

what service(s) and how much of each service is needed.

• The utilization of one or more of these services is based on the individual need of the child.

• The total cost of the CMHW service(s) to the child shall not exceed $1765 per month.

Environmental Modifications, Adaptive Devices and Therapeutic Resources

• Items installed within or purchased for the child’s home that are a specific documented health and safety concern for the child

• Smoke alarms, window/door alarms, page supports, fencing, motion detectors, etc.

• Therapeutic resources retained by the family to enhance the child’s formal mental health objectives

• Books, training packages, and visual or audio media recommended by the interdisciplinary mental health professionals. These resources are the property of the child and family.

• This service has a maximum of $6000 per yr/$500 per month.

• Providers are community businesses or enrolled home and vehicle mod providers under another HCBS waiver.

Providers Eligible To Enroll for

Environmental Modifications, Adaptive Devices and Therapeutic Resources

• Community businesses

• Home and Vehicle Modification providers currently enrolled under another HCBS waiver

Family and Community Support Services

• Based on the recommendation of the mental health professionals on the child’s interdisciplinary team, the following supports can be provided under this service:– Development of daily living skills– Development of positive socialization and

citizenship skills in the community– Development of a crisis support network

• A unit of service is one hour – up to $33.62 per hour or up to $75.83 per day

Providers Eligible To Enroll for

Family and Community Support Services

• RTSS providers designated under IAC 441—185 RTSS, Skill Development Services

• Community Mental Health Center and Mental Health Services Providers accredited according to IAC Chapter 24 – Outpatient Psychotherapy and Counseling standards.

In-Home Family Therapy• This service proves skilled therapeutic

services to the child’s family. The therapy addresses the fragmented relationships due to the effects of the child’s serious emotional disturbances.

• A unit of service is a minimum of one hour.

• The unit maximum is $90.00.

Providers Eligible To Enroll for

In-Home Family Therapy

• RTSS providers designated under IAC 441—185 RTSS, Therapy and Counseling Services 185.10(1)a

• Community Mental Health Center and Mental Health Services Providers accredited according to IAC Chapter 24 – Outpatient Psychotherapy and Counseling standards

Respite • Respite services are services provided to the child

that give temporary relief to the usual caregiver. • There are three types of respite care:

– Basic – one staff to one child – nurse is not needed– Specialized – one or more nursing staff (RN or LPN) to one

child– Group – one staff to two or more children – nurse is not

required

• Respite can’t be given when the caregiver is at work unless the respite is in a camp setting.

• The usual caregiver can not be absent over 14 consecutive days.

• A unit of service is one hour – hour/daily cost limits based on the provider enrollment status

Eligible Respite Providers• Home health agencies certified to participate in the Medicare

program• Nursing facilities, ICF/MR’s, hospitals • Group foster care facilities licensed under IAC 441—112, 114,

116• Child care facilities licensed under IAC –110• Camps certified by ACA• Home Care agencies meeting DPH rules• Adult Day Care providers certified by DIA and compiling with

DEA • RCF/MRs• Assisted Living programs certified by DIA• Providers certified or enrolled as a respite provider for other

HCBS waivers• Agencies that meet the requirements of subrule 77.37(1), (3-9)

Provider Enrollment• The projected date for the completion of the MMIS

programming that will allow eligible providers to enroll is August 15, 2005.

• The revised provider application and the date that enrollment can begin will be posted on the CMH Waiver website: www.ime.state.ia.us– Click on Children’s Mental Health Waiver under Quick Links.– Click on Provider Enrollment.

• IME Provider Services processes all potential provider applications– www.IME.state.ia.us– Attachment A Draft

• Current Medicaid HCBS Waiver Provider Application

• IME may request information needed to process the enrollment:– Current accreditations, evaluations, inspection reports, and reviews by regulatory licensing

agencies and associations– Fiscal capacity of the prospective provider to initiate and operate the specific programs on

an ongoing basis

CMH Waiver Services Documentation for the Provider Application

• Environmental Modifications, Adaptive Devices and Therapeutic Resources– Community Business Attach business tax identification number or

current proof of liability and workers compensation coverage.– Provider Enrolled Under HCBS MR or BI Supported Community

Living No documentation is required

• Family and Community Support Services– Community Mental Health Center or Mental Health Service

Providers Enter your Medicaid provider number or attach a copy of your certificate of accreditation.

– RTSS Provider Enter your Medicaid provider number or attach a copy of your certificate of accreditation in skill development

CMH Waiver Services Documentation for the

Provider Application

• In-Home Family Therapy– Community Mental Health Center or Mental Health Service Providers Enter

your Medicaid provider number or attach a copy of your certificate of accreditation.

– RTSS Provider Enter your Medicaid provider number or attach a copy of your certificate of accreditation in therapy and counseling

• Respite– Refer to the current HCBS Waiver Provider Application for available categories

and corresponding documentation required for enrollment.

The Provider Manual

• Once you are enrolled as a provider, a provider manual will be made available for your reference from IME Provider Services. It will look like this:

• This manual addresses service descriptions, completing claim forms, error notice information, etc. It is essential that you maintain and utilize this manual.

STATE OF IOWA DEPARTMENT OF HUMAN SERVICES

MEDICAID

PROVIDER MANUAL

WAIVER SERVICES

Types of Reimbursement

• Retrospectively-limited Prospective Rates– Family and Community Support Services

• Fee Schedule– Environmental Modifications, Adaptive Devices and

Therapeutic Resources– In-Home Therapy– Respite

Retrospectively-Limited Prospective Rates

• IAC 441—79.1(1)e – “Providers are reimbursed on the basis of a rate for a unit of service calculated prospectively for each participating provider based on projected or historical costs of operation, subject to maximums listed in 79.1(2) and to retrospective adjustment based on an actual, current cost of operation ….”

• Translation:– New providers must submit forms to IME to establish rates– Costs are reconciled annually via a cost report for the fiscal year which

runs from July 1 of the previous year through June 30 of the current year– Providers who have a minimum of six months of actual costs for that

fiscal year will have a rate set based on those costs– The rate must stay within the parameters of the upper limit for the

service as identified IAC 441—79.1(2)

Setting the Retrospectively-Limited Prospective Rate

• Specific forms must be submitted to the IME Provider Audits and Rate Setting Unit to set this rate for Family and Community Support Services.

– Contact Tom Donahue, IME Provider Audit and Rate Setting at tdonahu@dhs.state.ia.us or 515-725-1256.

Or

– Contact any of the regional HCBS Specialists listed on Attachment D for technical assistance or training.

Fee Schedule• IAC 441—79.1(1)c(1-2) “Fee schedules are determined by the

department with advice and consultation from the appropriate professional group. The fees are intended to reflect the amount of resources (time, training,experience) involved in each procedure. Providers on fee schedules are reimbursed the lower of:– (1)The actual charge made by the provider of the service– (2) The maximum allowance under the fee schedule for the

item of service in question”• Translation: Fee scheduled services do not require rate setting.

The schedule upper limits have already been determined by the department. Providers of fee schedule services should charge the actual cost of delivering the service or the maximum allowed for the fee scheduled service – which ever is the lowest.

PLEASE NOTE: Before CMH Waiver

Services Can Be Paid

• Waivers are paid through Title XIX funds. The following must be in place for a provider to be paid for services:– The provider must be enrolled as a waiver provider for the

service– The consumer must be an eligible waiver consumer– The team must agree on the service – The service must be ordered in the plan and on ISIS– The funder must approve the service/cost on ISIS– The rate for the service shall be the rate agreed on by the

team and meet the limitation guidelines under Chapter 79.– Units billed must meet the parameters of Chapter 78.

• Any waiver provider must complete form 470-2965, Agreement Between Provider of Medical and Health Services and Iowa DHS Regarding Participation in Medical Assistance Program. This form completion is part of the enrollment process through IME Provider Services.

• Including other statements of agreement, the waiver provider assures the Iowa DHS of the following:– That complete service and fiscal records are kept to show the

extent of goods and/or services provided to individuals receiving assistance under the Iowa Medical Assistance program.

The Provider Agreement Form

IAC 441 -- 79.3(2) Clinical Records (or Service Records)

• Providers of service shall maintain complete clinical records. Clinical records means “a service record that fully documents the extent of the Medicaid service provided.”

Clinical Records

Of Service Provision

• Clinical or service records shall contain the following:– Name of the waiver service provided– Date of service– Signature of staff providing the service– Duration of the services provided, if applicable– Service Interventions– Documented progress as a result of the service

intervention, if applicable to the service

Clinical or Service Record Requirements

IAC 79.3(1) Fiscal records (Billing)– Providers of service shall maintain fiscal records in support of

services for which a charge is made to the program and shall make the records available to the department or its duly authorized representative on request. The fiscal records shall support each item of service for which a charge is made to the program. The fiscal record does not constitute a clinical (service) record .

– Waiver providers must maintain fiscal records necessary to fully disclose the extent of the service provided.

– Fiscal reporting requirements are the responsibility of IME Provider Audit and Rate Setting. Future training will be provided.

Fiscal Records and Services

IAC 441 -- 79.3(3) Failure to maintain supporting fiscal and clinical (service) records may result in claim denials or recoupment.

IF YOU DON’T KEEP THIS INFORMATION ----

IAC 441—79.3(249A) Maintenance of fiscal and clinical records by providers of service.

• The fiscal and clinical records shall be maintained for a minimum of five years from when a charge was made to the program.• After five years, the fiscal and clinical records may be destroyed.

Maintaining Agency Records

DRAFTPolicy and Procedure Development

• Family and Community Support Services– Attachment B

• Respite– Attachment C

Quality Assurance• An outcome-based quality assurance review is

proposed for the following services:– Family and Community Support Services– Respite

• The review shall consist of in-person interviews with the children and their families receiving services conducted by the regional HCBS specialists.

• The review may also consist of interviews with the Medicaid targeted case manager and provider staff. Casefile review, staff training records and other organizational documentation specific to CMH Waiver services may be reviewed.

Technical Assistance

• Please remember that technical assistance and further training is available through the regional HCBS specialists assigned statewide.– Retrospectively-limited prospective rate development and

fiscal reporting requirements– Policy and procedure development– Documentation of service provision– The philosophy of waiver service delivery

• Please see Attachment D for the complete listing.