Department of Medical Assistance Services

1. Department of Medical Assistance Services Discuss Office of Behavioral Health The mission of the OBH is to provide high quality, person-centered, recovery based, and appropriate behavioral health and substance abuse services to Virginia Medicaid and CHIP participants. The operation of the CMH Waiver fits well within the mission of the OBH, and is a critical part of the agency’s strategic plan to increase community-based options for children with behavioral health needs, and reduce dependency on institutional settings. The OBH was created in January 2010 to oversee policy and operations of Medicaid-funded behavioral health services. Discuss Office of Behavioral Health The mission of the OBH is to provide high quality, person-centered, recovery based, and appropriate behavioral health and substance abuse services to Virginia Medicaid and CHIP participants. The operation of the CMH Waiver fits well within the mission of the OBH, and is a critical part of the agency’s strategic plan to increase community-based options for children with behavioral health needs, and reduce dependency on institutional settings. The OBH was created in January 2010 to oversee policy and operations of Medicaid-funded behavioral health services.

2. This presentation is to facilitate training of the subject matter in portions of the Virginia Medicaid manuals Training material contains only highlights of manuals and is not meant to substitute for or take their place For a complete copy of any manual:

3. Intensive In-home (IIH) Services to Children and Adolescents (H2012) SERVICE DEFINITION Time-limited interventions Provided typically in the home of consumer At risk of being moved into an out-of-home placement OR Being transitioned to home from an out-of-home placement due to a documented medical need of the child. Services must be provided by a QMHP or LMHP.

4. Intensive In-home Services to Children and Adolescents (H2012) IIH providers for children and adolescents must be licensed as a provider of Intensive In-Home Services by the Department of Behavioral Health & Developmental Services (DBHDS) Please note a DBHDS Licensing IIH Services Guidance Document is located at: http://www.dbhds.virginia.gov/documents/ol-guidance-intensive-inhomesvcs.pdf Requirements in the current CMHRS manual do not currently mirror those of DBHDS. Moving forward, based on making regulatory changes----these will corroborate. Requirements in the current CMHRS manual do not currently mirror those of DBHDS. Moving forward, based on making regulatory changes----these will corroborate.

5. Scope of IIH Services: This service provides: Crisis treatment Individual and family counseling Communication counseling Case management activities Coordination with all other services child receives 24-hour emergency response These are the allowed billable services Emphasize Crisis treatment---issues that would place the child at risk of out of home placement. Emphasize Crisis treatment---issues that would place the child at risk of out of home placement.

6. Does the childmeet the eligibility criteriafor the service?

7. Two of the following must be clearly documented for the individual on a continuing or intermittent basis….. 1. Problems in establishing / maintaining interpersonal normal relationships such that are: at risk of hospitalization or out-of-home placement because of conflicts with family or community; Eligibility Criteria (cont’d)

8. Eligibility Criteria (cont’d) Psychotic thinking Poor judgment----extreme risk taking behaviors Fighting with siblings / peers to the point that they are a danger to them---- Psychotic thinking Poor judgment----extreme risk taking behaviors Fighting with siblings / peers to the point that they are a danger to them----

9. “Out-Of-Home” Defined: An out-of-home placement (at risk of) is defined as one or more of the following: • Level A or Level B group home • Regular foster home (if currently residing with biological family and due to behavior problems is at risk of move to DSS custody) • Treatment foster care placement (if currently residing with biological family or a regular foster family and due to behavior problems is at risk of removal to higher level of care) (IIH services would be provided to the child and the biological family or the foster family)

10. Out-Of-Home” Defined (cont): Level C residential facility • Emergency shelter (for child only, due to MH/behavioral problems), • Psychiatric hospitalization • Juvenile justice/incarceration placement (detention, corrections)

11. At-Risk is defined as one or more of the following: • There is demonstrated (within the past two weeks of the date of the IIH assessment, screened by an LMHP or MH agency) escalating behaviors that have put the child or others at immediate risk of physical injury. • The parent or legal guardian is unable to manage the mental, behavioral or emotional problems in the home and is actively seeking alternate out of home placement --within the past 2-4 weeks [it needs to be a current problem, not a threat of removal from the home that the parent has made in the past and not acted on].

12. At-Risk defined as one or more of the following: An authority entity (such as juvenile justice, DSS, CSB or DOE or an LMHP who is not an employee or consultant to the IIH provider) has recommended an out-of-home placement unless there is an immediate change in behaviors and failed MH services are evident. History of failed services within the past 30 days from one of the following: Crisis Intervention Crisis Stabilization Outpatient Psychotherapy Outpatient Substance Abuse Services Mental Health Support (older adolescent age 16)

13. At-Risk defined as one or more of the following (cont): Recommendation for IIH by treatment team/FAPT team for a recipient currently in one of the following: RTC Level C (transition) Group Home Level A or B (transition) Acute Psychiatric Hospitalization (transition) Foster Home (transition, or foster parent is unwilling to continue) MH case management Crisis Intervention Crisis Stabilization Outpatient Psychotherapy Outpatient Substance Abuse Services

14. Eligibility Criteria (cont’d)

15. Eligibility Criteria (cont’d)

16. Eligibility Criteria (cont’d) IIH services are rehabilitative and are intended to improve the client’s functioning. Recipients must have the functional capability to understand and benefit from the required activities and counseling of this service. It is unlikely that individuals with severe cognitive and developmental delays / impairments would clinically benefit and meet the service eligibility criteria.

17. Eligibility Criteria (cont’d) If a child or adolescent has co-occurring mental health and substance abuse disorders, integrated treatment is allowed within IIH services as long as the treatment for the substance abuse condition is intended to positively impact the mental health condition. The impact of the substance abuse condition on the mental health condition must be documented in the treatment plan and the progress notes.

18. Assessment for Service--- Any assessment tool used must contain all the required data elements: Must be performed face to face (this is documented) and occurs prior to admission Must be completed by a Licensed Mental Health Professional (LMHP) or Qualified Mental Health Professional (QMHP) and reviewed and signed by a Licensed Mental Health Professional (LMHP) Required Activities for IIH:

19. Assessment (cont’d) Must list assessments completed in the 6 months prior to the IIH assessment (i.e. psychological testing, psychiatric evaluations, FAPT team referrals and CSB involvement). Include treatment and service recommendations for each assessment listed. Must include documentation on the specifics of how the child meets the service eligibility criteria

20. Assessment (cont’d) Document any treatment that have been tried or explored within the last 30 days. Documentation must include how the recipient is at risk of removal from the home related to their behavioral health issues Document how service needs can best be met through intensive in-home services As of December 1, 2009 if the data elements are not documented in the assessment there will be retractions (Support for these data elements should be clearly documented with child specific examples)

21. Billing Code for IIH Assessments Assessment billing code is H0031 (no PA required) Reimbursement rate allowed is flat rate of $60 The service limit for assessments will be changed from 2 per fiscal year (July 1 – June 30), to 2 per provider per recipient per fiscal year. This allows each provider to bill up to 2 assessments per recipient per SFY July 1 – June 30.

22. Billing For IIH Assessments In an effort to ensure that the regulatory requirements indicating assessments are performed prior to service delivery the assessment code (H0031) must be billed before the service treatment (H2012) will pay. Assessments must be billed separately from the service treatment.

23. Required Activities (cont’d) Individual Service Plan (ISP) fully completed by QMHP within 30 days of admission Document need for services Demonstrate need for 3 hour minimum of IIH treatment per week (if < 3 hours must document the why) Referral should be made for well-child or EPSDT screening as needed Include a discharge plan to less intense level of service ISP must be co-signed by parent/ child Psychiatric med evaluation is recommendedPsychiatric med evaluation is recommended

24. Comprehensive and regularly updated Specific to individual being treated Containing goals and measurable objectives to meet identified needs Services to be provided with recommended frequency to accomplish the measurable goals and objectives Estimated timetable for achieving the goals and objectives Maintained up to date as the needs and progress of the individual changes (all changes made on the original ISP must be clear & legible, dated and initialed) ISP Critical Elements:

25. Individual Service Plan (ISP) Goals (Broad, generalized statement about what is to be learned, changed) Each GOAL should have several objectives Each OBJECTIVE is 1 clearly described behavior that needs to change in order to reach the goal: Who will do what? How often? How measured? Objective achieved by when? Each objective must have staff INTERVENTIONS

26. IIH ISP DO’s INDIVIDUALIZED! Include all service needs identified in assessment All planned activities should be based on medically necessary clinical interventions and documented in the ISP. Objectives = specific desired client behaviors in quantitative terms Interventions = specific planned staff actions with a specific planned frequency

27. Services described in ISP are delivered primarily in the child’s home with the child present. Community Outings must be planned in the ISP and be clearly related to clinical needs Services MAY be provided in the community if supported by the assessment and ISP (lack of privacy, safety). Services must be provided by QMHP or LMHP Progress note documentation must be entered for all service hours that are billed. 

28. IIH PROGRESS NOTES DO’S & DON’TS Be sure to include ALL billable services provided to correlate with time billed--Be careful of excessive time Focus on including all staff actions that meet the service definition Address all ongoing ISP needs Describe the specific client behaviors, what staff did and clients’ responses--Client quotes are helpful Complete documentation when services are delivered

29. IIH PROGRESS NOTES DO’S & DON”TS(cont’d) Exact duplicate notes are disallowed. If service are provided in more than one location, always include time spent providing services in the home Describe ALL case management services provided Crisis intervention in the school and meeting with teachers, IEP meetings, etc. are billable Case Management services are billable and should be clearly documented

30. Case Management Services cannot be billed separately -- IIH provider must notify case management agency when services are started (document notification efforts) -- No separate mental health case management -- No separate mental retardation case management -- No separate DD case management -- No IIH for child in Treatment Foster Care -- Coordination by IIH worker must occur for all services that child receives Intensive In-Home: Limitations

31. Intensive In-Home: Limitations Outpatient therapy may occur concurrently -- as long as services are not duplicated and there is coordination. IIH may not be billed prior to discharge from acute care or a Level A, B, or C Residential Placement

32. Limitations (cont’d) Service is not appropriate for a family… while the child is not living in the home OR being kept together until an out-of-home placement can be arranged Staff Travel time is excluded

33. Limitations (cont’d) Tutoring or assisting with academic instruction is not a reimbursable service. Extensive observational sessions conducted in the school environment during the school day are not reimbursable. The clinical rationale for telephone interventions must be documented.

34. For reimbursement of this service, the individual must need 3 - 10 hours of therapeutic intervention per week. (can provide < 3 hours within the last weeks before discharge. In exceptional circumstances, and with appropriate supporting documentation that includes medical necessity, providers may perform up to 15 hours per week, however this should not be routine. KePRO will authorize up to 50 hours per month once it is determined medical necessity has been met. Limitations (cont’d) KePRO will authorize up to 50 hours per month once it is determined medical necessity has been met. Providers may only bill for the actual services provided, and this must be well documented. KePRO will authorize up to 50 hours per month once it is determined medical necessity has been met. Providers may only bill for the actual services provided, and this must be well documented.

35. IIH Discharge Criteria: Medicaid reimbursement is not available when other less intensive services will achieve stabilization. 1. Reimbursement shall not be made for this level of care if the following applies: a. The child is no longer at risk of being moved into an out-of-home placement related to behavioral health symptoms; or b. The level of functioning has improved with respect to the goals outlined in the ISP, and the child can reasonably be expected to maintain these gains at a lower level of treatment.

36. IIH Service Prior Authorizations (PA):

37. IIH Service Prior Authorizations (PA):

38. Existing recipients are defined as a recipient having IIH claims activity with any provider with dates of service January 1, 2009 & forward When the PA period ends and the recipient continues to need treatment, a request may be submitted to KePRO (DMAS prior authorization contractor) to extend the treatment period. IIH Service PA (cont’d)

39. When PA is required and requested, providers will receive official authorization determinations (denials or approvals) via First Health automatic letter generation process. If approved, the letter from First Health will include a PA number. This number must be used when submitting claims. Claims submitted for services that exceed the weeks authorized will be denied. PA decisions will be made utilizing DMAS criteria identified in the Community Mental Health Rehabilitative Services Manual.. IIH Service PA (cont’d)

40. Prior Authorization Requirements: The provider will need to submit recipients demographic information & also include the following: Procedure Code – H2012 PA Service Type - 0650 Number of weeks requested From (date is after the 12 units are used) & Through dates

41. KePRO PA Checklist- Initial Request 1) Provider Contact Name: 2) Provider Contact Number: 3) Is This a Retro Review: Yes / No a. If retro request, date provider was notified of Medicaid eligibility: 4) Have Health, Safety and Welfare issues been identified with this client? Yes / No a. Has a CPS referral been made? Yes / No b. If no, what intervention's have been taken to address this concern?

42. PA Checklist-Initial Request (cont’d) 5) Requested Start Date: 6) Admission Date: 7) Projected Discharge Date: 8) Have treatments / services been tried or explored in the past 30 days : Yes / No a. List treatments /services and indicate if successful or unsuccessful: 9) Has the local CSB been contacted to determine if Mental Health Case Management services are being provide? Yes / No 10) List assessments completed in the past 6 months (i.e. psychological testing, psychiatric evaluations, FAPT team referrals and CSB involvement).

43. PA Checklist-Initial Request (cont’d) 11) Identify how services set in child’s residence are more likely to be successful than a clinic. 12) Does the client demonstrate a clinical necessity arising from a condition due to mental, behavioral, or emotional illness that results in significant functional impairments in major life activities? Yes / No 13) Individuals must meet at least two of the following criteria on a continuing or intermittent basis: a. Does the client have difficulty in establishing or maintaining normal interpersonal relationships to such a degree that they are at risk of hospitalization or out-of-home placement because of conflicts with family or community? Yes / No

44. PA Checklist-Initial Request (cont’d) b. Does the client exhibit such inappropriate behavior that repeated interventions by the mental health, social services, or judicial system are necessary? Yes / No c. Does the client exhibit difficulty in cognitive ability such that they are unable to recognize personal danger or recognize significantly inappropriate social behavior? Yes / No 14) Current Symptoms/Behaviors: For the initial review, please provide a narrative of the behaviors exhibited in major life activities by the client over the past 30 days that warrant the requested level of care (identify frequency, intensity and duration of each behavior).

45. KePRO PA Checklist-Continued Stay (Concurrent) Request 1) Provider Contact Name: 2) Provider Contact Number: 3) Requested Start Date: 4) Projected Discharge Date: 5) Have Health, Safety and Welfare issues been identified with this client? Yes / No a. Has a CPS referral been made? Yes / No b. If no, what intervention(s) have been taken to address this concern?

46. KePRO PA Checklist-Continued Stay (Concurrent) Request 6) Have the 26 weeks under SPO been used? Yes/No a. If yes, is this a request for additional weeks of service under EPSDT, if medically necessity continues to be met? Yes / No 7) Have you contacted the local CSB to determine if MHCM is being provided? Yes / No 8) Identify how continued services set in child’s residence are more likely to be successful than a clinic.

47. PA Checklist-Continued Stay (Concurrent) Request (cont’d) 9) Does the client demonstrate a clinical necessity arising from a condition due to mental, behavioral, or emotional illness that results in significant functional impairments in major life activities? Yes / No 10) Individuals must meet at least two of the following criteria on a continuing or intermittent basis: a. Does the client have difficulty in establishing or maintaining normal interpersonal relationships to such a degree that they are at risk of hospitalization or out-of-home placement because of conflicts with family or community? Yes / No

48. PA Checklist-Continued Stay (Concurrent) Request (cont’d) b. Does the client exhibit such inappropriate behavior that repeated interventions by the mental health, social services, or judicial system are necessary? Yes / No c. Does the client exhibit difficulty in cognitive ability such that they are unable to recognize personal danger or recognize significantly inappropriate social behavior? Yes / No 11) Is the client at risk of being moved into an out-of-home placement? Yes / No. If yes, explain:

49. PA Checklist-Continued Stay (Concurrent) Request (cont’d) 12) Has the client’s level of functioning improved with respect to the goals outlined in the ISP, and the client can reasonably be expected to maintain these gains at a lower level of treatment? Yes / No 13) Provide a narrative of the behaviors exhibited over the past 30 days that place the child at risk of removal from the home due to a clinical need and warrant the requested level of care (Identify frequency, intensity and duration of each behavior, and progress/lack of progress towards treatment goals). Include medications/changes.

50. Submitting a Prior Authorization (PA) Request via iEXCHANGE® The preferred method for submitting a PA request is the iEXCHANGE® web-based program Registration required Information may be found by going to the KePRO website https://dmas.kepro.org For questions call 1-888-827-2884 or email at ProviderIssues@kepro.org

51. Billing for IIH Services The Medicaid week runs Sunday- Saturday Providers must bill sequentially One unit of Service = 1 hour As of February 1, 2010 the reimbursement rate for a the assessment reduced to $60 per unit As of February 1, 2010 the reimbursement rate for a unit of service was reduced to $60 per unit Accumulation of time is allowed across a providers billing period Providers may bill only in whole units only

52. Email any questions related to Behavioral Health Policy to: CMHRS@DMAS.Virginia.gov