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Magellan Training: Medicaid Rehabilitation Option

Magellan Training: Medicaid Rehabilitation Option. Magellan. NBHS. Medicaid. Initial Auth. What information do I need when I call? Current diagnosis (onset) Rehabilitation Assessment Functional Limitations Rehab Plan Licensed clinician contact. MRO Re-Auth Form. Client Name and SS#

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Magellan Training: Medicaid Rehabilitation Option

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  1. Magellan Training: Medicaid Rehabilitation Option Magellan NBHS Medicaid

  2. Initial Auth • What information do I need when I call? • Current diagnosis (onset) • Rehabilitation Assessment • Functional Limitations • Rehab Plan • Licensed clinician contact

  3. MRO Re-Auth Form • 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

  4. MRO Re-Auth Form • 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

  5. Specific Functional Limitations • 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

  6. MRO • Medicaid Chapter 35 • PRR, ACT, DR, CS • Active Life skill training • Assessment based • Client centered • Realistic goals • Crisis plan

  7. Medicaid Rehab Option Guidelines • Must meet SPMI status • Must have functional limitations • May have other diagnosis as secondary

  8. SPMI Guidelines • 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.

  9. SPMI Con’t • Not primary substance abuse • Not primary developmental disabilities

  10. Major Life Skills Areas • Voc/Educational • Social Skills • Activities of Daily Living

  11. Vocational/Educational • Inability to be employed • Inability to pursue education • Inability to carry out home management tasks (meals, laundry, budgeting, child care)

  12. Social Skills • Inappropriate • Inadequate • Participates only with extensive support • History of dangerousness

  13. Activities of Daily Living • Inability to consistently perform • Hygiene, grooming, meals • Personal business • Transportation, care of residence • Medical, legal, housing • Avoidance of common dangers

  14. MRO Authorization Considerations • 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.

  15. Authorization Considerations • 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

  16. Considerations con’t • Brain injury • Typically developmentally delayed have not met milestones • Axis I typically have met milestones

  17. Considerations con’t • Across settings • Long term • Requires support/intervention • Medication • Our case notes/hx of care • Compensation not cure

  18. Considerations con’t • Long term sub abuse and homelessness often look like SPMI, because many SPMI have both. • TBI often look like SPMI

  19. Psychiatric Residential Rehab • SPMI • These deficits require 24 hour psychiatric residential setting • The need is 24 behavioral monitoring

  20. Day Rehab • Day Rehab • The need: Day structure to work on socialization/self care/pre-voc • Community Support • The need: Case management • In home work on self care • Household/ADL tasks

  21. Community Support • The need: Case management and • In home work on self care • Household/ADL tasks

  22. Authorization Considerations • 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)

  23. ACT • Two in Omaha • One in Lincoln • One in Hastings

  24. 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

  25. General MRO Admission • Meets Admit guidelines • Does not require a higher LOC • A lower LOC is not indicated • Likelihood of benefit from service • Is making progress

  26. General MRO Continuing Stay • 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

  27. General MRO Exclusion • 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

  28. General MRO Discharge • Maximum benefit • Sustainability plan in place • Supports in place • Crisis relapse plan in place • Or the individual requests discharge

  29. Q & A

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