Individual Care Grant Program Training March 3

1
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

2
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.

3
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

4
Whats 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

5
Whats 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

6
Whats 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.

7
Whats 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  Matrix and the old ICG codes are no longer valid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

8
Whats 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

9
Whats 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

10
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.

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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.

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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 youths community in order to
  support the treatment plan. This includes
  participation in IEP meetings.

13
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 90th day of residential treatment.

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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 youths 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)

15
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.

16
The Role of the Collaborative
17
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.

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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

19
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

20
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.

21
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

22
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.

23
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.

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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.

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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 clients
  treatment? Describe the nature of their
  involvement and state whether or not it is
  sufficient to the clients 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.

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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.

27
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.

28
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

29
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/guardians 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.

30
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.

31
Medicaid Application

• The date of the application for Medicaid and the
  consumers Medicaid eligibility status will be
  required in order to obtain authorization for
  residential nights of care.

32
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.

33
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.

34
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.

35
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.

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SERVICE CROSSWALK
37
SERVICE CROSSWALK
38
SERVICE CROSSWALK
39
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.

40
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.

41
Authorization Requirements

• Authorizations will be reviewed by LPHAs with
  child/adolescent experience.
• If authorization is denied, the denial may be
  appealed.

42
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.

43
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.

44
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.

45
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.

46
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.

47
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.

48
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.

49
Differentiation of Quarterly/Annual Eligibility
Reviews and Authorizations

• Quarterly and Annual Eligibility reviews are
  required by Rule 135 and relate to the youths
  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.

50
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).

51
Billing for Services

• Residential providers are required to submit two
  types of claims - 1) per diem claims and 2)
  treatment encounters.

52
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.

53
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.

54
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, S9986W017B and
  S9986W019B, respectively.

55
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 S9986W020B, S9986W020M, S9986W021B and
  S9986W021M.

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QUESTIONS?