PHASE II IMD DETERMINATIONS 122C Facilities

1. PHASE II IMD DETERMINATIONS 122C Facilities

2. Why Are the Facilities Being Reviewed? • Complaints were submitted to CMS that Adult Care Homes were actually IMDs • Because some 122c facilities billed pcs just like billed in ACHs, 5600 group homes fell into this review • CMS review of newspaper articles regarding people with mh/sa diagnosis being served in ACHs • Obviously in 122c facilities, people are getting treatment and services designed for MH/SA • Legislative presentations about lack of funding going to serve recipients with MH/SA diagnosis in ACHs • As a result, CMS questioned the state and required review of the homes and facilities. The state implemented a two phase approach • Phase I • Those homes who based upon data run, showed high volume of mh/sa • Size of the homes • Phase II • All remaining homes

3. Resources Used to Develop the Process for Reviewing Homes • Consultation with and technical assistance from CMS • Atlanta Regional Office and Central Office in Baltimore • State Medicaid Manual (SMM) • This is a CMS publication that covers many topics regarding the operations of the Medicaid program. The manual provides CMS’s interpretation to the states for the enforcement, interpretation of rules or statutes and in essence, frequently asked questions by the states. • Manual has not been updated in many, many years. The language reflects facilities and services that were typical at the time of publication. Since the service delivery has changed, the use of the term institution is more broadly defined. • Consultation with other states who have been reviewed by Office of Inspector General (OIG), direction from CMS or their own IMD review initiation. • Private consulting firms who have conducted IMD reviews in collaboration with other State Medicaid programs

4. What is An IMD?Definition • IMDs are defined as “a hospital, nursing facility or other institution ofmore than 16 beds that is primarily engaged in providing diagnosis, treatment or care of persons with mental diseases, including medical attention, nursing care and related services” (42 CFR 435.1010). • 122C facilities are considered other stitution in the context of this discussion • An institution is considered an IMD if its overall character is that of a facility established and maintained primarily for the care and treatment of individuals with mental diseases, whether or not it is licensed as such. • An institution for the mentally retarded is not an IMD. However, facilities for the treatment of substance abuse are considered IMDs. • So group homes for MH/SA – yes Group homes for DD/IDD - no • More than 50% of all the patients in the facility will have a current need for institutionalization resulting from mental diseases. In applying the 50% guideline, North Carolina needs to determine if the primary diagnosis of mh/sa is the reason for living in the residential setting. • Obviously the person lives in a 122c facility due to mh/sa

5. What Is An IMD?IMD Exclusion • The IMD exclusion applies only to institutions with at least 17 beds. • Medicaid match is not available for any services provided to individuals under the age of 65, who are residing in an IMD (1905(a) of the Social Security Act) except for children under the age of 21 receiving care through inpatient psychiatric care. • When services are provided to persons age 65 or older in an IMD, the services may be reimbursed by Medicaid if the facility meets inpatient hospital or nursing facility requirements for Medicaid. • The under 21years old exception or the over age 65 exception are not options for ACHs because the facilities are not psychiatric residential treatment facilities (PRTF), inpatient hospitals or nursing homes. Remember the changes we made with Level III group homes several years ago. • This payment exclusion was designed to ensure that states, rather than the federal government, continue to have principal responsibility for funding inpatient psychiatric services.

6. IMD Exclusion (cont.’d) • Except as noted in the previous slide… • Under this broad exclusion, no federal financial participation is available for the cost or payment of services provided, either inside or outside the IMD, while the individual is a patient in the facility (including pharmacy, emergency room services and personal care).

7. What is an IMD?Criteria for IMDs • The Centers for Medicare & Medicaid Services (CMS) requires the State Medicaid agency to determine if facilities are IMDs. • If a facility has 17 beds or more and 50% of the residents have a diagnosis of mental disease, the State Medicaid agency is required to conduct an onsite review to determine if the facility meets IMD criteria. (SMM p4390) • The Manual speaks to any MH/SA diagnosis. NC will review the chart of the recipient to determine if the MH/SA diagnosis is • Primary • The reason the person is living in the facility – if the person resides in a 122c licensed facility and is not there due to mh/sa, then the person is inappropriately placed in the facility. • Presence of medical conditions do not necessarily override the MH/SA diagnosis. The decision is a case by case review and will be discussed more in later slides

8. Other Criteria for IMDs • Specializes in the treatment of person with mental illness (providing psychiatric/psychological care and treatment). The actual services and care provided to meet the psychiatric or psychological care. • Current need for institutionalization for at least 50% of the residents results from mental diseases • The facility is licensed as a psychiatric facility - 122c is licensed for mh/sa treatement and care • The facility is accredited as a psychiatric facility – possibly due to type of accreditation • Operates under the jurisdiction of a State mental health authority (that is providing services to mentally-ill persons) – Yes for all 122C • A final determination ….an evaluation of the information pertaining to the facility establishes that its overall character is that of a facility established and/or maintained primarily for the care/treatment of individual with mental disease.

9. Residential FacilitiesPhase II IMD ProcessDetermining if a Residential Facility is an IMD Is the current need for institutionalization of 50% or more of residents (using licensed beds) a direct result of a mental health/substance abuse illness being the reason for the placement? Is the overall character of the facility is primarily for the care and treatment of individuals with MH/SA? Define the institution – which means what facilities are being examined The institution is an IMD YES YES NO NO Are there 17 or more beds in the institution? The institution is not an IMD 8

10. Initial Facility Notification • The provider will get written notification of their upcoming review. • The notification will outline why they are being reviewed. • Over 16 beds • Possible multiple facilities • Over 50% mh/sa diagnosis on paid claims (see slide 14) • Obviously, all 122c facilities are going to have 100% mh/sa diagnosis. Some may also have dual with DD. • There is no weighted determination once the over 16 beds and 50% criteria are established • if any of the factors/criteria are met, then the process will continue for the provider.

11. What Does This Mean for North Carolina? Phase II IMD Determination Process Reviewing the Population (Medicaid Manual 4390) • The resident has current primary diagnosis of mh/sa OR • Had a behavioral health diagnosis (not dementia, Alzheimer, traumatic brain injury, mental retardation or organic brain disorder) at the time of admission if the patient was admitted within the past year. • A large portion of the residents are receiving psychopharmacological drugs. • This is reviewed from a CMS directive because facilities (national perspective) began to manipulate diagnosis so not to flag regulators of the mh/sa diagnosis. If volume and doses of these types of medications are used with recipients, it can also be flag for quality of care issues such as: • use to sedate or regulate behavior through medications rather than seeking alternative interventions or less intrusive alternatives. • possible polypharmacy

12. What Does This Mean for North Carolina? Phase II IMD Determination Process Reviewing the Population (Medicaid Manual 4390) -- cont.’d • What is the primary reason for the recipient living in the facility or in this case, the adult care home? • This slide is not as relevant for 122c facilities since all recipients should be living in the facility due to mh/sa diagnosis • Court orders don’t negate the decision of mh/sa or medical • The decision of mh/sa or medical doesn’t cast value or blame on the facility or the recipient. • The point is to prove that regardless of issues going on with the recipient, the person is in the facility related to non mh/sa reasons.

13. What Does This Mean for North Carolina? Phase II IMD Determination Process • State Medicaid agencies are responsible for designating IMD status: • IMD assessment must be made by a team that includes at least one physician or other skilled medical professional who is familiar with the care of mentally ill individuals. • No team member may be employed by, or have a significant financial interest in, the facility under review. NC has applied not only financial interest as possible conflict but also, any professional interest or service relationship with the facilities as being a possible conflict.

14. What Does This Mean for North Carolina? IMD Review of all Facilities/Agencies Phase II IMD Determination Process • North Carolina facilities that need to be assessed in Phase II • Adult care homes • Family care homes • Supervised living homes • Only those facilities who have Billed PCS are in phase II. Only 122c facilities who have billed ACH PCSare subject for Phase II. It does not mean ALL other 122c facilities are not subject to IMD compliance. • DMA will notify all 131 D and 5600 Group Home Providers regarding IMD reviews that are being conducted between July 1, 2012- Sept 1, 2012.

15. What Does This Mean for North Carolina?Phase II IMD Determination Process Identifying Facilities to be Reviewed Data Source Residential Settings billing PCS services (these are the claims billed by the facilities identified in ACH, group homes or family care homes) and • Review of 6 months paid claims by any provider with MH/SA diagnosis for recipient living in the facility (includes any services that the recipient may have received from other providers for the treatment or care of mh/sa diagnosis). November 2011-April 2012 • One month (April, 2012) in above facility PCS data period to identify unduplicated claims/recipients in the facility • EIN number and individual service site is reviewed, not just individual provider number or NPI • Initial scan of shared ownership • Licensed beds per NC Division of Health Services Regulation • Analyze data • Any recipient with at least one claim in 6month period that meets above • Calculate the 50% by: • Numerator: MH/SA diagnosis • Denominator: licensed beds • >50% gets further reviewed • BEING REVIEWED DOES NOT MEAN THAT THE FACILITY IS AN IMD • It means that the facility (single or shared) is over 16 beds (17 or more) and has more than 50% MH/SA (Medicaid Manual 4390)

16. What Does This Mean for North Carolina?I Phase II IMD Determination Process Identifying Facilities *For 122c facilities, these are the key factors for determining IMD Determine Single or Separate Facilities (Medicaid Manual 4390) 1. Are all components controlled by one owner or one governing body? 2. Is one chief medical officer responsible for the medical staff activities in all components? 3. Does one executive officer controls all administrative activities in all components? NO TO ANY OF THE ABOVE QUESTIONS MAY INDICATE A SEPARATE FACILITY (Medicaid Manual 4390)

17. What Does This Mean for North Carolina?I Phase II IMD Determination Process Identifying Facilities (cont.’d) Determine Single or Separate Facilities (Medicaid Manual 4390) 4. Are any of the components separately licensed? 5. Are the components so organizationally and geographically separate that it is not feasible to operate as a single entity? 6. If two or more of the components are participating under the same provider category (such as NFs) can each component meet the conditions of participation independently? YES TO ANY OF THE ABOVE QUESTIONS MAY INDICATE A SEPARATE FACILITY

18. What Does This Mean for North Carolina?Phase II IMD Determination Process Identifying Facilities – cont.’d Determine Single or Separate Facilities (Medicaid Manual 4390) • DMA will conduct phone interview with owner (if needed) to determine scope of the shared functions. Information gathered include but not limited to: • Review of shared policies and procedures, • Administrative functions such as payroll, food services, maintenance • Clinical services • Itinerant nurses or other health care professionals • Contractors serving the homes across facilities • Discussion of where the final authority for decision making rests?

19. Step 1 of the Decision Making Process • Does the data indicate that there could be more than 50% of mh/sa as POSSIBLE primary diagnosis or reason for living in the facility? This is going to be yes for 122c facilities unless there are some outlyer or exception • Does the shared ownership meet the criteria of a single entity or separate facilities even though they are operated or managed by shared owners/business entity? • Significant because if multiple facilities are determined to be “one” facility, then the beds and diagnosis are “rolled up” as if a single facility. • If deemed separate facility, then the % and number of beds remain separate. • Re-calculate % and beds and determine scope needed for onsite and next steps

20. What Does This Mean for North Carolina?Phase II IMD Determination Process Onsite Reviews Conducted NC DMA Shared Ownership Determination for Facilities • 1. Are all components controlled by one owner or one governing body? • 2. Is one chief medical officer responsible for the medical staff activities in all components? • 3. Does one executive officer control all administrative activities in all components. NO TO ANY OF THE ABOVE QUESTIONS MAY INDICATE A SEPARATE FACILITY • 4. Are any of the components separately licensed? • 5. Are the components so organizationally and geographically separate that it is not feasible to • operate as a single entity? • 6. If two or more of the components are participating under the same provider category (such as NFs) can each component meet the conditions of participation independently? YES TO ANY OF THE ABOVE QUESTIONS MAY INDICATE A SEPARATE FACILITY Notes: Thank you for your time answering these questions. This information will be given to the Division for review. If you have any questions, you may contact Judy Walton at 919-855-4260. Name of Interviewer: _________________________________________________________ Signature: _________________________________________________________ Date of Interview: ____________________________________________________

21. What Does This Mean for North Carolina? Phase II IMD Determination Process – Agency On-site Review (Cont’d) • Roles and responsibilities: • Clinical team lead: • Open and close onsite review • Agency interview/clarifying questions, as needed • Address team questions/contact DMA, as needed • Collection and delivery of documentation to DMA: • Resident Assessment Tool Cover* Sheet (per agency) • Other documents collected onsite • Team members: • Review resident charts • They have been given instructions to collect the data and copy the materials used to gather the data. • They have been instructed to not offer advice or to give opinions of findings while on site • Providers – please be respectful of the directions given to team members and understand that their refusal to answer a question is not due “hiding” information or being uncooperative.

22. What Does This Mean for North Carolina? Phase II IMD Determination Process – Agency Onsite Review • Onsite Review • Team composition: • Clinical team lead, medical record reviewer • Notify Owner/provider at least 24 hours in advance of onsite review • Review charts of all residents on census • Recipients who are Medicaid and private patients • Upon Entry, the team lead will • Introductions and discuss process/review plan for the day(s): • Current number of residents, estimated time for chart review • Identification of private pay residents • Request orientation to chart layout • Address any clarifying questions

23. What Does This Mean for North Carolina?Phase II IMD Determination Process – Agency Onsite Review, cont’d • Resident Chart Review Tool • Review tool and supporting documents: • ICD-9 diagnostic codes • The team will gather information on all records. • Commonly prescribed psychotropic medications (NAMI)* • Use of one of the drugs on the referenced list does not necessarily mean that the primary reason for being in the facility is due to MH/SA. This will be a flag for quality of care if the person in a 122c facility is getting psychotropic medication for condition other than mh/sa. • Resident Assessment Cover Sheet • Collect completed facility Questionnaire if available from Provider and all other documents on next slides

24. NC IMD Resident Chart Review ToolNot all forms listed below are applicable for 122c facilities – will discuss later

25. NC IMD Resident Chart Review Tool

26. NC IMD Resident Chart Review Tool

27. Medical Documents Checklist(different forms will be submitted for 122c)

28. Resident Questionnaire • ACHs were asked to complete a Resident Questionnaire form (sample of the form is located on the DMA website) • The form provides the facility with the opportunity to submit information about the individual recipient’s medical and personal care needs. The intent is to use the submitted information to further inform reviewers that medical needs are the primary reason for the recipient to reside in an ACH. • Due to 122c licensure, such justification is not warranted so the resident questionnaire does not have to be completed by 122c facilities.

29. Provider Questionnaire Please document need(s)addressed by the Residential Setting Facility Information: Does this ACH operate as an independently-owned facility, or is the ACH in partnership or under shared management with other ACHS  Y  N Independently owned/managed  Y  N Partnership/under shared management 2. If in partnership or shared management with other ACH facilities, please list. 3. If an independent business:  Y  N Is the ACH controlled by one owner?  Y  N Is there a licensed medical professional/staff person (either BH or PH) responsible for medical oversight of your ACH?  Y  N If yes, does he/she provide the same function for other ACHS?  Y  N Does the CEO or owner control all administrative activities in the ACH?  Y  N Are you the only ACH under your current license or accreditation? If other ACHs, please list city and state for each. *substitute 122c facility name in place of ACH 

30. Provider Questionnaire Please document need(s) addressed by the Residential Setting • Facility Information (cont.’d) • 4. If shared partnership or shared ownership of ACH facilities •  Y  N Are all ACHs controlled by one owner or governing body? •  Y  N Are any medical staff or direct care staff shared by the ACHs? •  Y  N Do the ACHs share administrative functions, such as lawn care, laundry, • billing/finance, food service, transportation? • If yes, please list functions. •  Y  N Do the ACHs share any licenses or accreditations? • If yes, please list. •  Y  N Are the ACHs organized and geographically close, making it feasible to • operate as one facility? •  Y  N Are any of the ACHs able to operate independently (e.g. no shared staff • or shared administrative services)? • 5. Is the ACH licensed or accredited? Collect hard copy of each license or accreditation. •  Y  N Licensed as a psychiatric facility •  Y  N Accredited as a psychiatric facility •  Y  N Other state licenses • *substitute 122c facility name in place of ACH 

31. Provider Questionnaire Please document need(s) addressed by the Residential Setting • Facility Information (cont.’d): • The facility is under the jurisdiction of the North Carolina Division of Mental Health, Developmental Disabilities and Substance Abuse Services (DMH/DD/SAS). •  Y  N • 7. How many licensed beds are in the facility? • #_____ • 8. How many physical beds are in the facility? • #_____ • 9. How many residents currently reside at this facility? • #_____ • 10. What is the average length of stay for residents in this facility? • #_____ months • 11. Do you accept residents under the age of 21? •  Y  N • 12. Does this facility have a policy to only admit residents with a mental disease diagnosis? •  Y  N • *substitute 122c facility name in place of ACH 

32. Provider QuestionnairePlease document need(s) addressed by the Residential Setting • Facility Information: • Does this facility advertise itself as specializing in the care and treatment of individuals with mental • disease? •  Y  N • 14. Does this facility have a pharmacy on-site? •  Y  N • Does this facility have access to medications other than those specifically prescribed for each resident? •  Y  N • Does this facility employ or have a contractual arrangement with any licensed mental health professionals • to provide mental health treatment to residents? •  Y  N If yes, how many? _____ • If yes, provide licensure and title of these professionals. • Does this facility employ staff with specialized psychiatric/psychological training, other than on-the-job training or experience? •  Y  N If yes, how many have specialized psychiatric/psychological training? • If yes, describe the nature of specialized training. • *substitute 122c facility name in place of ACH 

33. Provider QuestionnairePlease document need(s) addressed by the Residential Setting *substitute 122c facility name in place of ACH  • 18. Does this facility contain any locked or secured areas? •  Y  N If yes describe the nature and purpose of the secured areas. • Does this facility have a restraint room or utilize a four-point or greater restraint? [physical restraints • and/or chemical restraints?] •  Y  N If yes, do you have a P&P regarding seclusion and restraints? If yes, • reviewer to obtain a hard copy of their P&P. • If yes, describe the nature and purpose of these restraints, as well as the facility’s authority to utilize them.  • Are there any limitations, other than those imposed by a court or guardian, placed on a resident’s • ability to permanently leave the facility? •  Y  N If yes, describe the nature and purpose of those restrictions. • 21. How many residents terminated their residency since Jan 1, 2012, through the date of the interview? •  Y  N If yes, how many? _____ • Does this facility provide assistance to residents who need assistance with ADLs and/or IADLs? • If yes, describe the nature of these services. • Does this facility have any contractual arrangements with state mental facilities to accept patients? •  Y  N If yes, describe the nature of this contractual arrangement.

34. All components of this slide may not be relevant to 122c facilities • DMA determines IMD designation through • Review of data collected and other medical records • Facility questionnaire completed by provider • Any additional information sent by provider at time of on site or At Risk notification • THE PROVIDER MAY SEND OR WHILE ON SITE ANY INFORMATION FROM ANY SOURCE, THAT WOULD INDICATE THAT MH/SA IS NOT THE PRIMARY DIAGNOSIS OR THE REASON FOR FACILITY PLACEMENT. • Signed physician note from MD does not necessarily guarantee that the review will agree with primary reason for living in the facility • The physician may not be knowledgeable of the rules, regulations or appropriate clinical alternatives • Medical conditions alone do not override the mh/sa reason for placement or care • Discussion of examples

35. What Does This Mean for North Carolina?Phase II IMD Determination Process – Communication Process • The purpose of the at risk notification is to let the local community know up front of the possible designation so that local resources can begin to plan and to assure that DMA has full and accurate information needed to render the IMD determination. • Send At Risk Notification to Providers • Stating reasons for At Risk Letter • Specific reasons why DMA believes the provider could be an IMD • List of recipients who are designated as MH/SA placement (confidential/PHI attachment) • Implications if designated as an IMD • Instructions to provide additional information within 10 business days • DMA contact information will be in the letter • Send At Risk Notification to Recipients (and to Guardian/legal rep if needed) • Stating implications if facility is designated an IMD • Who to contact for housing alternatives • County DSS Directors (county of Medicaid eligibility and county where facility is located) • County LME Directors

36. What Can a Facility Do If Deemed “at risk”? • First, the facility should be continuously looking to see if they could be at risk and taking steps to make sure that they are addressing the criteria – this is prior to ever receiving an at risk letter • Once the at risk notification is received the facility may wish to: • Gather additional information to submit to DMA such as: • supports that placement is not related to mh/sa, • facilities are not shared or • % calculation is in error • Closely review census % with mh/sa • Work with families and recipients around discharge planning such as • alternative residential options • locating other facilities, and • discussing options about other wrap around supports and services • Collaborating with the DSS and LME

37. What Does This Mean for North Carolina? Phase II IMD Results • If not designated as an IMD at point in time • Owner notified of results of review • The provider will continue to submit annual attestation to DMA • Subject to onsite reviews and monitoring by DMA at any point in time for any reason • After phase II reviews are completed, compliance to IMD regulations are the responsibility of the facility • Failure to comply with IMD regulations or failure to submit attestation may result in termination from the Medicaid program and financial recoupment of payments made to the provider.

38. What Does This Mean for North Carolina?Phase II IMD Results- Designated an IMD Providers • Providers who are IMDs • Suspension/Termination letter sent via trackable mail • DMA will contact provider by all forms of communication on file such as email address and fax –make sure that correct information is collected at time of onsite review. • The local DSSs and LMEs will be notified (all DSS and LME counties of recipients based upon county of eligibility that reside in the facility and location) and county of location of the facility • Payment to the provider is suspended on the effective date stated in the IMD notification letter. Termination of the provider will be outlined in following slides • Providers will be contacted by LME and DSS to assist with transition. The provider may also initiate contact with the DSS and/or LME • Providers deemed IMD may bill after IMD determination for Date of Service (dos) prior to IMD determination effective date. All routine edits/audits/rules apply (*) unless Business continuity is interrupted

39. Getting Suspension Lifted • Provider remains in suspended status for 60 days to achieve IMD compliance • Providers send IMD Compliance Attestation to DMA within 60 calendar days of date of IMD Determination • If the attestation is submitted, DMA will lift suspension of payments effective the date of the attestation • Suspension will be lifted within 1 State Business Day(*) of DMA receipt of attestation • Submission of attestation that facility is no longer an IMD when the facility is may be considered fraud and appropriate referrals will be made • DMA will conduct on site review (within 30 days) to confirm IMD Attestation and compliance • If compliance is NOT confirmed, Provider Payment is recouped back to the date of the attestation and provider is Terminated in Medicaid. New provider Application is required in accordance to § 455.416 • If Attestation is confirmed, Provider will submit annual attestation and conduct ongoing IMD compliance self reviews • *unless business continuity is interrupted

40. What Does This Mean for North Carolina? Phase II IMD Results- Designated an IMD Providers • If Provider fails to send IMD Attestation within 60 calendar days? • Provider will be terminated from Medicaid in accordance to (§ 455. 416) on 61st calendar day or next state business day(*) whichever comes last • Provider will be required to submit new provider enrollment application § 455.420 • Providers applications will be processed according to routine procedures • Fees for re-enrollment will apply unless exempt per federal regulations (*) unless Business continuity is interrupted

41. NC Division of Medical Assistance Institution for Mental Diseases Provider Attestation

42. Recipient Notification • Nothing happens to the recipient’s Medicaid coverage during the AT RISK process. Medicaid remains active. • Recipients will receive written notification that the provider is NOT an IMD. • Due to delays in mailing, the provider will know before the recipients of NON-IMD facility determination. Please notify recipients so that families and recipients will know their Medicaid is still active.

43. What Does This Mean for North Carolina? Phase II IMD Results -- Designated an IMD Notification to Recipients • Recipients ( or Guardian, if applicable) • Recipient and legal guardian/responsible person as listed on file with DMA will Receive Notice that Medicaid payments will stop while residing in an IMD • Date benefit payments affected is the date stated in the letter, not at the end of the month • ALL payments for ANY covered Medicaid service will be denied • Responsible county (eligibility) of DSS will receive copy of letter • Responsible LME will be notified of recipients if they have MH/SA diagnosis • LME and DSS of county of eligibility can assist with housing options and other service access • On the date that the provider IMD designation is lifted, the Medicaid benefits payments will resume for the recipients who remain in residency of the facility, assuming that they remain otherwise Medicaid eligible. • If the recipient moves to another facility that is NOT an IMD at any point in the process, Medicaid benefit payments may be immediately re-instated as long as they remain otherwise eligible for Medicaid. DMA and the Division of Aging and Adult Services (DAAS) will provide guidance to the local DSSs regarding the process and procedures.

46. Appeals • There are no Medicaid appeal rights for recipients for two reasons • The adverse action was taken against the provider, not the recipient. • Since the recipient resides in a non-covered Medicaid facility, appeal rights do not apply because the Medicaid is not active • Providers may appeal to in accordance to NC appeal procedures with the Office of Administrative Hearing (OAH) • CMS guidance is that federal funding will cease during the pendency of the appeals. • If the appeal decision is in favor of the facility, the facility is not an IMD then payment will be made back to the date of the IMD determination finding as long as all other Medicaid rules and regulations were followed • If the appeal decision is upheld then the process described early for becoming incompliance is in play.

47. Tracking Recipients Who Were in IMD Facilities • DHHS will track recipients who move from facility to determine • Were discharge procedures followed in accordance to 122C licensure regulations. Did the facility make sure that health, safety and treatment needs are and were met? All licensure rules still apply. Where were the recipients moved? • What services or resources were required and by whom? • For those recipients who remained in the facility • How were the needs of the recipients met? • What resources were used?

48. What Does This Mean for North Carolina?IMD Annual Attestation Expectations • Provider submits an Annual Attestation attesting that the facility is not an IMD • Subject to onsite reviews by DMA/designee • DHHS is exploring • DHSR and other regulatory agencies reviewing for IMD as part of their routine or existing regulatory practices. For example, when DHSR conducts the licensure review, they will review for IMD compliance. • More information will be shared about this process in the future • Sampling of attestation rather than all facilities - possibly • Random • Identified through analytics • Even if other agencies gather the information, the State Medicaid Agency (DMA) may not delegate the designation to another entity.

49. QUESTIONS?