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Rule 132 Medicaid Community Mental Health Service Program

Rule 132 Medicaid Community Mental Health Service Program. History and development process. Why changes: Shift focus to recovery and resiliency Conform to CMMS requirements Continue efforts started in 2004 to improve rule How changes made: Establish System Restructuring Initiative (SRI)

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Rule 132 Medicaid Community Mental Health Service Program

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  1. Rule 132 Medicaid Community Mental Health Service Program Training presented May 2007

  2. History and development process • Why changes: • Shift focus to recovery and resiliency • Conform to CMMS requirements • Continue efforts started in 2004 to improve rule How changes made: Establish System Restructuring Initiative (SRI) Establish workgroup on each new service Review and incorporate other state experiences Research evidence-based practices/best practices Review recent CMMS audits and actions Training presented May 2007

  3. Underlying Vision of Recovery and Resilience • Fundamental components and role of services in supporting recovery and resilience can be found at www.dhs.state.il.us/revisedRule132/ Training presented May 2007

  4. Objectives for today • Understand why and how Rule 132 was amended • Understand how Rule 132 services support the fundamental principles of recovery and resilience • Understand general changes in Rule 132 • Understand changed requirements of existing Rule 132 services • Understand requirements of new and substantially changed services in Rule 132 • Understand general billing changes • Understand transition requirements • Present questions Training presented May 2007

  5. Handouts and Reference Materials • Handouts: • Agenda • PowerPoint presentation • Question cards • Evaluation Reference Materials: Found at www.dhs.state.il.us/revisedRule132/ Adopted Rule 132 Crosswalk (now known as Service Definition and Reimbursement Guide) Guidelines, Instructions and Checklist Summary of rule changes Training presented May 2007

  6. Certification Process • All currently certified providers will receive new certificates • Process for adding new services • Providers now certified for therapeutic behavioral services or skills training and development will be automatically certified for community support individual and group Training presented May 2007

  7. Certification Process (cont.) • If now certified for skills training and development or therapeutic behavioral services and have CILA (620), supervised residential (830) or crisis residential (860) – will be automatically certified for community support residential • If now certified for therapeutic behavioral services and comprehensive services – will be automatically certified for community support residential Training presented May 2007

  8. Transition Issues • Rule allows three month transition period for documentation • Treatment plans that currently have therapeutic behavioral service or skills training and development (ind/group) identified have until 9/30/07 to modify plans to community support (individual or group). • Providers may bill for CSI or CSG during these three months • Effective 7/1/07 services provided must meet CSI and CSG definition and service notes must indicate CSI or CSG Training presented May 2007

  9. Transition (cont.) • Mental health assessments – must be updated by 6/30/2008 • Treatment Plans • Must be updated by 9/30/07 • May be updated with signed & dated modification • 7/1/07 – provision, billing & documentation of services must be for revised rule services even when not yet in ITP Training presented May 2007

  10. Topics for future and separate discussions • DCFS specific transition • DHS/DMH contract requirements Training presented May 2007

  11. Rates, Billing and Coding Changes • Rates • Minor rate changes for services unaffected by the revisions to Rule 132 • Rates for community support (group and individual) and psychosocial rehabilitation (group and individual) based on the rendering provider (RSA, MHP, QMHP) • Rates for community support team and evidence-based assertive community treatment based upon interdisciplinary teams • Rates for transition ACT are current rates Training presented May 2007

  12. Rates, Billing and Coding Changes (cont.) • General billing issues • Bills with dates of service on or after 7/1/2007 will be rejected for: • Day treatment • Activity therapy • Skills training and development • Therapeutic behavioral services • Bills for these services with earlier dates of service will still be processed Training presented May 2007

  13. Rates, Billing and Coding Changes (cont.) • Coding changes • DHS activity codes and HIPAA standard procedure codes are in the Services Definition and Reimbursement Guide (www.dhs.state.il.us/revisedRule132/) • Each state agency has more specific instructions on billing and payment to be addressed in later training Training presented May 2007

  14. Training Follow-up and Next Steps • Moderated conference calls • Billing and Coding, May 29, 10 am – noon • 1(800)640-9765 • Passcode: 17862946 • Non-Medicaid Vocational Service • Non-Medicaid Outreach & Engagement • Technical assistance • ACT/CST decision support tools • PSR decision support tool • Q & A via dhsmh@dhs.state.il.us Training presented May 2007

  15. General Changes • Definition of Licensed Clinician • Definition of MHP • Definition of QMHP (still includes LPHA) • Definition of off-site • Medicare certification status • Consequence of Medicare decertification • Plan for clinical supervision of all non-licensed staff Training presented May 2007

  16. Summary of Service Changes • Mental health assessment • Treatment plan development, review and modification • Therapy/counseling • Skills training and development Training presented May 2007

  17. Summary of Service Changes (cont.) • Therapeutic behavioral services • Mental health day treatment • Mental health intensive outpatient • Activity therapy • Intensive family-based services Training presented May 2007

  18. Changes to Mental Health Assessment (132.148a) • Client preferences • Name and contact information for primary care physician • Completion within 30 days of first face-to-face contact • Annual update • MHAs must be updated by 6/30/08 • Medical necessity documentation Training presented May 2007

  19. Changes to Treatment Plan Development, Review and Modification (132.148c) • Progress note if no client signature • Frequency of services – included by 9/30/07 • Six month review includes review of goals for continuing care with client or guardian • Must be updated by 9/30/07 – may be done with a signed and dated modification • Before providing new services – must be in ITP Training presented May 2007

  20. Changes to Therapy/Counseling(132.150e) • Strengthen definition to distinguish focus on psychodynamic approach as opposed to skills development that is community support or psychosocial rehabilitation • Examples of therapy/counseling: • Cognitive behavioral therapy • Functional family therapy • Motivational enhancement therapy • Trauma counseling • Anger management • Sexual offender treatment Training presented May 2007

  21. Skills Training and Development • Service components now part of community support services and psychosocial rehabilitation • Service name deleted and will not be paid for if delivered beginning 7/1/2007 • Automatically certified to provide community support individual and group effective 7/1/2007 Training presented May 2007

  22. Therapeutic Behavioral Services • Service components now part of community support services and psychosocial rehabilitation • Service name deleted and will not be paid for if delivered beginning 7/1/2007 • Automatically certified to provide community support individual and group effective 7/1/2007 Training presented May 2007

  23. Mental Health Day Treatment • Service no longer in treatment taxonomy • Service name deleted and will not be paid for if delivered beginning 7/1/2007 • Providers encouraged to become certified to provide psychosocial rehabilitation and community support (individual & group) Training presented May 2007

  24. Activity Therapy • Service no longer in treatment taxonomy • Service name deleted and will not be paid for if delivered beginning 7/1/2007 • Providers encouraged to become certified to provide community support (individual & group) Training presented May 2007

  25. Intensive Family- Based Services • Service no longer in Medicaid state plan or treatment taxonomy • Service name deleted and will not be paid for if delivered on or after July 1, 2007 • Activities provided under this service may be billable as other rule 132 services Training presented May 2007

  26. Changes to Mental Health Intensive Outpatient (132.150l) • May be provided to clients at risk of hospitalization Training presented May 2007

  27. Questions Training presented May 2007

  28. New or Substantially Changed Services • Case Management – Mental Health • Community support – individual • Community support – group • Community support – residential • Community support – team • Assertive community treatment • Psychosocial rehabilitation Training presented May 2007

  29. Unless otherwise specified, providers must apply for certification of all new and substantially changed services, with the exception of case management, in order to provide them effective 7/1/2007. Training presented May 2007

  30. Changes to Case Management Services (132.165) Definition narrowed – active intervention components moved to community support Case management: • Identifies resource needs • Facilitates access/linkage • Advocates • Coordinates • Does not include provision of rehabilitation services Training presented May 2007

  31. Changes to Case Management (cont.) Case management may be provided for 30 days immediately preceding completion of the mental health assessment Includes administering of LOCUS – DHS only Training presented May 2007

  32. Case Management (cont.) • Case management vs. Community support: • Case management does for the client • Community support teaches the client how to do for self Training presented May 2007

  33. Community Support • Necessary mental health rehabilitation intervention and supports: • To build capacity with the person to achieve their self-identified rehabilitative, resiliency and recovery goals • Designed to meet the following types of treatment support needs of the person: • Educational Vocational • Residential Mental health • Co-Occurring Disorders Financial • Social Others Training presented May 2007

  34. Community Support – Individual (132.150f) • Provided face-to-face, by telephone or video conference • At least 60% delivered in natural settings • Delivered by at least RSA • Not provided to clients receiving community support team or assertive community treatment except during transition • If now certified for skills training and development or therapeutic behavioral services – will be automatically certified for community support individual Training presented May 2007

  35. Community Support – Group (132.150g) • Provided face-to-face in group settings ranging in size from 2 to 15 • At least 60% delivered in natural settings • Delivered by at least RSA • Not provided to clients receiving assertive community treatment except during transition • If now certified for skills training and development or therapeutic behavioral services – will be automatically certified for community support group Training presented May 2007

  36. Community Support – Residential (132.150h) • Provided face-to-face, by telephone or video conference in group or individual settings • Provided only to clients in public payer designated residential settings • This services must be provided in the residential setting • Services in other settings may be billable, but not as CSR • Delivered by at least RSA Training presented May 2007

  37. Community Support – Residential (cont.) • If now certified for skills training and development or therapeutic behavioral services and have CILA (620), supervised residential (830) or crisis residential (860) – will be automatically certified for community support residential • If now certified for therapeutic behavioral services and comprehensive services – will be automatically certified for community support residential Training presented May 2007

  38. Community Support – Team (132.150i) • Provided face-to-face, by telephone or video conference to client or family member • At least 60% delivered in natural settings • Client-to-staff ratio - 18 to 1 in program not in any specific group • No group rate – participation in group activities may be community support group • More than one staff member of the team engaged in direct service to client Training presented May 2007

  39. Community Support – Team (cont.) • Client must meet at least three eligibility criteria in 132.150i)4) • Delivered by a team of no fewer than 3 staff: team leader who is a QMHP & two other staff of which one is preferably someone in recovery • Service must be provided and billed only by one of the client’s team members at any given time • Not provided to clients receiving assertive community treatment or community support individual except during transition Training presented May 2007

  40. Questions Training presented May 2007

  41. Assertive Community Treatment (132.150j) • Definition • ACT services must be prior authorized • Provided face-to-face, by telephone or video conference • 75% of service provided out of office • Clients 18 or older • Not provided in combination with other 132 services except: • During transition to another level of care • To client in Crisis residential Training presented May 2007

  42. Assertive Community Treatment (cont.) • Crisis services for clients in ACT must be provided by ACT team • Client in ACT cannot receive services from any staff outside ACT team except during transition • Available 24 hours/day, 7 days/week Training presented May 2007

  43. Assertive Community Treatment (cont.) • Provided by at least 6 person interdisciplinary team led by licensed clinician • Team must include psychiatrist, nurse, program assistant and staff: • With special training & certification in substance abuse treatment and/or co-occurring mental health and substance abuse disorders • In recovery • With special training in rehabilitation counseling Training presented May 2007

  44. Assertive Community Treatment (cont.) • Team shall include a total complement of members; if any team member resigns or is on leave, the team will be considered incomplete if the team member is not replaced within 31 days • If team is not complete on the 32nd day: • Other services may be provided to the client per her/his ITP • Bills for ACT will not be acceptable Training presented May 2007

  45. Planning for New Assertive Community Treatment • By 6/30/07 providers must declare intent to convert to evidenced-based ACT & projected date for recertification (no later than 9/30/07) • New clients entering effective 7/1/07 must meet new requirements • ACT must be re-certified and services must be authorized as meeting new requirements Training presented May 2007

  46. Converting an Assertive Community Treatment Team • By 6/30/07 providers must declare intent to convert existing team to another service (conversion must be no later than 9/30/07) • No new clients will be added to existing teams who plan to convert to another service(s) • Between 7/1/07 and the conversion date, provider may bill at current ACT rate Training presented May 2007

  47. Other ACT Conversion Issues • Region offices will create register of existing ACT clients prior to 6/30/07 • Region offices will authorize ACT services compliant with new rule • BALC will recertify ACT when compliant with new rule • Current rates will apply to service provided prior to recertification date Training presented May 2007

  48. Questions Training presented May 2007

  49. Psychosocial Rehabilitation (132.150k) • Definition • Clients 18 or older • Facility based – no off-site billing • Available at least 25 hours/week at least 4 days/week • Adjunct service to community support • All providers certified for PSR must also be certified for community support Training presented May 2007

  50. Psychosocial Rehabilitation (cont.) • Program director must be at least QMHP • Delivered by at least an RSA • Staff to client ratio shall not exceed 1 to 15 • May not be provided in combination with assertive community treatment (except during transition to ACT), intensive outpatient or hospital-based psychiatric services type A • Document each session of service Training presented May 2007

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