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Target Population Review

Target Population Review. Mecklenburg County Local Management Entity 2008. Purpose of the Self-Guide. The purpose of this self-guide is to… Provide a portable, easy to follow self-paced orientation to the concept of target populations;

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Target Population Review

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  1. Target Population Review Mecklenburg County Local Management Entity 2008

  2. Purpose of the Self-Guide • The purpose of this self-guide is to… • Provide a portable, easy to follow self-paced orientation to the concept of target populations; • Educate the audience about how target populations may interface with certain business functions that take place between providers, the LME, and the State of NC; • And – to give providers a way to train new staff on site. • Note: Target Population Training is no longer offered as a face to face class. Mecklenburg LME - Target Pop Review

  3. What if I have questions after I go through the self-guide? • MeckLINK Behavioral Health • Customer Service Call Center • Kimberley Paul, LCSW Intake Help Desk Manager • 704-336-6404 Mecklenburg LME - Target Pop Review

  4. Presentation Format • To keep the size of the presentation manageable (keep it small enough to use as an email attachment) – there are no screen prints, pictures, graphics. • While the presentation consists of over 70 slides, the information is straightforward and one can move fairly quickly through it. Mecklenburg LME - Target Pop Review

  5. Source of Information • The information presented today is provided by the State of North Carolina. • The LME is simply passing this information on in an attempt to partner with providers so that consumers receive care that is correctly funded. • Throughout the presentation state web sites are listed from which to obtain original information. Mecklenburg LME - Target Pop Review

  6. Who is the audience of this presentation? • Provider Staff • Staff who make requests for authorizations. • Staff who submit billing or claims. • Staff who submit target population questionnaires. • LME Staff • Staff who give authorizations. • Staff who receive and adjudicate claims. • Staff who receive and score target population questionnaires. • Other interested citizens or staff Mecklenburg LME - Target Pop Review

  7. What is the training outline? • Major Funding Streams • What is a target population (TPop)? • How does a TPop get determined? • Getting and Using Provider Connect • How do TPop’s fit with Person Centered Plans? • How do TPop’s fit with Authorizations? • How do TPop’s fit with Claims or Bills? • LME Staff Roles With Respect to TPop’s • Provider Connect TPop Instructions Mecklenburg LME - Target Pop Review

  8. Major Funding Streams • Typically, consumers have… • Medicaid • IPRS* • Or Both *… IPRS = Integrated Payment and Reporting System IPRS is also known as state funding. Only an LME can submit claims to IPRS Mecklenburg LME - Target Pop Review

  9. Major Funding Streams • How do people get these funding streams? • Medicaid • Formal application at the Mecklenburg County (typically in person) Department of Social Services at 301 Billingsley Road in Charlotte, NC • IPRS • The LME and the provider work together to get the consumer enrolled in IPRS, or to make the consumer eligible for it. The consumer does not have to go anywhere or fill out a special application. • The enrollment processes for Medicaid and IPRS are very different. Mecklenburg LME - Target Pop Review

  10. Major Funding Streams • What does this mean to a provider? • Some providers serve Medicaid enrollees. • Some providers serve IPRS enrollees. • Some providers serve consumers who are enrollees of both Medicaid and IPRS. • IPRS Enrollees • In order to serve an IPRS enrollee, a provider must have a contract with the LME specifically for IPRS funds. • The LME serves as the enrollment authority for these consumers, and also as the managed care organization and the funding authority for these enrollees. Mecklenburg LME - Target Pop Review

  11. Major Funding Streams • What is a Medicaid-only provider? • This is a term that describes a provider who… • Serves Medicaid enrollees • Does not serve IPRS enrollees • Does not have an IPRS contract with the LME • May be endorsed by the LME and may also be referred to as “an endorsed only” provider. • Exception to this rule… • Targeted case management and Therapeutic Foster care are services paid by Medicaid, but authorized and billed through the LME. Mecklenburg LME - Target Pop Review

  12. Major Funding Streams • So who handles Medicaid? • Value Options • authorizations • NC Division of Medical Assistance (DMA) • Direct-billing of claims • Think of Medicaid as a health plan that is not managed by the LME, but by the State of NC and its contract managed care company, Value Options. • Think of IPRS as a health plan that is managed by the State of NC and its contract managed care company, the LME (actually, all 25 LME’s in NC). Mecklenburg LME - Target Pop Review

  13. Major Funding Streams • What is eCura/Provider Connect? • It is a web site. • It connects to the LME software system, known as eCura. • It allows for the submission of authorization plan requests and claims for payment. • It is used only by providers who have an IPRS contract with the LME. • Medicaid-only providers do not get authorizations from or submit claims to the LME, so they do not need a login to eCura/Provider Connect. Mecklenburg LME - Target Pop Review

  14. Major Funding Streams • The next slide has a presentation with a summary of the comparison between Medicaid and IPRS. • This comparison is fundamental to understanding what target populations are. • Remember, all consumers can have IPRS, but only some consumers can have Medicaid. • Yes – a consumer can have both at the same time. • Yes – both can be billed at the same time, depending upon the service rendered. Mecklenburg LME - Target Pop Review

  15. Major Funding Streams - Comparison • Medicaid • Entitlement • Direct Billing to Medicaid • Value Options for auth’s • Enrollment via county DSS offices • Not all providers are tracked within LME Provider Relations • NCTOPPS applies • Person Centered Planning applies • Adult – 21 years of age • IPRS • Not an Entitlement – can run out • Providers Bill the LME • LME for auth’s • Enrollment – via LME Meck Link (screening, triage and referral) • All providers are contracted with and tracked by the LME Provider Relations Division • NCTOPPS applies • Person Centered Planning applies • Provider Connect – eCura link for providers • Adult – 18 years of age Mecklenburg LME - Target Pop Review

  16. Major Funding Streams • Final note… • A Medicaid-only provider who does not serve IPRS enrollees must still work with the LME to enroll Medicaid consumers in IPRS. • Why? • Medicaid eligibility may end, or there may be periods of ineligibility. • For this reason, IPRS enrollment needs to be in place in order to cover the costs of services during those times. • Also, it is a state requirement that Medicaid providers register their new consumers with the LME (Screening, Triage and Referral registration form, etc.). Mecklenburg LME - Target Pop Review

  17. What is a target population (TPop)? • Think of IPRS as a health plan, like Cigna, Aetna, Blue Cross, Blue Shield, etc. • All health plans offer different types of plans within themselves. This can be an HMO, PPO, etc. • IPRS does this a little differently. It offers sub-plans that are based on the consumer’s age, diagnosis, legal situation, health status, etc. • This is what a target population is. It is a category within IPRS for a specific consumer group. • There are nearly 50 target populations within IPRS. • A consumer can be in more than one at the same time, and the target populations can change as the consumer’s situation changes. Mecklenburg LME - Target Pop Review

  18. What is a target population (TPop)? • How are the TPop’s organized? • Age: Adult or Child • Disability: MH, DD or SA • Psychosocial Situation: Finally, situations like DSS custody, criminal charges, probation, HIV status, pregnancy, homelessness, etc. determine the last level of target population. • Think of IPRS as a health plan that gives you coverage based on your actual clinical need and psychosocial situation, not on the amount of monthly insurance premium you pay; not based on the type of insurance plan your employer selected for you. This results in 6 basic categories. This results in ~50 specific categories. Mecklenburg LME - Target Pop Review

  19. What is a target population (TPop)? • The next slide provides a chart that illustrates the target populations. • It shows the two broad categories (child or adult), then the three disability categories (MH, DD, SA) and how these two factors make six groups, and then shows the actual TPop's. • Each TPop has an abbreviation. • The first letter indicates the age group (C or A). • The second letter indicates the disability (M, D, or S). • The remaining letters indicate the special group. Mecklenburg LME - Target Pop Review

  20. Legend: A = Adult C = Child M = Mental Health D = Developmental Disability S = Substance Abuse Mecklenburg LME - Target Pop Review

  21. What is a target population (TPop)? • Each of the 6 groupings (age x disability) has several TPop’s that always apply. • General TPop’s – clinically based, do have funds in them. • AO: Assessment Only • CEP: Consultation, Education, and Prevention activities • CS: Crisis Services; short-term TPop for emergent care • Non-Clinical TPop’s – not clinically based, no funds in them. These are also called “tracking” TPop’s • KTRNA: consumer is a Hurricane Katrina evacuee served now in NC • TNF: consumer is at or below 200% of the federal poverty level • CDF: consumer in more than one disability category (MH/DD/SA) • TNC: consumer is not in any TPop – this is a placeholder for counting • Providers will typically end up becoming familiar with the specific TPop’s they serve. Mecklenburg LME - Target Pop Review

  22. All TPop’s are important. Those left on this chart are the ones that typically concern providers the most. For the group(s) that your agency serves – it is critical that you are familiar with the eligibility criteria. Mecklenburg LME - Target Pop Review

  23. What is a target population (TPop)? • Why create TPop’s? • The Mecklenburg LME receives ~20m annually in IPRS funds from the NC Division of MHDDSA Services. • Having those funds designated or broken out into these specific TPop’s ensures that dollars are going to services for consumers in need. • Consumers in many of these TPop’s are hard to reach, may be treatment resistant, and difficult to engage in services. • TPop-specific funding is a strategy – to make LME’s serve specific groups of consumers. That is why they are called “target populations” – to focus effort to a certain group. • The next several slides describe the TPop’s shown in the chart on the previous slide with the most commonly used TPop’s noted by a . Mecklenburg LME - Target Pop Review

  24. Adult Mental Health • AMAO AM Assertive Outreach • AMCEP AM Community Enhancement Program • AMTNC AM Transitional Non-Covered • AMCS AM Crisis • AMDEF AM Deaf or Hard of Hearing • AMOLM AM Olmstead Plan Implementation • AMPAT AM Homeless • AMSMI AM Serious Mental Illness  • AMSPM AM Severe/Persistent Mental Illness  • AMSRE AM Stable Recovery Mecklenburg LME - Target Pop Review

  25. Adult Substance Abuse ASAO AS Assertive Outreach ASCEP AS Community Enhancement Program ASTNC AS Transitional Non-Covered ASCS AS Crisis Services ASCDR AS Communicable Disease Risk  ASCJO AS Criminal Justice Offender  ASDHH AS Deaf and Hard of Hearing ASDSS AS DSS Involved ASDWI AS DWI Treatment  ASHMT AS High Management  ASHOM AS Homeless  ASTER AS Treatment Engagement and Recovery ASWOM AS Women  Mecklenburg LME - Target Pop Review

  26. Adult Developmental Disability • ADAO AD Assertive Outreach • ADCEP AD Community Enhancement Program • ADTNC AD Transitional Non-Covered • ADCS AD Crisis Services • ADMRI AD MR/MI (Former Thomas S.)  • ADSN AD Adult with Developmental Disability  Mecklenburg LME - Target Pop Review

  27. Child Mental Health • CMAO CM Assertive Outreach • CMCEP CM Community Enhancement Program • CMTNC CM Transitional Non-Covered • CMCS CM Crisis Services • CMDEF CM Deaf or Hard of Hearing • CMECD CM Early Childhood Disorder (age 3-5) • CMMED CM Seriously Emotionally Disturbed  • CMPAT CM Homeless • CMSED CM Seriously Emotionally Disturbed with Out of Home Placement  Mecklenburg LME - Target Pop Review

  28. Child Substance Abuse CSAO CS Assertive Outreach CSCEP CS Community Enhancement Program CSTNC CS Transitional Non-Covered CSCS CS Crisis Services CSCJO CS Criminal Justice Offender CSDWI CS DWI Treatment CSIP CS Indicated Prevention CSMAJ CS Child in the MAJORS SA/JJ Program CSSAD CS Child with Substance Abuse Disorder  CSSP CS Selective Prevention CSWOM CS Women (age 17 & younger)  Mecklenburg LME - Target Pop Review

  29. Child Developmental Disability • CDAO CD Assertive Outreach • CDCEP CD Community Enhancement Program • CDTNC CD Transitional Non-Covered • CDCS CD Crisis Services • CDSN CD Child with Developmental Disability  Mecklenburg LME - Target Pop Review

  30. How does a TPop get determined? • The Criteria • The NC Division of MHDDSA Services has set the criteria for each TPop. • The criteria include all of the factors listed above (age, gender, disability, legal status, etc.) • The Method • LME’s do not meet consumers, so providers get the information from consumers directly. • Providers complete a TPop Questionnaire and submit it to the LME. • The LME uses this information to enroll the consumer in the correct TPop. Mecklenburg LME - Target Pop Review

  31. How does a TPop get determined? • Where can I find the criteria? Go to… • http://www.dhhs.state.nc.us/mhddsas/iprsmenu/index.htm • To the left you will see several drop down menus. • Use the one that is called “Target Populations” • Select any one of the population categories. • You will be taken to a document that lists all of the specific criteria. • This site also provides other useful guides such as a list of services paid for by each TPop (service array), what diagnoses apply to which TPop’s etc. Mecklenburg LME - Target Pop Review

  32. Hierarchy • Hierarchy: When a consumer has multiple TP’s, there is a ranking. • If a member is in more than one TP, and a service could be paid for by either one, the state uses the hierarchy to determine which one will pay. • This typically does not mean much to a provider, since any one consumer typically has one or just a couple of TPop's. • The IPRS Web Site offers a listing of the hierarchy. Mecklenburg LME - Target Pop Review

  33. Concurrency • Some TP’s cannot co-occur with one consumer at the same time. Obvious ones would be adult and child target populations. • CMMED/CMSED; AMSPM/AMSMI; AO and any same-disability target pop; are other examples of mutual exclusions. • The IPRS Web Site also has a table that shows concurrency violations. It is good to be aware of any concurrency violations within your Mecklenburg LME - Target Pop Review

  34. How does a TPop get determined? • Target Population Questionnaires • A set of questions, based on the state criteria, are answered by providers. • IPRS Contract Providers: An eCura/Provider Connect login is provided and the questionnaire is filled out on line. • Medicaid-Only Providers: A paper TPop Questionnaire is faxed to the LME (704-319-9114). • The LME uses this information to determine the right TPop and enroll the consumer into it via a State database. Mecklenburg LME - Target Pop Review

  35. How does a TPop get determined? • There are three forms. Providers typically use one, but may possibly need to use two. • Adult MH/SA: used to gather information for enrollment of an adult (18 or over) consumer into a mental health and/or substance abuse TPop • Child MH/SA: used to gather information for enrollment of an child (17 or younger) consumer into a mental health and/or substance abuse TPop • Child and Adult DD: used to gather information for enrollment of any consumer age 3 or over into a developmental disability TPop • If a consumer is in both a MH/SA and a DD TPop – then both a MH/SA form and a DD form must be completed. Mecklenburg LME - Target Pop Review

  36. How does a TPop get determined? • The TPop questions themselves? • The questions come directly from state criteria. • The form can be completed from a chart review – not necessarily a face to face consumer meeting. • Date: the date of completion is asked for • Completer: name of the evaluator • Yes/No: most of the questions call for a simple “Yes” or “No” answer. • Drop Down Menus: others have choices • Disability: (MH, DD, or SA) • Functional Assessment Score: (GAF, SNAP, etc.) Mecklenburg LME - Target Pop Review

  37. Getting and Using Provider Connect • How do I get a Provider Connect login? • Contact your Service Analyst – the LME staff member who sets up your contract. • He or she will let the IT staff of the LME know that you are eligible for this login because you have an IPRS contract with the LME. Mecklenburg LME - Target Pop Review

  38. Getting and Using Provider Connect For IPRS Contract Providers Only… You will have an email from the LME with your Provider Connect certificate or license attached after you have requested it from your Service Analyst. Download it to the specific computer(s) you plan to use to log into Provider Connect. The provider can have one free login/password, and pays ~180.00 annually for each thereafter. In order to log into Provider Connect the certificate must be loaded onto that computer. This is an extra security step (rather than just going to the internet site from any computer). If the provider has one login/password – only one person can log in at one time. To have multiple staff logged in at one time – multiple logins and passwords must be purchased. Mecklenburg LME - Target Pop Review

  39. Getting and Using Provider Connect • With the certificate loaded and the login and password in hand, go to… • http://amhecuraweb/ecurapc/wc.dll?imebs~ebshome • Log in. • At this point, follow the Provider Connect Introductory Training Guide (separate document) and consult with your coworkers who have been using Provider Connect, if applicable. Mecklenburg LME - Target Pop Review

  40. Getting and Using Provider Connect • How many Provider Connect log-ins does my agency need? Strategy #1: • Get the one, free license and have an administrative support professional be the main user; have your clinicians use Word documents to document their TPop or auth information and submit those forms to the assistant, who keys them into Provider Connect. • This keeps clinicians away from the computer more, and ensures greater consistency in the data entry. • Paper forms that match many Provider Connect forms are available – contact Bill Battaile @ William.Battaile@MecklenburgCountyNC.gov). Mecklenburg LME - Target Pop Review

  41. Getting and Using Provider Connect • How many Provider Connect log-ins does my agency need? Strategy #2: • Get the one, free license and then buy more so that each clinician and/or billing staff member has his or her own login. • Pro: The staff know their work, and can directly enter the auth requests, TPop’s, billing, etc. on their own. • Con: Greater risk of inconsistency, and clinicians will spend more time on a computer; increased cost for the provider Mecklenburg LME - Target Pop Review

  42. How TPop’s fit with Person Centered Plans • They are not formally connected. • But, they are often completed at the same time. • Initial assessments of a new consumer. • Ongoing updates. • Significant clinical changes in the case • The consumer turns 18 and can sign own PCP • Or, 18 = adult status – different TPop’s now apply • In each of these situations, a target population update is needed (complete the form again in Provider Connect or on paper). Mecklenburg LME - Target Pop Review

  43. How do TPop’s fit with authorizations? • The TPop is the insurance benefit plan. • It determines what services can be provided. • Any provider working with the consumer needs to know that the TPop’s are updated and valid. • Providers cannot obtain an authorization if the TPop’s are not current. The LME will deny the authorization plan request. • Imagine that a consumer has an IPRS insurance card in his or her wallet and on that card is the TPop. • Obtaining services depends on the status of that benefit plan or TPop. Mecklenburg LME - Target Pop Review

  44. How do TPop’s fit with authorizations? • Example 1: adult female consumer • TPop form submitted 10/15/08 • AMSPM is the TPop that is now in effect • Assertive Community Treatment Team is a service that is funded by this target population • 11 months later – TPop update by provider • AMSMI is now the new target pop (improvement) • Assertive Community Treatment Team is not funded by AMSMI • A new PCP with different services must be put in place • TPop updates may change the array of services to choose from. Mecklenburg LME - Target Pop Review

  45. How do TPop’s fit with authorizations? • Example 2: adult male consumer • TPop form submitted 10/15/08 • AMSMI is the TPop that is now in effect • Outpatient mental health services begin • 5 months later the consumer is given a DWI • Assessment reveals a substance abuse problem • This clinical change warrants a TPop update • The update results in him having AMSMI & ASDWI • TPop updates may add a disability area to a consumer’s TPop's and make additional services available that may not have been before Mecklenburg LME - Target Pop Review

  46. How do TPop’s fit with authorizations? • Example 3: adolescent male consumer • TPop form submitted 10/15/08 • CMMED is the TPop that is now in effect • Community Support services begin • 2 months later he is admitted to the inpatient unit at the Behavioral Health Center Randolph • His symptoms obviously have worsened so a TPop update is needed (now at risk of out of home placement) • The new TPop is CMSED • CMSED pays for inpatient care, but CMMED does not • Consumers should be getting only the services that their current TPop’s pay for, and to achieve this the TPop’s must be updated ASAP when a non-covered service is actually needed. Mecklenburg LME - Target Pop Review

  47. How do TPop’s fit with authorizations? • Example 4: community support consumer • TPop form submitted 10/15/08 • CMMED is the TPop that is now in effect • CMMED expires on 10/14/09 • Community support provider forgets to update • A different provider on the PCP logs into Provider Connect to submit an authorization plan request but cannot, because there is no active TPop • This places the consumer at risk and interrupts the business processes of providers • TPop updates ensure that all engaged providers can get authorizations. Mecklenburg LME - Target Pop Review

  48. How do TPop’s fit with claims or bills? • Since the TPop is the insurance benefit plan, it is used to pay for services. • Providers who submit claims or bills will not be paid if those benefit plans are not current and valid. • The TPop is identified when the authorization is obtained and is then used as the funding source to pay the claim. Mecklenburg LME - Target Pop Review

  49. LME Staff Roles with Respect to TPop’s Mecklenburg LME - Target Pop Review

  50. Provider Connect TPop Instructions • The following slides are for providers who have an IPRS contract with the LME. • To save space in this document, no screen prints are provided. • IPRS contract providers are given screen-print guides that illustrate how to use Provider Connect. • Medicaid-only providers will find some of the following slides useful – the ones about answering specific questions. Mecklenburg LME - Target Pop Review

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