1 / 60

Training Objectives

Training Objectives. Authority and Requirements for Medicaid State Plan Missouri Medicaid State Plan through MO HealthNet Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Healthy Children and Youth (EPSDT in Missouri)

varana
Télécharger la présentation

Training Objectives

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Training Objectives • Authority and Requirements for Medicaid State Plan • Missouri Medicaid State Plan through MO HealthNet • Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) • Healthy Children and Youth (EPSDT in Missouri) • State Plan services offered through Department of Health and Senior Services, Division of Senior and Disability Services • State Plan Behavioral Health Services • MO HealthNet State Plan Durable Medical Equipment • Non-Emergency Medical Transportation • Five Medicaid waivers operated through MO Department of Health and Senior Services • Managed Care in Missouri • Health Homes

  2. Missouri Medicaid State Plan • State plan services under the authority of Title XIX Social Security Act • Federal and state entitlement program • Through Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) • Administered in Missouri by MO HealthNet (Missouri Medicaid authority)

  3. Missouri Medicaid State Plan • States must meet certain service requirements: • Services • Shall be similarly offered in all parts of a state – “statewideness” • Provided to all eligible groups must be equal and comparable in scope, intensity, and duration • Not have Limitations that discriminate among Medicaid recipients based on medical condition or diagnosis

  4. Missouri Department of Social Services (DSS)Programs Divisions

  5. Missouri Department of Social Services (DSS)Medicaid State Plan

  6. Missouri Medicaid State Plan • Missouri Department of Social Services, MO HealthNet Division (MHD) • www.dss.mo.gov/mhd/ • Medical Services through MO HealthNet • State plan offers medical services and items to persons who meet certain eligibility requirements as determined by Missouri Department of Social Services, Family Support Division (FSD) • http://www.dss.mo.gov/fsd/msmed.htm • Extensive services covered, such as inpatient and outpatient hospital services, physician, nursing, x-ray and laboratory, ambulance

  7. MO HealthNet Provider Search

  8. MO HealthNet State Plan and DD Waiver Services CMS requires that any services available in MO HealthNet State Plan that can meet the individual’s assessed need(s), shall first be accessed and exhausted prior to providing MO Division of DD waiver services

  9. MO HealthNet State Plan and 1915 ( c ) Waiver Services • CMS Instructions, Technical Guide and Review Criteria for 1915 ( c ) Waivers: • Waiver services shall not duplicate state plan services However, 1915 ( c ) waiver services may: • Supplement state plan services – surpassing amount, intensity and/or duration (“extended state plan” service) • Complement state plan services – waiver services not covered under state plan • There are ten 1915 ( c )Waivers in Missouri • Five MO Division of DD Waivers • Five MO Department of Health and Senior Services Waivers

  10. State Plan and Waiver Services Through Missouri Department of Health and Senior Services (DHSS)

  11. Early and Periodic Screening, Diagnosis and Treatment (EPSDT) • Early and Periodic Screening, Diagnosis and Treatment (EPSDT) available for persons under age 21 who are MO HealthNet eligible • Expanded services to benefit the child under SSA 1905 (r) of the Social Security Act - authority to “diagnose, treat, or ameliorate” areas identified through screening • Needs determined by medical necessity • In Missouri, EPSDT is called “Healthy Children and Youth Program” (HCY)

  12. Healthy Children and Youth (HCY) Services Authorized by Bureau for Special Health Care Needs (BSHCN) • BSCHN within the DHSS Division of Community and Public Health, Section for Healthy Families and Youth • Specific services in HCY are prior authorized by DHSS Bureau for Special Health Care Needs (BSHCN) for children with Fee-for-Service MO HealthNet coverage: • Private Duty Nursing • Personal Care Aide • Advanced Personal Care Aide • Skilled Nursing Visits • Authorized Registered Nurse Visits • Administrative Case Management • BSHCN receives the referrals for these six services • The referral may come from the family, provider agency, physician or other state agency • Authorization of all services is based on medical necessity • All HCY services authorized through BSHCN requires a physician’s order

  13. BSHCN Contact Information • BSHCN link: • http://health.mo.gov/living/families/shcn/ • If questions about BSHCN, contact Jefferson City office: • 800-451-0669 • Can refer you to a BSHCN regional office based on where you reside in the state • BSHCN Regional Offices Contact Information: • http://health.mo.gov//living/families/shcn/pdf/SHCNRegionMap.pdf

  14. EPSDT and DD Waiver Services • If service available to child under state plan or expanded EPSDT, it may not be covered through the waiver for the child • There are services which can be distinctly provided in a waiver that serves children, such as respite, and not duplicate what is in EPSDT • In a waiver that serves just children (e.g., MOCDD), similar services in EPSDT cannot be furnished in the waiver (e.g., OT, PT, ST) • If a waiver covers both children and adults, any waiver services that could be furnished in accordance with 1915 ( r ) of SSA shall be limited to adults because comparable services are available for children under EPSDT

  15. Basic Personal Care-Agency Model (State Plan) • Authorized through Missouri Department of Health and Senior Services (DHSS), Division of Senior and Disability Services (DSDS) • Medically oriented services provided to assist with activities of daily living • Personal care services are provided in accordance with a service plan approved by the state or ordered by a physician • Person assessed to have “impairments and unmet needs”, where if it were not for Personal Care services the person would need hospital or long-term care facility services • Reasonable and necessary and with the intent to sustain or improve the person’s functional capacity • Meet individual physical needs – not for purposes of general housekeeping

  16. Basic Personal Care-Agency Model (State Plan) • Services provided in the person’s home • Provided by a qualified individual who is not a family member or member of household • Basic Personal Care • Examples of reimbursable tasks • May include Advanced Personal Care Services • Examples include use of a lift for transfer, assist with oral medications prepared by LPN, passive range of motion according to care plan • May include an authorized nurse visit(s) • Only DHSS or designee conducts assessments and determines a person’s eligibility for state plan personal care, type, amount, etc. • Division of DD Support Coordinator may refer persons to DHSS and document the determination made by DHSS

  17. Basic Personal Care-Agency Model (State Plan) • Code of State Regulation • http://www.sos.mo.gov/adrules/csr/current/13csr/13c70-91.pdf • Provider Manual-Section 13-Benefits and Limitations • http://manuals.momed.com/collections/collection_per/Personal_Care_Section13.pdf • DHSS DSDS Home and Community Based Manual • http://health.mo.gov/seniors/hcbs/hcbsmanual/index.php • Click on Basic Personal Care-Agency Model (State Plan)

  18. State Plan Personal Care Referral and Authorization Referral and authorization • Process differs for individuals up to age 21 • Provider or BSHCN may receive a referral from family, physician, hospital, other state agency, etc. • Provider requests approval through BSHCN • For individuals age 21 and older • DHSS Case Manager initially receives referral, conducts assessment for Personal Care service eligibility, and notifies provider of authorization

  19. Basic Personal Care-Agency Model (State Plan) and Division of DD Waiver Services • DD waiver Personal Assistant may be authorized when: • The person’s need is outside the State Plan Personal Care limits • Example: Limits on number of Personal Care units are reached and/or more assistance with ADLs and/or IADL’s is needed • Individual requires Personal Assistant outside of their residence. • Caregivers under State Plan Personal Care – Agency Model cannot accompany the person outside of the home • Person has behavioral or medical needs, and they require a more highly trained personal assistant than is available under state plan (requires documentation in the Individual Support Plan to validate need for behavioral/medical service through Division of DD) • When the personal assistant worker is related to the participant • Caregivers under State Plan Personal Care-Agency Model cannot hire family members to provide Personal Care

  20. Personal Care-Consumer Directed Model (State Plan)(CDS) • A person with a physical disability can hire, train, supervise, and direct persons to provide their state plan personal care • DHSS determines person’s eligibility for CDS • Eligibility Criteria: • At least age 18 • Physical disability • Be able to self-direct their own care • MO HealthNet eligibility • Meet Nursing Facility Level of Care

  21. Personal Care-Consumer Directed Model (State Plan)(CDS) • Person exercises individual choice when choosing who provides personal care • A family member may be hired to be a personal care support through CDS, but cannot be the participant’s spouse or legally responsible relative • Person self-directing is the Employer of Record • CDS participant selects an HCBS provider, enrolled with MO HealthNet as a CDS provider. Payment is sent to HCBS provider to process employee payroll on behalf of the participant (Employer of Record) • Types of Personal Care CDS tasks included but not limited to assistance with self-care, passive range of motion, mobility/transfer, turning/positioning

  22. Personal Care-Consumer Directed Model (State Plan)(CDS) • Code of State Regulation for CDS • http://www.sos.mo.gov/adrules/csr/current/19csr/19c15-8.pdf • DHSS DSDS Home and Community Based Manual • http://health.mo.gov/seniors/hcbs/hcbsmanual/index.php • Click on Personal Care-Consumer Directed Model (State Plan)

  23. Personal Care-Consumer Directed Model (State Plan)and Division of DD Self-Directed Services If a person is enrolled with Personal Care Consumer-Directed Model (State Plan), they cannot receive self-directed services through the Division of DD

  24. State Plan Personal Care and DD Waiver Services • When a person’s need for personal assistance is strictly related to ADL’s and can be met through State Plan Personal Care program, the person will not be eligible for Division of DD waiver Personal Assistant service in accordance with requirement that state plan services must first be exhausted before waiver services can be provided • State Plan Personal Care cannot be provided for anyone who is authorized to receive DD waiver Group Home or ISL Service • Persons authorized Division of DD Host Home/Companion services are not eligible for State Plan Personal Care

  25. DHSS, Division of Senior and Disability Services Home and Community Based Services Manual • For further information about and how to access DHSS Division of Senior and Disability (DSDS) services • http://health.mo.gov/seniors/hcbs • Referrals for Home and Community Based Services (HCBS) can be called in to DSDS by phone at 866-835-3505 • DSDS HCBS Regional Evaluation Teams contact information is also in this link-to call for assistance with referrals • Also provides information for entities that are interested in becoming service providers

  26. DD Waiver Providers and DHSS Home and Community Based Service providers • Division of DD waiver providers may wish to enroll with MO HealthNet as providers of Home and Community Based Services authorized through DHSS • Advantage: • Can better ensure consistency in services for participants receiving both State Plan Personal Care-Agency Model and Personal Assistant through the Division of DD Waiver

  27. DHSS Home and Community Based Service providers • Providers of State Plan Personal Care and other Home and Community Based services authorized through the Department of Health and Senior Services are required to enroll with Missouri Medicaid Audit and Compliance MO HealthNet Enrollment • http://mmac.mo.gov/

  28. Home and Community Based Provider Requirements • http://mmac.mo.gov/providers/provider-enrollment/home-and-community-based-services/ • http://www.sos.mo.gov/adrules/csr/current/19csr/19c15-7.pdf

  29. MO HealthNet Behavioral Health Services • Medically necessary mental health services for MO HealthNet eligible persons • Services include but are not limited to: • Diagnostic assessment • Psychological testing • Individual Therapy • Family Therapy • Group Therapy

  30. MO HealthNet Behavioral Health Services • MO HealthNet Behavioral Health services be may included in the school based services program for public schools • Only services identified in the Individualized Education Plan will be reimbursable • Link to Behavioral Health Services Manual: • http://manuals.momed.com/collections/collection_psy/Behavioral_Health_Services_Section13.pdf • For Behavioral Health Services Questions – Contact Provider Education at 573-751-6683

  31. MO HealthNet Durable Medical Equipment (DME) • MO HealthNet State Plan covers a wide variety of medical equipment and supplies for both children and adults • Services must be provided by a MO HealthNet enrolled DME provider • Some items require prior authorization • Some items require pre-certification; a real time authorization process initiated by a physician utilizing an on-line tool called CyberAccessSM • Although Division of DD Support Coordinators cannot pre-certify or pre-authorize DME, they can help facilitate these processes

  32. Durable Medical Equipment Resources • Before requesting any type of medical equipment or supplies through any Division of DD waiver, the Support Coordinator should check for potential coverage through MO HealthNet State plan by reviewing the DME provider manual • http://207.15.48.5/collections/collection_dme/Durable_Medical_Equipment_Section13.pdf • http://manuals.momed.com/collections/collection_dme/Durable_Medical_Equipment_Section19.pdf

  33. DME for Children Through Age 20 • Examples include but are not limited to: • Incontinence supplies • Bath and shower chairs • Pediatric hospital beds • Nutrition • Enteral feeding supplies • Nasogastric tubing • Metabolic formula

  34. DME for Children and Adults • Examples include but are not limited to: • Augmentative communication devices • Canes and crutches • Commodes, bed pans, urinals • Supplies for decubitus care • Diabetic shoes and inserts • Hospital beds • Orthotics and repairs • Ostomy supplies

  35. DME for Children and Adults • Patient trapeze lifts • Hydraulic patient lifts • Prosthetics and repairs • Walkers • Wheelchairs, including manual, power chairs, scooters and accessories • NOTE: Vehicle modifications such as wheel chair lifts are not covered by state plan, and may be covered through the Division of DD waivers

  36. Incontinence Supplies for Adults • MO HealthNet may cover incontinence supplies, when medically necessary, for adults NOT participating in a DD waiver • Adults enrolled in any Division of DD waiver requiring incontinence supplies will have this need met through their waiver • The need for incontinence supplies alone does not justify enrollment in a Division of DD waiver

  37. DME Contact Information • Individuals and families contact Participant services at 800-392-2161 • Regional Offices and providers contact Provider Communications Unit at 573-751-2896 for general program information

  38. Non-Emergency Medical Transportation (NEMT) • NEMT used for MO HealthNet-eligible persons or persons in a MO HealthNet managed care plan who do not have access to free appropriate transportation to and from MO HealthNet covered services • Person in a MO HealthNet managed care plan gets NEMT from the health plan • NEMT provides for arrangement of transportation and ancillary services • Ancillary services: If away from home overnight, NEMT may assist with meals and lodging • http://dss.mo.gov/mhd/participants/pages/medtrans.htm

  39. Non-Emergency Medical Transportation (NEMT) • NEMT may use public transportation and other sources such as bus tokens, vans, taxis • If person has their own car, or if a friend or neighbor provides transportation – may be able to get help with gasoline costs • NEMT are for services near where person lives; if provider far away, may need approval from physician

  40. How is NEMT Accessed? • For regular appointments: • Must arrange NEMT at least 5 days before health care appointment • Call 866-269-5927, M-F, 8-5 p.m. • For “urgent care appointments” NEMT may be arranged sooner if a medical problem comes up and physician says person can be seen • Call 866-269-5927, 24 hours/day, 7 days/week • If an emergency, dial 911 or local emergency phone number

  41. How is NEMT Accessed? • Charge is $2 for each NEMT trip • NEMT cannot be denied if one cannot pay $2 • No $2 charge if person: • Is under age 19 • Pregnancy • Is blind • Lives in a nursing home • Uses public transportation, bus tokens, or if receives help to pay for gasoline

  42. NEMT Will Not Provide a MO HealthNet Participant a Ride to These Services • Pharmacy • Certain DME Services • Services provided in the individual’s home such as personal care • Adult Day Health Care services • DD Waiver Services • Some Comprehensive Substance Treatment Abuse and Rehabilitation (CSTAR) services • Some Community Psychiatric Rehabilitation (CPR) services

  43. MO HealthNet Exceptions Process • MHD may authorize payment for an essential non-covered medical service or item • Reviewed on a case-by-case basis • Exceptions requests only accepted from authorized health care prescribers licensed as a physician or advanced practice nurse

  44. MO HealthNet Exceptions Process • Exceptions Process: • http://207.15.48.5/collections/collection_rhp/General_Section20.pdf • Frequently Asked Questions: • http://www.dss.mo.gov/mhd/faq/pages/faqexcept.htm • Participant contact for Exceptions Process: Participant Service Agent 800-392-2161

  45. Medicaid Waivers Through MO DHSS • May be an option for persons with developmental disabilities if determined to most effectively meet their unique needs • Medically Fragile Adult Waiver • Aged and Disabled Waiver • Independent Living Waiver • Adult Day Care Waiver • AIDS Waiver

  46. Medically Fragile Adult Waiver • Intended for persons served in the HCY Program who turn age 21 (hence, no longer eligible for HCY Program) • Operated through MO DHSS BSHCN • Services offered include: • Private Duty Nursing • Specialized Medical Equipment and Supplies • Attendant Care Services • Requires prior authorization through DHSS BSHCN

  47. Aged and Disabled Waiver • Intended for MO HealthNet eligible persons aged 63 and older • Operated through DHSS DSDS • Meet Nursing Facility Level of Care • Services offered include: • Homemaker Services • Chore Services • Respite Care Services • Advanced Respite Care • Nurse Respite Care • Home Delivered Meals • Adult Day Care • All waiver services must be authorized by a DSDS prior to service delivery • DHSS DSDS Home and Community Based Manual • http://health.mo.gov/seniors/hcbs/hcbsmanual/index.php • Click on each of the services in the Aged and Disabled Waiver

  48. Independent Living Waiver • Intended for MO HealthNet eligible persons aged 18-64 years who have a physical disability (and possibly a cognitive disability) • Persons who have also have a cognitive impairment must have had the onset on or after age 22 • Persons who turn age 65 while enrolled in this waiver may stay on the waiver • Operated through MO DHSS DSDS • Services include: • Consumer-directed personal care • Persons must be able to self-direct their own care • ILW provides additional personal care when state plan limits associated with CDS are exhausted • Case Management • Environmental Accessibility Adaptations • Specialized Medical Equipment • Specialized Medical Supplies • DHSS DSDS Home and Community Based Manual • http://health.mo.gov/seniors/hcbs/hcbsmanual/index.php • Click on the Independent Living Waiver

  49. Adult Day Care Waiver • Intended for MO HealthNet eligible persons aged 18-63 years who meet Nursing Facility Level of Care • Operated through MO DHSS DSDS • Sole service is Adult Day Care • Effective 1/1/13 • For persons over age 63, the Adult Day Care service has been added to the DHSS Aged and Disabled Waiver • Adult Day Care waiver service replaces MO state plan Adult Day Health Care service - which will end 6/30/13 • DHSS DSDS Home and Community Based Manual • http://health.mo.gov/seniors/hcbs/hcbsmanual/index.php • Click on the Adult Day Care Waiver

  50. DHSS Home and Community Based Services and Division of DD Waivers • A person can only be enrolled in one waiver at a given time • It is important for the Support Coordinator to determine if the person is receiving Home and Community Based services through State Plan and/or DHSS waivers

More Related