All Providers Frequently Asked Questions (FAQs)

Transcription

1 All Providers Frequently Asked Questions (FAQs) The new Independent Assessment / Community-Based Care Management process for access to Medicaid Adult Home and Community Based Services available through the Louisiana 1915(i) State Plan Amendment Abbreviations: 1915(i) SPA - HCBS - IA/CBCM - LBHP - POC - Louisiana 1915(i) State Plan Amendment Home & Community Based Services Independent Assessment & Community-Based Care Management Louisiana Behavioral Health Partnership Plan of Care 1. What is the Louisiana 1915(i) State Plan Amendment? The Louisiana 1915(i) State Plan Amendment defines eligibility determination and services for adults seeking expanded Home and Community Based Services (HCBS) within the Louisiana Behavioral Health Partnership (LBHP). These services foster Recovery & Resiliency through a strengths-based approach, fostering natural supports and coordinating expanded services in the member s home community. 2. What are the Home and Community Based Services (HCBS) of the 1915(i) State Plan Amendment? Home and Community Based Services are intensive services offered in the outpatient domain and require that at least 51% of services be provided in the member s home or community rather than in the provider s office. Adults 21 and over must have eligibility under the 1915(i) SPA to receive these services. A member is eligible for either ACT or a Combination of CPST/PSR/Crisis Intervention. Assertive Community Treatment (ACT) services are therapeutic interventions that address the functional problems of individuals who have the most complex and/or pervasive conditions associated with a major mental illness or co-occurring addictions disorder. These interventions are strength-based and focused on promoting symptom stability, increasing the individual s ability to cope and relate to others and enhancing the highest level of functioning in the community. OR Community Psychiatric Supports & Treatment (CPST) are goal-directed supports and solution-focused interventions intended to achieve identified goals or objectives as set forth in the individual s individualized treatment plan. CPST is a face-to-face intervention with the FAQs All Providers (Created ) Page 1

2 individual present; however, family or other collaterals may also be involved. A minimum of 51% of CPST contacts must occur in community locations where the person lives, works, attends school and/or socializes. Psychosocial Rehabilitation (PSR) services are designed to assist the individual with compensating for or eliminating functional deficits and interpersonal and/or environmental barriers associated with their mental illness. Activities included must be intended to achieve the identified goals or objectives as set forth in the individual s individualized treatment plan. The intent of PSR is to restore the fullest possible integration of the individual as an active and productive member of his or her family, community and/or culture with the least amount of ongoing professional intervention. PSR is a face-to-face intervention with the individual present. Services may be provided individually or in a group setting. A minimum of 51% of a PSR s contacts must occur in community locations where the person lives, works, attends school and/or socializes. Crisis Intervention (CI) services are provided to a person who is experiencing a psychiatric crisis and are designed to interrupt and/or ameliorate a crisis experience, via a preliminary assessment, immediate crisis resolution and de-escalation and referral and linkage to appropriate community services to avoid more restrictive levels of treatment. The goals of CIs are symptom reduction, stabilization and restoration to a previous level of functioning. All activities must occur within the context of a potential or actual psychiatric crisis. CI is a face-to-face intervention and can occur in a variety of locations, including an emergency room or clinic setting, in addition to other community locations where the person lives, works, attends school and/or socializes. The above services are offered and intended to help a member remain in their home community and prevent or reduce the need for more restrictive treatment options. For a full description of each service, please refer to the LBHP Services Manual located at: 3. What behavioral health conditions indicate an adult may be eligible for the HCBS services of the 1915(i) SPA? Any adult (21 and up) who has a mental health disorder where risk factors or functionality result in this adult needing services above the routine in order to remain successfully in the community. General eligibility for 1915(i) SPA services includes: An adult with a serious mental illness diagnosis (Schizo, Bipolar & Psychotic DOs) or Major Depressive DO and a LOCUS of 12 or more with a risk or functionality of 2 or more. Other mental health disorders may also meet eligibility depending on the severity of the impacts on the member s ability to successfully remain in the community. If in doubt, please refer for an assessment Toll Toll-free: TTY: FAQs All Providers (Created ) Page 2

3 4. How do I ask for a member to be assessed for eligibility? A member, provider, or IA/CBCM may request Magellan have a member assessed for the benefit of HCBS. Magellan will screen to determine if the member is a likely candidate, and, based on the outcome, a referral will be made for an independent assessment. The provider or member may also contact Pathways directly to request an independent assessment. Whether eligible or not for 1915(i) SPA services, treatment recommendations/referrals will be made by the IA/CBCM and/or Magellan. If in doubt, please refer for an assessment Toll Toll-free: TTY: What is the role of the IA/CBCM? The IA/CBCM serves three primary roles: 1. The IA/CBCM is responsible for the completion of a comprehensive psychosocial assessment of a member s strengths and needs to assist in determining eligibility for 1915(i) SPA services. 2. Upon the member gaining eligibility, the IA/CBCM develops a comprehensive Plan of Care, based upon the needs identified during the assessment process. Services defined within the Plan of Care will include expanded outpatient services - ACT, CPST, PSR and Crisis Intervention. 3. Following the assessment, the IA/CBCM is the point of contact for any Plan of Care updates, as defined by a member s changing needs. 6. How will the IA/CBCM process benefit me as a provider; i.e., hospital, residential facility? A provider of specialty services will benefit by having rapid access to LMHPs who can facilitate the process of assessing a member for 1915(i) SPA eligibility. This eligibility, once confirmed by Medicaid, greatly enhances the planning options for a member with the goal of increasing the member s community tenure. 7. Who is Pathways and what is their role in the IA/CBCM process? Pathways Community Health has partnered with Magellan in Louisiana to develop what will eventually be a statewide network of IA/CBCMs. Pathways Community Health is a not for profit community mental health center. Their mission is to enhance wellness in the lives of individuals and communities by instilling hope, building partnerships and supporting recovery. Their commitment to these values has been clear throughout our collaborative IA/CBCM planning process, and, in recent discussions Donni Kuck, VP of SW Operations - Pathways, shared We are excited about the opportunity to join the treatment community in a collaborative effort to assure members receive the very best care. FAQs All Providers (Created ) Page 3

4 8. What are the benefits of using Pathways? Pathways Community Health has a long history of providing a full continuum of mental health and addiction recovery services. Pathways has qualified and contracted IA/CBCM staff designated to providing Independent Assessments and Care Management for individuals in the 1915(i) SPA, which allows service providers to focus on the delivery of treatment services. Pathways staff understand the importance of the relationship with the provider for strong coordination of care and recognize the need for the consumer to have freedom of choice amongst service providers. 9. Can I refer to the Independent Assessors I have been using or do I have to use Pathways? Once the implementation date for your parish is reached, anyone providing an independent assessment for 1915(i) SPA must be certified and contracted as an IA/CBCM. If the certified assessor you have been using becomes certified and contracted as an IA/CBCM; then you may continue to use that professional. All Pathways Independent Assessors are contracted under the new IA/CBCM criteria and will be ready to complete 1915(i) SPA eligibility assessments as of the implementation date for your parish. 10. Why can a Certified Assessor no longer perform eligibility assessments, once the new IA / CBCM process is implemented in my parish? In order to align with 1915(i) SPA rules, issued by the Centers for Medicare and Medicaid Services, independent assessments must be conducted by an independent entity not providing 1915(i) SPA services and not financially connected to an agency providing those services. In other words, the IA/CBCM must be conflict-free. The Louisiana 1915(i) SPA recognizes the following Conflict of Interest Standards: related by blood or marriage to the individual, or any paid caregiver of the individual financially responsible for the individual empowered to make financial or health-related decisions on behalf of the individual providers of State plan HCBS for the individual, or those who have interest in or are employed by a provider of State plan HCBS; except, at the option of the State, when providers are given responsibility to perform assessments and plans of care because such individuals are the only willing and qualified provider in a geographic area, and the State devises conflict of interest protections. 11. Where can the IA/CBCM conduct an independent Assessment; e.g. hospital, community (nonoffice) location? The independent assessment can be conducted at a location convenient for the member. It may occur at a Pathways (or other IA/CBCM) office, a hospital, a provider location, or a community setting of the member s choice. FAQs All Providers (Created ) Page 4

5 12. How long does the process take from assessment date to authorization date? In general, the process and time required for moving a member from assessment to 1915(i) SPA eligibility will not change. The IA/CBCM will be contacted by a provider, member, or Magellan and make arrangements to complete the assessment at the earliest possible time appropriate for the member and the setting. Priority will be given to those members in acute or specialized settings, as appropriate. Once the IA/CBCM has completed the assessment, the information is submitted to Magellan, processed and, where appropriate, a request is sent to Louisiana Medicaid for eligibility determination. 13. How will a member choose a provider? An eligible member will be provided with the list of provider names in their region that represent the service(s) being recommended. This list will come from the Provider Search function of the Magellan of Louisiana homepage. Pathways staff is/will be making contacts with area providers to learn more about each and gather additional information that may not be included on the Magellan provider website. Providers should ensure the accuracy and completeness of their Provider Profile on In addition, brochures or program descriptions can be provided to area IA/CBCM s to make available to eligible members. 14. How long will the Plan of Care be valid? The Plan of Care will be valid for up to one year or until the unique member needs change. If it is determined a member might need more or less services or a different type of service than what was originally authorized, the IA/CBCM will meet with the member to develop an updated Plan of Care to be submitted to Magellan for reauthorization. FAQs All Providers (Created ) Page 5