1915(i) Adult Home and Community Based Service (HCBS) Programs:

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1 Divisin f Mental Health and Addictin 1915(i) Adult Hme and Cmmunity Based Service (HCBS) Prgrams: Adult Mental Health Habilitatin (AMHH) and Behaviral and Primary Healthcare Crdinatin (BPHC) 1915(i) State Evaluatin Team Jcelyn Piechcki and Marsha Williams Octber 18, 2017

2 Adult Mental Health Habilitatin (AMHH) and Behaviral and Primary Health Care Crdinatin (BPHC) Marsha Williams

3 1915(i) Adult Prgrams AMHH Members May have AMHH and BPHC May NOT have AMHH and Medicaid Rehabilitatin Optin (MRO) AMHH and MRO are mutually exclusive BPHC Members May have BPHC and AMHH May have BPHC and Medicaid Rehabilitatin Optin (MRO) May NOT have BPHC, AMHH and Medicaid Rehabilitatin Optin (MRO) Since AMHH and MRO are mutually exclusive

4 1915(i) Adult Prgrams Referral and Applicatin Prcessing Referrals Fr bth prgrams, refer individuals t ne f the 25 state-certified Cmmunity Mental Health Centers (CMHCs) CMHCs are the exclusive prviders fr bth prgrams Listing f all prviders fr the prgrams may be fund at: Applicatin Prcessing CMHCs are respnsible fr: Evaluatins, assessments, and applicatin cmpletin fr each individual Submissin f cmpleted applicatin and Individual Integrated Care Plan with supprting dcumentatin t the 1915(i) State Evaluatin Team (SET) fr clinical eligibility review Prvisin f services t apprved members fr each prgram 1915(i) State Evaluatin Team (SET) is respnsible fr review f each applicatin AMHH SET: Determines eligibility fr each member Submissin f apprved applicatin and service authrizatin t DXC fr prir authrizatin fr AMHH service(s) BPHC SET: Determines clinical eligibility fr each member Submissin f BPHC clinical apprval t Divisin f Family Resurces (DFR) DFR determines eligibility fr Medicaid Submissin f apprved applicatin and service authrizatin t DXC fr prir authrizatin fr BPHC service

5 Adult Mental Health Habilitatin (AMHH) Marsha Williams 1915(i) Adult State Evaluatin Team

6 AMHH Habilitatin vs. MRO Rehabilitatin The distinctin f whether a service is habilitative vs. rehabilitative is ften mre rted in an individual s level f functining and needs than in the actual service prvided Habilitative service means activities that are designed t assist members in acquiring, retaining, and imprving skills necessary t reside successfully in hme and cmmunity setting: 405 IAC (g) Rehabilitative service fcuses n restring functin Many f the AMHH services are similar t MRO but the member s treatment gals, alng with their treatment apprach and bjectives, have a habilitative fcus AMHH expectatin is the individual s gals address reinfrcement, management, adaptatin, and/r retentin f a level f functining (habilitative gals) activities that are designed t assist individuals in acquiring, retaining, and imprving the skills necessary t reside successfully in cmmunity settings MRO has an expectatin that the individual will steadily imprve their level f functining ver time (rehabilitative gals) fr maximum reductin f physical r mental disability and restratin f a recipient t their best pssible functinal level

7 Adult Mental Health Habilitatin (AMHH) Adults that have reached maximum benefit frm a rehabilitative treatment apprach Individuals wh want habilitatin services t help them maintain the gains made frm rehabilitatin Individuals wh are at risk f institutinalizatin withut intense hme and cmmunity based services May NOT be enrlled in AMHH and MRO at the same time.

8 AMHH Eligibility DMHA Adult 1915(i) State Evaluatin Team determines AMHH prgram eligibility Maximum 360 day eligibility perid May apply t renew eligibility within 60 days f the end date f the currently apprved AMHH eligibility perid

9 AMHH Eligibility Criteria At least age 35 at time f applicatin Enrlled in an eligible IHCP Medicaid prgram Resides in a Hme and Cmmunity Based Service (HCBS) cmpliant setting AMHH eligible primary mental health diagnsis Have recmmendatin fr intensive cmmunity based care n the Adult Needs and Strengths Assessment (ANSA) by scring level f need (LON) f 4 r higher Meets needs based criteria as evidenced by the ANSA algrithm which is calculated frm a cmbinatin f scres f applicant s strengths and risk factrs

10 AMHH Services Individuals may apply fr each f the fllwing AMHH services: Adult day services Hme and cmmunity-based habilitatin and supprt Respite care Therapy and behavir supprt services Addictin cunseling Peer supprt services Supprted cmmunity engagement services Care crdinatin Medicatin training and supprt

11 Behaviral and Primary Healthcare Crdinatin (BPHC) Marsha Williams 1915(i) Adult State Evaluatin Team

12 Behaviral and Primary Healthcare Crdinatin (BPHC) Assists individuals in managing physical health issues due t barriers r impairment as a result f a mental health disrder Any physical health issue that the cnsumer has difficulty managing and/r crdinating A frmal medical diagnsis fr the physical health issue is nt required

13 BPHC Eligibility Criteria Targeting Criteria At least age 19 BPHC eligible primary mental health diagnsis Needs-Based Criteria Demnstrated health need which requires assistance and supprt in crdinating behaviral health and physical health treatment Demnstrated need related t management f behaviral and physical health Demnstrated impairment in selfmanagement f physical and behaviral health services Have recmmendatin fr intensive cmmunity based care n the Adult Needs and Strengths Assessment (ANSA) by scring level f need f 3 r higher Meets an algrithm based n answers t health questins used t assess applicant s strengths and risk factrs

14 BPHC Eligibility 1915(i) Adult State Evaluatin Team determines clinical eligibility If determined t be clinically eligible fr BPHC, infrmatin is transmitted t DFR DFR determines nn-clinical/financial Medicaid eligibility Individuals determined t be clinically eligible fr BPHC have a Special Incme Level (SIL) cnsideratin that is 300% r belw the Federal Pverty Level (FPL) which may be applied during Medicaid eligibility review Maximum 180 day BPHC clinical eligibility perid May apply t renew eligibility within 60 days f the end date f the currently apprved BPHC eligibility perid

15 BPHC Service Activities BPHC service has ne (1) service which includes the fllwing activities: Crdinatin f healthcare services Direct assistance in gaining access t services Crdinatin f care within & acrss systems Oversight f the entire case Linkage t services Assistance in utilizing the healthcare system Lgistical supprt Advcacy Educatin Referral & linkage t medical prviders Crdinatin f services acrss systems Physician cnsults Cmmunicatin cnduit Ntificatin f changes in medicatin regimens & health status Caching fr mre effective cmmunicatin with prviders

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17 Hme and Cmmunity Based Service (HCBS) Jcelyn Piechcki 1915(i) Adult State Evaluatin Team

18 CMS HCBS Backgrund CMS HCBS Final Rule published January 2014, with an effective date f March 17, 2014 Addressed HCBS setting requirements acrss: 1915(i) State Plan Amendment prgrams: AMHH and BPHC 1915(c) waiver prgrams 1915(k) Cmmunity First Chice prgrams

19 What is a Hme and Cmmunity-Based Service (HCBS) Cmpliant Setting? Per CMS, an HCBS setting can be any f the fllwing: 1) Member wned/leased 1) Residential Prvider wned/perated/cntrlled 1) Third-party wned/perated/cntrlled

20 What is nt an HCBS Cmpliant Setting? The fllwing settings are identified by CMS as institutinal, and are NOT cnsidered hme and cmmunity-based: 1) Nursing facilities 2) Institutes fr Mental Disease (IMD) 3) Intermediate Care Facilities fr Individuals with Intellectual Disability (ICF/IID) 4) Hspitals Federal requirements apply t all settings in which a member may reside and/r receive services

21 Qualities f an HCBS Cmpliant Setting: The Big 5 CMS established five qualities (the Big 5 ) that apply t ALL settings 1) The setting is integrated in and supprts full access f individuals receiving Medicaid HCBS t the greater cmmunity, 2) The setting is selected by the individual frm amng setting ptins, 3) The setting ensures an individual s rights f privacy, dignity, and respect, and freedm frm cercin and restraint 4) The setting ptimizes, but des nt regiment, individual initiative, autnmy, and independence in making life chices, including but nt limited t daily activities, physical envirnment, and with whm t interact 5) The setting facilitates individual chice regarding services and supprts, and wh prvides them

22 POCO Residential Settings POCO (Prvider Owned, Cntrlled and/r Operated) residential settings, as defined by CMS, are thse settings in which an individual resides that are specific physical places that are wned, c-wned, and/r perated by a prvider f HCBS Indiana has fur types f DMHA-certified residential facilities fr adults: 1) alternative family hmes fr adults (AFA) 2) transitinal residential living facility (TRS) 3) semi-independent living facilities (SILP) 4) supervised grup living (SGL) Each f these DMHA-certified residential facilities meets the definitin f a POCO residential setting

23 Additinal Required Qualities f POCO Residential Settings: The POCO 5 POCO residential settings must meet additinal cnditins in rder t be fully HCBS cmpliant: 1) Member signs a lease r resident agreement that prvides the same prtectins frm evictins under the landlrd/tenant law f the state, cunty, city 2) Each individual has privacy in their sleeping r living unit: 3) Individuals have the freedm and supprt t cntrl their wn schedules and activities, and have access t fd any time 4) Individuals are able t have visitrs f their chsing at any time 5) The setting is physically accessible t the individual

24 Presumed Institutinal The HCBS Final Rule states that any setting that has any f the fllwing three qualities f an institutin des nt meet the federal HCBS requirements: 1. Any setting that is lcated in a building that is als a publicly r privately perated facility that prvides inpatient institutinal care (that is, a hspital, IMD, ICF/IID, r nursing facility) 2. Any setting in a building n the grunds f, r immediately adjacent t, a public institutin (defined by CMS as an institutin that is the respnsibility f a gvernmental unit r ver which a gvernmental unit exercises administrative cntrl) 3. Any ther setting that has the effect f islating individuals receiving Medicaid HCBS frm the brader cmmunity f individuals nt receiving Medicaid HCBS

25 1915(i) Adult Prgrams Summary AMHH BPHC HCBS 35 years and lder LON 4 r abve N lnger able t rehab AMHH eligible primary mental health diagnsis Maximum 360 day apprved eligibility perid (can renew eligibility) Can be enrlled in AMHH and BPHC Cannt be n enrlled in bth AMHH and MRO; prgrams are mutually exclusive 19 years and lder LON 3 r abve Mental health impedes ability t manage and/r crdinate physical health issue(s) MRO eligible primary mental health diagnsis Maximum 180 days apprved eligibility perid (can renew eligibility) Can be enrlled in BPHC and AMHH Can be enrlled in BPHC and MRO Individuals must live in an HCBS cmpliant setting t be eligible fr AMHH/BPHC services Private/Independent hmes must meet all f the Big 5 Requirements POCO settings must meet bth the Big 5 and the POCO 5 requirements HCBS services are prhibited frm being prvided in an institutinal setting

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27 1915(i) Adult HCBS Prgrams Cntact Infrmatin Divisin f Mental Health and Addictin: (317) Hme and Cmmunity Based Services (HCBS) DMHAAdultHCBS@fssa.in.gv Adult Mental Health Habilitatin (AMHH) AMHHservices@fssa.in.gv Behaviral and Primary Healthcare Crdinatin (BPHC) BPHCservice@fssa.in.gv

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