Medicaid SED Program

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2 Medicaid SED Program Referrals Provider Self Other Independent Assessment Person Centered Plan Updates Ongoing Treatment Engagement Medicaid Eligibility CANS Updates Receipt of Services Access to Services 2

3 Objectives Medicaid SED Program: Medicaid Authority Medicaid Eligibility Person Centered Planning Independent Assessment Access to Medicaid Services Ongoing Medicaid Services 3

4 Medicaid Authority - Funding Utilization of 1915(i) Why: 1. Target SED population under 18 YOA 2. Increase Medicaid income limit for individuals who are < 18 YOA and are SED to 300% FPL 3. Utilize Medicaid dollars for services not traditionally covered under Medicaid State Plan 4

5 Medicaid Authority (continued) 1915(i) Requirements 1. Independent Assessment Provider An independent evaluation and assessment of each individual who applies for services under this benefit 2. Person Centered Plan Person-centered planning is a process, directed by the family or the individual, intended to identify the strengths, capacities, preferences, needs and desired outcomes of the individual. The family or individual directs the family or person-centered planning process. 5

6 Medicaid Authority (continued) Independent Assessment Provider Independent face to face functional assessment Determine or c0nfirm diagnosis Annual reassessment of class membership 6

7 Medicaid Authority (continued) Person Centered Plan Code of Federal Regulations (CFR) Approved by a Medicaid agent (Optum) All Medicaid services received must be on Person Centered Plan Updates 12 months Member requested Clinical need 7

8 Medicaid Eligibility Who s eligible for Medicaid? 1. Current eligibility groups 2. New members through 1915(i) SED confirmed by Independent Assessment Provider Qualifying diagnosis & functional impairment Under 18 years of age Income <= 300% Federal Poverty Level 8

9 Medicaid Eligibility (Continued) Medicaid SED Program Benefits: Enhanced Plan Benefits: State Plan Services to include Idaho Behavioral Health Plan Services (Optum) Medical services (Molina) Transportation services (MTM) Dental services (MCNA) 1915(i) Services Respite (IBHP) 9

10 Independent Assessment Provider Who: Liberty Healthcare Role: Assess class member applicants to confirm SED (Class Member Determination) make appropriate linkages Frequency: Annually SED - Section , Idaho Code 10

11 Independent Assessment (Cont.) Independent Assessment Setting Community (Chosen by Applicant) Tools Comprehensive Diagnostic Assessment (CDA), CANS 50 & Collateral Information CDA Determine or confirm a diagnosis CANS 50 Determine functional impairment 11

12 Access to Medicaid SED Program Two groups: 1. Current Medicaid members 2. Non-Medicaid members 12

13 Group 1: Current Medicaid Members Question: Does the individual or family need 1915(i) services? (i.e. Respite) Answer: NO No Action Why? Currently all other Medicaid SED services are available under Medicaid State Plan. Should be referred to IBHP provider for access to services. Answer: YES Referral to Independent Assessment Provider (IA) Why? 1915(i) services only available through the Medicaid SED Program. 13

14 Group 2: Not Currently Medicaid Question: Does the child need behavioral health services? Answer: NO No Action Why? No need for services Answer: YES Referral to Independent Assessment Provider Why? Class member determination by the IA and referral to Self-Reliance for Medicaid eligibility 14

15 Linkages Currently Medicaid: Class Members IBHP DBH Non-Class Members IBHP Not Currently Medicaid: Class Members Medicaid Self-Reliance DBH Non-Class Members Community Provider Medicaid Self-Reliance 15

16 Liberty conducts Independent Assessment CDA to determine diagnosis CANS 50 to determine functional impairment CDA + CANS = Class Membership Determination 16

17 Liberty sends class membership notice of decision to applicants Class Member Approval Notice Class Member Denial Notice Appeal rights always enclosed, appeals will be handled by Medicaid 17

18 Non-Medicaid applicants apply for Medicaid through Self-Reliance Class members can qualify up to 300% FPL Non-class members can qualify under up to 185% FPL Current Medicaid applicants bypass this step 18

19 Self-Reliance sends Medicaid eligibility notice: Notice of approval for Medicaid Notice of denial for Medicaid Appeal rights enclosed 19

20 Class members are contacted by DBH DBH schedules initial visit DBH verifies Medicaid eligibility If Medicaid eligible Plan Facilitator convenes person centered planning team State Plan Medicaid benefits can be accessed during plan development 20

21 Person centered planning team Continues to work to finalize the Person Centered Plan with approval and input from all team members 30 Day Goal for plan development Finalized plan submitted to Optum Idaho by DBH 21

22 Person Centered Plan Review Optum ensures all necessary requirements set by Medicaid are documented on the Person Centered Plan within 5 calendar days of receipt 22

23 Plan Needs Correction DBH Plan Facilitator consults person centered planning team and updates plan to meet requirements DBH submits plan back to Optum Idaho 23

24 Plan Meets Requirements DBH sends plan to person centered planning team Providers submit service requests to Optum Idaho for service authorizations Service Request Forms should align with services documented on the Person Centered Plan but will identify intensity and frequency of those services (Authorization subject to medical necessity) 24

25 Authorization of Medicaid PCP services Optum Idaho s Utilization Management Process will ensure frequency and intensity requested meets medical necessity 25

26 Ongoing Services (PCP) Person Centered Plan updates Needs to be approved by Optum Idaho after updates Service Request Forms submitted to Optum as needed for continued services 26

27 Ongoing Services (CANS) CANS Every 90 days Member requested When clinically appropriate CANS will inform when there is a clinical need to update the Person Centered Plan 27

28 Questions? 28