General Program FAQ's HCBS-AMH 1. Why was the decision made to do a State Plan Amendment 1915(i) rather than a 1915(c) Medicaid waiver? The decision to seek a SPA rather than a waiver was made because HCBS waivers would generally require that the person qualify medically for a nursing home or Intermediate Care Facility (ICF) IDD. This would exclude the target population of the program (individuals who no longer require an institutional level of care). The 1915(i) SPA allows the state to develop its own needs based criteria, appropriate to the population served. 1915(c) waivers require that the individual meet a level of care for a Medicaid qualified institutional setting; Institutions of Mental Disease for people between 21 and 65 are not a qualified institutional setting under Medicaid. A 1915(c) waiver would exclude a majority of the target population for the program who are between the ages of 21 and 65. 2. Are HCBS-AMH services billed as fee-for-service? Yes, HCBS-AMH enrollees are served through a fee-for-service delivery system where providers are paid for each service. Rates are posted at Health and Human Services Commission s website at http://www.hhsc.state.tx.us/rad/long-term-svcs/amh/index.shtml 3. What is the maximum income level for participants to be eligible for the HCBS-AMH program? Individuals receiving HCBS-AMH services must have income that does not exceed 150% of the Federal Poverty Line. The guideline for the Federal Poverty Line is found at: http://familiesusa.org/product/federalpoverty-guidelines 4. Are HCBS-AMH Provider Agencies and Recovery Managers guaranteed a certain number of enrolled participants? HCBS-AMH Providers and Recovery Managers are selected by the individual receiving services, therefore, HHSC is unable to guarantee a certain number of participants. 5. Are the HCBS-AMH Provider Agencies and Recovery Managers required to go through any special training? The Training requirements can be viewed in the Provider Manual, Appendix A located at http://www.hhsc.state.tx.us/mhsa/hcbs-amh/documents/ 6. Can the same agency apply for both the Recovery Management Entity and Provider Agency Open Enrollments (OE s)? Yes, the same agency may apply for both OE s. However, that agency can not provide both service components to the same individual. CMS mandates that the Recovery Manager be a separate entity 1
from the HCBS-AMH service provider. HCBS-AMH Recovery Management Entities may not be a Provider of other HCBS-AMH services listed on the individual s IRP, unless the HCBS-AMH Recovery Management Entity is the only willing and qualified entity in a geographic area where the individual chooses to receive the services. This policy/procedure is subject to change upon CMS final approval of the State Plan Amendment (SPA). 7. How do I submit my billing claims? Billing is a manual process, Direct Service Providers and Recovery Management Providers will request payment using the State of Texas Purchase Voucher Form B-13 and Billing Invoice Template which can be downloaded at: http://www.dshs.state.tx.us/grants/forms.shtm http://www.dshs.state.tx.us/mhsa/hcbs-amh/billing 8. How were billing rates set? HHSC held a rate hearing on March 3, 2014 to gain input from potential providers in order to ensure the rates were set appropriately and correspond to the intensity of the provision services required to meet the needs of the individual. Payment rates for HCBS-AMH services were developed based on payment rates determined for other programs that provide similar services. 9. Are individuals on parole or probation able to participate in HCBS-AMH? Individuals who are eligible for HCBS-AMH but 10. Who can refer an individual for the HCBS-AMH program? An individual can be referred by a local mental health authority (LMHA) a local behavioral health authority (LBHA) or by a state hospital. 11. How is an Individual determined eligible for the HCBS-AMH program? Individuals must meet the following initial criteria in order to be eligible for HCBS-AMH: Be 18 years or older with a diagnosis of a serious mental illness (SMI) Not be enrolled in enrollment in Long-term Services and Supports (LTSS), Community Living Assistance and Support Services (CLASS), Deaf Blind with Multiple Disabilities (DBMD), Home and Community-based Services Waiver (HCS), or Texas Home Living Waiver (TxHmL), or STAR+PLUS HCBS Waiver Have an income that does not exceed 150% of the Federal Poverty Line). Experience one of the following: o Long Term Psychiatric Hospitalization Reside 3 or more years (cumulatively) in an in-patient psychiatric hospital Be Medicaid eligible o Jail Diversion 4 or more arrests and 2 or more psychiatric crises during the 3 years prior to referral 2
Active Medicaid benefit o Emergency Department Diversion 15 or more ED visits and 2 or psychiatric crises during the 3 years prior to referral Active Medicaid benefit In addition to meeting initial eligibility criteria HCBS-AMH eligibility is determined using demographic, clinical, functional and financial criteria. Individuals are assessed using the HCBS-AMH Uniform Assessment. 12. Are QMB and CBA HCBS programs that individuals cannot be dually enrolled in? Individuals enrolled in QMB would not qualify for the traditional Medicaid-funded HCBS - AMH program, since they are not Medicaid eligible. However, they could qualify for HCBS-AMH as a non-medicaid participant using general revenue if funding permits. If this individual is enrolled as a non-medicaid participant, their enrollment in QMB may impact providers when claiming for some services. Community based Alternatives (CBA) has been replaced by the STAR+PLUS Home and Community-based Services (HCBS) waiver. The STAR+PLUS Home and Community-based Services (HCBS) waiver is a HCBS program and the individual could not be dually enrolled. 13. Does HCBS-AMH Adaptive Aids service cover Applications for individual s phones to assist with medication reminders and other prompts to assist in independent living? Yes, applications for individual s phone will be covered in Adaptive Aids. 14. Peer Support: What is the current rate based on? Can Peer Support be billed for a group? Why is the rate lower than Rehabilitation? The current rate for peer support is based on a rates hearing HHSC held on March 3, 2014 to gain input from potential providers in order to ensure the rates were set appropriately and correspond to the intensity of the provision services required to meet the needs of the individual. Peer Support can t be billed for a group. The peer support services in the HCBS-AMH program are designed to provide advocacy and foster recovery-oriented skills to help an individual enhance their recovery. In the HCBS-AMH program, peer support is considered different than psychosocial rehabilitation. Because of this, the educational requirements required for HCBS-AMH peer supports differ than those requirements for HCBS-AMH providers of psychosocial rehabilitation. Instead, the educational requirements for peer support are in line with those requirements for paraprofessionals and the service rates were based off the service rates for a paraprofessional. 15. Is STAR+PLUS state wide in Texas? Why is the HCBS-AMH target population mostly eligible to receive services from a STAR+PLUS MCO? Yes, as of September 1, 2014, STAR + PLUS was available statewide. The HCBS-AMH target population will mostly be enrolled in STAR + PLUS MCO because they meet one of the following criteria: a. Have a disability and qualify for Supplemental Security b. Income (SSI) or Medicaid because of low income 3
c. Qualify for Medicaid because they receive STAR+PLUS Home and Community Based Services d. (HCBS) waiver services e. Are not dually eligible and are receiving services through one of the five DADS programs for individuals with intellectual and developmental disabilities (IDD) 16. Will the Provider Agency offer all services, including Recovery Management? No. HCBS-AMH has two separate providers, the Provider Agency and Recovery Management Entity. The Provider Agency provides the full service array and Recovery Management coordinates the services from the service array on the Individual s IRP. 17. Are Provider Agencies and Recovery Management Entities required to offer quality management assurances? Yes, the HCBS-AMH QM Plan is available on the webpage at http://www.hhsc.state.tx.us/mhsa/hcbs-amh/. 18. If a Provider Agency becomes unable to provide authorized services as described in the IRP, who is responsible for service provision for the Individual? The Recovery Manager will work with the individual and applicable parties to coordinate service provision. 19. What is frequency and expectation of interaction with the MCO? It is expected that the MCO service coordinator will participate in weekly phone calls with the Recovery Manager and HCBS-AMH providers. 20. Who do I contact with questions about the Open Enrollments applications? All procurement related questions should be referred to Procurement and Contract Services (PCS). Questions concerning requirements relating to the dates of submission and completion of required forms should be forwarded to PCS at pcs_cst_hhsc@hhsc.state.tx.us. 21. What are housing options for HCBS-AMH participants? HHSC has been working closely with TDHCA to ensure the HCBS-AMH target population will be eligible to participate in Section 811 and Project Access. Additionally, HHSC is currently working with community providers and different opportunities to expand housing opportunities. 22. Will the recovery managers be the persons responsible for finding and matching the person to housing and housing vouchers? Are there special trainings for them to understand the work that has been done with the 811 waivers and other work on housing capacity? 4
The Recovery Manager will be responsible for coordinating and monitoring services, including housing services for the individual enrolled in HCBS-AMH. HHSC is working on accessing special trainings on housing for the Recovery Manager and will notify the Recovery Manager when these trainings become available. Also, it is the expectation that the Recovery Manager will have knowledge of housing resources currently available in the areas the RM serves. 23. Can a Provider Agency render services from a home-based office? Yes, provided the office meets HCBS Settings requirements. Settings requirements may be found at: http://www.ecfr.gov/cgi-bin/text-idx?sid=f375991e7967285a4ecef8f9e5e97b86&node=pt42.4.441&rgn=div5%20- %20se42.4.441_1530#sp42.4.441.m 24. Does HCBS-AMH have the same training requirements as other HHSC programs? Training requirements may be viewed in the Provider Manual (Appendix A) or on the HCBS-AMH on our webpage at http://www.dshs.texas.gov/mhsa/hcbs-amh/qualifications/. 25. When an individual is still enrolled in a facility and trying to transition to the community, how should the Recovery Manager bill for services? Should the provider bill under "Transition Services" or "Recovery Management Services?" Recovery Management Transitional Fee. The Recovery Management Transitional Fee is a one- time fee that is paid to the Recovery Manager for the first three months of the provision of Recovery Management transitional services. The amount of this one- time Recovery Management Transitional Fee is not dependent on the individual s length of stay during these three months of Recovery Management transitional services. The Recovery Management Transitional fee is 1,842.87. Recovery Management Transitional Day rate After a period of three months, Recovery Management transitional services will be paid at a day rate. The Recovery Manager is not eligible to bill for Recovery Management transitional services provided after the individual s stay exceeds 180 days. The day rate is $19.28. 26. How often is IRP approved? It is anticipated that the RM and the individual will update the individual s IRP every 90 days to ensure IRP is reflection of the individual s current needs and desires. 27. If the Provider has a current contract with HHSC is this opportunity a conflict? No. 28. What is the Recovery manager to individual ratio? Caseload sizes for the individual RM shall preferably be 10 individuals or less and shall be no more than 15 individuals. 5
29. State hospitals can refer to the HCBS program? What is the process if the referring LMHA to the State hospital is not a provider of HCBS? State Hospitals will be responsible for referring any individual that is residing in that state hospital who meets the initial criteria. This referral is submitted to the HCBS-AMH program. The LMHA that is linked with that State Hospital does not need to be a provider of services in order for the referral process to take place. If the individual is enrolled, they will have a choice of which provider (of those available in their chosen community) they want to have provide HCBS-AMH services. 30. Can interns provide Community Psychiatric Supports and Treatment? Yes. Licensure candidates may provide services as part of a graduate program, under the direct supervision of an appropriately licensed professional. 6