OPTUM LEVEL OF CARE GUIDELINES: TARGETED CASE MANAGEMENT INTENSIVE CASE MANAGEMENT FLORIDA MEDICAID MMA LEVEL OF CARE GUIDELINES: TARGETED CASE MANAGEMENT INTENSIVE CASE MANAGEMENT FLORIDA MEDICAID MMA Guideline Number: Effective Date: January, 2017 Table f Cntents Page INTRODUCTION...1 TARGETED CASE MANAGEMENT INTENSIVE CASE MANAGEMENT.....1 REFERENCES... 4 HISTORY/REVISION INFORMATION... 5 Relevant Services Targeted Case Management Flrida Medicaid MMA Related Behaviral Clinical Plicies & Guidelines: Level f Care Guidelines: Case Management INTRODUCTION The Level f Care Guidelines is a set f bjective and evidence-based behaviral health criteria used t standardize cverage determinatins, prmte evidence-based practices, and supprt members recvery, resiliency, and wellbeing 1 fr behaviral health benefit plans that are managed by Optum and U.S. Behaviral Health Plan, Califrnia (ding business as OptumHealth Behaviral Slutins f Califrnia ( Optum-CA )). The Level f Care Guidelines is derived frm generally accepted standards f behaviral health practice. These standards include guidelines and cnsensus statements prduced by prfessinal specialty scieties, as well as guidance frm gvernmental surces such as CMS Natinal Cverage Determinatins (NCDs) and Lcal Cverage Determinatins (LCDs). The Level f Care Guidelines is als derived frm input prvided by clinical persnnel, prviders, prfesisnal specialty scieties, cnsumers, and regulatrs. Fr mre infrmatin n guiding principles fr the Level f Care Guidelines and their develpment, apprval, disseminatin, and use, please see the Intrductin t the Level f Care Guidelines, available at: www.prviderexpress.cm > Clinical Resurces > Level f Care Guidelines. Befre using this guideline, please check the member s specific benefit plan requirements and any federal r state mandates, if applicable. TARGETED CASE MANAGEMENT INTENSIVE CASE MANAGEMENT TARGETED CASE MANAGEMENT (TCM) assists member in gaining access t needed medical, scial, educatinal, and ther services. 1 The terms recvery and resiliency are used thrughut the Psychlgical and Neurpsychlgical Testing Guidelines. SAMHSA defines recvery as a prcess f change thrugh which individuals imprve their health and wellness, live a self-directed life, and strive t reach their full ptential. SAMHSA defines resilience as the ability t adapt well ver time t life-changing situatins and stressful cnditins. The American Sciety f Addictin Medicine defines recvery as a prcess f vercming bth physical and psychlgical dependence n a psychactive substance, with a cmmitment t sbriety, and als refers t the verall gal f helping a patient t achieve verall health and well-being. Targeted Case Management and Intensive Case Management-Flrida Medicaid MMA Page 1 f 5
The primary gal f Targeted Case Management is t ptimize the functining f members wh have cmplex needs by crdinating the prvisin f quality treatment and supprt services in the mst efficient and effective manner. Targeted Case Management services include wrking with the member and the member s natural supprt system t develp and implement the member s service plan. Services als include fllw-up t determine the status f services, and the effectiveness f activities related t enhancing the member s inclusin in the cmmunity. INTENSIVE CASE MANAGEMENT (ICM) prvides case management t adults wh have a Serius and Persistent Mental Illness, and is intended t assist members with remaining in the cmmunity and aviding institutinal care. Intensive Case Management case managers crdinate needs assessments, service planning, and prvide service versight. In additin, case managers als prvide crisis supprt, and skills training in the member s natural envirnment including training t prmte independent living. 1. Admissin Criteria see Cmmn Criteria and Best Practices fr All Levels f Care : see Admissin Criteria in the Level f Care Guideline, Case Management: Services are medically necessary i Additinal TCM Admissin Criteria fr Children and Adlescents The member is 17 years f age r yunger. The member has an emtinal disturbance ii r a serius emtinal disturbance iii. The member is in ut-f-hme mental health placement r is at dcumented risk f ut-f-hme mental health placement. The member is nt receiving duplicate case management services except in the fllwing circumstances: Optum Behaviral Health refers the member fr 30-day certificatin and the area Medicaid ffice assigns a different case manager fr the purpse f cnsultatin, peer review, and prvisin f service planning. The member s regular case manager is unavailable. The member is a transitin yuth age 18-22. A member may receive TCM fr up t 30 calendar days withut meeting the abve criteria under either f the fllwing cnditins: The member has been referred by Optum Behaviral Health after a denied admissin t r discharge frm an inpatient psychiatric unit. The member has been admitted t an inpatient psychiatric unit and has been identified as high risk by Optum Behaviral Health. Cverage f TCM is nt available beynd the 30-day perid unless the member meets the criteria fr TCM. Additinal TCM Admissin Criteria fr Adults The member is 18 years f age r lder. The member has a Severe and Persistent Mental Illness iv and, based upn prfessinal judgment, the illness will last fr at least 1 year. At least ne f the fllwing requirements are met: The member is awaiting admissin t r has been discharged frm a state mental health treatment facility. The member has been discharged frm a mental health residential treatment facility. The member has had mre than 1 admissin t a crisis stabilizatin unit (CSU), shrt-term residential facility (SRT), inpatient psychiatric unit, r any cmbinatin f these facilities in the past 12 mnths. The member is at risk f institutinalizatin fr mental health reasns. The member is experiencing lng-term r acute episdes f mental impairment that may put the member at risk f requiring mre intensive services. Targeted Case Management and Intensive Case Management-Flrida Medicaid MMA Page 2 f 5
The member is nt receiving duplicate case management services. If the member has relcated frm a Department f Children and Families (DCF) district r regin where he/she was receiving TCM, the member des nt need t meet the abve criteria. A member may receive TCM fr up t 30 calendar days withut meeting the abve criteria under either f the fllwing cnditins: The member has been referred by Optum Behaviral Health after a denied admissin t r discharge frm an inpatient psychiatric unit. The member has been admitted t an inpatient psychiatric unit and has been identified as high risk by Optum Behaviral Health. Cverage f TCM is nt available beynd the 30-day perid unless the member meets the criteria fr TCM. Additinal ICM Criteria fr Adults The member is 18 years f age r lder. The member meets at least ne f the fllwing requirements: The member has resided in a state mental hspital fr at least 6 mnths in the past 36 mnths. The member has had 3 r mre admissins t a crisis stabilizatin unit (CSU), shrt-term residential facility (SRT), inpatient psychiatric unit, r any cmbinatin f these facilities in the past 12 mnths. The member resides in the cmmunity and, due t a mental illness, exhibits behavir r symptms that culd result in lng-term hspitalizatin if frequent interventins fr an extended perid f time were nt prvided. If the member has relcated frm a Department f Children and Families (DCF) district r regin where he/she was receiving ICM, the member des nt need t meet the abve criteria. 2. Cntinued Service Criteria see Cmmn Criteria and Best Practices fr All Levels f Care : 3. Discharge Criteria see Cmmn Criteria and Best Practices fr All Levels f Care : 4. Clinical Best Practices see Cmmn Criteria and Best Practices fr All Levels f Care : see Clinical Best Practices in the Level f Care Guideline, Case Management: The case manager assesses each recipient f TCM/ICM as sn as pssible cmmensurate with the member s needs but n later than 30 calendar days frm first receiving TCM/ICM. The assessment includes infrmatin prvided by: The member; The referring persn r agency; The member s family and friends (with cnsent); The schl district (fr members under age 18 r wh are still attending schl(; Previus treating prviders. The case manager makes at least 1 hme visit prir t cmpletin f the assessment. If a hme visit is nt pssible, the case manager cnducts a face-t-face interview with the member in anther setting. The case manager creates an Individual Service Plan within 30 days f initiating ICM/TCM. Services and service frequency reflect the member s, needs, gals, and abilities and must nt simply reflect the Medicaid maximum allwable fr this service (48, 15-minute units per day f ICM, 344 15- minute units per mnth f TCM). Fr members receiving ICM, the case management team is available 24 hurs per day, 7 days per week. Targeted Case Management and Intensive Case Management-Flrida Medicaid MMA Page 3 f 5
The case manager cnvenes case staffing at majr decisin pints during the member s invlvement with the behaviral health system such as mvements t a lesser r mre restrictive envirnment in the cmmunity, r transfers t r frm state hspitals. Case staffing cnferences are attended, as apprpriate, by the member, family members, service prviders and significant thers. The case manager ensures that service plan gals and bjectives are cnsistently pursued, and assesses prgress tward the achievement f gals and bjectives thrugh mnitring activities such as telephne calls, hme visits, case and treatment reviews, interviews and site visits. When a member misses an appintment related t the service plan r is absent frm a treatment prgram withut ntificatin, the case manager attempts t cntact the member by telephne r face-t-face meeting within 24 hurs. If initial attempts t cntact the client are unsuccessful, the case manager makes additinal effrts by telephne, face-t-face meetings, r crrespndence. Upn cntacting the member, the case manager explres the reasn fr the absence r the missed appintment and wrks with the member t reslve issues inhibiting the implementatin f the service plan. The service plan is reviewed and revised as significant changes ccur in the member s cnditin, situatin, r circumstances, but n less frequently than every 6 mnths. The service plan review is a prcess cnducted t ensure that services, gals, and bjectives cntinue t be apprpriate t the member s needs and t assess the member s prgress and cntinued need fr TCM/ICM. The member s eligibility fr TCM/ICM is re-evaluated during the service plan review. Evaluatin and Service Planning: Additinal Clinical Best Practices fr Members in a Statewide Inpatient Psychiatric Prgram (SIPP) TCM is available fr children in a SIPP fr the last 180 days prir t discharge. Fr cntinuity, TCM is prvided by the agency lcated in the same district as the member s aftercare placement. If a case manager is assigned prir t r at the time f placement, the case manager des the fllwing: Prvides relevant infrmatin t SIPP staff regarding the member s strengths as well as prblems and symptms that have resulted in the need fr placement. Infrms the SIPP f previus mental health interventins and services, the member s respnse t these services, and f significant individuals invlved with the member. TCM services prvided t the member include the fllwing: Meeting the member, parent r guardian, and cntacting ther peple (guardian ad litem, child welfare, cmmunity-based care, and ther agencies) t explain the rle f the case manager fr a member in a SIPP placement. Attending at least 1 team meeting mnthly and determine if treatment plan gals address the prblems and symptms that resulted in the need fr the member s restricted placement and the child s strengths and assets. Fr children wh are placed ut f district, attendance may ccur by phne. Having face-t-face cntact with the member and the member s therapist mnthly and cntact with the family r guardian t supprt the family s invlvement in treatment and t further the treatment and discharge planning gals. If the case manager is unable t visit the member, the case manager must call the member at least nce every 14 days. Assisting the parent r guardian in crdinating aftercare services in the hme, schl, and cmmunity envirnments t assess and assist the member s transitin and adjustment t discharge placement. Recmmending and implementing any changes r revisins t the aftercare services array, as needed. After discharge, cllecting utcme data t include a tw-mnth fllw-up and reprting the infrmatin t the SIPP. TCM services fr members in a SIPP are limited t 8 hurs mnthly. This limit may be increased t 12 hurs mnthly during the last mnth f the member s SIPP placement t facilitate implementatin f the aftercare plan. Evaluatin and Service Planning: Additinal Clinical Best Practices fr Members in a State Mental Health Facility ICM is available fr members in a state mental health facility fr the last 60 days prir t discharge. The case manager carries ut linkage and brkerage activities in the cmmunity prir t the member s discharge in rder t implement the service plan. The case manager has face-t-face cntact with the member within 2 business days f discharge. REFERENCES* 1. State f Flrida, Administrative Cde. (2006). Rule 59G-1.010, Definitins. Targeted Case Management and Intensive Case Management-Flrida Medicaid MMA Page 4 f 5
2. State f Flrida, Admnistrtive Cde. (2006). Rule 59G-4.199 Mental Health Targeted Case Management Services. 3. State f Flrida, Administrative Cde. (1996). Rule 65E-15.051, Case Management. 4. State f Flrida, Agency fr Healthcare Administratin. (2014). Cmmunity behaviral health services cverage and limitatins handbk. *Additinal reference materials can be fund in the reference sectin(s) f the applicable Level f Care Guidelines and in the related Behaviral Clinical Plicy HISTORY/REVISION INFORMATION Date May, 2014 Versin 1 January, 2015 Versin 2 January, 2016 Versin 3 January, 2017 Versin 4 Actin/Descriptin i Rule 59G-1.010 (166), Flrida Administrative Cde defines medically necessary r medical necessity as fllws: The medical r allied care, gds, r services furnished r rdered must meet the fllwing cnditins: 1) be necessary t prtect life, t prevent significant illness r significant disability, r t alleviate severe pain 2) be individualized, specific, and cnsistent with symptms r cnfirmed diagnsis f the illness r injury under treatment, and nt in excess f the patient s needs 3) be cnsistent with generally accepted prfessinal medical standards as determined by the Medicaid prgram, and nt experimental r investigatinal 4) reflect the level f services that can be safely furnished, and fr which n equally effective and mre cnservative r less cstly treatment is available statewide 5) be furnished in a manner, nt primarily intended fr the cnvenience f the recipient, the recipient s caretaker, r the prvider. The fact that a prvider has prescribed, recmmended, r apprved medical r allied care, gds, r services, des nt, in itself, make such care, gds r services medically necessary r a cvered service. ii Per F.S. 394.492 an emtinal disturbance is present when a child is diagnsed with a mental, emtinal, r behaviral disrder f sufficient duratin t meet ne f the diagnstic categries specified in the mst recent editin f the Diagnstic and Statistical Manual f the American Psychiatric Assciatin, but wh des nt exhibit behavirs that substantially interfere with r limit his r her rle r ability t functin in the family, schl, r cmmunity. The emtinal disturbance must nt be cnsidered t be a temprary respnse t a stressful situatin. The term des nt include a child r adlescent wh meets the criteria fr invluntary placement. iii Per F.S. 394.492 a serius emtinal disturbance is present when a child diagnsed as having a mental, emtinal, r behaviral disrder that meets ne f the diagnstic categries specified in the mst recent editin f the Diagnstic and Statistical Manual f Mental Disrders f the American Psychiatric Assciatin; and exhibits behavirs that substantially interfere with r limit his r her rle r ability t functin in the family, schl, r cmmunity, which behavirs are nt cnsidered t be a temprary respnse t a stressful situatin. iv Accrding t Federal Register 58, Number 96, the federal definitin f Serius Mental Illness (SMI) includes persns aged 18 r lder wh currently r at any time in the past year have had a diagnsable mental, behaviral, r emtinal disrder (excluding develpmental, dementias, mental disrders due t a medical cnditin and substance use disrders) f sufficient duratin t meet diagnstic criteria specified within the DSM that has resulted in serius functinal impairment, which substantially interferes with r limits ne r mre majr life activities. Targeted Case Management and Intensive Case Management-Flrida Medicaid MMA Page 5 f 5