CHILDRENS MENTAL HEALTH WAIVER

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CHILDRENS MENTAL HEALTH WAIVER

• Virginia Department of Medical Assistance
  Services (DMAS)
• Website www.dmas.virginia.gov
• 2007

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What is the Childrens Mental Health Waiver?

• A demonstration waiver intended to show that home
  and community based services are beneficial (and
  budget neutral) to individuals who would
  otherwise be in a Psychiatric Residential
  Treatment Facility (PRTF)
• Demonstration is for 5 years
• Anticipated that VA will be able to convert the
  demonstration into a HCBW after 5 years
• Implementation Date of 12/1/07

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Background

• PRTFs are the primary provider for youth with
  serious mental health issues requiring an
  institutional level of care
• Until the release of this demonstration, states
  were not allowed to have waivers that used PRTFs
  as an alternate institution

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Eligibility

• Medically needy persons incomes up to 133 of
  the AFDC payment standard as of July 16, 1996
• Monthly income of 251.14, 289.78 or 376.71
  depending on place of residence (319.80, 356.88
  or 454.22 for family of 2)
• Certain aged, blind or disabled adults incomes
  up to 80 percent of the federal poverty level
  (654/mo.)

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Eligibility

• Children adolescents under the age of 21
• Who have been in a PRTF at least 90 days
• Who have a psychiatric diagnosis
• Who remain eligible for Medicaid after
  they leave the PRTF
• Who have a family (foster or biological)
  willing to take the child home

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Eligibility

• Who have community services available
  immediately upon discharge from a PRTF
• Who will continue to meet the PRTF level
  of care
• Who have a case manager

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Initial Enrollment Process

• Children who are in a PRTF and have been there at
  least 90 days will be identified by DMAS
• Either CSA or CSB meets with child/family to
  offer choice and determine eligibility

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Initial Enrollment Process

• If CMH services are chosen, Transition
  Coordinator is chosen to assist with enrollment
  process
• Transition Coordinator will initiate contact with
  DSS to determine eligibility

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Initial Enrollment Process

• Must have CAFAS
• Complete Medicaid eligibility documents
• Sign choice form choosing waiver
• Notify PRTF of desire to obtain waiver services
• Develop Comprehensive Services Plan (CSP) or
  IFSP
• Medical and Psychological Evaluations

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Initial Enrollment Process

• CSP and Individual Service Plans (ISPs) for
  specific services will be submitted to DMAS for
  review
• All services must be preauthorized
• Anticipate KePRO will assume ISP review in May
  2008
• Individual will be admitted to the waiver based
  on their date of application for the waiver

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CMH Waiver Services Overview
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Waiver Services

• Transition Coordination
• Environmental Modifications
• Companion Services (agency and consumer directed)
• Respite Services (agency and consumer directed)
• Service Facilitation for consumer-directed only
• Therapeutic Consultation
• Family Care Giver Training
• In Home Residential Supports

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Transition Coordination Services

• Services that are provided to individuals who
  are in the PRTF and who choose to receive
  services in the community

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Transition Coordination Services

• The assessment of the individual/family
  situation
• Assistance with meeting the requirements of the
  waiver enrollment
• Referral for Medicaid re-determination
• Developing a community plan of care in
  coordination with the family, and others
• Identifying community service providers
• ? Monitoring the initial transition
  to the community

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Transition Coordination Service Limits

• Limited to 3 months prior to discharge from the
  PRTF and one month post discharge
• May only be billed after the individual leaves
  the PRTF

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Transition CoordinationServices

• Documentation
• Individual Service Authorization Request (ISAR)
• Individual Service Plan (ISP)
• Comprehensive Services Plan (CSP)

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Transition Coordination Provider Requirements

• Must be either
• Treatment foster care case manager
• Mental health case manager
• Coordinator with the CSA program
• FAPT members

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Billing Codes for Transition Coordination

• H2015 Transition Coordination -
• Unit is 15 minutes with up to a maximum of 80
  Units for 4 months
• 16.50 per unit

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Consumer Direction (CD)

• Allow recipients or family caregivers direct
  control over who, how, and when services are
  provided.
• Waiver recipient is the employer of record with
  the IRS.
• In Virginia personal assistants are classified as
  domestic servants and are not subject to workers
  compensation claims.

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Consumer Direction

• Attendants cannot be a legally responsible
  relative, a spouse or a parent of a minor child.
• Payment is not made to other family members
  unless there is objective, written documentation
  as to why there are no other providers available
  to provide the service.
• Children under 18 must have an adult to direct
  their services individuals 18 and over may
  direct their own care if they are competent to do
  so.

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Consumer Direction and Fiscal Management

• The assistant is paid on behalf of the waiver
  recipient by a fiscal management entity, Public
  Partnerships Limited (PPL)
• PPL is recognized by the IRS and allows
  recipients to receive consumer-directed services
  while being assured that all employment tax
  responsibilities are properly handled.

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Service Facilitation

• Supports for assisting the individual (if over
  18) or the person who is managing the
  individuals consumer-directed services. The
  service facilitator helps train the individual on
  how to become the employer.

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Service FacilitationProvider Qualifications

• Enrolled as a Medicaid CD Services Facilitator
• Possess a minimum of an undergraduate degree in a
  human services field
• or be a QMHP and have 2 years of satisfactory
  experience working with seriously emotionally
  disturbed individuals

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Service Facilitation

• Responsibilities include
• Conducting assessments regarding the
  individuals particular needs
• Assisting in the development of the ISP
• Providing training to family/caregiver on their
  responsibilities as an employer
• Provide ongoing support
• Be available by telephone

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Service Facilitation

• Responsibilities (cont.)
• Provide employee management training
• Submit criminal record to PPL and Child
  Protective Services Central Registry to DSS
• Verify bi-weekly timesheets are signed
• Face to face every 6 months to reassess
  services and appropriateness for companion care
  and respite

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Service Facilitation

• Documentation
• ISPs, reassessments
• All correspondence and contacts
• Trainings provided
• Individual/family/caregiver satisfaction
• Acknowledgement that individual/family/
  caregiver know their responsibilities of the
  services

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Service Facilitation

• Initial visit is done only once upon entry into
  the CD model of services
• If a change in service facilitators is made, the
  new service facilitator must complete and bill
  for a reassessment

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Service Facilitation

• The service facilitator must work with the
  individual and family to make arrangements to
  transfer to agency directed services if there is
  consistent difficulty hiring and retaining
  employees.

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Service Facilitation

• Individual/Family/Caregiver Responsibilities
• Interview
• Hire/ check references
• Train/ supervise
• Manage/ approve timesheets submit to CD
  service facilitator and PPL
• Fire attendants
• Have an emergency back-up plan

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Billing Codes for Service Facilitation

• H2000 CD Initial Comprehensive Visit -
• 174.12 Rest of State, 226.03 NOVA
• S5109 CD Employee Management Training/Consumer
  Training -
• 173.04 Rest of State, 224.95 NOVA
• 99509 CD - Routine Home Visit -
• 54.08 Rest of State, 70.30 NOVA

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Billing Codes for Service Facilitation

• T1028 CD Reassessment visit
• 86.52 Rest of State, 113.56 NOVA
• S5116 CD Management Training
• 21.63 Rest of State, 28.12 NOVA
• 99199 Criminal Check - 15.00
• 99199 CPS Registry Check - 5.00

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Respite Services (agency and CD)

• Services provided to individuals and their
  families/caregivers to offer temporary, periodic
  and routine relief to unpaid caregivers
• Respite services may be provided in the
  individuals home or place of residence, in the
  community, or in a licensed respite facility

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Respite Services (agency and CD)

• Respite services include the following
• Assistance with/or monitoring of personal
  hygiene
• Nutritional support/ meal preparation
• Safety
• Does not include nursing care

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Respite Services (agency and CD)

• Service units and limitations of respite
• In-Home Residential Support and Companion
  Services can not be provided at the same time as
  Respite
• Can receive consumer-directed respite and agency
  respite, but combination of services cannot
  exceed 720 combined hours in a calendar year
• Must have a service facilitator if choosing CD
  respite

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Respite Services(Consumer Directed)

• Qualifications for attendant
• Must be 18 years of age
• Have the required skills to perform CD services
  as specified in the individuals ISP
• Capable of following a care plan with minimal
  supervision
• Submit to criminal history background check and
  Child Protective Services Central Registry (if
  working with a minor)

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Respite Services(Agency Directed)

• Attendant must have satisfactorily completed
  a training curriculum
• Registered as a certified nurse
• or
• 2) Graduation from approved educational
  curriculum that offers certificates for nursing
  assistant, home health aide, or meeting
  paraprofessional criteria

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Respite Services (agency and CD)

• Qualifications of Supervisor
• QMHP or LMHP to supervise all attendants
• QMHP or LMHP supervisor must make initial home
  visit and assessment prior to start of services
• Conducts reassessments or changes to ISP

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Respite Services (agency and CD)

• Documentation needed for PA
• Individual Service Authorization Request (ISAR)
• Individual Service Plan (ISP)
• Respite authorization must be requested for each
  calendar year (1/1 12/31)

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Billing Codes for Respite(agency and CD)

• S5150 CD Respite (paid to attendant by fiscal
  agent)
• Unit hour
• 8.60 per unit for rest of state, 11.14 for
  NOVA
• T1005 Agency Respite
• Unit hour
• 12.53 per unit for rest of state, 14.76 for
  NOVA

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Companion Services(Agency and CD)

• Provides
• Assistance with skill development
• Understanding family interaction
• Behavioral interventions for support and safety
• Community integration

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Companion Services(Agency and CD)

• Criteria
• There must be clear and present danger to the
  child if left unsupervised
• The child can never be left alone any time due to
  severe emotional disturbance

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Companion Services (Agency and CD)

• Criteria (cont.)
• Must be necessary to ensure the childs health
  and safety
• Can be authorized when no one else is in the home
  who is competent to monitor the child for safety

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Companion Services(Agency and CD)

• Units and limitations
• May not exceed 8 hours a day, either separately
  or in a combination of CD and agency directed
  companion services
• Hours are based on the childs needs
• Can be authorized for family/caregivers to sleep
  (day or night time) when the individual can not
  be left alone at any time

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Companion Services(Agency and CD)

• Companion services may include
• Assistance or help with meal preparation
• Community access and activities
• Laundry
• Shopping
• Light housekeeping
• Reminder for medication (self- administered)
• Support to assure safety

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Companion Services Qualifications(Agency
Directed)

• Must be a licensed by DMHMRSAS as a residential
  services provider, supportive in-home residential
  services, day support service provider, or
  respite service provider
• Or meet the DMAS criteria to be a personal
  care/respite service providers

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Companion Services Qualifications(Consumer
Directed)

• Qualifications for attendant
• Must be 18 years of age
• Have the required skills to perform CD services
  as specified in the individuals ISP
• Capable of following a care plan with minimal
  supervision
• Submit to criminal history background check and
  Child Protective Services Central Registry (if
  working with a minor)

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Companion ServicesQualifications (Agency and CD)

• QMHP or LMHP to supervise all assistants
• QMHP or LMHP supervisor must make initial home
  visit and assessment prior to start of services
• Conducts reassessments or changes to ISP

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Companion Services(Agency and CD

• Responsibilities of supervisor
• Developing of the ISP with assistance from the
  individual/family/caregiver
• Must provide follow up home visits to monitor the
  provision of services (every three months)
• Annual Reassessment

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Companion Services(Agency and Consumer Directed)

• Documentation needed for PA
• Individual Service Authorization Request (ISAR)
• Individual Service Plan (ISP)
• Initial and subsequent assessments and change to
  ISP
• Reviews on quarterly/annual/ or as often as
  needed

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Billing Codes for Companion Services

• S5135 Agency-directed Companion Care
• Unit hour
• 12.53 per unit rest of state, 14.76 per unit
  for NOVA
• S5136 CD Companion Care
• Unit hour
• 8.60 per unit rest of state, 11.14 per unit
  for NOVA

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Therapeutic Consultation

• Provides expertise, training, and technical
  assistance by a licensed professional to assist
  family members, caregivers, and other service
  providers in supporting the individual.

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Therapeutic Consultation

• Specialty Areas
• Psychology
• Behavioral Consultation
• Therapeutic Recreation
• Speech and Language Pathology
• Occupational Therapy
• Rehabilitation Engineering

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Therapeutic Consultation

• Criteria
• Have a demonstrated need for consultation in any
  of these services.
• ISP cannot be implemented effectively without
  such consultation from this service.

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Therapeutic Consultation Provider Qualifications

• Virginia-licensed or certified practitioners
• Psychology ? Social Work
• Occupational Therapy ? Medicine
• Therapeutic Recreation
• Rehabilitation
• Speech/Language Therapy
• Counseling
• Marriage and Family Therapy
• Psychiatric Clinical Nurse Specialists /
  Psychiatric Nurse Practitioners

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Therapeutic Consultation

• Units and limitations
• Unit of service is one hour,
• May not include direct therapy to waiver clients
  or monitoring activities, and may not duplicate
  the activities of other services offered
  through State Plan for Medical Assistance

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Therapeutic Consultation

• Units and limitations
• The need for these services is based on the
  individuals ISP, and is clinically necessary
• May be provided in the individuals home, and in
  appropriate community settings
• Intended to meet desired outcomes as identified
  in the ISP

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Therapeutic Consultation

• Documentation
• Individual Service Authorization Request (ISAR)
• ISP detailing the recommended interventions or
  support strategies for providers and
  family/caregivers to use to better support the
  individual in the service
• Ongoing documentation of consultative services
  rendered, contacts, monthly notes

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Therapeutic Consultation

• Documentation
• Monthly, quarterly, semi-annual and annual notes
• 3 months or less, the provider must forward the
  monthly notes or a summary to the case manager
• 3 months or longer, written quarterly
  semi-annual reviews must be completed by the
  provider and forwarded to the case manager

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Therapeutic Consultation

• Documentation
• If consultation service extends beyond one year,
  the ISP must be reviewed by the provider with the
  individual and family/caregiver and case manager
• A final disposition summary must be forwarded to
  the case manager within 30 days following the end
  of service

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Billing Codes for Therapeutic Consultation

• 97139 Therapeutic Consultation
• Unit hour
• 55.13 per unit for rest of state, 63.40 per
  unit for NOVA

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Family/Caregiver Training

• Training and education related to seriously
  emotionally disturbed individuals in the areas
  of
• community integration
• family dynamics
• stress management
• behavioral interventions and mental health

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Family/Caregiver Training

• Services provided to the family/caregiver to
  assist with maintaining the individual at home.
• Family is defined as the persons who live with
  or provide care or support to a waiver
  individual.
• for example parent/step-parent, children, other
  relatives, legal guardian, foster family, spouse,
  and in-laws

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Family/Caregiver Training

• Criteria
• The need for training and the content of the
  training in order to assist the family/
  caregivers with maintaining the individual at
  home must be documented in the ISP
• The training must be necessary in order to
  improve the family or caregivers ability to
  provide care and support

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Family/Caregiver Training Provider Qualifications

• Individual Family/Caregiver Trainers must be
  licensed or certified to practice in Virginia
• Licensed Professional Counselors
• Licensed Clinical Social Worker
• Licensed Psychologist
• Licensed Marriage and Family Therapists
• Psychiatric Clinical Nurse

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Family/Caregiver Training Service

• Units and limitations
• Individuals family/caregiver can receive up to
  80 hours of Family/Caregiver Training services
  per ISP treatment year
• Training cannot be a service already being
  provided under Medicaid State Plan
• Individuals employed to care for the consumer
  cannot receive training

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Family/Caregiver Training

• Requirements
• Training shall be provided on an individual
  basis, in small groups, through seminars or in
  conferences provided by Medicaid-allowed
  Family/Caregiver Training Providers
• The training must be prior authorized by DMAS
  before it can be provided

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Family/Caregiver Training

• Documentation
• ISAR/ISP
• Assessments/ reassessments
• Documentation of dates of services and type of
  service
• Documentation to support that services provided
  are appropriate and necessary

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Billing Code for Family/Caregiver Training

• S5111Family/Caregiver Training
• Unit hour
• 46.86 per unit for rest of state, 53.89 per
  unit for NOVA

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In-Home Residential Support

• Assistance or specialized supervision provided
  primarily in an individuals home or foster home
  to allow the individual to acquire, retain, or
  improve the self-help, socialization, behaviors
  and adaptive skills necessary to reside
  successfully in home and community-based settings.

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In-Home Residential Support

• Training and assistance in or reinforcement of
• Functional skills and appropriate behavior
• Health and safety
• Personal care
• ADLs
• Use of community resources
• Assistance with medication management
• Monitoring health, nutrition, and physical
  condition
• Life skills training and cognitive
  rehabilitation

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In-Home Residential Support

• Criteria
• Have a demonstrated need for in-home residential
  support services
• Individual must be present during treatment

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In-Home Residential Support

• Units and limitations
• May not be provided simultaneously with respite
  or companion care
• Majority of service rendered is in the home that
  the individual resides in
• Reimbursed on an hourly basis for time the
  in-home residential support staff is working
  directly with the individual
• Not to use as a 24 hour service

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In-Home Residential Support Provider
Qualifications

• Must be licensed by DMHMRSAS as a provider of
  supportive residential services
• Must have training in mental health and
  appropriate interventions, strategies, and
  support methods for persons with severe emotional
  disturbance

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In-Home Residential Support

• Responsibilities of supervisor
• Routine supervision/oversight of direct care
  staff
• Have and document at least one supervisory
  contact per month per staff person regarding
  delivery and performance
• Observe staff at least semi-annually

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In-Home Residential Support

• Responsibilities of supervisor
• Monthly contact with individual and
  family/caregiver regarding satisfaction with
  services delivered by each staff person

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In-Home Residential Support

• Documentation
• Individual Service Authorization Request (ISAR)
• ISP (semi-annually and annually)
• Assessments
• Ongoing documentation (confirm attendance, time,
  specific information regarding the individuals
  response to ISP objectives)

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In-Home Residential Support

• Documentation contd
• Assessments available in at least a daily note or
  a weekly summary
• Semi-annual observation documentation, including
  satisfaction

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Billing Code for In-Home Residential Support

• H2014 In-Home Residential Support Service -
• Unit hour
• 19.85 per unit for rest of state, 22.82 per
  unit for NOVA

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Environmental Modifications

• Physical adaptations to the home or to a vehicle
  that are necessary to ensure the health, welfare,
  and safety of the individual.

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Environmental Modifications

• Such adaptations include
• Items to ensure the safety of the individual,
  family or caregiver and the community
• Modifications can be made to an automotive
  vehicle only if it is the primary vehicle used by
  the individual

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Environmental Modifications

• Units and limitations
• Available if individual is receiving at least one
  other waiver service
• A maximum limit of 5,000.00 may be reimbursed
  per ISP year
• Costs for environmental modifications can not be
  carried over from ISP year to ISP year

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Environmental Modifications

• Exclusions
• General utility carpeting, roof repairs, central
  air conditioning, etc.
• Adaptations to add square footage to the home
• Modifications to bring substandard dwelling up to
  a minimum habitation standards

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Environmental Modifications

• Criteria
• The individual must have a demonstrated need for
  equipment or modifications in the individuals
  primary home and/or primary vehicle.
• Must be in accordance with all applicable
  federal, state or local building codes and
  laws

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Environmental Modifications Provider
Qualifications

• Services provided by provider with a durable
  medical equipment participation agreement with
  DMAS

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Environmental Modifications

• Documentation
• ISAR that documents the need for service
• Documentation of the time frame involved to
  complete the modification and the amount of
  services and supplies
• Documentation of satisfaction of client,
  family/caregiver
• Instructions regarding warranty, repairs,
  complaints, and servicing needs

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Billing Codes for Environmental Modifications

• S5165 Environmental Modification, Mods Only.
• 99199 Environmental Modification,
• Maintenance Cost Only.
• Not to exceed 5,000.00 in the CSP year

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QUESTIONS

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DMAS Contacts

• Mendy Meeks, Childrens Mental Health Waiver
  Project Manager, 804-225-4285 email
  mendy.meeks_at_dmas.virginia.gov
• Tammy Whitlock, 804-225-4714
• website www.dmas.virginia.gov

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Thank You