Medicaid Rehabilitative and Case Management Services


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Presented at the National Academy for State Health Policy's 20th Annual State Health Policy Conference in Denver, Colorado. Author: Linda Peltz

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Medicaid Rehabilitative and Case Management Services

  1. 1. _ llgoo(AlI£ 3. Maintain SEIIVICES cm! in MEDICARE 3. MEDICAID SERVICES cmmls roll MEDIU is ' ' ' ~ _ / ' . f ‘C . l ' ' ifimicaicl Rehabilitative and ‘ Case Management Servi Linda Peltz, Division of Coverage & Integration Disabled & Elderly Health Programs Group CMSO/ CMS Clllf.
  2. 2. Rehabilitation in Medicaid Jr Rehabilitation is an optional Medicaid benefit, and currently all States provide some coverage under this benefit category.
  3. 3. General State Plan ’ Requirements I Must comply with rules on statewideness and free choice of provider I Must be of sufficient amount duration and scope to reasonably achieve its purpose I Must be available to all eligible Medicaid recipients
  4. 4. Rehabilitation To qualify for Federal financial participation under Medicaid, rehabilitation services SHOULD: — Meet the definition of rehabilitation services (i. e., maximize the reduction of a physical or mental disability and restore a recipient to his best possible functional level); — Be included in the Medicaid state plan; — Adhere to all provider qualifications set forth by the Code of Federal Regulations;
  5. 5. Rehabilitation Rehabilitative services SHOULD: — Be available to all eligible Medicaid recipients based upon medical necessity; — Be based on a specific claim delineating services provided to an eligible individual; — Be paid by a State Medicaid program only when documentation is consistent with the Medicaid State Plan; and — Comply with all Medicaid payment rules.
  6. 6. Rehabilitation Medicaid rehabilitation services should NOT: — Be defined by provider type instead of service (e. g. adult medical day care, schools, etc. §; — Be reimbursed without identification and description in the State's Medicaid Plan; — Be delivered by non-qualified staff; — Be limited to Medicaid recipients based upon a specific diagnosis, type of illness, or condition;
  7. 7. Rehabilitation Rehabilitative services should NOT: — Be “habi| itative” in nature instead of “rehabi| itative; ” — Duplicate payments made by any other source for the same activity; or — Include payment for services that are provided at no charge to non-Medicaid individuals.
  8. 8. Rehabilitation Proposed Rule Jr This Administration is firmly committed to ensuring the integrity of the Medicaid program by clarifying appropriate Medicaid payments for rehabilitative services and defining allowable services.
  9. 9. Intent of Rehabilitative ’ Services Rule In his 2007 budget proposal, the President sought to clarify and refine the rehabilitation benefit through a regulation that will define allowable services and exclude payment for services that are intrinsic to programs other than Medicaid, such as foster care, juvenile justice, and education.
  10. 10. + Intent of Rehabilitative Services Rule (cont. ) F The Rehabilitation rule is designed to allow for State flexibility and growth in the field of rehabilitative services by setting broad parameters for allowable services rather than defining specific allowable services (e. g. assertive community treatment). F The rule does not address payment methodologies. 10
  11. 11. Rehabilitative Services + F Proposed rule for Medicaid Coverage of Rehabilitative Services published August 13, 2007 in Federal Register (CMS 2261-P) V Amends 42 CFR § 440.130 Dia nostic, screening, preventive and reha ilitative services F Creates new section: 42 CFR § 441.45 Rehabilitative Services P 60 day public comment period through October 12, 2007.
  12. 12. Rehabilitative Definition ‘ Section 1905(a)(13) of the Act and 42 CFR § 440.130(d) provide that States may cover rehabilitative services: “including any medical or remedial services (provided in a facility, a home, or other setting) recommended by a physician or other licensed practitioner of the healing arts within the scope of their practice under State law, for the maximum reduction of physical or mental disability and restoration of an individual to the best possible functional Ieveh".
  13. 13. Key Definitions — Restorative services: Services that are provided to an individual who has had a functional loss and has a specific rehabilitative goal toward regaining that function.
  14. 14. Key Definitions (cont. ) — Scope of services: Rehabilitative services may include assistive devices, medical equipment and supplies, not otherwise covered under the plan, which are determined necessary to the achievement of the individual’s rehabilitation goals. Rehabilitative services do not include room and board in an institutional or community setting.
  15. 15. Key Definitions (cont. ) N I Impairments to be addressed: Services provided to the Medicaid eligible individual to address the individual’s physical impairments, mental heath impairments, and or substance-related disorder treatment needs.
  16. 16. Key Definitions (cont. ) l I Medical services: Services specified in the rehabilitation plan that are required for the diagnosis, treatment, or care of a physical or mental disorder and are recommended by a physician or other licensed practitioner of the healing arts within the scope of his or her practice under State law.
  17. 17. Key Definitions (cont. ) l I Remedial services: Services that are intended to correct a physical or mental disorder and are necessary to achieve a specific rehabilitative goal specified in the individual’s rehabilitation plan.
  18. 18. Key Definitions (cont. ) I Under the Direction of: For physical therapy, occupational therapy, and services for individuals with speech, hearing and language disorders, the Medicaid qualified therapist providing direction must meet qualifications at 42 CFR § 440.110. - Please note: This definition only applies to the specific services listed above.
  19. 19. Key Definitions (cont. ) l I Under the Direction of: The supervision must include face-to-face contact with the beneficiary, prescription of services, reviewing the need for continued services, and acceptance of professional responsibility for the services provided.
  20. 20. Key Definitions (cont. ) l I Written rehabilitation plan: The written rehabilitation plan shall be reasonable and based on the individual’s condition(s) and on the standards of practice for the provision of rehabilitative services to an individual with the individual’s condition(s). 20
  21. 21. Written Rehabilitation Plan I The written rehabilitation plan must meet the following requirements: — Be developed by a qualified provider, with input from the individual and others who are important to the individual. CMS recommends a person- centered planning process. — Follow guidance obtained through the active participation of the individual and/ or persons of the individual’s choosing, in the development, review, and modification of plan goals and services
  22. 22. Written Rehabilitation ’ Plan (cont. ) I Specify the individual’s rehabilitation goals to be achieved, including recovery goals for persons with mental health and/ or substance use disorders I Identify the medical and remedial services intended to reduce the identified physical impairment, mental health and/ or substance related disorder
  23. 23. Written Rehabilitation ' Plan (cont. ) I Identify the methods that will be used to deliver services (e. g. specific type of therapy) I Specify the anticipated outcomes I Indicate the frequency, amount and duration of the services I Be signed by the individual responsible for developing the rehabilitation plan 23
  24. 24. Written Rehabilitation I Plan (cont. ) I Indicate the provider(s) of the service(s). I Specify a timeline for reevaluation of the plan, based on the individual’s assessed needs and anticipated progress, but not longer than one year
  25. 25. Written Rehabilitation Plan (cont. ) I Be reevaluated with the involvement of the individual, family or other responsible individuals. I Be reevaluated including a review of whether the goals set forth in the plan are being met and whether each of the services described in the plan has contributed to meeting the stated goals
  26. 26. Written Rehabilitation I Plan (cont. ) I If it is determined that there has been no measurable reduction of disability and restoration of functional level, any new plan would need to pursue a different rehabilitation strategy including revision of the rehabilitative goals, services and/ or methods. 26
  27. 27. Case Record Requirements I Providers of rehabilitative services must maintain case records that include: — A copy of the rehabilitative plan — The name of the individual — The date of the rehabilitative services provided — The nature, content, and units of the rehabilitative services — The progress made toward the functional improvement and attainment of the individual’s goals as identified in the rehabilitative plan and case record 27
  28. 28. Excluded Services I Rehabilitation services do not include services that are intrinsic elements of programs other than Medicaid including, but not limited to: — Foster care — Child Welfare — Education — Child Care — Vocational and prevocational training — Housing — Parole and probation — Juvenile justice — Public guardianship 28
  29. 29. Excluded Services (cont. ) I Examples — Therapeutic Foster Care: Services furnished by foster care providers to children, except for medically necessary rehabilitation services for an eligible child that are clearly distinct from packaged therapeutic foster care services and that are provided by qualified Medicaid providers 29
  30. 30. Excluded Services (cont. ) l I Habilitation Services: Including services for which FFP was formally permitted under the Omnibus Budget Reconciliation Act of 1989. Habilitation services include services provided to individuals with mental retardation or related conditions. 30
  31. 31. Statutory Exclusions I Services provided to inmates living in the secure custody of law enforcement and residing in a public institution. I Services provided to residents of an institution for mental disease (IMD) who are under the age of 65, including residents of community residential treatment facilities with more than 16 beds that do not meet the requirement of inpatient psychiatric service for individuals under age 21.
  32. 32. History of Case Management and N Targeted Case Management I Since 1981 several statutory and regulatory provisions have shaped the optional Medicaid case management service I COBRA of 1985 amended the SSA, adding 1915(9) defining TCM services which enable States to limit case management to specific groups and to particular areas within the State
  33. 33. History of Case Management and N Targeted Case Management I Currently defined at 1915(g) of the SSA Case management services means services which will assist individuals eligible under the plan in gaining access to needed medical, social, educational, and other services. I Later provisions allowed States to limit the providers for persons with developmental disabilities or chronic mental illness
  34. 34. Types of coverage issues ' that have been identified I Services did not meet the requirements of Section 1915(g) or 1905(a) I violated free choice of provider requirements I Responsibility of another federal program such as foster care, special education, juvenile justice I Rates included child protection and welfare services salaries I Claims for ineligible participants
  35. 35. Excessive Medicaid Outlays for Case Management I Example I: — $12 mil. Federal share for TCM — Juvenile justice and Child welfare programs — State law authorized I Example II: — $86.6 mil. Federal share for TCM — Rates included child protection and welfare services salaries I Example III: — Services provided by Counties did not meet TCM definition — Claims for ineligible participants — Variation in rates from $58 to $1644 per encounter I Example IV: — Maximus, Inc. assisted a State's Child and Family Services Agency to submit claims to Medicaid for TCM services provided to children in its foster care program whether or not the services had in fact been provided. — Maximus agreed to pay the Federal government $30.5 million in a civil False Claims Act settlement. 35
  36. 36. Medicaid Targeted e Management spen ' (In Millions) — W
  37. 37. Provisions of I Section 6052 of the DRA I Effective January 1, 2006 I Further defines and provides examples of Medicaid case management and targeted case management I Defines activities that are not reimbursable
  38. 38. Section 6052 Defines Case Management ’ I Case management services assist eligible individuals in gaining access to needed medical, social, educational, and other services. fat? 38
  39. 39. Examples of Case I Management in DRA — Assessing individual service needs — Taking Client History — Referral to services — Care Plan Development — Monitoring and follow-up activities. 39
  40. 40. Targeted Case ’ Management I Section 6052 reiterates the definition of targeted case management contained in section 1915(g): — States may “target” case management services to specific classes of individuals, or to individuals who reside in specified areas of the State (or both). 40
  41. 41. To qualify for FFP, CM or TCM must: I Be defined in the State Plan as it pertains to the needs of a specific population I Be used to achieve specific, identified purposes or outcomes that would not be achieved without the Medicaid case management service I Comprise clearly defined activity separate from the services to which the individual is referred I Be based on a specific claim delineating services provided to an eligible individual
  42. 42. To qualify for FFP, CM or TCM m ust: I Adhere to the requirements for freedom of choice of all qualified providers (except that States may limit choice of providers for persons with mental illness or developmental disabilities) I Be paid by a State Medicaid program only when documentation is consistent with the Medicaid State Plan I Comply with all Medicaid payment rules 42
  43. 43. FFP is NOT available ’ when CM activities are: I Integral components of other covered Medicaid services I Constitute the direct delivery of underlying medical, educational, social, or other services to which an individual has been referred I Integral to the administration of foster care programs I Integral to the administration of another non-Medical program 4
  44. 44. Foster Care Activities Not Eligible for FFP I Research Gathering and completion of documentation required by foster care programs Assessing adoption placements Recruiting or interviewing potential foster care parents Serving legal papers Home investigations Providing transportations Administering foster care subsidies Placement Arrangements
  45. 45. Statutory Exclusions l I Services for individuals under the age of 65 residing in Institutions for Mental Disease (IMDs) I Services for individuals involuntarily living in the secure custody of law enforcement, judicial or penal systems (inmates of public institutions) 45
  46. 46. Medicaid Savings V I Due to this provision of the Deficit Reduction Act, it is estimated that Federal Medicaid spending on CM/ TCM will be reduced by $1.2 billion between FY 2008 and FY 2012. 46
  47. 47. Next Steps V I Interim Final Rule with Comment Period (IFC) is in clearance process I Comment period to follow publication I The Secretary may change or revise the regulation after completion of the period of public comment period I IFC will include effective dates 47
  48. 48. CMS SPA Process I Must be a 1905(a) service I The State should provide a specific service description for each service provided within a model of care or program I For example, with an ACT program, describe each of the service components such as mental health assessment, individual therapy, peer support services, etc. 48
  49. 49. C at MS SPA Process For each of the specific 1905(a) services, the State must identify the providers that are providing that service, and the provider qualifications. 49
  50. 50. CMS SPA Process I I The provider qualifications should include the level of education/ de ree required, and any additional general in ormation related to icensing, credentialing, or registration. I The provider qualifications should also reference any required supervision. 50
  51. 51. CMS SPA Process | I State submits SPA to CMS mailbox I 15‘ 90-Day clock I Request for Additional Information (RAI) from CMS can stop clock I 2”“ 90-Day clock starts upon State response to RAI I Approval or Disapproval
  52. 52. Technical Assistance at CMS welcomes and encourages States to seek technical assistance and guidance while in the process of developing State plan amendments, prior to formal submission.
  53. 53. Contact Information + I Linda Peltz 410-786-3399 | inda. pe| tz@cms. hhs. gov