Oregon Health Plan. 1915(i) Home and Community Based Services. Division of Medical Assistance Programs

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Augustine Shelton
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1 Oregon Health Plan 1915(i) Home and Community Based Services Division of Medical Assistance Programs June 2014

2 What is the 1915(i) Plan? The Home- and Community-Based Services (HCBS) 1915(i) is a state Medicaid plan amendment that allows for the use of Medicaid funding for Home-Based Habilitation, Behavioral Habilitation and Psychosocial Rehabilitation services for qualified Medicaid recipients who have been diagnosed with a mental illness. 2

3 HCBS 1915(i) Objectives For Recipients Increase access to services and supports that promote independent living and choice Expanded service options for recipient and provider Support the development of skills that aid in transition to independence Support independent community living or transition from licensed care Promote recovery and improved outcomes Support recipients to maintain independence and avoid changes in residence Promote a holistic treatment delivery system Decrease reliance on restrictive levels and on homelike levels of care For System and Providers Support and expand the continuum of care Support treatment planning and increase options Expand options for transition to lower levels of care and independent living Simplify documentation for frequently delivered services Allow for services not traditionally covered Support full utilization of community and treatment resources 3

4 1915(i) Services Individuals may receive State Plan HCBS services while residing in any community-based living situation including independent living situations, supported housing, adult foster homes or residential treatment facilities or homes provided the individual meets the established criteria for eligibility Individuals residing in a program licensed as a Secured Residential Treatment Facility (SRTF) cannot be offered services under the 1915(i) Home and Community-Based Services State Plan Option. 4

5 HCBS Services Services provided under the HCBS 1915(i) include Home- Based Habilitation, Behavioral Habilitation and Psychosocial Rehabilitation Services. HCBS 1915(i) services can be provided in licensed and non-licensed home and community based settings. 5

6 HCBS Home-Based Habilitation Home-Based Habilitation services support individuals who have been impaired by the symptoms of a mental illness to attain or maintain their maximal level of independence and reside in the least restrictive and most independent community setting possible. 6

7 HCBS Home-Based Habilitation Provider Types Qualified Mental Health Professional (QMHP) Qualified Mental Health Associate (QMHA) Peer Support Specialist Recovery Assistant (Community Habilitation Provider) *** The local mental health authority must verify provider qualifications every three years 7

8 HCBS Behavioral Habilitation Behavioral Habilitation services support and assist an individual to attain or maintain their maximal level of independence, including acceptance of a current residence and the prevention of unnecessary changes in residence when impaired by symptoms of a mental illness. Behavioral Habilitation is provided to recipients who reside in the community or a licensed AFH, RTH or RTF. 8

9 HCBS Behavioral Habilitation Provider Qualifications Participants requiring skills development, behavioral support, activity therapy or supports for the maintenance of psychosocial skills on a 24/7 basis would be authorized to receive Home- Based Habilitation from providers who meet or have employees who meet qualifications to deliver habilitation: Qualified Mental Health Professional (QMHP) Qualified Mental Health Associate (QMHA) Peer Support Specialist Adult Foster Home Provider Recovery Assistant (Community Habilitation Provider) *** The local mental health authority must verify provider qualifications every three years 9

10 Psychosocial Rehabilitation Psychosocial Rehabilitation services are any medical or remedial services recommended by a physician or other licensed practitioner of the healing arts, within the scope of his practice under state law, for maximum reduction of physical or mental disability and restoration of a recipient to his best possible functional level. 10

11 HCBS Psychosocial Rehabilitation Provider Qualifications Participants requiring psychosocial rehabilitation services in home- and community-based settings may receive services from qualified psychosocial rehabilitative providers: Licensed Medical Professional (LMP) Licensed Health Professional (LHP) Qualified Mental Health Professional (QMHP) Qualified Mental Health Associate (QMHA) *** The local mental health authority must verify provider qualifications every three years 11

12 Individual Eligibility Eligibility for the HCBS 1915(i) is based upon determination that the individual is eligible for Medicaid at the time of review and the individual requires daily assistance, due to mental health issue, with at least (2) two activities of daily living that take at least (1) one hour daily to provide. *** As a requirement, eligibility determinations must be conducted by an impartial third-party clinical reviewer 12

13 Acumentra Health Acumentra Health is the designated eligibility reviewer for 1915(i) If you know a Medicaid-eligible individual who is residing in a licensed setting or in the community who may be eligible, FAX a referral to Acumentra, including: Acumentra Health s HCBS Fax Cover Sheet A mental health assessment that has been completed within the last 365 days A person-centered treatment plan Progress notes that cover one week of services provided 13

14 14 Acumentra Health Documents

15 Acumentra Health Contact Information Acumentra Health FAX: Mailing address: 2020 SW 4 th Ave, Suite 520 Portland, OR

16 Acumentra Process Acumentra will notify the referrer in writing within 3 business days whether or not the individual is eligible for the 1915(i) Once a person is determined eligible, the next step is to submit a service authorization notice to OHA For individuals currently in a licensed residential setting: If the plan of care is current. You may begin providing and documenting personal care, habilitation and rehab services as authorized If the person is new to residential or the plan of care is expired. Submit a plan of care request to AMH as you typically do. The only change is you will need to check the i-plan eligible box on the POC form. Once approved, You may begin providing and documenting personal care, habilitation and rehab services as authorized 16

17 Process, continued If the person is residing in their own home, with family or in supported housing: Submit a Prior Authorization (PA) form to OHA either by fax to or by to amh.retrievers@state.or.us. Requests must include supporting clinical documentation Request procedure code H0046 HK HW and the number of units you have assessed the person as needing One (1) unit of H0046 = One (1) hour of service paid at a rate of $27.50 per unit PAs are approved for up to six months 17

18 18 OHA Prior Authorization Request Form

19 Billing for 1915(i) Services In an AFH, Personal Care Services and Habilitation Services are billed using one code monthly and the HK and HW modifiers - S5141 HK HW In an RTH Personal Care and Habilitation Services are billed using one code daily and use the HK and HW modifiers - T1020 HK HW In an RTF Personal Care and Habilitation Services are billed using one code daily and use the HK, HE and HW modifiers - T1020 HK HE HW Habilitation Services rendered in non licensed community settings are billed using one code hourly and utilize the HK HW modifiers H0046 HK HW 19

20 Provider Enrollment 1915(i) Providers must be enrolled with the Division of Medical Assistance Programs (DMAP) as a Mental Health Provider and have been previously authorized to bill MH Rehab HK Fee-for-Service. Providers shall meet all requirements in OAR , Medical Assistance Programs Provider Enrollment; OAR , Provider Requirements; and , Provider Enrollment. 20

21 Community Habilitation Providers Currently enrolled and newly enrolled mental health (type 33) providers providing Personal Care / Habilitation services using the H0046 code with modifiers HK and HW will need to obtain the Community i-plan Provider specialty (specialty code 448). 21

22 Questions and Training Requests Please direct questions and requests for training to: Chad Scott Division of Medical Assistance Programs (DMAP)

Treatment Services for Individuals with Co-Occurring Mental Health and Intellectual Disability/Developmental Disabilities

Treatment Services for Individuals with Co-Occurring Mental Health and Intellectual Disability/Developmental Disabilities Two types of individuals 1. People with primary diagnosis of intellectual disability/developmental disability Mental health diagnosis is secondary Primary services through ID/DD system Residential/Housing