Medical Services Handbook

Transcription

1 Medical Services Handbook Children and Family Services DCFS Child Protection & Safety Training Version 3 November 2014 Developed for DHHS-DCFS by UNL-CCFL 11/10/14 Page 1

2 Developed by Gregg F. Wright, M.D., M.Ed. University of Nebraska, Lincoln Center on Children, Families, and the Law for The Division of Children and Family Services Nebraska Department of Health and Human Services Revised 2013 Gregg F. Wright, M.D., M.Ed. Revised April, 2014 Lisa Casullo, PsyD, CPSW Magellan Behavioral Health of Nebraska, Inc. Revised October, 2014 Catherine Gekas Steeby, Administrator II, Eligibility Policy Crystal Georgiana, Program Manager II, Eligibility Policy Flora Coan, Administrator I, Professional Services Unit Cindy Buesing, LIMHP, LADC, Behavioral Health Program Specialist Division of Medicaid and Long-Term Care Nebraska Department of Health and Human Services Revised November, 2014 Amber Pelan, Field Training Specialist, Center on Children, Families and the Law Developed for DHHS-DCFS by UNL-CCFL 11/10/14 Page 2

3 UNDERSTANDING NEBRASKA MEDICAID An Overview of Medicaid Medicaid provides important medical services to eligible Nebraska residents. Medicaid is a diverse program that can be confusing to those who are not familiar with Medicaid or managed care. This guide is intended to help better understand Medicaid in Nebraska. Key Considerations 1. Medicaid is a health insurance program. As a health insurance, Medicaid will pay only for medically necessary care. It will never pay for a place to live or for many other important needs that are not medical in nature.... for more, see Page 5 2. Medicaid is a state program with federal cost-sharing. The federal government has developed broad guidelines for each state to follow regarding how their Medicaid programs are run. Each state is able to develop their own eligibility rules, program, etc. as long as they operate within the set federal guidelines.... for more, see Page 7 3. A person must be eligible to receive Medicaid. Rather than one set of Medicaid eligibility rules, there is a list of programs, each with their own eligibility rules; eligibility for one of these programs confers Medicaid eligibility as well.... for more, see Page 8 4. There are 2 parts to Medicaid: Medical/ Surgical Services and Behavioral Health Services. The administration of Medicaid is different for medical/surgical services (including wellchild care and regular medical care) and for behavioral health services provided by a psychiatrist or psychologist or any licensed mental health provider.... for more, see Page All Medicaid services are now managed care. Aetna and United provide managed care services for medical/ surgical care in 10 counties in southeast Nebraska and Aetna and Arbor manage medical/surgical care in the rest of the state. Magellan Behavioral Health of Nebraska Inc. provides managed care services for all behavioral health services (which includes mental health and substance use disorder services).... for more, see Page It is possible to appeal a managed care decision. When decisions regarding behavioral health services are made, legal guardians (when the child is a state ward, the legal guardian is DHHS CFSS), the client, parent, and the provider can request the appeal when payment is denied. On the medical side, it s a medical decision and only a licensed provider can appeal when payment is denied....for more, see Page Nebraska can (sometimes must) pay for medical care when Medicaid cannot. Nebraska uses Medicaid when possible because of federal cost sharing. However, if a court orders payment for care not authorized by Magellan, the state pays 100% of the costs. This is also true for nonmedical psychological services.... for more, see Page 26 Developed for DHHS-DCFS by UNL-CCFL 11/10/14 Page 3

4 ADDITIONAL INFORMATION ON MEDICAID MANAGED CARE DHHS website offers these explanations of Medicaid Managed Care. Medicaid Managed Care is the way some clients receive their Medicaid benefits. Managed Care is a service delivery system where Nebraska Medicaid contracts with a Managed Care Organization (MCO) to operate a health plan that authorizes, arranges, provides and pays for the delivery of services to enrolled clients. Nebraska utilizes Managed Care to provide physical and behavioral (mental health and substance use disorder) health services and is working to implement a program to provide Managed Long-Term Services and Supports. The care of enrolled clients in the Physical Health plans is managed by MCOs through their networks of Primary Care Providers (PCPs), specialists, hospitals, and other providers of care who contract directly with the MCO. Managed care offers an opportunity to assure access to a PCP, coordination of medical care, emphasizes preventive care, and encourages the appropriate utilization of services in the most cost-effective settings. The care of enrolled clients in the Behavioral Health plan is offered through a network of providers who contract directly with a Managed Care Plan. The goal of this new delivery system is to provide services consistent with best practices that will decrease reliance on emergency and inpatient levels of care, increase evidence-based treatment, increase outcome-driven community-based programming and support, increase coordination between service providers, promote a Recovery Oriented System of Care, and increase access to high quality services to meet the needs of our diverse clients. Information specific to Magellan Behavioral Health Plan is in a FAQ document link: What is Medicaid Managed Care? Managed Care is a service delivery system where Nebraska Medicaid contracts with a Managed Care entity to operate a health plan that authorizes, arranges, provides, and pays for the delivery of Behavioral Health services to enrolled clients. The care of the clients enrolled in the health plan is managed by Magellan Behavioral Health, through its network of providers who contract directly with Magellan. The following categories of Medicaid eligible individuals are mandatory to enroll in Behavioral Health managed care: Families, children, and pregnant women eligible for Medicaid under Section 1931 of the Social Security Act or related coverage groups; Blind/Disabled Children, Adults, and Related Populations who are eligible for Medicaid due to blindness or disability; Aged and Related Populations. Those Medicaid beneficiaries who are age 65 or older and not members of the Blind/Disabled population or members of the 1931 Adult population; Foster Care Children. Medicaid beneficiaries who are receiving foster care or adoption assistance (Title IV-E), are in foster-care, or are otherwise in an out-of-home placement; Title XXI CHIP. An optional group of targeted low-income children who are eligible to participate in Medicaid in Nebraska and; All of the following waivers: Child Development Disability, Aged and Disabled, Adult Developmental Disability, Adult Developmental Disability Comprehensive, Adult Developmental Disability Day and Traumatic Brain Injury (TBI). Nursing home residents. Are there any excluded categories from BHMC? Yes, the following Medicaid eligible individual s categories are excluded from BHMC: Medicaid members for the period of retroactive eligibility; Aliens who are eligible for Medicaid for an emergency condition only; Members who have excess income or share of cost who are designated to have a Premium Due; Members eligible during the period of presumptive eligibility; Participants in an approved DHHS PACE program, and; Clients with Medicare coverage where Medicaid only pays co-insurance and deductibles. Developed for DHHS-DCFS by UNL-CCFL 11/10/14 Page 4

5 UNDERSTANDING NEBRASKA MEDICAID 1. Medicaid is Health Insurance Medicaid is a health insurance program set up by the U.S. Government, run by each state, and funded by cost sharing between the federal and state governments. Key Considerations Services must be medically necessary to be covered by Medicaid. As with any insurance company, services under Medicaid must be medically necessary. This means they are necessary to diagnose, treat, cure, or prevent an illness, or be reasonably expected to relieve pain, improve health, or be essential to life. Mental health services must be based on a current behavioral health diagnosis as outlined in the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The DSM-5 is used to define the allowable mental health and substance use disorders for Medicaid. In addition to a diagnosis, the patient must experience functional impairment from the condition and be expected to benefit from the treatment. The line between mental health treatment and necessary living support often needs clarification to understand. Children with difficult behaviors may need complex living supports. Medicaid will never pay for living supports, only for the least restrictive medical treatment. Necessary living supports must be paid from 100% state funds. A Medical Home is Important A medical home is a continuing relationship with a primary care physician who remains involved with and receives reports from any specialty care needed. Nebraska Medicaid regulations seek to establish a medical home for every child. The importance of a medical home was first recognized in children with disabilities. A child who has a neurologist, an orthopedist, a dermatologist, an ophthalmologist, a neurosurgeon, and a cardiologist is likely to lose connection with their primary care physician. A child s physical health and behavioral health care should be overseen by one primary care physician. Each specialist assumes that someone else is providing well child care, when in reality; the child may not be immunized. The parents may become the only means of communication and coordination of a complicated care plan. Children in foster care also need a medical home. 60% have a chronic illness and 25% have three or more. Chapter 7 of NAC 390 specifies To assure continuity in medical care, if a child has a primary care physician when entering care, the Department will attempt to use this provider whenever possible. Currently, 85% of medications prescribed for a behavioral health condition are done so by a primary care physician. The DSM-5 is the most recent text revision of a series of manuals produced by the American Psychiatric Association to standardize the language and terminology used in describing mental disorders and to enable clinicians and investigators to diagnose, communicate about, study, and treat people with various mental disorders. It is an important book because Medicaid Behavioral Health (MH/SA) only pays for the treatment of a DSM-5 diagnosis. Nebraska Medicaid does NOT reimburse for diagnosis of Intellectual Disability (previously Mental Retardation). As of October 1, 2014, Autism Spectrum Disorders WILL be covered by Nebraska State Medicaid. Developed for DHHS-DCFS by UNL-CCFL 11/10/14 Page 5

6 MEDICAL NECESSITY IS DEFINED IN MEDICAID REGULATIONS (based on 471 NAC ) Treatment services are medically necessary if they: a) are necessary to diagnose, treat, cure, or prevent an illness; or b) may reasonably be expected to relieve pain, improve health, or be essential to life. Clients receiving Mental Health/Substance Use (MHSU) treatment services: a) must have a diagnosable mental health or substance use diagnosis, and b) must be experiencing functional impairments as a result of this condition. Diagnosable behavioral health conditions are the diagnoses listed in the current version of the Diagnostic and Statistical Manual (DSM-5). Biopsychosocially necessary treatment interventions and supplies are those which are: a) Consistent with the behavioral health condition; b) Conducted with the treatment of clients as a primary concern; c) Supported by evidence demonstrating that i) the treatment can be expected to produce intended effects on behavioral health outcomes; and ii) the beneficial effects outweigh its expected harmful effects; d) Cost effective in addressing the behavioral health outcome; e) Determined by the presentation of behavioral health conditions, not necessarily by the credentials of the service provider; f) Not primarily for the convenience of the client or the provider; and g) Delivered in the least restrictive setting that will produce the desired results in accordance with the needs of the client. A supervising practitioner must conduct a face-to-face assessment and establish that the client meets the eligibility criteria for a particular service before the client is admitted for treatment and each time the client is admitted or readmitted for services. WILL PHYSICIANS ACCEPT MEDICAID PATIENTS? A national GAO study (GAO , June 2011) showed that 83% of primary care physicians and 71% of specialty physicians are enrolled as Medicaid providers. The graphs below show that of enrolled providers, 47% accept all and 44% accept some new Medicaid patients (compared to 79% and 18% for privately insured patients). However, physicians have much more difficulty obtaining specialty referrals for their Medicaid patients than for their privately insured patients. The report also shows that rural providers are more likely to accept new Medicaid patients. Once Medicaid patients are accepted, the study shows that the wait times to obtain an appointment was similar for Medicaid patients and those covered by private insurance. Developed for DHHS-DCFS by UNL-CCFL 11/10/14 Page 6

7 UNDERSTANDING NEBRASKA MEDICAID 2. Medicaid is a State Program with Federal Cost-sharing Although the U.S. Government pays a portion of the costs, each state runs its own Medicaid program and may configure Medicaid eligibility, benefits, and procedures for their own state. Key Considerations Each state configures Medicaid differently. Within broad guidelines, the federal government allows each state to determine the shape of its Medicaid program. If children move to or from another state, they may find that Medicaid covers more or fewer services than the state they are leaving. Don t make assumptions when children change states. Check. Don t confuse Medicaid with Medicare. In contrast to Medicaid, Medicare is a federal program which is the same in every state. Medicare covers medical care and some medications for the elderly and for individuals with some kinds of chronic illness. Both Medicaid and Medicare are managed out of the same federal agency: Centers for Medicare and Medicaid Services (CMS). In Nebraska, the federal government pays approximately 50% of Medicaid costs. Each year the federal government calculates a matching rate for each state based on the average per capita income in the state. For many years, the federal share of Nebraska s costs has been near 50%. Nebraska must pay approximately 50% of all Medicaid costs. TOTAL MEDICAID COSTS Federal Funding, Monitoring, and Oversight NE SHARE U.S. SHARE Developed for DHHS-DCFS by UNL-CCFL 11/10/14 Page 7

8 UNDERSTANDING NEBRASKA MEDICAID 3. Medicaid Eligibility Medicaid is a public health insurance program created to provide health insurance for low-income individuals. Medicaid is targeted to low-income individuals in certain groups, including children, individuals with disabilities, and the elderly. Individuals must meet all eligibility requirements to receive Medicaid. Key Considerations The federal government requires states to cover some categories; others are required by state law. The list of Nebraska Medicaid eligibility categories is given on the following pages. Although the federal government gives states great latitude on how to run their Medicaid program, many categories are required as a minimum. The Nebraska legislature has mandated many categories considered optional by the federal government. All Medicaid eligibility categories require some documentation of financial need. Financial need is determined using the annually announced Federal Poverty Guidelines. For example, CHIP (Children s Health Insurance Program) covers children in families making less than 213% of the Federal Poverty Level (FPL). A Medicaid eligibility determination is required for all state wards. State wards who are IV-E eligible are eligible for Medicaid. Medicaid eligibility for all other state wards will be determined based on the income and resources of the child (state ward) or the family depending on the child s living situation. DHHS ensures the application process is completed for all state wards, the state ward s living arrangements determine who is responsible for completing the application. Non-citizen state wards need a letter of entitlement from IMFC to receive medical services. Persons in Family 2014 Federal Poverty Guidelines 48 Contiguous States & D.C. Alaska Hawaii 1 $11,670 $14,580 $13,420 2 $15,730 $19,660 $18,090 3 $19,790 $24,740 $22,760 4 $23,850 $29,820 $27,430 5 $27,910 $34,900 $32,100 6 $31,970 $39,980 $36,770 7 $36,030 $44,060 $41,440 8 $40,090 $50,140 $46,110 For each add l person, add: $4,060 $5,080 $4,067 What does it mean to live at the poverty level? Dr. Amy Glasmeier at Penn State University* estimates the following monthly costs for a family of four in Nebraska: Food... $684 Child Care... $854 Medical... $384 Housing... $584 Transportation $810 This totals to $3,316 per month. The poverty level in Nebraska works out to be $1,921 or almost $1400 short each month. Where would you cut back to make ends meet and be able to buy something nice for your kids? * see Developed for DHHS-DCFS by UNL-CCFL 11/10/14 Page 8

9 The Affordable Care Act resulted in the development of a federal Marketplace where people without health care coverage or those searching for different coverage can go to apply for a private health plan. Medicaid is an Insurance Affordability Program. If an individual applies for healthcare on the federal Marketplace and they are assessed as Medicaid or CHIP eligible, their application will be sent to Medicaid to make a determination. There is a No Wrong Door approach. If you apply through ACCESSNebraska and do not qualify for benefits, they will send your application to the marketplace, and vice versa. You can apply for Medicaid and CHIP at any time during the year. If it is determined that you are not eligible for Medicaid, you can apply for private insurance through the federal Marketplace. There are premium tax credits and other savings available to assist individuals with securing a private health plan. However, the amount of financial assistance through the Marketplace is also dependent on income level.see Page 44. NEBRASKA MEDICAID ELIGIBILITY (as of 9/1/2010) MEDICAID ELIGIBILITY CATEGORIES FAMILIES AND CHILDREN PARENT OR CARETAKER OF A CHILD (P/CR) Parents and other Caretaker Relatives of dependent children who meet the income guidelines are eligible for Medicaid. Income: $557 a month for one individual $689 a month for two individuals $822 a month for three individuals Resources: There is no resource test. Required under Federal and State law. MEDICALLY NEEDY MEDICAID (SHARE OF COST) These individuals have income over the standard but less than the Medically Needy income Standard and have a medical need. This program includes children, and parents or caretaker relatives. Income: $392 a month one or two individuals Resources: $492 a month three individuals $4,000 one individual $6,000 two individuals EXCESS INCOME: As Medically Needy, these cases have income over the income limit but can spenddown or share the cost by paying for medical bills over the medically needy income level and establish eligibility. Once the excess income is met they establish Medicaid eligibility. Federal option required under State law (68-915). P/CR cases closed due to Spousal Support Collections These are cases closed due to collection of spousal support and are automatically eligible for Medicaid (both children and adults) without an income or resource test for four months. Required under Federal Law. Developed for DHHS-DCFS by UNL-CCFL 11/10/14 Page 9

10 TMA Transitional Medical Assistance Cases are cases that are ineligible for Medicaid due to earnings and a member of the unit was eligible for a grant or under in 3 of the preceding 6 months. The first six months are without regard to income. In the next 6 months earned income must be below 185% of the Federal Poverty Level. All members of the family are eligible if their earned income is below 100% FPL, if above 100% FPL the family can pay a premium and be Medicaid eligible. Income (185% FPL): $1,800 one individual $2,425 two individuals $3,051 three individuals Resources: There is no resource test. Only earned income is used to establish eligibility. PREGNANT WOMEN Pregnant women whose family income is equal to or less than 194% FPL. No ability to obligate income above the standard to establish eligibility. An eligible pregnant woman remains Medicaid eligible through the sixty-day postpartum period. Income (194% FPL): $1,888 a month one individuals $2,543 a month two individuals $3,199 a month three individuals Resources: There is no resource test. Under Federal Law a child born to a Medicaid eligible woman is eligible for Medicaid for 12 months as long as the child remains in Nebraska. MEDICAID FOR CHILDREN Newborn up to age one whose family income is less than 162% of the Federal Poverty level. No ability to obligate income above the standard to establish eligibility. Only the children in the family are eligible, no adults can be Medicaid eligible under this category. Income (162% FPL): $1,576 a month one individual $2,124 a month two individuals $2,671 a month three individuals Resources: There is no resource limit Required under Federal and State Law (68-915). Children ages 1 through 5 (through the month of their sixth birthday) and family income equal to or less than 145% FPL. No ability to obligate income to establish eligibility. Only the children are eligible, no adults. Income (145% FPL): $1,411 a month one individual $1,901 a month two individuals $2,391 a month three individuals There is no resource test. Resources: Required under Federal and State law (68-915). Children 6 through 18 years of age (through the month of the child s 19th birthday) and family income is equal to or less than 133% FPL. Only the children are eligible, no adults. No ability obligate income above the standard to establish eligibility. Income (133%FPL): $1,294 a month one individual $1,744 a month two individuals $2,193 a month three individuals Resources: There is no resource test. Required under Federal and State law (68-915) Developed for DHHS-DCFS by UNL-CCFL 11/10/14 Page 10

11 Individuals age 19 and 20 may be found eligible for services if they are receiving inpatient care in an Institution for Mental Disease and meet the established income standard. If an individual is an inpatient in an IMD when s/he reaches 21 years of age, s/he may remain eligible for services either until discharge or until s/he reaches age 22, whichever comes first. Income: $492 a month for one individual $527 a month for two individuals $661 for three individuals Resource: There is no resource test Federal Option, required under State law. CHIP: Children s Health Insurance Program (Title XXI). Children up to age 19 with family income below 213% FPL who do not have creditable health insurance coverage and who do not qualify for one of the Medicaid Eligibility groups listed above. Only the children are eligible, not adults. No ability to obligate income above the standard to establish eligibility. Income (213% FPL): $2,072 a month one individual $2,792 a month two individuals $3,513 a month three individuals Resources: There is no resource Test Children are not eligible if they have creditable health insurance. Federal Option, required under State law (68-915). 599 CHIP 599 CHIP provides health coverage for the unborn child of otherwise ineligible pregnant women for prenatal care and pregnancy related services connected to the health of the unborn child, when the mother is uninsured and the household has income at or below 197% of the FPL. Income: $1,917 a month for one individual $2,583 a month for two individuals $3,249 a month for three individuals Resources: There is no resource test Individuals are not eligible if they have creditable health insurance that covers pregnancy related services. State law (68-972). FORMER WARD Individuals age 19 through 21 years of age who meets the requirements for Former Ward grant payment and has income below the established standard. Income: $492 a month for one individual $527 a month for two individuals $661 for three individuals Resource: There is no resource test Federal Option, required under State law. FORMER FOSTER CARE CHILDREN Individuals age 19 through 26 years of age who were in foster care and receiving Medicaid when the individual attained age 18 or 19 and are not eligible for or enrolled in P/CR, Pregnant Women, Children, or AABD Medicaid. Income: There is no income test Resource: There is no resource test Required under Federal law. Developed for DHHS-DCFS by UNL-CCFL 11/10/14 Page 11

12 SIX MONTHS CONTINUOUS COVERAGE: Children 18 and younger who are found Medicaid eligible for one month are initially eligible for six months with no income or resource test after month one. This only applies to the children in the family, regardless of which eligibility category they qualify under. Federal option, required under State law (68-915). PRESUMPTIVE ELIGIBILITY Process whereby a qualified provider can presumptively (based on a declaration of income at or below 194% FPL, residency, and eligible citizenship/alien status) determine pregnant women eligible for Medicaid. Medicaid covers ambulatory prenatal care for pregnant women on the basis of presumptive eligibility. The pregnant women must obtain a full Medicaid determination by Medicaid and Long-Term Care for full services and continued coverage. Federal option, required under State Law (68-915). HOSPTIAL PRESUMPTIVE ELIGIBLITY Process whereby a qualified hospital can presumptively (based on a declaration of income at or below the applicable income level, residency, and eligible citizenship/alien status) determine eligibility for Children, Pregnant Women, Parents and Caretaker Relatives, Former Foster Care Children, and Breast and Cervical Cancer Patients (limited to those participating in the National Breast and Cervical Cancer Early Detection Program under authority of the Centers for Disease Control and Prevention). Required under Federal law. MEDICAID ELIGIBILITY CATEGORIES AGED, BLIND, AND DISABLED AID TO THE AGED, BLIND, AND DISABLED (AABD) Aged Blind and Disabled who receive a Supplemental Security Income payment or a State Supplement Program payment. Aged are over 65, the Blind and Disabled are determined as such utilizing the Social Security Administration s definitions. Income: $721 a month single $1,082 a month couple Resources: $2,000 single person $3,000 a couple Federal option required under State Law ( ). AID TO THE AGED, BLIND, AND DISABLED AABD clients who have income over cash assistance (Medically Needy) standards but have a medical need and are not eligible under the 100% FPL standard. This Medicaid category allows the individual to obligate their income above the standard on their own Medical bills and establish Medicaid eligibility. Income: $392 a month single or couple Resources: $4,000 single $6,000 couple Federal Option required under State Law (68-915). AID TO THE AGED, BLIND AND DISABLED 100% FPL AABD clients whose income is below 100% of FPL. The Federal Law requires us to pay only Medicare premiums, co-payments and deductibles for clients less than 100% FPL. Due to computer system limitations and the additional Medicaid services involving quality of life issues, the decision was made to offer full Medicaid coverage to this group instead of limiting payment to just Medicare premiums, copayments, and deductibles. No obligation of income above this standard allowed. Income (100% FPL): $973 a month single $1,311 a month couple Resources: $4,000 single $6,000 couple State is federally required to cover Medicare clients to 100% of the FPL, and choose to cover under Medicaid. Developed for DHHS-DCFS by UNL-CCFL 11/10/14 Page 12

13 AID TO THE AGED, BLIND AND DISABLED MEDICARE BENEFICIARIES AABD clients for whom the State is required to pay Medicare related expenses and Part B Premiums. MSP/QMB individuals have up to 100% FPL and are entitled to Medicare co-insurance and deductibles on Medicare Part A and B services, as well as payment of the Part B premium. They are not entitled to non-medicare related services. SLMB individuals have income between 100% and 120% FPL. QI individuals have income between 120% and 135% FPL. Both Service Limited Medicare Beneficiary (SLMB) and Qualified Individuals (QI) only receive payment of Part B premium. Resource allowances are subject to Federal annual increase. Resources: $7,160 for one individual; $10,750 for a couple Federally Required. QUALIFIED WORKING DISABLED INDIVIDUALS AABD clients who were eligible for Medicare as a disabled individual and who return to work, as a result they are required to pay their Medicare Part A (hospital) premiums to maintain coverage. The agency is required to pay the Part A premium for individuals with income less than 250% FPL. The premium is currently $316 per month. Income (250%FPL): $2,258 a month single $3,038 a month couple Resources: $4,000 single $6,000 couple Federally Required. MEDICAID INSURANCE FOR WORKERS WITH DISABILITIES Disabled clients who are eligible for Medicaid but for their earnings, they are disabled trying to work but need to keep their Medicaid coverage to enable them to work. They are eligible without paying a premium to 200%FPL, between 200% FPL and 250% FPL they must pay a premium. Income (250% FPL): $2,433 a month single $3,278 a month couple Resources: $4,000 single $6,000 couple Federal Option, State Law requires (68-915). 1619b CLIENTS Former SSI and State Supplement clients that are working, who exhaust their trial work period but have earnings below the average State expenditures for a disabled client in Medicaid, SSI, State Supplement and Block Grant payments. As long as SSI carries them in a 1619b status the State continues Medicaid. Federally Required. BREAST AND CERVICAL CLIENTS Women screened for breast or cervical cancer by the Every Women Matters Program and found to need treatment. Women are below 225% FPL using EWM criteria. Federal Option, required by State Law (68-915). KATIE BECKETT WAIVER Medicaid State plan amendment for children under 18 who would require institutional services. We do not hold parents financially eligible for their children eligible under this provision. The income and resource test is dependent upon the client s living arrangement. Federal Option Developed for DHHS-DCFS by UNL-CCFL 11/10/14 Page 13

14 MEDICAID ELIGIBILITY CATEGORIES OTHER SPOUSAL IMPOVERISHMENT Process whereby more resources are retained and more income is allocated to the community spouse when one member of a married couple is institutionalized. The value of the couple s resources is determined according to the first month of one s institutionalization to determine the community spouses reserved resources. The maximum community reserved resource is $117,240. The maximum is only allowed if the couples combined countable resources are at least $234,480. For any total amount less than $234,480, the community spouse reserved amount is ½ the total, with a minimum community spouse reserved at $23,448. If the community spouse does not have income equal to 150% FPL for two ($1,967 a month), income is allocated from nursing home spouse to the community spouse up to that level. Federally Required. EMERGENCY MEDICAL FOR ALIENS An emergency medical condition is defined as a medical condition (including emergency labor and delivery) manifesting itself by acute symptoms of sufficient severity where the absence of immediate medical attention could reasonably be expected to result in: 1. Serious jeopardy to the patient s health; 2. Serious impairment of a bodily function; or 3. Serious dysfunction of any body organ or part. The State Review Team (SRT) makes the determination that the client has an emergency medical condition. The client must meet all eliibility criteria except citizenship or qualified alien status. Income and resource vary depending on the category of eligibility. Federally Required Developed for DHHS-DCFS by UNL-CCFL 11/10/14 Page 14

15 UNDERSTANDING NEBRASKA MEDICAID 4. Two Parts of Medicaid Nebraska Medicaid is divided into Medical/Surgical Care (Medical/Surgical) and Mental Health/Substance Abuse Care (Behavioral Health (MH/SU). The rules are different for each kind of service. In Child Welfare, both parts are equally important in a child s well-being. Key Considerations Medical/surgical services include regular medical care. These include the services delivered by a physician, dentist, eye specialist or hearing specialist and the medications these professionals might prescribe. This includes physical exams, well-child-care (called EPSDT for Medicaid), immunizations, regular trips to the doctor, lab tests, dental care, vision and hearing services, and health education from the physician s office. Behavioral Health Services include mental health and substance use care. Behavioral health services encompass a wide array of care including, but not limited to, Inpatient Mental Health services, Residential Mental Health services, Outpatient Mental Health services, Substance Use Disorder Services, Psychiatric Services, Medication management, and Psychological Assessments / Psychological Testing. See page 28 EPSDT is well-child care an important Med/Surg service EPSDT stands for Early Periodic Screening Diagnosis and Treatment. It is Medicaid s term for well-child care. Medicaid will pay for the treatment of any condition found through EPSDT screening and diagnosis. EPSDT is available to everyone under 21 years of age and follows the Academy of Pediatrics recommended health care visits at birth, 1 month, 2 months, 4 months, 6 months, 9 months, 12 months, 15 months, 18 months, 2 years, and yearly to age 21 years. EPSDT includes a health and developmental history and a review of gross and fine motor development, self-help skills, social-emotional development and cognitive skills. EPSDT should also include an assessment of nutritional status and a risk assessment of children and adolescents for early identification of mental health or substance abuse concerns. EPSDT forms can be located here: Lab tests should include screening for anemia in children with risks (low income, eligible for WIC, migrant or recent refugee status). All children are considered at risk for lead toxicity and children should be screened at 12 and 24 months and at each visit if children are at special risk such as peeling paint in a house built before 1978 or living near major traffic. Screening for lead poisoning and anemia are both important in children with developmental, behavioral, or learning problems. Important Dental Services DHHS Administrative Memo # points out that a child s dental health is directly related to the child s physical health and well-being. Several DHHS programs help enhance dental health for all children. spx Office of Oral Health and Dentistry can help locate dental care for a child and provides educational materials for parents and caseworkers. Fluoride Varnish is a Medicaid service that prevents up to 45% of dental decay. It should be considered for every child. It can be administered in a dental or medical office. Head Start Toothbrush Initiative has provided 6,600 children in Head Start with a toothbrush. For more information about these programs and for help in locating dental care for a child, call A listing of public dental clinics in Nebraska is available by searching Nebraska Public Dental Clinics. Developed for DHHS-DCFS by UNL-CCFL 11/10/14 Page 15

16 Who Provides Physical Health Services? Physician (MD) Qualifications: A physician has earned the degree of M.D. (Doctor of Medicine) from an accredited medical school and has passed a certifying exam and a required internship. In addition to their license to practice (a permission given by the state of Nebraska) a physician may be certified (given a stamp of approval) by an independent specialty board and practice as a specialist in surgery, psychiatry, pediatrics, etc. Scope of Practice: Physicians are qualified to diagnose or treat diseases, ailments, pain, deformity, or any physical or mental condition or injury of human beings. Only physicians can prescribe medications. Osteopathic Physician (DO) Qualifications: An osteopathic physician has earned the degree of D.O. (Doctor of Osteopathic Medicine) from an accredited osteopathic school and has passed a certifying exam and a required internship. Scope of Practice: Osteopathic physicians have the same scope of practice as MDs. Physician s Assistant (PA) Qualifications: A Physician Assistant has graduated from an approved physician assistant training program usually at the master s degree level, and completed a proficiency exam. Scope of Practice: A PA can perform medical services under the supervision of a physician or group of physicians approved by the board to supervise a Physician Assistant. Advanced Practice Registered Nurse: Nurse Practitioner (APRN-NP) Qualifications: A nurse practitioner is an RN who has additional education and licensure. Most have a Masters or Doctoral Degree in Nursing and they must have passed a national certifying examination. Scope of Practice: NPs can manage common health problems and chronic conditions including prescribing treatments and medications in collaboration and consultation with a physician. Registered Nurse (RN) Qualifications: Two to four years of education at a college, university, or hospital nursing program. Scope of Practice: Registered nurses may practice nursing scope of practice independently Licensed Practical Nurse (LPN) Qualifications: Nine months to one year of education in a community college. Scope of Practice: Must always practice under the direction of a registered nurse or other licensed practitioner. Nebraska licenses the health care professionals who provide Medicaid services. A license, given by the state, is permission (a green light) to practice a given profession. You can t practice without it. Physicians must be certified by a specialty board to provide Medicaid behavioral health services. Certification is a stamp of approval from someone saying, You are good! Developed for DHHS-DCFS by UNL-CCFL 11/10/14 Page 16

17 Dentist (DDS) Qualifications: Graduation from an approved dental college, passing of a National Certification Exam and a Proficiency test. Scope of Practice: The practice of dentistry includes the ability to diagnose, treat, prescribe, or operate for any disease, pain, deformity, deficiency, injury, or physical condition of the teeth, jaws or adjacent structures. Pharmacist (Pharm D) Qualifications: Graduation from an approved College of Pharmacy and passing of the Accreditation Exam. Scope of Practice: Pharmacists interpret and implement medical orders, compound and dispense prescription drugs and devices, perform drug product selection and drug utilization review, and provide patient counseling. Pharmacists are also authorized to administer drugs and devices and can provide pharmaceutical care through agreements with physicians. Chiropractor Qualifications: Graduation from an approved, accredited school of chiropractic and passage of a National Certifying Exam. Scope of Practice: The science and art of treating human ailments, disorders, and disease by locating and removing any interference with the transmission and expression of nerve energy in the human body by chiropractic adjustment, chiropractic physiotherapy, and the use of exercise, nutrition, dietary evidence, and colonic irrigation. Audiologist Qualifications: A doctoral audiology degree from an accredited school, passage of a certifying exam, and a supervised internship. Scope of Practice: Includes prevention, assessment, habilitation, rehabilitation, and maintenance of persons with hearing, auditory function, and vestibular function impairments and related impairments. Occupational Therapist (OT) Qualifications: Graduation from an approved program and passing of a certifying exam. Scope of Practice: The use of purposeful activity with individuals who are limited by physical injury or illness, psychosocial dysfunction, developmental or learning disabilities, or the aging process in order to maximize independence, prevent disability, and maintain health. Occupational therapy encompasses evaluation, treatment, and consultation. Physical Therapist (PT). Qualifications: Graduation from an approved program and passage of a certifying exam Scope of Practice: The practice of physical therapy includes the use of exercises and other treatments to 1) restore physical function; 2) promote fitness and health; and 3) reduce the risk of injuries. Developed for DHHS-DCFS by UNL-CCFL 11/10/14 Page 17

18 Who Provides Behavioral Health Services? Psychiatrist (An MD with a Certification in Psychiatry) Qualifications: A psychiatrist is a licensed M.D. (see above) who has completed a residency in psychiatry and passed a test approved by the American Board of Psychiatry and Neurology, an independent group. Scope of Practice: The scope of practice of all physicians includes treating psychiatric conditions. However certification as a psychiatrist indicates additional specialty training and allows for Medicaid billing for mental health and substance abuse services. An MD can only bill Medicaid for mental health and substance abuse services if they are certified as a psychiatrist. Osteopathic Psychiatrist (A DO with a Certification in Psychiatry) Qualifications: A DO is qualified to practice as described above. A DO may also complete psychiatric specialty training like an MD, and become certified in psychiatry. Scope of Practice: The same scope of practice for MDs applies to DOs. Licensed Psychologist Qualifications: Must have a doctoral degree in professional psychology, two years of supervised clinical practice, and must pass an examination. Scope of Practice: Includes psychological testing and the evaluation or assessment of personal characteristics such as intelligence, personality, abilities, interests, aptitudes, and psychophysiological and neuropsychological functioning; counseling, psychoanalysis, psychotherapy, hypnosis, biofeedback, and behavior analysis and therapy; diagnosis and treatment of mental and emotional disorders, alcoholism and substance abuse, disorders of habit or conduct, and the psychological aspects of physical illness, accident, injury, or disability; psychoeducational evaluation, therapy, remediation, and consultation; and supervision of qualified individuals performing services specified in this section. Mental Health Practice Nebraska licenses several different kinds of Licensed Mental Health Practitioners as described below: Licensed Independent Mental Health Practitioner (LIMHP) Qualifications: Graduation from an accredited program or equivalent and 3000 hours of supervised practice within a 2 to 5 year period or a non-accredited program and 10,000 hours within 10 years. Scope of Practice: Provides treatment, assessment, psychotherapy, counseling, or equivalent activities to individuals, couples, families, or groups for behavioral, cognitive, social, mental, or emotional disorders, including interpersonal or personal situations and diagnoses major mental illness or disorder, using psychotherapy with individuals suspected of having major mental or emotional disorders, or using psychotherapy to treat the concomitants of organic illness, with or without consultation with a qualified physician or licensed psychologist. Licensed Mental Health Practitioner (LMHP) Qualifications: A masters or doctoral degree relating primarily to therapeutic mental health and including an internship, 3000 hours of supervised practice within 5 years of receipt of master s degree and passing an exam. Scope of Practice: An LMHP may not diagnose major mental health disorders but may provide treatment, assessment, psychotherapy, counseling, or equivalent activities in consultation with a qualified physician or licensed clinical psychologist. Developed for DHHS-DCFS by UNL-CCFL 11/10/14 Page 18

19 Certified Master Social Worker Qualifications: Must be licensed as a LMHP and be certified as a Master Social Worker by an independent organization after completion of an accredited master s level training program. Scope of Practice: The same as an LMHP but allowed to call themselves a Certified Master Social Worker. Certified Professional Counselor Qualifications: Must be licensed as a LMHP and be certified as a professional counselor by an independent organization after completing an accredited education program. Scope of Practice: The same as an LMHP but allowed to call themselves Certified Professional Counselor. Certified Marriage and Family Therapist Qualifications: Must be licensed as a LMHP and be certified as a Marriage and Family Therapist after completing 39 semester hours in an accredited education program. Scope of Practice: Same as LMHP but allowed to call themselves Certified Marriage & Family Therapist. Licensed Alcohol and Drug Counselor (LADC) Qualifications: Provisional must have a high school diploma and 270 clock hours of related education plus 300 hours of supervised practical training. License requires 6000 supervised hours and passing a test Scope of Practice: application of general counseling theories and treatment methods adapted to specific addiction theory and research for the express purpose of treating any alcohol or drug abuse, dependence, or disorder. Clinical evaluation does not include mental health assessment or treatment. Developed for DHHS-DCFS by UNL-CCFL 11/10/14 Page 19

20 UNDERSTANDING NEBRASKA MEDICAID 5. Managed Care The state manages services by contracting with one or more organizations that must assure that Medicaid pays only for the least restrictive, medically necessary care. Magellan manages MH/SU care while separate organizations manage the med/surg care. Key Considerations For many years, all insurance was fee-forservice. The provider is the gatekeeper in fee-forservice care, deciding what services are necessary. Eventually many insurance programs, including Medicaid, began managing care to control rapidly increasing costs. Magellan manages all Nebraska s mental health and substance use care. Nebraska hired Magellan to review care for medical necessity and least restrictiveness. Magellan has an at risk contract with Nebraska and is a Health Maintenance Organization (HMO). Managed care for medical/surgical care varies in some counties. In the ten county area shown below, clients must sign up with either and Aetna or United Healthcare. In all the rest of the state they must choose either Aetna or Arbor Health Plan (by AmeriHealth). Moving within Nebraska may require a Medicaid change. Make sure that N-FOCUS has the child s placement correctly noted so that they may be enrolled in the appropriate Medicaid plan: either one of the two managed care plans or fee-for-service, depending on where they are placed. Medical/Surgical Care Aetna and United Healthcare manage care in ten counties in southeast Nebraska. Behavioral Health Services Mental Health/Substance Abuse Cass Dodge Douglas Gage Lancaster Otoe Sarpy Seward Saunders Washington Magellan manages care in the entire state for behavioral health services. In all other counties Aetna and Arbor Health Plan provide managed care services for medical/ surgical care. Managed care organizations must provide medically necessary care in the least restrictive manner. Developed for DHHS-DCFS by UNL-CCFL 11/10/14 Page 20

21 Managed Care Organization (MCO) Magellan, Aetna, United Healthcare, and Arbor are MCO s Magellan is a national health care company with a variety of contracts in many states. Magellan is the contracted Behavioral Health Managed Care Organization. Aetna, United Healthcare, and Arbor companies successfully bid for the Physical Health managed care contract with Nebraska for the areas indicated on the previous page. Magellan manages the entire state of Nebraska s behavioral health services. MCO s are paid a flat rate for each enrollee and benefit financially if they can provide appropriate care at a lower cost. They are at risk when care is more expensive. These contracts includes these activities: 1. They review and approve services based on medical necessity and least restrictiveness; and 2. They help find available services and develop coordinated alternatives to more restrictive care. The care approval decisions that Magellan makes must follow guidelines approved by the state which are available on their website (see below). Magellan s medical director (a physician certified as a psychiatrist) or a contracted psychiatrist will review any disputed decisions and a second psychiatrist will review cases when an appeal is requested. Masters level care managers at Magellan become involved with cases to help find the best alternatives for an individual child. Choosing a Plan In all of Nebraska, every Medicaid client must choose to enroll in one of the available managed care plans for medical/surgical care. For children who are wards of the state, a state worker (CFSS or CFOM) should make a thoughtful choice between them. Consideration should be given to maintaining a child s past connections to health care providers and health care facilities. The plans vary in what doctors and hospitals are available within the plan and in the types of services available. Information about the plans is available from the phone numbers listed on the back cover of this booklet. The choice should be conveyed to the Medicaid Enrollment Center at (888) When a child or family is enrolled in United Healthcare (in the 10 county area) or Arbor Health Plan (in the rest of the state) they must choose a different plan when they move from one area of the state to another area. N-FOCUS will trigger this change if the child s placement is correctly entered in N-FOCUS. Developed for DHHS-DCFS by UNL-CCFL 11/10/14 Page 21

22 UNDERSTANDING NEBRASKA MEDICAID 6. Appeals in Managed Care When Magellan decides that a provider s treatment plan is not medically necessary or is more restrictive than necessary, this is a clinical judgment. If there is disagreement with the decision, the provider/legal guardian may discuss it with a Magellan psychiatrist (or one contracted by Magellan). If the care is not authorized, he/she may ask for an appeal (a second opinion) from a second psychiatrist (who may still be a Magellan employed psychiatrist). State Fair Hearing can be initiated at any point in the process. Key Considerations A care manager makes the initial authorization decision. When a provider asks for authorization of a treatment plan, it is first reviewed by a clinical masters-level care manager. After gathering clinical information and using criteria outlined in the Clinical Guidelines, the reviewer either authorizes the care or discusses the case with a Magellan psychiatrist within 24 hours. The Magellan psychiatrist reviews the case. If, after this discussion, the Magellan psychiatrist also cannot authorize the treatment requested, the provider is offered an opportunity to discuss the case, one-on-one with the Magellan psychiatrist (or a contracted psychiatrist) within one day. Provider requests treatment plan If the treatment still cannot be authorized, an appeal can be requested. A review is done within 30 days by an additional psychiatrist who has not been involved with the case. If this individual finds it still does not meet medical necessity criteria they will continue not to authorize the treatment, then a state-level Fair Hearing is available. Either the provider or the guardian may request an appeal. The child s guardian should expect the provider to ask for an appeal if they still believe the requested care is needed. At this stage, the guardian (the state in the case of a state ward) could also ask for an appeal, but it would be unusual if the provider was unwilling to do so. Authorize d Care manager reviews case If cannot authorize Authorize d Discussion with Magellan psychiatrist If denied Authorize d One-on-one discussion with provider Still denied Authorize d Reconsideration by a new Magellan psychiatrist Still denied State level Fair Hearing Developed for DHHS-DCFS by UNL-CCFL 11/10/14 Page 22

23 Clearer on the Medical Side If a physician believed that a child needed to have her tonsils out, and a managed care organization, after reviewing the case, determined that three weeks of antibiotics is the least restrictive, appropriate treatment, this is clearly a clinical decision. A case worker or legal representative (attorney or judge) would probably not be tempted to argue strongly for one course or another. On the mental health side, however, the decisions about treating the child in residential treatment or in community based care may seem less clinical and more related to where the child needs to live. But, in the end, it is still a clinical decision about clinical treatment. This is a difficult area for case managers when explaining to the courts why a higher level of care was denied when the county attorney or judge feel it s a necessary level of care. At times, courts may court order a denied level of care. This will not be paid for by Medicaid and will be paid for 100% out of state funds. A child should never be placed in a treatment facility due to a need for a place to live. Placement and treatment are completely SEPARATE. See the next two pages for flow charts by Magellan Behavioral Health of Nebraska that offer more complete information on the peer review and appeal processes. Developed for DHHS-DCFS by UNL-CCFL 11/10/14 Page 23

24 Developed for DHHS-DCFS by UNL-CCFL 11/10/14 Page 24