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

25 Developed for DHHS-DCFS by UNL-CCFL 11/10/14 Page 25

26 UNDERSTANDING NEBRASKA MEDICAID 7. When Medicaid Can t Pay The state will use Medicaid to pay for medical care of state wards whenever possible. However, sometimes the state will (or must) pay for care with 100% state funds when Medicaid is not available. The Behavioral Health system may assist with funding care when Medicaid cannot. Key Considerations If a court orders the state to pay, they must comply or appeal. The third alternative to be found in contempt of court and subject to fines or imprisonment - is not an acceptable alternative. Judges must decide what is in the child s best interest and should be provided both sides when the appropriate level of care is in dispute. When a state ward is not a citizen, Medicaid cannot pay for care. Medicaid is not available to individuals who are not citizens. The state, however, is responsible for the medical care of state wards. A letter of entitlement must be prepared to allow the state to provide care with 100% state funds. Necessary psychological services which are not treatment of mental illness must be covered. Counseling or family therapy needed to help deal with maltreatment issues may be very important to the case plan, but because it is not medical care of an illness, the state must pay the bill without Medicaid match. A letter of agreement (LOA) is needed. When the state must pay for treatment, it must have a letter of agreement with the provider that defines the treatment needed and the cost. This letter essentially says, If you will treat as if it were Medicaid, the state will pay you as if it were Medicaid. Nebraska s Behavioral Health System also assists with payment for BEHAVIORAL HEALTH (MH/SU) treatment. The NBHS delivers services through contracts with six regions, providing an array of services including but not limited to, public inpatient, outpatient, and emergency services and community mental health, substance use and gambling services on a sliding scale basis. Contractors Role (NFC) In areas of the state where contractors provide child welfare services, the contractors are responsible for paying the costs of court ordered care. These costs have been included in their contracts. Contractors are also responsible for preparing letters of agreement (see above) to pay for medical care when Medicaid will not pay. Contractors also provide counseling and other necessary non-medical psychological services in the child s case plan when not Medicaid eligible. Nebraska Behavioral Health System Services through the Nebraska Behavioral Health System are provided by contracts with six Regions. The NBHS provides mental health and substance use evaluation and treatment for individuals across the state who are clinically and financially eligible. Some treatment resources may be limited or have waiting lists. However, you should contact the appropriate Region to insure all treatment options have been considered. Developed for DHHS-DCFS by UNL-CCFL 11/10/14 Page 26

27 Nebraska Behavioral Health System Purposes The NBHS was established to ensure the public safety and the health and safety of persons with behavioral health disorders, and to ensure state-wide access to high quality, cost-effective behavioral health services. (NRS ) Funds allocated to NBHS support state-wide initiatives as well as treatment services in the regions to meet this mission. The division of BHS within DHHS is the chief behavioral health authority for Nebraska. The six regions are responsible for development and coordination of publicly funded behavioral health services in each region. Community-Based Behavioral Health Services NBHS funds many of the same mental health and substance use services as Medicaid, often using the same service definitions. This includes Medication Management; Individual, Group, or Family Psychotherapy; and Day Treatment. If a person is clinically and financially eligible for NBHS services, intensive case management is available. This may include flexible service categories such as Intensive Community Service and Community Support to support an individual awaiting availability of more intensive services. Substance Abuse Priorities NBHS has set 4 priority groups for substance abuse services: 1) Pregnant women using I.V. drugs; 2) Pregnant women; 3) I.V. Drug Users; and 4) Women with dependent children whether or not they have custody of these children. Window of Opportunity When a child is removed, a parent may lose Medicaid eligibility. Coverage only ends at the end of a month, however, and requires a 10 day notice period. If this 10 days carries into the next month, coverage continues to the end of that month. It may be very important to use this time of continued Medicaid coverage to obtain a Pretreatment Assessment (PTA) evaluating a parent s mental health or substance abuse problems. Even though Medicaid coverage may terminate before treatment can be obtained, this evaluation can be helpful for getting services from the Behavioral Health System. Residential Treatment at Three Regional Centers Hastings Regional Center has 40 licensed beds for adolescent residential substance abuse treatment for young men paroled from the YRTC in Kearney. Average length of stay is 4-6 months. Services must be authorized by Magellan. Lincoln Regional Center is a 250 bed accredited state mental health hospital for people with severe, persistent mental illness. The LRC also provides evaluation, assessments and treatments ordered by the court. A Sex Offender service provides treatment for patients with a history of sexually deviant behavior. The Whitehall campus provides family centered care for adolescent boys who have offended sexually. Norfolk Regional Center is a 120 bed Sex Offender Treatment Center providing Phase I treatment. Phase II and III treatment is provided at the LRC. Sliding Fee Scale Nebraska Behavioral Health System has established a sliding scale for fees the patient must pay. These scales are determined by the Department of Behavioral Health and then each region is responsible for developing their own scales based off of DBH s financial eligibility schedule. This is based off of state statute passed in 2012: Title 206 NAC 6. N.R.S , , and Developed for DHHS-DCFS by UNL-CCFL 11/10/14 Page 27

28 UNDERSTANDING NEBRASKA MEDICAID 8. Medicaid Behavioral Health (MH/SU) Services Levels of care range from residential services to outpatient services in the community. The goal is to ensure that the child is receiving the care that is needed at the least-restrictive level. Key Considerations An assessment is needed before most services. The current Medicaid assessment is the Initial Diagnostic Interview (IDI). This assessment is completed by a practitioner that is able to diagnose a mental illness.. A DSM diagnosis is needed for medical necessity. Medicaid pays for medically necessary services - in Behavioral Health (MH/SU) services this is a psychiatric diagnosis. Only a psychiatrist, a licensed psychologist or a licensed independent mental health practitioner (LIMHP) can diagnose mental illness. Services must be at the least restrictive level. Medicaid requires services to be at the least restrictive level. Residential Treatment Services. Psychiatric Residential Treatment Facilities (PRTF) and Therapeutic Group Homes (ThGH) are the highest levels of care and the most restrictive setting that Nebraska offers to children. Recovery Care Management (RCM) is available. Magellan provides RCM to children and youth with the most difficult problems. It can creatively configure communitybased services to provide many of the benefits of residential care without the serious disadvantages. CMS BEHAVI Why Change? IMD CAP Do You Know These Acronyms? PRFC CAP can See Page 32 mean two See Pages See Pages things CTA CAP Community-Based Services ThGH PRTF Residential Services PDD TBI CD ODD Other Terms IOP ICM MR SO ASAM ADH SI/HI MST See Pages See Page 37 PTA Evaluations IDI Developed for DHHS-DCFS by UNL-CCFL 11/10/14 Page 28

29 Mental Health/Substance Use Services Nebraska Medicaid provides three kinds of Mental Health/Substance Abuse services for children and youth: Assessment Services, Community-based Services, and Residential Services. The services in each category are listed here with their common acronyms. Assessment Services (see p ) Initial Diagnostic Interview Substance Use Focused or Sexual Offender Risk Focused Community-based Services (see p ) Outpatient Services Crisis Services; Client Assistance; Individual, Group and Family Psychotherapy; Community Treatment Aide (CTA); Medication Management Intensive Outpatient (IOP) Day Treatment Partial Hospitalization Recovery Care Management RCM Nebraska Made Changes to Comply with Federal Rules Federal Medicaid rules specify that no child can be served in an IMD (Institution for Mental Disease) unless it meets the criteria for a Psychiatric Residential Treatment Facility (PRTF). What s an IMD? An Institute for Mental Disease is a hospital, nursing facility, or other institution of more than 16 beds that is primarily engaged in providing diagnosis, treatment or care of persons with mental disease, including medical attention, nursing care, and related services, according to federal regulations. What s a PRTF? A Psychiatric Residential Treatment Center is a facility of any size under the direction of a psychiatrist which provides comprehensive services to treat psychiatric conditions on an inpatient basis. The goal of these services is to improve the resident s condition or prevent further regression so that the services will no longer be needed. They cannot be seen as a long-term placement. Residential Services (see p ) Professional Resource Foster Care (PRFC) Therapeutic Group Home (ThGH) Psychiatric Residential Treatment Facility (PRTF) MH only SA only Dual (BEHAVIORAL HEALTH (MH/SA) ) Low Functioning Sex Offending Developed for DHHS-DCFS by UNL-CCFL 11/10/14 Page 29

30 Mental Health/Substance Use Evaluations The first step in obtaining Medicaid mental health and/or substance abuse services is to obtain a complete evaluation to answer two questions: 1. What is the most likely cause of the child s problems (a diagnosis defining medical necessity)? and 2. What is the most appropriate, individualized and least restrictive therapy that will address this child s needs? The evaluation that a child or youth receives depends on who needs to know the answers, and to some extent who the child s guardian chooses to ask. If the child s guardian (or the state in the case of a child who is a ward of the state) wants to know how best to deal with the child s mental health and/or substance abuse problems, then the child must be referred for an Initial Diagnostic Interview (IDI). An IDI will also be completed in order to determine the best way to address an adult s mental health and/or substance abuse problems. Components of an IDI An Initial Diagnostic Interview is the integrated bio-psychosocial assessment including history, mental status examination, and treatment recommendations. IDI Who does an IDI? The Initial Diagnostic Interview can only be done by a psychiatrist, a licensed psychologist, or an LIMHP, because only these people are qualified to diagnose mental illness according to Medicaid rules. I By regulation, there are two different assessments that gather information depending on the identified need. Each must be followed by an Initial Diagnostic Interview to establish a diagnosis and treatment. These three are summarized on the next page. An Adolescent Substance Use Assessment A Sexual Offending Risk Assessment Regardless of which assessment is initially done, a child can eventually get whichever assessment or assessments are needed. However, this can be accomplished much more efficiently if the person making the referral thinks carefully about where to refer the child and articulates clearly the questions needing answers. If it is likely that a child will need a more in-depth assessment of substance abuse issues or an assessment of sexual offending risk, an initial referral should be made to a provider who is qualified to do this type of assessment. Care should also be taken, however, not to overly limit the type of assessment given by the referral that is made. Although a child may need an assessment of sexual offending risk, he or she may also need a comprehensive look at other mental health issues including substance abuse. A safe approach is to clearly articulate questions that will help plan for the child s needs and refer the child to a psychologist or psychiatrist who can evaluate broadly. Developed for DHHS-DCFS by UNL-CCFL 11/10/14 Page 30

31 The Varieties of Initial Diagnostic Interviews Adolescent Substance Use Assessment This is based on the Patient Placement Criteria developed by ASAM (see page 38). In addition to a more structured bio-psychosocial evaluation, it must include at least one of a list of nationally accepted substance abuse screening tools and development of a Multidimensional Risk Profile assessing the following six dimensions: 1) Acute intoxication and/or withdrawal; 2) Biomedical conditions and complications; 3) Emotional, behavioral or cognitions and complications; 4) Readiness to change; 5) Relapse, continued use, or continued problem potential; 6) Recovery environment. This can be used in lieu of the usual biopsychosocial evaluation. Initial Diagnostic Interview Using the results of one or more of the Initial Diagnostic Interviews above, a psychiatrist, psychologist, or a licensed independent mental health practitioner (LIMHP) must conduct this evaluation in person prior to the start of any treatment beginning. The Psychiatric diagnostic evaluation is an integrated bio-psychosocial assessment, including history, mental status, and treatment recommendations. This evaluation may include communication with family or other sources and the ordering of diagnostic studies. A diagnosis from the DSM- 5, if any exists, is made. The provider must then specify complete recommendations including: a. treatment needs and recommended interventions for the client and family; b. identification of all who should be involved in the treatment; c. an overall plan to meet the treatment needs including transitioning to lower levels of care and discharge planning; d. a means to evaluate treatment progress; e. recommended linkages with other community resources; and f. areas that need further evaluation. Sexual Offending Risk Assessment This assessment identifies how mental health and/or substance abuse may relate to sexual offending behavior and guides treatment and recovery from a mental health or substance abuse diagnosis. In addition to an assessment of biopsychosocial factors, it includes a structured assessment of: 1) Level of cognitive/adaptive functioning; 2) Personality and behavior Factors; 3) Sexual offending risk assessment using both static and dynamic factors; 4) Sexual misconduct patterns; 5) Perception/understanding, motivation/empathy for the victim; 6) Current supervision and access to victim; and 7) Risk to reoffend. Also may be used in lieu of the usual biopsychosocial evaluation. Only a psychiatrist, a licensed psychologist or a licensed independent mental health practitioner (LIMHP) can diagnose behavioral health conditions for Medicaid purposes. Developed for DHHS-DCFS by UNL-CCFL 11/10/14 Page 31

32 Community-based Medicaid Behavioral Health (MH/SU) Services Based on the IDI, the psychiatrist, licensed psychologist, or LIMHP must determine the least restrictive, individualized, appropriate and effective treatment for the child or youth. When possible, a child or youth is always best served in their home community and in a home-like setting. It has been said, If possible, no child should have to live where there are exit signs or where the refrigerator is off-limits. The following communitybased services can help accomplish this for many children and youth receiving Medicaid services. Crisis Outpatient Services: Outpatient Services This is an immediate service provided to a client assessed with emergent/urgent conditions. An IDI is not required before treatment but a short-term plan must be developed including a plan for completing the assessment. No more than five sessions per crisis episode can be authorized. Client Assistance Program (CAP) A CAP service is much like an employee assistance program. Interventions are short-term and solutionfocused and up to five sessions per year can be scheduled to help a client reduce or eliminate stressors that interfere with daily living and wellbeing. An IDI is not necessary nor is a mental health diagnosis. The licensed provider must call Magellan for authorization. Individual, group, and family psychotherapy Medicaid provides reimbursement for individual, group, and family sessions for psychotherapy or for substance abuse counseling. An active treatment plan is required outlining achievable goals are consistent with a mental health diagnosis and which restore previous function. The goals, frequency, and duration of the service can vary according to the individual needs and identified symptoms. Treatment cannot be primarily for maintenance, social, or educational purposes. Community Treatment Aid (CTA) Community Treatment Aide Services are supportive and psychoeducational interventions provided in the child s natural environment including home, foster home, school, or other suitable community location. CTA services must enhance the caregiver s ability to manage the child s symptoms and be directed to identify goals in the child s treatment plan. Medication Management Medication management is considered part of therapy when therapy is done by a physician, physician s assistance or advanced practice registered nurse. A physician may provide medication management when the therapy is done by a practitioner whose scope of practice does not include prescribing medication. CTA Role A CTA provides training and rehabilitation for basic personal care; promotes social and relationship skills; instructs caregivers in crisis and de-escalation techniques; teaches and models interventions, techniques, and coping skills; teaches about medication and relapse prevention and teaches and models effective parenting practice. Developed for DHHS-DCFS by UNL-CCFL 11/10/14 Page 32

33 Intensive Outpatient Services (IOP) Intensive Outpatient Psychiatric Services provide group-based, non-residential, intensive outpatient mental health and/or substance abuse treatment consisting primarily of psychotherapy and substance abuse counseling. It is considered a step-up between traditional outpatient services (see above) and Day Treatment. Services can include individual, group and family therapy sessions. The program shall be offered at least 9 hours per week with sessions lasting 3 hours per day. Services should follow an individualized active treatment plan specifying achievable, appropriate goals. The goals, frequency and duration of the IOP program can vary according to individual need and treatment response. When symptoms include uncontrolled disruptive behavior, the plan must include de-escalation and anger management and should be aggressively enforced. An IDI is required and should guide the treatment plan. Day Treatment Day treatment is supervised by a psychiatrist or licensed psychologist and provides more intensive and comprehensive treatment than can be provided at the outpatient level. It includes individual therapy at least once a week, group therapy on a daily basis, and family therapy at least once a week. When symptoms include uncontrolled disruptive behavior, the plan must include de-escalation and anger management and should be aggressively enforced. Day treatment is appropriately used as a transition from higher levels of care and can be used for patients who are at risk of needing more intensive care. Nursing services must be provided in day treatment programs. Day Treatment may not be provided in the facility where the child lives. Psychiatric Partial Hospitalization The level of intensity of this service is similar to an inpatient program but the child returns home each day. Individual therapy must be provided 2-3 times per week; group therapy is required daily, and family therapy must occur 2 times per week. Psychoeducational groups are also required. Staffing must be adequate to evaluate individual and family needs; establish individual and family treatment goals; and implement a broad range of psychiatric interventions including professional, psychiatric, medical, nursing, social services, psychological, psychotherapy, psychiatric rehabilitation and recovery therapies required to carry out individual treatment plans for each patient and their family. Recovery Care Management (RCM) Magellan provides Recovery Care Management services as part of their contract with DHHS. A Masters-level Care Manager is assigned to each eligible individual as a contact for all information from Magellan (authorizations, referrals, etc.). Care Managers have a comprehensive knowledge of providers across Nebraska and are able to develop creative solutions to meet an individual s unique needs. They participate in team meetings and decision making and provide closer oversight into all aspects of treatment. Criteria for RCM are on the next page. RCM is a service provided by Magellan as part of their contract with DHHS. Finding community-based alternatives to residential care is their goal. Developed for DHHS-DCFS by UNL-CCFL 11/10/14 Page 33

34 Recovery Care Management Priority Any client 13 years old or older with 2 or more inpatient admissions within the last 60 days with a diagnosis of Bipolar Disorder or Schizophrenia Any client 12 years old or younger with one inpatient psychiatric admission Any female client who is pregnant and abusing substances Any client with 25 inpatient days in a rolling 12- month period Non-state ward youth who have been approved for a residential level of care but are not able to be admitted State ward youth who have been approved for a residential level of care but have been unable to admit Any youth who is deemed appropriate for individualized IOP programming A youth who has discharged from a residential treatment facility and holds no open authorization at 45 days post-discharge 18 year old youth who will need coordination for adult mental health services (Transitional Age Youth); at a minimum youth would have to meet minimum diagnostic criteria for SPMI diagnoses Non-state ward youth denied for residential services and the alternative level of care offered is community-based treatment service higher than Outpatient or Medication Management Non-state ward youth who have been in a residential level of care (priority will be given to RTC and ETGH) and will be discharging back into a community in Nebraska Case Management Goal Reduce re-admission into hospitals and decrease state hospital admissions Reduce inpatient re-admissions as well as decrease the number of youth residential referrals/placements Ensure treatment needs are being met to reduce risk of relapse during pregnancy Reduce inpatient readmissions for youth and adults, decrease state hospital admissions for adults, and decrease residential referrals/placements for youth Reduce the need for residential care by identifying and implementing appropriate community based services Reduce the need for residential care by identifying and implementing appropriate community based services To identify and implement creative, personalized treatment service packages to reduce the need for higher levels of care To decrease readmissions to residential facilities by identifying community-based services that will successfully serve the youth in their community Assist with transition into adult living Reduce the need for inpatient or residential treatment by identifying effective community based services Reduce the frequency of youth residential/inpatient readmission and assist with a successful transition into a community setting. Developed for DHHS-DCFS by UNL-CCFL 11/10/14 Page 34

35 Residential Medicaid MH/SU Services Children s mental health and/or substance use problems are sometimes so severe that they cannot be adequately treated in a community-based setting. Residential services fill this need, but should never be seen as a long-term place to live, any more than a hospital would be an appropriate place to live. Medicaid residential services are listed below in order of increasing restrictiveness. Both cost and child development considerations, as well as Medicaid rules, make it important to use the least restrictive, effective placement, and to plan creatively to move the child to community-based services. Professional Resource Family Care (PRFC) A Professional Resource Family promotes social skills and family/peer relationships; teaches caregiver crisis and de-escalation techniques; teaches and models appropriate behavioral treatment interventions, coping skills to manage dysfunctional behavior, and effective parenting skills; provides information about medication compliance and relapse prevention to the prescribing and/or supervising practitioner; provides training to the client and caregiver about basic personal care; helps develop positive peer relationships; and helps the family identify community resources. Professional Resource Family Care provides a short-term and intensive supportive resource for the child and family. It is intended to serve as a crisis stabilization option for the family in order to avoid inpatient or institutional treatment. A parent or parent substitute must be willing to participate in a co-parenting approach with ongoing, active participation in the treatment. A permanent family (not a temporary family or group home) must be available for the child after discharge. PRFC is appropriate for a child whose symptoms are difficult to manage and occur primarily in the home. Symptoms and functional impairments must be consistent with a DSM diagnosis and be reasonably expected to benefit from a family-based treatment approach. PRFC would not be appropriate for children whose symptoms or impairments are primarily the result of mental retardation, persistent developmental disability or autism, traumatic brain injury, conduct disorder, oppositional defiant disorder or ADHD. PRFC cannot be used as an alternative to incarceration, for preventive detention, as a means of ensuring community safety, for the equivalent of safe housing or as a permanency placement. Payment issues: While a child is in PRFC, Medicaid pays for the clinical and rehabilitative services, but the parent or guardian (the state in the case of a child who is a ward of the state) must pay the costs of room and board. While in PRFC care, the child is still eligible for Medicaid benefits for treatments that may be necessary outside the PRFC. Therapeutic Group Home (ThGH) A Therapeutic Group Home is designed to be home-like and community based and can have 4 to 8 youth living in an environment with an organized, professional staff who deliver safety, supervision, treatment and rehabilitative services. Existing grandfathered facilities providing ThGH care may have up to 16 youth. Services must be provided under the direction of a psychiatrist or a licensed psychologist. The goal is to maintain a child s connection with the community including attendance at a community school. Individual and/or group therapy must be provided three times per week and family therapy twice a month. Psychoeducational services are available (see box on page 40). Discharge planning should begin upon admission with concrete plans for the child to transition back into the community. The length of stay in a ThGH is expected to be 14 days to six months. Developed for DHHS-DCFS by UNL-CCFL 11/10/14 Page 35

36 ThGH Treatment shall: 1. Focus on reducing the behavior and symptoms of the mental health and/or substance abuse disorder that necessitated the removal of the client from his/her usual living situation; 2. Decrease problem behavior and increase developmentally-appropriate, normative and pro-social behavior in clients who are in need of out-of-home placement; and 3. Transition clients from therapeutic group homes to home- or community-based living with outpatient treatment (e.g., individual and/or family therapy). A ThGH is appropriate for children whose symptoms and/or functional impairments occur in all settings, are due to a DSM diagnosis, and which require a 24/7 treatment environment under the direction of a psychiatrist or psychologist. A ThGH must reasonably be expected to achieve treatment objectives. A ThGH is not appropriate for children whose symptoms or impairments are primarily the result of mental retardation, persistent developmental disability or autism, traumatic brain injury, conduct disorder, oppositional defiant disorder or ADHD. PRFC cannot be used as an alternative to incarceration, for preventive detention, as a means of ensuring community safety, for the equivalent of safe housing or as a permanency placement. A specialized ThGH may focus primarily on substance abuse, on mental health, on sexual offending, or on children or youth with dual behavioral health (MH/SA) diagnoses. When substance abuse treatment is provided, the need should be consistent with ASAM criteria for level III.5 (see page 39). When sex offender treatment is provided, a sex offender specific assessment should indicate a moderate or higher risk to reoffend if not treated and indicate that a community-based, 24/7 treatment environment with a safety plan is appropriate. Payment issues: While a child is in a ThGH, Medicaid pays for the clinical and rehabilitative services, but the parent or guardian (the state in the case of a child who is a ward of the state) must pay the costs of room and board (currently $88.73/day). The child is still eligible for Medicaid benefits for treatments that may be necessary outside the ThGH. The parent or guardian must also provide transportation to medical visits and therapeutic home visits. Psychiatric Residential Treatment Facility (PRTF) Psychiatric Residential Treatment Facilities are accredited and provide clinically necessary services to children who require 24 hour inpatient care and treatment in a highly structured, closely supervised environment. Treatment must be under the direction of a psychiatrist. At a minimum, individual psychotherapy and/or substance abuse counseling must occur twice a week with weekly family psychotherapy including on the day of admission and the day of discharge. Psychoeducational services are individualized to the child s needs (see box on page 44). If the PRTF has more than sixteen beds it is considered an institution for mental disease (IMD) but it is the only type of IMD that can be reimbursed by Medicaid for children s services. A PRTF is appropriate for children with severe and persistent (six months or more) mental health, substance abuse, and or sexual offending symptoms and functional impairments which are consistent with a DSM diagnosis and which require 24/7 residential care under the direction of a psychiatrist. Children approved for this level of care will have either suicidal ideation or homicidal ideation behaviors (SI/HI), significant self-injury behaviors, physical or verbal aggression unrelated to a behavior disorder, an eating disorder, severe mood disorder, or psychotic symptoms. It must also be determined that the PRTF can reasonably expected to improve symptoms so that a PRTF is no longer necessary. A PRTF is not appropriate for children who require inpatient psychiatric hospitalization or children requiring primary medical or surgical treatment. It is also not appropriate for children whose symptoms or impairments are primarily attributed to a developmental disability or autism, traumatic brain injury, conduct disorder, oppositional defiant disorder or ADHD. PRTF cannot be used as an alternative to incarceration, for preventive detention, as a means of ensuring community safety, for the equivalent of safe housing or as a permanency placement. Developed for DHHS-DCFS by UNL-CCFL 11/10/14 Page 36

37 A specialized PRTF may focus primarily on substance abuse, on sexual offenders, or on children with dual BEHAVIORAL HEALTH (MH/SA) diagnoses, or on low functioning individuals. When substance abuse alone is addressed, the need should be consistent with ASAM criteria for level III.7R. In a dual diagnosis BEHAVIORAL HEALTH (MH/SA) program, the need should be consistent with ASAM III.5. (See page for ASAM criteria.) When sexual offense is addressed, the sex offender specific assessment should recommend SO PRTF level of care, and the child must have the ability to comply with the didactic portion of the program. Payment Issues: While a child or youth is in a PRTF, the facility is responsible for room and board and all treatment costs including both mental health/substance abuse treatment and treatment for all medical conditions where the treatment need can be anticipated. The facility receives a flat rate reimbursement from Medicaid and is responsible for any costs beyond this amount. The parent or guardian (the state if the child is a ward of the state) is responsible for all emergency and unanticipated medical care services while the child is in a PRTF, and the child is not eligible for any Medicaid services outside of the PRTF. Other Acronyms Residential treatment in one of the three levels (PRTF, ThGH, and PRFC) is not appropriate when a child s symptoms are primarily due to: -Mental Retardation (MF) or Pervasive Developmental Disorder, (PDD) or (see comment) -Organic mental disorders, traumatic brain injury or other medical condition -In September, 2011, ADHD, Conduct Disorder (CD), and Oppositional Defiant Disorder (ODD) were removed from this list of exceptions so that residential treatment is available when the child s symptoms are primarily due to these conditions. PDD CD ODD Other Terms MR SO ASAM SI/HI MST MST (Multi-Systemic Therapy) is an evidencebased highly structured, family-centered and community-based treatment for youth with CD and ODD. It is an intensive outpatient service. SI/HI refers to suicidal ideation or homicidal ideation, one of criteria that may qualify a child for PRTF care if imminently dangerous. All three new levels of residential treatment may specialize in Sexual Offending behaviors (SO). ASAM is the American Society of Addiction Medicine. It is explained further on the next page. Developed for DHHS-DCFS by UNL-CCFL 11/10/14 Page 37

38 Addiction Evaluation Tools Health Stressful Life Events Education Drug and Alcohol Use Use of Free Time Peer Relationships Sexual Behavior Family Relationships Legal Issues Mental Health Substance Abuse Screening Instruments SASSI - Substance Abuse Subtle Screening Inventory TII - Treatment Intervention Inventory SUDDS (Substance Use Disorder Diagnostic Schedule MADIS - Michigan Alcohol Drug Inventory Screen MAST - Michigan Alcoholism Screening Test MINI - Mini International Neuropsychiatric Interview WPI - Western Personality Inventory PBI - Problem Behavior Inventory RAATE - Recovery Attitude and Treatment Evaluator CIWA - Clinical Institute Withdrawal Assessment ASAM Placement Criteria The American Society of Addiction Medicine (ASAM) has published criteria that define the levels of care appropriate for the treatment of substance abuse. In 2008, Medicaid began using the ASAM Patient Placement Criteria for the treatment of substance-related disorders with Medicaid eligible clients age 20 and younger. These criteria were adopted to assure that the most appropriate level of substance abuse treatment services are delivered to each client. The ASAM levels of care used by Nebraska Medicaid are summarized here briefly with criteria for each of six assessment dimensions. A substance abuse evaluation must address each of these dimensions. A more extensive description is available on Magellan s website and can be accessed by going to: Level I (Outpatient Services) D1: Youth has no withdrawal symptoms beyond lingering and improving sleep disturbance. D2: Is stable with no biomedical conditions or complications. D3: Youth has adequate impulse control to deal with thoughts of harm to self and others. Mental status does not preclude ability to understand materials or participate in treatment; D4: One of the following: Willing to cooperate with treatment; or ambivalent but acknowledges alcohol or drug problem and wants help; acknowledges either psychiatric diagnosis or substance abuse diagnosis when both are present; or admits substance abuse problem but is focused on avoiding negative consequences. D5: Can significantly reduce use with only minimum support; Needs regular therapeutic contact to help with preoccupation, craving, peer pressure, or impulse control and lifestyle/attitude change. D6: Environment is sufficiently supportive given adolescent s motivation and willingness to obtain supports, or family is supportive but needs help to improve. D1 = Acute Intoxication and/or Withdrawal; D2 = Biomedical Conditions and Complications; ASAM Dimensions D3 = Emotional, Behavioral or Cognitive Conditions and Complications; D4 = Readiness to Change; D5 = Relapse, Continued Use or Continued Problem Potential; D6 = Recovery Environment. Developed for DHHS-DCFS by UNL-CCFL 11/10/14 Page 38

39 Level II.1 (IOP and Day Treatment) D1: Youth is not experiencing and not at risk of acute withdrawal or able to tolerate mild subacute withdrawal symptoms and has made a commitment to sustain treatment and has external supports. D2: Biomedical conditions, if any, are stable or being addressed and will not interfere with treatment. D3: One of the following: Mild risk of behaviors endangering self, others, or property requiring frequent monitoring (but not daily); recovery efforts are affected by emotional, behavioral or cognitive problems causing mild interferences and requiring more support; symptoms are causing mild to moderate difficulty but is able to manage activities of daily living or fulfill responsibilities at home, school, work, or community; mild to moderate impairment in managing activities of daily living requiring frequent monitoring and treatment intervention; or history and present conditions suggest that emotional, behavioral or cognitive condition would become unstable without frequent monitoring and maintenance. D4: youth requires structured therapy and a programmatic milieu to promote progress; is verbally compliant but inconsistent in behavior; is only passively involved in treatment; is variably compliant with attendance in outpatient sessions, self-help meetings or support groups. D5: Youth is at significant risk of relapse or continued use and deterioration without frequent outpatient monitoring and therapy, and demonstrates impaired recognition and understanding of relapse issues; D6: Continued exposure to current school, work, or living environment will impede recovery; youth has insufficient resources and skills to maintain level of functioning without support but maintains adequate functioning between sessions; lacks social contact or has inappropriate social contacts, few friends or peers who do not use; or youth s family is supportive but family conflicts and dysfunction impede recovery. Level II.5 (Partial Hospitalization) D1: Youth is experiencing acute or subacute withdrawal marked by mild symptoms that are diminishing; youth is likely to attend, engage and participate in treatment as shown by an ability to tolerate withdrawal symptoms, a commitment to sustain treatment, and external supports from family and/or court that promote treatment engagement. D2: Youth s biomedical conditions are stable or being concurrently addressed and will not interfere with treatment at this level; they are severe enough to distract from recovery and treatment at a lower level of care. D3: Youth s risk of behaviors endangering self, others, or property is mild and requires frequent monitoring during non-treatment hours but does not require 24 hour supervision; recovery efforts are affected by emotional, behavioral or cognitive problems with cause moderate interference with treatment requiring increased intensity. Symptoms cause mild to moderate difficulty in social functioning but is able to manage activities of daily living and fulfill responsibilities at home, school, work, or community. The adolescent is experiencing moderate impairment in activities of daily living and requires near daily monitoring and treatment. Problems may involve disorganization and inability to manage daily selfscheduling, a progressive pattern of promiscuous or unprotected sexual contacts, or poor vocational or pre-vocational skills that require habilitation and training. History and present situation suggests that emotional, behavioral or cognitive condition would become unstable without daily or near daily monitoring and maintenance. D4: Youth requires structured therapy and programmatic milieu as seen by a demonstration of verbal and behavioral opposition to treatment, minimal involvement in treatment, poor attendance at outpatient sessions, escalating substance use contributing to school failure, truancy, or suspension. Youth s perspective and lack of impulse control inhibits progress through stages of change. D5: Youth is at high risk of relapse or continued use without almost daily outpatient monitoring and structured therapy. Less intensive treatment has been tried or given serious consideration and has been insufficient to stabilize condition. Youth has impaired recognition and understanding of relapse issues and requires near daily structure to prevent or arrest deterioration in functioning. Developed for DHHS-DCFS by UNL-CCFL 11/10/14 Page 39

40 D6: Continued exposure to the youth s current school, work, or living environment will render recovery unlikely. Youth lacks social contacts or has inappropriate social contacts that jeopardize recovery, or has few friends or peers who do not use. Family members and/or significant others living with the youth are not supportive of the youth or recovery goals or are passively opposed to treatment. Youth requires structured treatment and relief from the home environment to remain focused on recovery, but may live at home because there is no active opposition to or sabotaging of the effort. Level III.5 (ThGH and PRTF) D1: Youth is at risk for acute and subacute intoxication or withdrawal with mild to moderate symptoms; needs containment and increased treatment intensity to support engagement in treatment and ability to tolerate withdrawal and prevention of immediate continued use. Alternatively the youth has a history of failure in treatment at the same or less intensive level or care. D2: Biomedical conditions distract from recovery efforts and require residential supervision to ensure adequate treatment with adequate nursing or medical monitoring provided, or continued substance use would place the youth at risk of serious damage to physical health because of a biomedical condition or an imminent dangerous pattern of high-risk use. D3: Youth is at moderate but stable risk of imminent harm to self or others and needs medium-intensity 24- hour monitoring and/or treatment for protection and safety, or the youth s recovery efforts are affected by emotional, behavioral or cognitive problems in significant or distracting ways requiring 24-hour structured therapy and a programmatic milieu, or youth has significant impairments and moderate to severe symptoms such as poor impulse control that seriously impair the ability to function in family, social, school or work settings, or youth has moderate impairment in ability to manage the activities of daily living requiring 24-hour supervision and staff assistance with intensive modeling and reinforcement of personal grooming and hygiene or youth has a pattern of continuing indiscriminate or unprotected sexual contact in context of advanced substance dependence or a need for intensive teaching of personal safety techniques following physical or sexual assault, or the history and present situation suggest a need for 24-hour supervision and a medium intensity structured programmatic milieu. D4: Youth requires 24-hour supervision and structured programmatic milieu to promote progress through the stages of change as evidence by lack of previous treatment engagement and/or extensive functional impairment, or the youth has not related his or her problems to substance use or accepted the need to change, or youth does not believe there is a problem in daily substance use despite serious life threatening consequences. D5: Lack of monitoring or supervision between treatments at a less intensive level of care has been a major barrier to abstinence and recovery, or youth requires residential containment, treatment and structured programmatic milieu to develop recovery skills that are not yet sufficient to overcome environmental triggers such as peer substance use or family stressors or craving, or youth s history of chronic use, repeated relapse, and/or resistance to treatment predicts need for this level of care, or the youth s likelihood of relapse and/or continued use pose a high risk of serious impairment in absence of 24-hour monitoring and structured support because of ongoing exposure to substances in the context of trafficking, gang or other delinquent or drug involved peers. D6: Youth has been living in an environment with high risk of neglect or initiation or repetition of physical, sexual, or severe emotional abuse, or youth has family or other household member with an active substance use disorder or there is endemic use in the home environment, or the home environment or social network is too chaotic or ineffective to support treatment, or logistical impediments such as distance from treatment facility, mobility limitations, lack of transportation preclude participation at a less intensive level of care. Developed for DHHS-DCFS by UNL-CCFL 11/10/14 Page 40

41 Level III.7 (PRTF(SA) and Inpatient) (BEHAVIORAL HEALTH (MH/SA) ) D1: Youth is experiencing or at risk of acute or subacute intoxication or withdrawal with moderate to severe symptoms; 24-hour treatment including availability of active medical and surgical monitoring is needed to manage withdrawal and support engagement in treatment and prevention of immediate use; youth has a history of treatment failure at this or lower levels of care. Intoxication and withdrawal must be manageable at this level of care. For example, youth may require sedative-hypnotic substitution or other medication assisted therapy managed with standing orders and without the need of extensive titration; additional examples are given at the internet address above. D2: Youth has a biomedical complication of addiction or co-occurring biomedical conditions that require active nursing or medical monitoring not requiring the resources of an acute care hospital, or continued substance use places the youth at imminent risk of serious damage to physical health because of a biomedical condition such as brittle diabetes, pregnancy or HIV, requiring active nursing and medical monitoring. D3: Adolescent is at moderate and possibly unpredictable risk of imminent harm to self or others needing 24-hour monitoring and/or treatment in a high intensity programmatic milieu and/or enforced containment for safety; or recovery efforts are affected by emotional, behavioral, or cognitive problems in significant and distracting ways; or significant impairments such as poor impulse control and disorganization would seriously impair the ability to function in family, social, school or work settings and cannot be managed at a lower level of care (for example recent history of aggressive or severely disruptive behavior with sever inability to manage peer conflict, or a recurrent or persistent pattern of runaway behavior requiring enforced confinement.) ; or youth has a significant lack of personal resources and moderate to severe impairment in the ability to manage activities of daily living (These may involve progressive and severe dilapidation and D4: Youth has not related his or her problems to substance use or has not accepted need to change so that treatment at a lower level would not be likely to be successful, for example, substance use causes disorganization that interferes with diabetes care or other chronic illness; or youth has demonstrated a need for intensive motivating strategies available only in a 24-hour high-intensity structured milieu with medical monitoring. D5: Youth is unable to interrupt high frequency/high severity pattern of use with imminent severe risk of dangerous consequences, or the modality of treatment or the intensity of monitoring, case management and documentation requires level III.7 care, such as safe and effective titration of antagonist therapy, agonist substitution therapy, or aversion therapy. D6: The youth has been living in an environment in which supports that might otherwise have enabled treatment at a less intensive level are unavailable; the family may undermine treatment, may have active substance use disorders, facilitate access to substances, be dangerously chaotic or abusive, or be unable to adequately supervise medications or implement a needed behavior management plan; or logistical impediments preclude participation in treatment at a less intensive level. Level IV (Inpatient Detoxification) (Medical Surgical) Adolescent Level IV medically managed inpatient detoxification, stabilization and treatment is an organized service delivered in an acute care inpatient hospital setting. It is appropriate for youth whose acute biomedical, emotional, behavioral and cognitive problems are so severe that they require primary medical and nursing care. Level IV program services are delivered by an interdisciplinary staff of addiction trained and experienced physicians, nurses, and other appropriately credentialed professionals. Developed for DHHS-DCFS by UNL-CCFL 11/10/14 Page 41

42 On The Web Magellan Magellan s website contains much useful information. Under For Providers on the home page you can find the Medical Provider Handbook which includes Clinical Guidelines outlining criteria used to approve or deny care (Appendix C). New residential services are listed under New and Revised Children s Services, also under For Providers. Treatment Record Review is under For Providers and under that link is a sample PTA indicating what Magellan (and you) should expect from providers performing this evaluation service. A Provider Search link is available to search for mental health and substance abuse providers in Nebraska. A Providing Care link provides Clinical Practice Guidelines that give best practice recommendations for many conditions. Aetna Better Health of Nebraska Information for members and providers is available at United Healthcare Information, including the Member Handbook is available from the Americhoice website. Select Member Handbook under Members and then choose Nebraska when prompted for the state. Arbor Health Plan Information, including the Member Handbook will be available from the Arbor Health Plan website. Network of Care The Nebraska Behavioral Health Network participates in Network of Care, a national website providing county specific (in our case Region specific) information about services and many mental health issues. Nebraska Resource and Referral System The Nebraska Resource and Referral System provides information about medical services (and many other services) across Nebraska. Search by county and type of service. Developed for DHHS-DCFS by UNL-CCFL 11/10/14 Page 42

43 Useful Hotline Numbers Nebraska Child Abuse Hotline Nebraska Families Hotline The Nebraska Families Hotline is intended to provide 24/7/365 assistance to youth and parents/caregivers of a youth experiencing an urgent behavioral health situation. It began operating on January 1, 2010 in response to LB03. It is managed by Alegent Health. (See Right Turn The Right Turn hotline provides 24/7 support on a voluntary basis to families who have adopted or agreed to be the guardian for a child or teen who had previously been in the state s care. Families are eligible if the child is 1) 18 years old or younger, 2) was in the custody of DHHS prior to finalization of the adoption or guardianship, and 3) Parents have a valid adoption subsidy agreement with DHHS. Families can be connected to respite care, mentoring, counseling, classes, support groups, and more. Right Turn is managed by Lutheran Family Services of Nebraska and Nebraska Children s Home Society. It was established in response to some of the post adoption/guardianship issues that arose from Nebraska s original Safe Haven law. (See Nebraska DHHS Lead Hotline This is the Consumer Health and Environmental Health hotline from DHHS Environmental Health. Choose option 3 for questions related to high lead levels in a child or a potentially risky environment. Other options on this line might be helpful with questions about mercury spills from broken thermometers (Option 4 ), Radon, especially in basement living environments and those that have been sealed for energy efficiency (Option 5 ), or indoor air quality and mold (Option 6 ). Nebraska Resource and Referral System (NRRS) Hotline Listing There are many other hotline numbers available from the Nebraska Resource and Referral System which is sponsored by DHHS and managed by the Answers4Families program. These numbers are available at this website: Listed hotlines are categorized under the following headings: abuse/neglect, adoption, children, missing/runaway, diseases chronic and sexually transmitted, education, employment, food and nutrition, healthy mothers and babies, mental retardation, physical disability, suicide prevention, transportation, wellness, and many other categories. Developed for DHHS-DCFS by UNL-CCFL 11/10/14 Page 43

44 Mental Health/ Substance Use Managed Care Medical and Surgical Services Managed Care Ten County Area Toll Free Number (800) DHHS: Medicaid Physical Health Managed Care Contract Managers Michelle Williams(Aetna) (402) Mary Minarich(Arbor) (402) Lacie Pika(UHCCP) (402) IntelliRide(transportation) Contract Manager Dawn Vosteen (402) Medicaid Enrollment Center To choose a managed care plan (888) Magellan Contract Manager Lori Lewis (402) Medicaid Enrollment Center To choose a managed care plan (888) Customer Service Contact (855) In Lincoln: (402) In Omaha: (402) :00am 5:00pm Monday thru Friday Questions about Medicaid Eligibility [email protected] Website: DHHS: Behavioral Health For help navigating the Nebraska Behavioral Health System, contact Sue Adams at (402) HEALTH CARE MARKETPLACE Better Health of Nebraska Customer Service (888) Case Management (800) Jason Schmit Manager, Community Development Aetna Better Health of Nebraska [email protected] Help Desk (866) Cass Douglas Lancaster Sarpy Seward Dodge Gage Otoe Saunders Washington All Other Counties Arbor Health Plan Customer Service (866) Speak with a nurse (888) Medical Director, Dr. Tom Tonniges [email protected] Customer Service (888) Case Management (800) Medicaid Transportation Toll Free: (844) Local Omaha: (402) TTY Line: (402) Provider Line: (402) Developed for DHHS-DCFS by UNL-CCFL 11/10/14 Page 44