Behavioral Health and Developmental Disabilities Administration Waiver Conference 11/18/14

Transcription

1 Behavioral Health and Developmental Disabilities Administration Waiver Conference 11/18/14 1

2 Introductions Lisa Grost, Autism Section Manager, MDCH Morgan VanDenBerg, Autism Behavioral Specialist, MDCH 2

3 Overview Applied Behavior Analysis (ABA) Medicaid and MIChild Autism ABA Benefit Updates on Autism and ABA in Michigan WSA 101 Resources 3

4 What is ABA? Applied Behavior Analysis The science of analyzing and improving socially significant human behavior.

5 Applied Behavior Analysis Applied Behavior Analysis (ABA) services for ASD Focuses on increasing communication, language acquisition, peer interactions and social skills, responding to group instruction, academic/cognitive skills, following daily routines, play skills, self-help and daily living skills, learning in and from the natural environment, and reducing inappropriate behavior(s) that may be interfering with learning or participation in community. 5

6 Evidence-Based Treatment Applied Behavior Analysis (ABA) It is supervised by a Board Certified Behavior Analyst (BCBA) Parents/aides/friends/siblings/teachers/peers/Behavioral technicians can deliver the treatment Can be provided in a school setting, private practice, center, community, or health organization Research shows that early intervention treatment services can greatly improve a child s development Scientific studies have demonstrated that early intensive behavioral intervention improves learning, communication and social skills in young children with autism.

7 Autism Insurance Reform Pre Autism Legislation It was very challenging to obtain insurance approval for services to assist children and adolescents with autism. There were parents reporting they did not want to have the diagnosis autism for their child because it may mean not receiving services siblings could obtain. Physicians struggled with recommendations for treatment because of the lack of insurance benefits and resources to assist families. Applied Behavior Analysis was an unknown service and/or not an option for many families. 7

8 Autism Insurance Reform Coverage for the treatment of ASD went into effect October 15, Diagnosis must be made by a licensed physician or licensed psychologist to be eligible for services. Insurance carriers may require an evaluation every three years. 8

9 Autism Insurance Reform Treatment must be evidenced based and includes the following care as determined by a licensed physician or a licensed psychologist: Behavioral health treatment (applied behavior analysis) Therapeutic care (speech therapy, occupational therapy) Pharmacy care Psychiatric care Psychological care 9

10 Self-Funded Insurance Not mandated to offer the autism services under state legislation Can utilize Autism Fund for reimbursement For additional information about the Autism Benefit Reimbursement Program visit: 10

11 Autism Insurance Reform Pre Medicaid/MIChild Autism Benefit Children received primarily family training, occupation and speech therapy Family Training utilized for Parent Mediated Interventions to children with ASD that targeted socialization, communication, and other developmental approaches. Applied behavior analysis was not an option Added Board Certified Behavior Analysts to the network of qualified providers. Older children and adults have access to behavior and other services. 11

12 Medicaid/MIChild Autism Benefit The Michigan Medicaid and MIChild Autism Benefit went into effect on April 1, Applied Behavior Analysis(ABA) is the approved Autism Benefit service. Children enrolled in the Autism Benefit are also eligible for any medically necessary services provide by the Managed Specialty Supports & Services Plan under the authority of Section 1915(b) of the Social Security Act (the b-waiver b-3s or b-3 services ) 12

13 Managed Specialty Services and Supports Waiver 1915(b), 1915(b)(3) and EPSDT Covered Services 1915(b) include Assertive Community Treatment, Assessments, Behavioral Management Review, Child Therapy, Clubhouse Psychosocial Rehabilitation, Crisis Intervention & Residential, Family Therapy, Health Services, Home-Based Services, Individual & Group Therapy, Inpatient Psych Hospitalization, Intensive Crisis Stabilization, ICF/IID, Medication Administration/Review, Nursing Facility MH Monitoring, OT, PT, Speech, Personal Care in Specialized Homes, Substance Abuse, Targeted Case Management, Telemedicine, Transportation, Treatment Planning, Wraparound Additional 1915(b)(3) Services include Assistive Technology, Community Living Supports*, Enhanced Pharmacy, Environmental Modifications, Family Support & Training*, Fiscal Intermediary, Housing Assistance, Peer-delivered or -operated services (i.e., Peer Support Specialists/Drop-In Centers)*, Prevention Direct Service Models*, Respite, Skill-Building*, Support Coordination*, Supported / Integrated Employment*, *Services in bold italics are provided under the authority of EPSDT for children birth to 21 years and provided under the authority of 1915(b)(3) of the Social Security Act for adults 21 years and older. 13

14 Medicaid/MIChild Autism Benefit Determination of ELIGIBILITY for the Autism Benefit: Children must meet all three of the following criteria to be eligible: Be 18 months through 5 years of age, Have diagnosis of Autism Spectrum Disorder and Meet needs based criteria

15 Medicaid/MIChild Autism Benefit The child demonstrates substantial functional impairment in Social Interaction (as evidenced by needing ABA to address 2 or more from A.) and significant functional impairment in ageappropriate activities due to the interference by restricted repetitive & stereotyped patterns of behavior, interests and activities (as evidenced by needing ABA to address 1 or more from B.). A. Qualitative impairment in social interaction, as manifested by at least two of the following: (1) marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction (2) failure to develop peer relationships appropriate to developmental level (3) a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest) (4) lack of social or emotional reciprocity B. Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following: (1) encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus (2) apparently inflexible adherence to specific, nonfunctional routines or rituals (3) stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole body movements) (4) persistent preoccupation with parts of objects The child may possess age-appropriate expressive and receptive language skills, learning [defined as cognitive development (D.Q. or I.Q. > 75)], self-care skills, mobility, adaptive behavior (other than in social interaction), and curiosity about the environment. 15

16 Medicaid/MIChild Autism Benefit Initial Assessment and diagnostics Qualified Providers Physician, fully licensed psychologist, limited licensed psychologist, or a child mental health professional will provide the diagnostic testing of Autism Spectrum Disorder. ASD Assessment Tools ADOS-2 (Autism Diagnostic Observation Schedule) Structured Interview ADI-R (Autism Diagnostic Interview-Revised) Other developmental history interview ***Other assessments may be use to provide evidence to MDCH/BHDDA for making the needs-based eligibility determination.

17 Medicaid/MIChild Autism Benefit After the child is diagnosed with ASD, the Pre-Paid Inpatient Health Plan (PIHP) will provide evidence from the diagnostic tests and assessments to MDCH who will make the decision of whether the child meets the needs based eligibility criteria to receive the Autism ABA Benefit MDCH will review once submitted usually within 24 hours. 17

18 Medicaid/MIChild Autism Benefit Independent Assessment Qualified Providers Licensed Psychologist and Limited Licensed Psychologist Assessment Tools Vineland Adaptive Behavior Scales-Second Edition (VABS-2) Cognitive Assessment Mullens, Wechsler III or IV, or Differential Ability Scales-II 18

19 Medicaid/MIChild Autism Benefit Independent Assessment Recommendation of the hours of ABA will be based on assessments by the psychologist. Actual hours are determined during the person centered planning (PCP) process and individual plan of service (IPOS) with the family and service providers. 19

20 Medicaid/MIChild Autism Benefit ABA Supervisors and ABA skill assessments Qualified Providers BCBA LP,LLP, CMHP (has graduate level coursework and pursuing BCBA, must complete by 9/30/2016) Behavior Outcome measurement tool VB-MAPP ABLLS-R Administered every 6 months 20

21 Assessment Encounters Service HCPCS Code Mandatory Modifier Assessment 90791, 90792, 90833, 90836,90838, 90785, , , , , , 96102, 96118, and H0031 U5 21

22 Medicaid/MIChild Autism Benefit Person-Centered Planning and Individual Plan of Service (IPOS) The PIHP is responsible for the development and implementation of the IPOS. Qualified Providers are Support Coordinators and Case Managers Must be able to perform the following functions: 1. Planning and/or facilitating planning using PCP principles 2. Develop an IPOS using the PCP process, including revisions to the IPOS at the request of the family. 3. Linking to, coordinating with, follow up of, and advocacy with all medically necessary supports and services 4. Monitoring of ABA service and other services 5. Brokering of providers of services/supports 6. Assistance with access to entitlement and/or legal representation 22

23 Medicaid/MIChild Autism Benefit Services-Applied Behavior Analysis (ABA) There are two levels of intensity within ABA services; EIBI and ABI. The PIHP s Utilization Management will authorize the intensity of services prior to delivery. 23

24 ABA Service The Board Certified Behavior Analyst (BCBA) would develop and implement the EIBI or ABI treatment programs as part of the individuals plan of service (IPOS). A team, including the parents/guardians, will be developing the child s goals and plan. EIBI is available to any child who has an ADOS score that falls in the Autism range. ABI is an intervention available for any child with ASD who is not receiving EIBI and has an ADOS score that falls in the Autism or ASD range. 24

25 Autism Benefit-ABA Service Delivery Model Board Certified Behavior Analyst (BCBA, BCBA-D) Develops and implements EIBI or ABI treatment program. Provides supervision and training of staff and families. CODES: H0031, H0032, S5108, S5111 Board Certified Assistant Behavior Analyst (BCaBA) Provides support and technical assistance of treatment program under the supervision of BCBA. CODES: H2019 ABA Aide 1 Works with the child, collects data, and delivers treatment protocol CODES: H2019 ABA Aide 2 Works with the child, collects data, and delivers treatment protocol CODES: H

26 Medicaid/MIChild Autism Benefit Reevaluation The Vineland is the adaptive behavior tool that is required and needs to be completed annually. MDCH/BHDDA will make the determination of continuing eligibility based on evidence provided by the PIHP that the child meets the needs-based criteria. 26

27 Medicaid/MIChild Autism Benefit The child demonstrates substantial functional impairment in Social Interaction (as evidenced by needing ABA to address 2 or more from A.) and significant functional impairment in ageappropriate activities due to the interference by restricted repetitive & stereotyped patterns of behavior, interests and activities (as evidenced by needing ABA to address 1 or more from B.). A. Qualitative impairment in social interaction, as manifested by at least two of the following: (1) marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction (2) failure to develop peer relationships appropriate to developmental level (3) a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest) (4) lack of social or emotional reciprocity B. Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following: (1) encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus (2) apparently inflexible adherence to specific, nonfunctional routines or rituals (3) stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole body movements) (4) persistent preoccupation with parts of objects The child may possess age-appropriate expressive and receptive language skills, learning [defined as cognitive development (D.Q. or I.Q. > 75)], self-care skills, mobility, adaptive behavior (other than in social interaction), and curiosity about the environment. 27

28 Roles and Responsibilities of Qualified Providers Board-Certified Behavior Analyst (BCBA): Develops and implements EIBI or ABI treatment program. Reviews and monitors data and makes programmatic changes based on the data. Provides skill development training and supervision of BCaBA, ABA Aide and CMHP. Administers one of the behavioral outcome measurement tool. 28

29 Roles and Responsibilities of Qualified Providers Board-Certified Assistant Behavior Analyst (BCaBA): Works under the supervision of BCBA to provide the technical assistance and implementation of the treatment plan. Provides direct oversight of data collection. 29

30 Roles and Responsibilities of Qualified Providers ABA Aide: Works under the direction and supervision of BCBA to provide the direct implementation of the treatment plan. Gathers data and makes program adjustments under the direction of the BCBA. 30

31 Roles and Responsibilities of Qualified Providers Licensed Psychologist: Provides diagnosis of child and treatment within scope of practice which includes; psychological testing, evaluations Administers ADOS and ADI-R Recommends the intensity of the ABA service Administers one of the behavioral outcome measurement tools. 31

32 Roles and Responsibilities of Qualified Providers Limited Licensed Psychologist: Works within scope of practice Provides psychological testing Psychological evaluations, therapy Administers ADOS and ADI-R Recommends the intensity of the ABA service Administers one of the behavioral outcome measurement tools. 32

33 Roles and Responsibilities of Qualified Providers Autism Benefit-Child Mental Health Professional (master s degree minimum): Works under the direction and supervision of the BCBA Works within scope of practice Administers ADOS and ADI-R (*licensed for diagnostic) Participates in treatment team Administers one of the behavioral outcome measurement tools 33

34 Provider Service HCPCS Code Mandatory Modifier Coverage LP*, LLP* Assessment (Cognitive and Vineland Adaptive Behavior) 96101, 96102, 96118, and U (i) state plan amendment BCBA LP, LLP, or CMHP Assessment (ABLLS or VB-MAPP) H0031 U (i) state plan amendment ABA Aide, BCBA, BCaBA, CMHP, Other Bachelor s degreed professional Applied Behavior Analysis H2019 U (i) state plan amendment BCBA, LP, LLP, or CMHP Home Care Training to Home Care Client (Supervision of Direct Care Provider) S5108 U (i) state plan amendment BCBA, LP, LLP, or CMHP BCBA, LP, LLP, CMHP Family Training S5111 HAB and 1915 (b),(3) Treatment Planning H0032 State Plan * = does not require BACB approved coursework to provide this service 34

35 Autism Program Updates Children 18 months to 6 years old 1,493 children covered by Medicaid/MIChild received diagnostic services 984+ children are enrolled in the Autism ABA Benefit 5,898 children received other medically necessary Medicaid services Monthly Autism Webinars the 3rd Wednesday of every month at 2 PM 35

36 Autism ABA Benefit Beneficiaries

37 Michigan Autism Increase ABA service providers to assure all children with ASD can access the intensity and hours of ABA authorized for them. Expand the education services and supports for students with ASD in the public schools. Improve the crisis management systems and coordination of responses and care for families experiencing extreme behavior challenges with youth and young adults with ASD. 37

38 Michigan ABA Successes Families are reporting amazing improvements and the outcomes are changing their daily lives. Universities will be graduating 67 candidates in Increase focus on ASD/Mental Health Mental Health and Wellness Commission Report. Approved Autism Evaluation Centers from 4 to 12 locations in less than two years. Behavior Analyst Certification Board reports 248 BCBA s in Michigan 38

39 Michigan ABA Successes $2.6M in autism contracts in 2014 $9M in autism contracts in 2015 Michigan now has 7 universities offering ABA degree programs up from 2 in 2012 (8 th in the works) 39

40 Michigan ABA Challenges ABA Providers ABA providers are indicating they have room for more children; MDCH staff have provided leads and we are learning regions are not following up on increasing capacity. This elevates our non-compliance with ABA. Meeting level of ABA service recommended and authorized as medically necessary PIHP Restructure (from 18 to 10) PIHP/CMH autism coordinators Training of behavioral support staff 40

41 PIHP Autism Benefit Children Enrolled 3/1/14-6/30/ Region 1 Region Region 3 Region4 75 Region 5 62 Region 6 Region Region 8 Region 9 39 Region 10 41

42 Percent of children enrolled in the Autism Benefit 100 Michigan PIHP ABA Services 3/1/14-6/30/14 % Received ABA % Received ABA as outlined in IPOS

43 Centers for Medicare and Medicaid Services (CMS) Bulletin July 7, 2014 CMS Bulletin Bulletin reviewed approaches available under Medicaid for providing services to individuals with Autism Spectrum Disorder (ASD) It also reviewed state obligations under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit, where states must cover all medically necessary services for children, including services to address ASD. MDCH is pursuing an expansion of behavioral intervention services for children with ASD beyond age 6 and we will update stakeholders about the policy and effective dates when they become more apparent 43

44 Autism Training Survey Top training needs identified: Parent and Family Training Parent and Family Engagement Autism safety training for staff Family and peer mediated interventions Reimbursement: payments, cost settlement, etc. 44

45 FUNCTIONS OF THE WAIVER SUPPORT APPLICATION PRODUCTION AND PENDING ENVIRONMENT PRODUCTION AND PENDING DATA ROADMAP REPORTS COMMON ISSUES

46 PRODUCTION AND PENDING ENVIRONMENT HOW TO VIEW PRODUCTION AND PENDING DATA

47 PRODUCTION AND PENDING DATA PRODUCTION AND PENDING DATA COMPARISON PENDING DATA Modification allowed Only Pending view allows modifications of data Tracks changes from one work queue to another Work-in-Progress Data PRODUCTION DATA View Only No modification can be done in Production View Data used to verify encounters Data used in reports Data used in site visits Official Data

48 PRODUCTION AND PENDING ENVIRONMENT HOW TO VIEW PRODUCTION AND PENDING DATA

49 ADDING A NEW CASE PIHP USERS ONLY PENDING TO PRODUCTION DATA ROADMAP PLEASE FOLLOW THE ROADMAP TO CONFIRM DATA HAS BEEN MOVED TO PRODUCTION ADDING/UPDATING AN EVALUATION or STATUS PIHP AND CMH USERS ACTIONS ADDING/UPDATING AN INDIVIDUAL PLAN OF SERVICE ROLES PERMITTED TO PERFORM ACTIONS PIHP AND CMH USERS ADDING/UPDATING A PERIOD OF INACTIVITY PIHP AND CMH USERS ENDING ELIGIBILITY FOR A CASE PIHP USERS ONLY ROADMAP PIHP USER ADDS A NEW CASE CMH USER ADDS/UPDATES AN EVALUATION or STATUS APPROVES ACTION MOVES TO PIHP QUEUE CMH USER ADDS/UPDATES AN INDIVIDUAL PLAN OF SERVICE APPROVES ACTION MOVES TO PIHP QUEUE CMH USER ADDS/UPDATES AN INACTIVITY PERIOD APPROVES ACTION MOVES TO PIHP QUEUE PIHP USER ENDS ELIGIBILITY FOR A CASE APPROVES ACTION MOVES TO DCH QUEUE BECOMES PRODUCTION DATA MOVE TO COMPLETED WORK QUEUE PIHP USER REVIEWS THE EVALUATION or STATUS APPROVES ACTION MOVES TO DCH QUEUE DCH USER REVIEWS THE EVALUATION or STATUS DETERMINES ELIGIBILITY PIHP USER REVIEWS THE INDIVIDUAL PLAN OF SERVICE APPROVES ACTION BECOMES PRODUCTION DATA MOVE TO COMPLETED WORK QUEUE PIHP USER REVIEWS THE PEROID OF INACTIVITY APPROVES ACTION BECOMES PRODUCTION DATA MOVE TO COMPLETED WORK QUEUE DCH USER REVIEWS THE END ELIGIBILITY APPROVES ACTION BECOMES PRODUCTION DATA MOVE TO COMPLETED WORK QUEUE BECOMES PRODUCTION DATA MOVE TO COMPLETED WORK QUEUE

50 PENDING TO PRODUCTION DATA ROADMAP THE AUTISM CASE SEARCH PAGE The Autism Case Search Page allows for search to be filtered by the work queue. Cases should only be in a work queue if a user is working on its data. If a case is not being worked on, it should be in the completed work queue.

51 The p in the horizontal tab indicates a modification has been made in the specific tab. o The data in the production and pending environment will be different. The actions dropdown bar allows the CMH/PIHP/DCH user to approve changes in the pending environment. When the final appropriate user approves the pending environment data, the changed information will be saved in the production environment. PENDING TO PRODUCTION DATA ROADMAP WORK QUEUE ACTION

52 COMMON ISSUES There are only three different status types: Open Approved for the Autism Benefit Closed Was once eligible for the benefit and is no longer, or was not eligible for the benefit Pending Between the process of referral and evaluation for the Autism Benefit

53 COMMON ISSUES PIHP

54 COMMON ISSUES REFERRAL DATE AND IPOS TIMELINE Referral date The date the Access center was contacted by the consumer regarding Autism Benefit Services If the current Referral date are incorrect, please contact Morgan at with a list of case IDs and their correct Referral date Individual plan of Service should capture the complete history of the plan of service, and not just the most recent Plan of Service.

55 REPORTS REPORTS AND THEIR COLUMNS All Cases All Data Reports Case ID ID Type Beneficiary ID Beneficiary Name Status Closing Reason Diagnosis Code Birthday Age Referral Date Evaluation Date Eligibility Date ReEvaluation Due Date Eligibilty End Date IPOS Exist (Yes or No) Level of Intensity IPOS Start Date IPOS Due Date ABA Service Start Date PIHP CMH Name Days Between Referral and Evaluation Days Between Eligibility and IPOS

56 REPORTS REPORTS AND THEIR COLUMNS Autism Potential Non Payment Reports Case ID MIChild ID Medicaid ID Beneficiary Name Year/Month CMH PIHP Reason for Potential Non Payment

57 REPORTS REPORTS AND THEIR COLUMNS Autism Referral, Eligibility and Service Timeline Report PIHP / CMH CASE ID ID TYPE - (MEDICAID OR MICHILD) BENEFICIARY ID BENEFICIARY NAME Days between referral and evaluation Days between referral and eligibility Days between referral and IPOS start date Days between eligibility and IPOS start date

58 REPORTS REPORTS AND THEIR COLUMNS Autism Re-Evaluation Report PIHP / CMH Status Closing Reason Case ID ID Type (Medicaid or MIChild) Beneficiary ID Beneficiary Name Re-evaluation (1, 2, 3, or 4) Evaluation Start Date VABS-2 Cumulative Score Communication Score Daily Living Skills Score Socialization Score Motor Skills Score Maladaptive Behavior Score Impairment in social communication & social interaction Restricted, repetitive and stereotypical pattern of behavior, interests and activities

59 Resources Website Created the Autism Benefit Map is an interactive map that can be used to get information about the Medicaid and MIChild Autism Benefit Coordinator in a specific region. Provider FAQ ispa Policy Links to current codes and encounter reporting Other resource documents for Autism ABA Benefit 59

60 Resources Autism Alliance of Michigan Autism Society of Michigan Autism Speaks Michigan Alliance for Families Michigan Department of Education Great Start Office of Special Education Michigan Department of Human Services National Autism Center 60

61 Questions? 61

62 Thank You! Additional Information: Lisa Grost, MDCH Morgan VanDenBerg, MDCH 62