Overview of June 28th Learn & Share with Responses to Questions

Licensed and Certified Residential: Reporting Community Living Support (CLS) and Personal Care (PC) (H2016/T1020)

Data Integrity Issues

  • There are numerous problems with the current PRICING approaches used for these TWO services, such as
  • Inappropriate rolling in of other services into the per diem.
  • Inappropriate rolling in of room and board costs.
  • One rate applied to everyone in the residential setting.
  • Due diligence is needed in adherence to reporting rules and practices
  • Place of service codes
  • Temporary re-location
  • Leave of absence and transfers
  • Use of H2015 as day-time activity - when also getting CLS as per diem
  • Interface with ASAP (personal care in licensed setting but not certified ‘beds’)
  • Discontinue use of H2015 for emergency staffing (CEASES 10/1/16)

Some examples that we have heard regarding inappropriate purchasing, billing /reporting practices

Incorrect approaches to purchasing and pricing of H2016 and T1020

  • Bundling non-CLS, PC services into rate for CLS or PC

Case management and other clinical supports should be billed separately as they are NOT CLS or PC.

  • Use of local procedure code to make a combined payment for a "day" of licensed/certified residential services, then splitting it at payer level to H2016/T1020

The original transaction is not a Medicaid covered service

  • Neglecting to net out patient pay/SSI and food-stamps and then deal with residual costs as PC/CLS. Some PIHPs/CMHSPs have not done due diligence to assure exclusion of room/board from PC and CLS costs.

Do not include room/board costs into PC/CLS while awaiting disability determination; OR when had an empty bed. These approaches are incorrect -- must be charged to GF

Note -- recent changes with Food Stamps -- means more of cost hitting GF

  • Splitting daily rate for CLS, PC 50%

Individual rates should be used based on need

  • Using the same per diem rates for all the residents in the licensed/certified residential home

Need to start individualizing the rates based on individual needs assessment. Must be implemented by 10/1/16.

PIHP/CMHSP must adhere to the rules and practices for reporting H2016 and T1020

  • Day of Discharge Rule and/or Leaves of Absence and/or Vacant beds

CANNOT report a day if the consumer was not in the home

Can report a day if the consumer received at least one activity -- that allows for home/family visits away from the licensed setting. EXCEPTION - when going to another per diem setting - CANNOT report day of "exit"

  • Use of valid HCPCS code at the Federal level that is not on MDHHS Encounter and Code Costing Chart

The need for new codes should be vetted through EDIT to insure consistency.

  • Use of local modifiers

It is OK to use local modifiers to assist with claims processing - as long as not in conflict with DHHS approved modifiers or federal requirements under HIPPA.

Use of national/state modifiers MUST comply with those requirements.

  • Using S5140 or S5145 in a certified/licensed home

Uses up limited GF.

  • Reporting of location code

We know that we have not had due diligence in regard to what Place of Service codes to use with H2016.

ONLY one code to be used starting FY17: Place of Service = 14 (Specialized Residential AFC).

Data shows we have been using the following Place of Service codes with H2016

  • 58% with 14
  • Office 10%
  • Home 9%
  • General AFC 15%
  • Psych res tx 4%
  • Other (99) 3%
  • Mobile Unit, nursing homes, assisted living facilities, public health clinics
  • Verifying the home is licensed AND certified

PIHPs/CMHSPs MUST confirm the home is certified as a specialized mental health home (Mental Health Code section 330.1153) while using H2016/T1020.

Need to regularly check with licensing

  • Relationship to ASAP Personal care billing by General AFCs for persons not in a specialized "bed"

There can be NOpayment for residential services (CLS, PC) to an AFC that is also billing Personal Care directly through ASAP. You can provide other services to the person - basically case management and other clinical supports.

Note - if the personis residing as a General AFC residence and they are getting community activities during daytime,these activities are not provided by the AFC and should be done by another qualified "day time" provider and should be reported as H2015 with the non-residential place of service.

  • Use of exception H2015 in licensed/certified settings

DHHS had previously approved short-term use of H2015 in licensed/certified settings where already paying H2016/T1020. As a note, short-term does not mean a year-long authorization. The use of H2015 for emergency CLS in a specialized licensed setting will CEASE 9/30/16.

  • Requiring the use of a paper log to track actual CLS, PC time for the purposes of reporting encounter/claim. Medicaid verification and audits of provider records should alleviate this need.

Many CMHSPs require completion of the 3806 or similar form, however, this form should not be required if it’s redundant of electronic claim or a paper claim.

Crisis residential

  • Must exclude facility/food costs (i.e., Room/Board) from H0018 (MH) and from H0018/H0019 SUD residential. Costs go to GF or SUD fund source (Block Grant/PA2)
  • Residential use of H2015 cannot be reported in a crisis home where an H0018 is occurring. If the persons need community activity outside of the CRU that should not be done by CRU staff.

KEY CHANGES

  • Focus on needs assessment process for individual consumer –must determinestaff time needed for each service.
  • Emphasis on Place of Service code (plus preponderance rule).
  • Need to fold emergency staffing costs (i.e., H2015) into per diem reporting.
  • Ensure H2015 as day-time activity is a) different provider, b) goals in IPOS, c) use place of service 99.

RESIDUAL ISSUES/QUESTIONS

  1. Is there a best practice way to come up with the assessment used for daily individualized rates for clients receiving H2016/T1020 and H0043 and how is it rolled out at the CMHSP level? Does each supports coordinator/case manager complete the assessment document? Can good examples be shared? What is the assessment document used by the ICO’s in the MIHealthLink regions?

DHHS at this time does not have a recommended best practice regarding this assessment, including forms/tools or who should be part of the assessment. The case manager/supports coordinator as the holder of the IPOS should be involved. It should be noted that the personal care component will require authorization by a health care professional. Most places are using a variation on the old 3803. Some assessment forms also delineate the various functions that take place under each activity in order to guide the overall residential plan. EDIT will make an effort to collect some examples of forms being used by entities that have been conducting these individualized assessments to determine need and price.

There has been a proliferation of assessments – SIS, DLA, LOCUS as well as ones developed to manage the “bridge” in the dual eligible sites. Most of these do not go into the level of detail required for CLS and PC assessment.

  1. Any limitations/guidance re assessment process (e.g., use 4 weeks as base)?

You should select a time frame that you can reasonably expect will give you a good estimate of future expenditures.

  1. Who can do a Personal Care assessment – is it limited to doctors/health care professional? That severely limits the whole assessment process.

The residential provider, case manager or supports coordinator typically inform as to the consumer’s level of need for Personal Care services. Personal Care services must be authorized by a physician or other health care provider in accordance with an individual plan of service. ‘Health Care Professional’ is defined as a physician, registered nurse, physician’s assistant, nurse practitioner, or dietitian.

When the health care professional signs the plan or prescription for Personal Care (such as form 3803) this demonstrates that the professional has authorized the Personal Care services provided to the individual.

  1. The Medicaid Provider Manual states that ‘supervision of personal care services must be provided by a health care professional who meets the qualifications contained in this chapter’. How do we document the supervision of the personal care service?

When the health care professional signs the plan or prescription for Personal Care (such as form 3803) this demonstrates that the professional is supervising the Personal Care services provided to the individual.

  1. When will H2015 as day-time activity be eliminated if getting H2016?

During FY17, DHHS will work to develop another approach for reporting day-time activities that are currently reported as community living support.

  1. In reference to slide 35, the 1st bullet point indicates that we may continue to use H2015 for community activities in conjunction with H2016 (this will change in the future). The 2nd bullet point indicates that the H2015 service must be provided by a provider other than the provider for the per diem service. Is bullet point #2 effective beginning October 1, 2016?

Yes, starting October 1, 2016 for consumers living in a specialized licensed residential setting, Community Living Support that is provided out in the community (H2015) must be delivered by a different provider than the one that is providing the residential, per diem Community Living Support (H2016).

  1. We use a request for funding for short-term increased staffing needs in per diem residential homes. These RAF’s are usually client specific. The contractor bills for the additional staffing on an hourly or 15 minute basis, in addition to the per diems established in the contract. Can we still contract with the provider on an hourly/15 minute basis for these short term staffing needs, pay on an hourly/15 minute basis, and use this to estimate the amount to be added to the encounter data per diems transmitted to our PIHP?

The preference is that the licensed/certified provider pays for the added staff and increases the billed per diem for these days.

DHHS is exploring other options when the licensed/certified provider is not the best entity to purchase this enhancement.

  1. There is a difference between our CMHs on whether we can bill for a day of care based on presence of the individual. One CMH still ascribes to the “midnight rule” which requires that the individual be present at the home at midnight in order to bill. All the other CMH’s have changed the rule to allow billing if any services were provided for even a portion of the day. Please provide clarification and evidence of which approach should be taken.

If the consumer is not in the home at midnight due to a leave of absence such as a visit with family, Community Living Support and Personal Care can be reported for that day as along as the consumer received at least one element of the service being reported as described in the consumer’s IPOS.

If the consumer is out of the home at midnight due to a discharge to another residential placement or an inpatient facility, that day cannot be reported by the specialized residential provider regardless of what services were provided. This practice prevents two providers (e.g., the specialized residential home and the inpatient facility) from billing for the same day.

If a consumers is in the home at midnight, but did not receive either personal care or CLS for that day, the day cannot be reported by the specialized residential provider.

  1. Challenges of pricing. Please provide some guidance and examples of how to approach pricing.

EXAMPLES OF HOW TO APPROACH PRICING

  1. ALL methods MUST make sure not including any room/board costs
  1. Preference – also exclude day-time activity transportation costs. Use a separate contract.
  1. Based on individual assessments of needs – Personal Care and CLS
  1. NOT acceptable – all residents in same home have same per diems – UNLESS home is set up as a specialty for a particular sub-group of persons with similar/identical needs
  1. NOT acceptable – easy math
  1. If only one Individual lives in the specialized residential facility this is a pure ‘purchasing‘ model based solely on level of need of the beneficiary (as long as home staffed at overall right level to meet their needs).
  1. Purchasing capacity and CMHSP direct-run homes and CMHSP purchased homes:
  • In this case, basically have a total spend that has been developed based on the overall nature and size of the home.
  • In the past the residents were all reported at same per diem regardless of each person’s level of need
  • Use the individual needs assessment to create aggregated level of PC and CLS needs. Use these totals to derive a cost for each of PC and CLS; then drop down to individual pricing based on their share of the total staff hours. This can be rebased as needs change, without changing overall spend – unless change in overall spending needs to change based on resident mix.
  • This will result in each resident having a different rate that matches their need.
  • The CMHSP has to estimate absentee rates in order to develop the total spend and filtered down to the individual consumer.

NON-Licensed REPORTING H0043 and Residential H2015

Data Integrity Issues

  • There are numerous problems with the current pricing and reporting of H0043 and H2015 services, such as
  • Great Variance in cost/day for H0043
  • Variance in H2015 units
  • Inappropriate rolling in other services into the H0043 per diem
  • Room and board costs included, incorrectly
  • Lack of clarity as to when to use H0043 vs H2015
  • H0043 is being used, incorrectly, in licensed settings
  • Due diligence is needed in adherence to reporting rules and practices
  • Use of H0043 for what will not go under supported housing ( e.g., apartment programs)
  • Place of service codes
  • Use of TT for shared living arrangements
  • Rules for leave of absence and transfers
  • Interface with Home Help (personal care in non-licensed settings)
  • Use of H2015 as day-time activity - when also getting CLS as per diem H0043
  • Needs assessment driven rate setting – especially for per diem

Some examples that we have heard regarding inappropriate purchasing, billing /reporting practices

  • Settings

Non-licensed = NON licensed.

Cannot be used in General AFCs, Group homes, CCIs, Foster homes

Place of Service currently reported for H0043:

  • 67% in Home ( 12) - THIS IS THE ONLY ONE TO BE USED for H0043
  • 14% office
  • 10% Specialized Group Home; 1% AFC
  • Other (99) 7%
  • Mobile unit 1%
  • Per Diem H0043

CANNOT be reported if the CLS staff did nothing with the consumer that day

Should NOT be used if contact is very brief (e.g., 15 minutes) - hope to shift those apartment programs to another service/code

  • Peers

CANNOT use H0043 unless they are paid CLS staff

  • H2015 and Utilization Guidelines

MUST have UM guidelines for consistency and to with-stand appeals

  • Night Hours

CLS goals (i.e., community inclusion) and definition of activities (health and safety) allows CLS to be authorized, billed and reported when the consumer is sleeping

  • Co-mingling H2015 residential supports and day-time activity

Usually BEST done by two different staff under two different contracts/sections of IPOS.

CHANGES

  • Needs assessment process – must get to time needed for CLS PLUS must take into account (net out) Home Help time
  • When to use H0043 vs H2015
  • H0043 – three levels/modifiers ; AVERAGE
  • Use of TT re-introduced
  • Place of service code (plus preponderance rule)
  • Ensure H2015 as day-time activity is a) different provider, b) goals in IPOs, c) use place of service 99

RESIDUAL ISSUES/QUESTIONS

  1. Any limitations/guidance re assessment process (e.g., use 4 weeks as base)

See answer above for H2016/T1020 assessment

  1. When will H2015 as day-time activity be eliminated if getting H2016?

DHHS will work during FY17 to develop another approach for reporting day-time activities that are currently reported as community living support.

  1. How are we to handle H0043 and H2015 when the consumer has multiple Self Determination providers coming into the home and providing community CLS?

Each provider may provide a couple of hours a day and each provider documents using H2015 regardless of how much time is spent.This use above the 3 hour thresh-hold can be identified as self-determination through the use of a fiscal intermediary (T2025).

  1. For H0043 in a shared living arrangement how would we report the level modifier TF or TG when only 1 of the 3 residents is present? ( ?? assumption is that the remaining person gets more time than they are assessed at??)

Level of care is for the person not the home. Therefore the cost is based on the cost for that individual and the modifier would not change.

  1. What is the recommendation for per diem determination for consumers in unlicensed settings who have high variability in their “schedules”? Examples: School aged who are off for breaks in short and long term intervals throughout the year, consumers who have frequent LOAs, consumers who lost family supports or roommates. Should we be calculating authorizations for shorter time frames?

If the choice is to report these activities using H0043 (per diem) rather than H2015 (15 minute), it is correct that the CMHSP will need to calculate authorizations more frequently given the situations described. It should be noted that if the leave of absence is frequent and steady it should be included in the calculation of the average over time to come up with the basic H0043 rate. Yes - to clarify if family supports change, that would require a reassessment of the individual’s need. If a person loses a roommate the individual’s needs have not changed and this should not impact the rate.

  1. What is the recommendation to determine per diems in an unlicensed setting with consumers who do not have similar needs; few hours and up to 24 hours of support in same home?

Each individual should have their needs assessed and different rates for H0043 should be derived for each person. If one of the individuals is very low need, H2015 could be used to report residential CLS in an unlicensed setting.

  1. When deducting Home Help do we remove the hours of Home Help or the dollars paid? 2, Is the Home Help evaluation accessible to us to verify the hours?

Deduct the hours of Home Help provided to the consumer in order to determine the hours of Community Living Support that the consumer will need. You can then determine your staffing costs based on the hours of CLS. BHDDA is looking into whether the CMHSPs can use CC360 to access information on the amount of Home Help provided to a beneficiary.