Psychiatric Residential Treatment Facility

Helping Eligibility StaffNavigate the PRTF Maze

Created 12/2008

Updated 6/2010

Resources

Implementation Memos dated 3/14/05, 9/16/05, and 6/27/07

KEESM 8112.4(3) (PRTF), 2666 (Child in Institution)

Informational website has current list of PRTF facilities

Tim Schroeder, KHPA, Elderly & Disabled Medical Policy Manager

; 785/296-1144

Kim Burnam, KHPA, Training & Outreach Manager for Elderly & Disabled Medical

; 785/296-8362

Sandra Hashman, SRS Mental Health Central Office, PRTF Program Manager ; 785/296-7926

Fran Seymour-Hunter, PRTF Medicaid Liaison

; 785/296-2212

Table of Contents

PRTF Questions & Answerspages4-6

Pages 6-13will explain how to process eligibility and approve payment for a child admitted or discharged from a PRTF dependent on the child’s medical program involvement.

SSI program at Clearinghousepage 7-8

SSI program at SRSpage 9-10

HCBS programpage 11-12

HealthWave Title 19 programpage 13-14

HealthWave Title 21programpage 15-16

SRS & Clearinghouse PRTF Contactspage 17

PRTF Facilitiespage 18

PRTF Questions and Answers

  1. What is a PRTF (Psychiatric Residential Treatment Facility)?

A PRTF is a facility designed to provide active treatment in a structured therapeutic environment for childrenand young adults with significant functional impairments resulting from an identified mental health diagnosis, substance abuse diagnosis, or a mental health diagnosis with a co-occurring disorder.

  1. Who does the PRTF contact when a child is admitted or discharged?

Each SRS region and the Clearinghouse have designated a contact for the PRTF facilities and staff. See pages 17 and 18 for a list of SRS/Clearinghouse PRTF contacts and PRTF facilities.

  1. How does the facility communicate with the SRS PRTF contact?

The facility uses the MS-2126 form (Notification of Facility Admission/Discharge). The facility completes the form and sends it to their SRS Regional PRTF contact.

  1. What happens when the PRTF contact receives the MS-2126 form?

The contact is responsible for

inquiring in the KAECSES system to find out the child’s Medical program involvement and region where the case is located.

routing the MS-2126 to another regional PRTF contact, Clearinghouse PRTF contact or to the appropriate SRS (CFS/EES) worker in their region.

keeping a file of MS-2126 forms received and sent

assisting with resolution of billing concerns with facilities

  1. What is considered a temporary stay for a child (18 yrs & under) admitted to a PRTF?

A stay of 30 days or longer is considered a long term stay in a PRTF.

  1. What is a patient liability?

A patient liability is what a person owes for services provided in the institution. A person who enters a Medicaid approved institution and is eligible for Medicaid is allowed to protect $60 of their income. This is called the protected income level. Income exceeding the protected income level of $60 will be considered a person’s patient liability to the facility. The protected income level will increase to $62 effective January 2009.

  1. Will a child admitted to a PRTF have a patient liability?

It depends!

For a stay less than 30 days, a child will have a zero patient liability.

For a stayof 30 days or more, all of the child’s income(except for SSI income per KEESM 2637) is considered when determining a patient liability. Remember that adoption support and child support income are considered when determining a patient liability for a child in a PRTF per KEESM 8150.

  1. What happens to a child’s SSI income when they enter a PRTF for a stay exceeding 30 days or more? Do they continue to be covered under the SI Medical program?

For youth receiving SSI income only, the Social Security Administration will reduce the SSI income to $30. There will be a zero patient liability for these children. As long as the child remains in SSI recipient status, they will continue to receive medical coverage under the SI Medical program.

If the child receives SSI and other income such as child support, the Social Security Administration will terminate the SSI income. The child will no longer receive SSI income and therefore will no longer remain in SSI recipient status. The child’s eligibility for medical coverage must be determined under CI (Child in an Institution) long term care rules. Other income received by the child must be used to determine the patient liability to the PRTF.

  1. How does the PRTF get paid?

First the child must be receiving Medicaid or an eligibility determination must be made. Once medical eligibility has been approved, the KAECSES LOTC screen must have the appropriate codes and dates entered by SRS or Clearinghouse staff in order for the PRTF to receive payment. The LOTC screen is used to record information needed to track long term care status and allows payment of PRTF services.

  1. What happens if the LOTC screen is not updated when a child is discharged from the facility?

There can be serious consequences for the child. A child discharged from a PRTF may need immediate services via an HCBS waiver or through a mental health provider. When ‘‘BF/MH’’ is coded on the LOTC screen, the MMIS system will not allow payment for mental health services to any mental health provider other than the PRTF. It is important for the worker to receive the MS-2126 and code LOTC as quickly as possible so the child will not have a disruption of services.

Note: There is no Medicaid payment to the PRTF the date the child is discharged from the facility. The KAECSES LOTC screen must be coded to reflect this.

SSI Medical Program at Clearinghouse

If the child’s stay in the PRTF is less than 30 days, the SRS PRTF contact will send the MS-2126 form to the CH PRTF contact.

1)The child remains on the SI Medical program at the Clearinghouse

2)The LOTC screen is coded ‘BF/MH’ effective date of admission with a zero patient liability

3)Send notices to the consumer and facility regarding approval of facility payment

Once the child is discharged from the PRTF

1)Code LOTC‘‘IL/NA’’effective date of discharge

2)Send notices to the consumer and facility regarding change in living arrangement and termination of facility payment.

If the child’s stay in the PRTF is for 30 days or longer, the responsibility for the SI Medical Program will transfer from the Clearinghouse to the local SRS office. The SRS PRTF contact will send the MS-2126 to the CH PRTF contact. In addition, the SRS contact will send an e-mail outlining requests for information and which SRS office will be responsible for setting up the case. Requests for information may include a request for an Elderly and Disabled Medical Application be sent to the family to be completed and returned to the appropriate SRS office, any necessary file documentation, and for the CH PRTF contact to end child’s participation on the Clearinghouse SI Medical program.

If the child receives SSI income only

1)SRS staff will open an SI Medical program (SEPA coding SI/AC)

2)Code LOTC ‘BF/MH’ for PRTF payment effective date of admission

3)There will be no patient liability for a child receiving SSI only

4)Send notices to the consumer and facility regarding approval of facility payment

When the child is discharged from the PRTF

1)If the child will be receiving HCBS services based on information provided on the ES-3160, the case will remain with SRS

  1. Remove program subtype ‘AC’ from SEPA
  2. Code LOTC‘HC/ (and the appropriate waiver coding)’ the date of discharge
  3. There will be no HCBS patient obligation.
  4. Send notices to the consumer, facility and HCBS case manager regarding change in living arrangement, approval of HCBS, and termination of facility payment

2)If the child returns home

  1. Code LOTC‘IL/NA’ effective the date of discharge
  2. Close the SRS SI Medical program
  3. Notify the CH PRTF contact to reinstate/reopen SI medical

If the child receives SSI and other incomesuch as child support, an Elderly and Disabled Medical application will need to be completed by the family. Since the child will be in the PRTF for 30 days or longer, the child’s SSI income will end.

1)The child will have to be determined eligible under long term care (CI/LI) guidelines. Per KEESM, LTC budgeting begins the date the child enters the facility. (Child enters the PRTF 10/1/08, the first LTC budgeting month is October)

2)When determining a patient liability, use the child’s other income minus the NF protected income level. (KEESM 2637)

3)Code LOTC‘BF/MH’ for PRTF payment

4)Send notices to the consumer and facility regarding approval of CI medical and facility payment

When a child is discharged from the PRTF

1)If a child will be receiving HCBS services based on information provided on the ES-3160, the case will remain with SRS

  1. Code LOTC‘HC/ (and the appropriate waiver coding)’ the date of discharge
  2. There will be no HCBS obligation
  3. Send notices to the consumer, facility and HCBS case manager regarding change in living arrangement, approval of HCBS, and termination of facility payment

2)If the child returns home

  1. Code LOTC‘IL/NA’effective the date of discharge
  2. Close the SRS CI medical program
  3. Send notices to the consumer and facility regarding change in living arrangement and closure of CI medical program
  4. Notify the Clearinghouse PRTF contact to reinstate/reopen the SI medical program.

SSI Medical Program at SRS

The SRS PRTF contact will send the MS-2126 to the SRS worker or if the case is located in another region to the SRS PRTF contact.

If the child’s stay in the PRTF is less than 30 days

1)Child remains on the SI Medical program

2)CodeLOTC‘BF/MH’effective date of admission with a zero patient liability

3)Send notices to the consumer and facility regarding approval of facility payment

Once a child is discharged from the PRTF

1)Code LOTC‘‘IL/NA’’ effective date of discharge

2)Send notices to the consumer and facility regarding change in living arrangement and termination of facility payment.

If the child’s stay in the PRTFis for 30 days or longerand the child receives SSI income only

1)Change SEPA coding from SI to SI/AC

2)Code LOTC ‘BF/MH’ for PRTF payment effective date of admission.

3)There will be no patient liability for a child receiving SSI only.

4)Send notices to the consumer and facility regarding approval of facility payment.

When a child is discharged from the PRTF

1)If the child will be receiving HCBS services once discharged

  1. Change SEPA coding from SI/AC to SI/HC
  2. Code LOTC‘HC/ (and the appropriate waiver coding)’the date of discharge
  3. Send notices to the consumer, facility and HCBS case manager regarding change in living arrangement, approval of HCBS and termination of facility payment

2)If the child returns home

  1. Change SEPA coding from SI/AC to SI
  2. Code LOTC‘IL/NA’ effective the date of discharge
  3. Send notices to the consumer and facility regarding change in living arrangement and termination of facility payment

If the child’s stay in the PRTF is 30 days or longer and the child receives SSI and other income such as child supportan Elderly and Disabled Medical application will need to be completed by the family. Since the child will be in the PRTF for longer than 30 days, the child’s SSI income will end.

1)The child will have to be determined eligible under long term care (CI/LI) guidelines.

2)Determine child’s patient liability (income- NF PIL) (KEESM 2637)

3)Code LOTC‘BF/MH’ for PRTF payment effective date of admission.

4)Send notices to the consumer and facility regarding approval of CI medical and facility payment.

When the child is discharged from the PRTF

1)If the child will be receiving HCBS services once discharged

  1. CI/LI case will switch to SI/HC case.
  2. There will not be an HCBS obligation for services
  3. Code LOTC ‘HC/ (and the appropriate waiver coding)’ the date of discharge
  4. Send notices to the consumer, HCBS casemanager and facility regarding change in living arrangement, approval of HCBS and termination of facility payment

2)If the child returns to the community

  1. Close CI/LI Medical program
  2. Reopen the SI Medical program
  3. Code LOTC ‘IL/NA effective date of discharge from PRTF
  4. Send notices to the consumer and facility regarding change in living arrangement, closure of CI medical and reopening of SI medical.

HCBS Medical Program

The SRS PRTF contact will send the MS-2126 to the SRS worker or if the case is located in another region to the SRS PRTF contact.

If the child’s stay in the PRTF is less than 30 days

  1. The child’s medical case will remain MS/HC
  2. Code LOTC

□BF/MH for DD Waiver children (There is no TC coding for the DD waiver at this time therefore BF/MH must be used)

□TC/SE for SED Waiver children

□TC/PR for PRTF-CBA Waiver children

  1. The child will have no patient liability to the PRTF.
  2. Send notices to the consumer, facility and HCBS casemanager regarding approval of facility payment

When child is discharged from the PRTF

  1. If the child is returning to HCBS services, code LOTC

□HC/DD for DD Waiver children

□HC/SEfor SED Waiver children

□HC/PR for PRTF-CBA Waiver children

  1. Send notices to the consumer, facility and HCBS casemanager regarding change in living arrangement, termination of facility payment and reinstatement of HCBS.

If the child’s stay in the PRTF is for 30 days or longer, per KEESM, LTC budgeting begins the date the child enters the facility.

1)Change SEPA coding from MS/HC to MS/AC

2)Code LOTC one of the codes below for the first day of admission into the PRTF

□BF/MH for DD Waiver children (There is no TC coding for the DD waiver at this time therefore BF/MH must be used)

□TC/SE for SED Waiver children

□TC/PR for PRTF-CBA Waiver children

3)Reenter the LOTC screen and code BF/MH effective the 2nd day of admission into the PRTF

4)Determine child’s patient liability (income- NF PIL)

5)Send notices to the consumer, HCBS casemanager, and facility regarding approval of facility payment and termination of HCBS.

When a child is discharged, verify if HCBS services will be reinstated or if another medical program will need to be determined.

  1. If HCBS will be reinstatedbased on information on the ES-3160
  2. Change SEPA screen coding to MS/HC
  3. Determine the HCBS patient obligation (income – HCBS PIL)
  4. Code LOTC HC/(and the appropriate waiver coding) effective the date of discharge
  5. Send notices to consumer, facility and HCBS case manager regarding the change in living arrangement, approval of HCBS and termination of facility payment
  1. If HCBS is not reinstated, it is important to explore eligibility for other medical programs for the child. Send the family a HealthWave application to complete so eligibility for Family Medical can be determined.
  2. Close CI/LI medical case
  3. Code LOTC IL/NAeffective date of discharge
  4. Send notices to the consumer and facility regarding termination of CI medical and facility payment

HealthWave Title 19 - Medicaid (program codes on CAP2 would be MP, WA-WT, MA-EM or MA_CM.

If the child’s stay in the PRTF is less than 30 days, the child remains part of the original HealthWaveTitle19 – Medicaid case. The SRS contact will send the MS-2126to the CH PRTF contact.

1)The CHPRTF contact will code LOTC ‘BF/MH’effective date of admission for the temporary stay

2)The child will not have a patient liability to the PRTF

3)Send notices to the consumer and facility regarding change in living arrangement and approval of facility payment

When the child is discharged from the PRTF

1)The CH PRTF contact will change LOTC coding from ‘BF/MH’ to ‘IL/NA’ effective date of discharge

2)Send notices to the consumer and facility regarding change in living arrangement, termination of facility payment and reinstatement of HealthWave Title 19-Medicaid

If the child’s stay in the PRTF is for 30 days or longer,the responsibility for the child’s eligibility will transfer from the Clearinghouse to the local SRS office. The SRS PRTF contact will send the MS-2126 to the CH PRTF contact. The SRS contact will send an e-mail requesting the CH contact end participation for the child on the HealthWave Title 19 program and an Elderly and Disabled Application be sent to the family to be complete and returned to the appropriate SRS office.

1)The child will have to be determined eligible under long term care (CI/LI) guidelines.

2)If the child is determined eligible, the worker will establish a patient liability (income –NF PIL)

3)Code LOTC ‘BF/MH’ effective date of admission.

4)Send notices to the consumer and facility regarding approval of CI medical coverage and facility payment

When the child is discharged from the PRTF

1)If the child will be receiving HCBS services once discharged

  1. Change SEPA screen coding to MS/HC
  2. Code LOTC ‘HC/ (and the appropriate waiver coding)’ the date of discharge
  3. Send notices to the consumer, facility and HCBS casemanager regarding change in living arrangement, approval of HCBS and termination of facility payment

2)If the child returns home

  1. Code LOTC‘IL/NA’ effective the date of discharge
  2. Close the CI/LI medical program
  3. Send notices to the consumer and facility regarding change in living arrangement, termination of facility payment and CI medical program coverage.
  4. Search KAECSES to determine if the custodial family has an open case at the Clearinghouse.
  5. If there is an open case, contact the Clearinghouse at to request child be added to the case the date of discharge.
  6. If there is not an open case, send the family a Healthwave application to complete so eligibility for Family Medical can be determined.

HealthWave Mailing Address:

HealthWave

PO Box 3599

Topeka, KS 66601

Fax: 1-800-498-1255

HealthWave Title 21 Medical Program(program coding on CAP2 will be T5, T6, and T7.

There is no HealthWave Title 21 funding for PRTF stays.