IMD Training NC Department of Health and Human Services by alicejenny

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									NC Department of Health and Human Services   north carolina
                                                 medicaid



                  PHASE II
                    IMD
              DETERMINATIONS




                                                              DMA
 Why Are the Facilities Being Reviewed?
                                                  1


 Complaints were submitted to CMS that Adult Care Homes were actually IMDs

 CMS review of newspaper articles regarding people with MH/SA diagnosis
  being served in ACHs

 Legislative presentations about lack of funding going to serve recipients with
  MH/SA diagnosis in ACHs

 As a result, CMS questioned the state and required review of the homes and
  facilities. The state implemented a two phase approach

     Phase I
         Those homes who based upon data run, showed high volume of MH/SA
         Size of the homes
     Phase II
         All remaining homes
Resources Used to Develop the Process for
           Reviewing Homes
                                             2

 Consultation with and technical assistance from CMS
     Atlanta Regional Office and Central Office in Baltimore


 State Medicaid Manual (SMM)
     This is a CMS publication that covers many topics regarding the operations of the
      Medicaid program. The manual provides CMS’s interpretation to the states for
      the enforcement, interpretation of rules or statutes and in essence, frequently
      asked questions by the states.
     Manual has not been updated in many, many years. The language reflects facilities
      and services that were typical at the time of publication. Since the service delivery
      has changed, the use of the term institution is more broadly defined.

 Consultation with other states who have been reviewed by Office of Inspector
  General (OIG), direction from CMS or their own IMD review initiation.

 Private consulting firms who have conducted IMD reviews in collaboration
  with other State Medicaid programs
                        What is An IMD?
                          Definition      3



 IMDs are defined as “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 diseases, including medical attention, nursing care and
  related services” (42 CFR 435.1010).

 An institution is considered an IMD if its overall character is that of a facility
  established and maintained primarily for the care and treatment of individuals
  with mental diseases, whether or not it is licensed as such.

 An institution for the mentally retarded is not an IMD. However, facilities for the
  treatment of substance abuse are considered IMDs.

 More than 50% of all the patients in the facility will have a current need for
  institutionalization resulting from mental diseases. In applying the 50% guideline,
  North Carolina needs to determine if the primary diagnosis of mental health is
  the reason for living in the residential setting.
                           What Is An IMD?
                            IMD Exclusion
                                                  4


 The IMD exclusion applies only to institutions with at least 17 beds.

 Medicaid match is not available for any services provided to individuals under
  the age of 65, who are residing in an IMD (1905(a) of the Social Security Act)
  except for children under the age of 21 receiving care through inpatient
  psychiatric care.

 When services are provided to persons age 65 or older in an IMD, the services
  may be reimbursed by Medicaid if the facility meets inpatient hospital or
  nursing facility requirements for Medicaid.

     The under 21years old exception or the over age 65 exception are not options for ACHs
      because the facilities are not psychiatric residential treatment facilities (PRTF), inpatient
      hospitals or nursing homes.

 This payment exclusion was designed to ensure that states, rather than the
  federal government, continue to have principal responsibility for funding
  inpatient psychiatric services.
               IMD Exclusion (cont.’d)
                                             5




 Except as noted in the previous slide…


     Under this broad exclusion, no federal financial participation is available for the
      cost or payment of services provided, either inside or outside the IMD, while the
      individual is a patient in the facility (including pharmacy, emergency room
      services and personal care).
                             What is an IMD?
                             Criteria for IMDs
                                                  6



 The Centers for Medicare & Medicaid Services (CMS) requires the
  State Medicaid agency to determine if facilities are IMDs.

 If a facility has 17 beds or more and 50% of the residents have a
  diagnosis of mental disease, the State Medicaid agency is required
  to conduct an onsite review to determine if the facility meets
  IMD criteria. (SMM p4390)

     The Manual speaks to any MH/SA diagnosis. NC will review the chart of the
      recipient to determine if the MH/SA diagnosis is

         Primary
         The reason the person is living in the facility
     Presence of medical conditions do not necessarily override the MH/SA diagnosis.
      The decision is a case by case review and will be discussed more in later slides
               Other Criteria for IMDs
                                               7


 Specializes in the treatment of person with mental illness (providing
   psychiatric/psychological care and treatment). The actual services and care provided
   to meet the psychiatric or psychological care.

 Current need for institutionalization for at least 50% of the residents results from
   mental diseases

 The facility is licensed as a psychiatric facility

 The facility is accredited as a psychiatric facility

 Operates under the jurisdiction of a State mental health authority (that is providing
   services to mentally-ill persons)

 A final determination ….an evaluation of the information pertaining to the facility
   establishes that its overall character is that of a facility established and/or maintained
   primarily for the care/treatment of individual with mental disease.
                           Residential Facilities
                                Phase II IMD Process
              Determining if a Residential Facility is an                                       IMD


                                                                   Is the current need for
                                                                    institutionalization of
Define the                                                      50% or more of residents
institution                                                     (using occupied beds) a
                                                                                                      The
                                                                 direct result of a mental
– which                                          YES             health/substance abuse         YES   institution
means                                                            illness being the reason             is an IMD
                                                                for the placement? Is the
what                                                              overall character of the
facilities                                                      facility is primarily for the
are being                                                          care and treatment of
                   Are there 17 or more                         individuals with MH/SA?
examined          beds in the institution?



                          NO                                              NO


                                    The institution is not an IMD

                                                    8                                                          8
         Initial Facility Notification
                                               9




 The provider will get written notification of their upcoming review.


 The notification will outline why they are being reviewed.

     Over 16 beds
     Possible multiple facilities
     Over 50% MH/SA diagnosis on paid claims (see slide 14)


 There is no weighted determination once the over 16 beds and 50%
  criteria are established

     if any of the factors/criteria are met, then the process will continue for the provider.
                      What Does This Mean for North Carolina?
                        Phase II IMD Determination Process
                  Reviewing the Population (Medicaid Manual 4390)
                                                     10


       The resident has current primary diagnosis of MH/SA OR

       Had a behavioral health diagnosis (not dementia, Alzheimer, traumatic brain
        injury, mental retardation or organic brain disorder) at the time of admission if
        the patient was admitted within the past year.

       A large portion of the residents are receiving psychopharmacological drugs.

           This is reviewed from a CMS directive because facilities (national perspective) began to
            manipulate diagnosis so not to flag regulators of the MH/SA diagnosis. If volume and
            doses of these types of medications are used with recipients, it can also be flag for
            quality of care issues such as:

             use to sedate or regulate behavior through medications rather than seeking
              alternative interventions or less intrusive alternatives.
             possible polypharmacy
                   What Does This Mean for North Carolina?
                      Phase II IMD Determination Process
           Reviewing the Population (Medicaid Manual 4390) -- cont.’d
                                             11


 What is the primary reason for the recipient living in the facility
  or in this case, the adult care home?


     Court orders don’t negate the decision of MH/SA or medical

     The decision of MH/SA or medical doesn’t cast value or blame on the facility or
      the recipient.

     The point is to prove that regardless of issues going on with the recipient, the
      person is in the facility related to non MH/SA reasons.
                  What Does This Mean for North Carolina?
                    Phase II IMD Determination Process
                                              12


 State Medicaid agencies are responsible for designating IMD status:


     IMD assessment must be made by a team that includes at least one physician or
      other skilled medical professional who is familiar with the care of mentally ill
      individuals.

     No team member may be employed by, or have a significant financial interest in,
      the facility under review. NC has applied not only financial interest as possible
      conflict but also, any professional interest or service relationship with the facilities
      as being a possible conflict.
      What Does This Mean for North Carolina?
             IMD Review of all Facilities/Agencies
              Phase II IMD Determination Process
                                   13




 North Carolina facilities that need to be assessed in Phase II

  Adult care homes
  Family care homes
  Supervised living homes
  Only those facilities who have
     Billed PCS are in phase II.
 Only 122c facilities who have billed ACH PCS.

 DMA will notify all 131 D and 5600 Group Home Providers
  regarding IMD reviews that are being conducted between July 1,
  2012- Sept 1, 2012.
           What Does This Mean for North Carolina?
                                Phase II IMD Determination Process
                               Identifying Facilities to be Reviewed
                                                         14

Data Source
Residential Settings billing PCS services (these are the claims billed by the facilities identified in ACH,
group homes or family care homes) and
          Review of 6 months paid claims by any provider with MH/SA diagnosis for recipient living in the facility
           (includes any services that the recipient may have received from other providers for the treatment or care
           of MH/SA diagnosis). November 2011-April 2012
          One month (April, 2012) in above facility PCS data period to identify unduplicated claims/recipients in
           the facility
          EIN number and individual service site is reviewed, not just individual provider number or NPI
            Initial scan of shared ownership
          Licensed beds per NC Division of Health Services Regulation

      Analyze data
        Any recipient with at least one claim in 6month period that meets above
        Calculate the 50% by:
           Numerator: MH/SA diagnosis
           Denominator: occupied beds


      >50% gets further reviewed
      BEING REVIEWED DOES NOT MEAN THAT THE FACILITY IS AN IMD
        It means that the facility (single or shared) is over 16 beds (17 or more) and has more than 50%
          MH/SA
                                                                           (Medicaid Manual 4390)
        What Does This Mean for North Carolina?
      I Phase II IMD Determination Process Identifying Facilities
                                          15




Determine Single or Separate Facilities (Medicaid Manual 4390)

1. Are all components controlled by one owner or one governing body?

2. Is one chief medical officer responsible for the medical staff activities in all
   components?

3. Does one executive officer controls all administrative activities in all
   components?

  NO TO ANY OF THE ABOVE QUESTIONS MAY INDICATE A SEPARATE FACILITY

                                                  (Medicaid Manual 4390)
       What Does This Mean for North Carolina?
I Phase II IMD Determination Process Identifying Facilities (cont.’d)
                                       16


Determine Single or Separate Facilities (Medicaid Manual 4390)

4. Are any of the components separately licensed?

5. Are the components so organizationally and geographically separate that it
   is not feasible to operate as a single entity?

6. If two or more of the components are participating under the same provider
   category (such as NFs) can each component meet the conditions of
   participation independently?

       YES TO ANY OF THE ABOVE QUESTIONS MAY
              INDICATE A SEPARATE FACILITY
              What Does This Mean for North Carolina?
                        Phase II IMD Determination Process
                          Identifying Facilities – cont.’d
                                           17


Determine Single or Separate Facilities (Medicaid Manual 4390)
  •   DMA will conduct phone interview with owner (if needed) to
      determine scope of the shared functions. Information gathered
      include but not limited to:
      •   Review of shared policies and procedures,

      •   Administrative functions such as payroll, food services, maintenance

      •   Clinical services
          •   Itinerant nurses or other health care professionals
          •   Contractors serving the homes across facilities

      •   Discussion of where the final authority for decision making rests?
Step 1 of the Decision Making Process
                                             18




 Does the data indicate that there could be more than 50% of MH/SA as
  POSSIBLE primary diagnosis or reason for living in the facility?

 Does the shared ownership meet the criteria of a single entity or separate
  facilities even though they are operated or managed by shared
  owners/business entity?

     Significant because if multiple facilities are determined to be “one” facility, then
      the beds and diagnosis are “rolled up” as if a single facility.
     If deemed separate facility, then the % and number of beds remain separate.

 Re-calculate % and beds and determine scope needed for onsite and next
  steps
      What Does This Mean for North Carolina?
                            Phase II IMD Determination Process
                               Onsite Reviews Conducted
                                                          19



                   NC DMA Shared Ownership Determination for Facilities

1.      Are all components controlled by one owner or one governing body?
2.      Is one chief medical officer responsible for the medical staff activities in all components?
3.      Does one executive officer control all administrative activities in all components.

          NO TO ANY OF THE ABOVE QUESTIONS MAY INDICATE A SEPARATE FACILITY

4.      Are any of the components separately licensed?
5.      Are the components so organizationally and geographically separate that it is not feasible to
        operate as a single entity?
6.      If two or more of the components are participating under the same provider category (such as
         NFs) can each component meet the conditions of participation independently?

          YES TO ANY OF THE ABOVE QUESTIONS MAY INDICATE A SEPARATE FACILITY

         Notes:

         Thank you for your time answering these questions. This information will be given to the Division for review. If
         you have any questions, you may contact Tasha Woodard-Charity at 919-855-4317.

Name of Interviewer: _________________________________________________________
Signature: _________________________________________________________
Date of Interview: ____________________________________________________
  What Does This Mean for North Carolina?
Phase II IMD Determination Process – Agency On-site Review (Cont’d)
                                                20


 Roles and responsibilities:
     Clinical team lead:
             Open and close onsite review
             Agency interview/clarifying questions, as needed
             Address team questions/contact DMA, as needed
             Collection and delivery of documentation to DMA:
              • Resident Assessment Tool* (each resident)
              • Resident Assessment Tool Cover* Sheet (per agency)
              • Other documents collected onsite
     Team members:
       Review resident charts
       They have been given instructions to collect the data and copy the materials
        used to gather the data.
       They have been instructed to not offer advice or to give opinions of findings
        while on site
     Providers – please be respectful of the directions given to team members and
      understand that their refusal to answer a question is not due “hiding” information or
      being uncooperative.
 What Does This Mean for North Carolina?
      Phase II IMD Determination Process – Agency Onsite
                           Review
                              21


 Onsite Review
     Team composition:
         Clinical team lead, medical record reviewer
     Notify Owner/provider at least 24 hours in advance of onsite review
     Review charts of all residents on census
         Recipients who are Medicaid and private patients
         SCUs and general population


 Upon Entry, the team lead will
     Introductions and discuss process/review plan for the day(s):
             Current number of residents, estimated time for chart review
             Identification of private pay residents
              Request orientation to chart layout
             Address any clarifying questions
 What Does This Mean for North Carolina?
Phase II IMD Determination Process – Agency Onsite Review, cont’d
                                           22




  •   Resident Chart Review Tool
         Review tool and supporting documents:
           ICD-9 diagnostic codes

           The team will gather information on all records.

           Commonly prescribed psychotropic medications (NAMI)*
                Use of one of the drugs on the referenced list does not necessarily
                 mean that the primary reason for being in the facility is due to
                 MH/SA.
     Resident Assessment Cover Sheet
     Collect completed facility Questionnaire if available from
      Provider and all other documents on next slides
NC IMD Resident Chart Review Tool
                23
NC IMD Resident Chart Review Tool
                24
NC IMD Resident Chart Review Tool
                25
              Medical Documents Checklist
                                                    26

                                                              Copy Submitted to:
                    Document                             DMA On-site Review Team Leader
FL2 or MR2 (most recent)                                        □   Yes     □   No
Physician Orders (since most recent FL2 or MR2)                 □   Yes     □   No
Medical Administration Records (MAR) for the past               □   Yes     □   No
three months
3050R (most recent)                                             □   Yes     □   No
Resident Register                                               □   Yes     □   No

Care Notes for the last 30 days                                 □   Yes     □   No
Home Care Visits in last 12 months                              □   Yes     □   No

Hospitalizations and ED visits in past 12 months.               □   Yes     □   No
Primary Care Physician Notes (most recent)                      □   Yes     □   No
Licensed Health Professional Review                             □   Yes     □   No
                           Resident Questionnaire
             (To Be Completed by the Provider for Each Resident)
                                                         27

          Please answer the following questions about NAME OF RESIDENT:
1.    Please describe this resident’s medical needs and how they are addressed in your facility:


2.    Please describe this resident’s personal care needs such as bathing, dressing, mobility,
      toileting, eating, meal preparation and medication management:


3.    Please describe any additional needs this resident has that are not documented above but are
      currently met in this facility:


4.    Please describe any safety or supervision needs of this resident, if any:


5.    Please explain the reason(s) you believe this resident is living in your facility:

     Name of Resident: ______________________________________________________________
     Adult Care Home Name and Address: _________________________________________________
     Name of Person Completing Form: ___________________________________________________
     Signature of Person Completing Form: ________________________________________________
     Date Form Completed: ___________________________________________________________
     Name of ACH Administrator or Designee: ______________________________________________
     Signature of ACH Administrator or Designee: ___________________________________________

     These are the same elements that were part of the original Phase I documents – original
      forms can be accessed via DMA website
                           Provider Questionnaire
                       Please document need(s)addressed by the Residential Setting

                                                     28

Facility Information:
1.   Does this ACH operate as an independently-owned facility, or is the ACH in partnership or under shared
     management with other ACHS
               Y    N Independently owned/managed
               Y    N Partnership/under shared management

2.   If in partnership or shared management with other ACH facilities, please list.

3.   If an independent business:
               Y    N Is the ACH controlled by one owner?
               Y    N Is there a licensed medical professional/staff person (either BH or PH)
                       responsible for medical oversight of your ACH?
               Y    N If yes, does he/she provide the same function for other ACHS?
               Y    N Does the CEO or owner control all administrative activities in the ACH?
               Y    N Are you the only ACH under your current license or accreditation? If
                       other ACHs, please list city and state for each.
                         Provider Questionnaire
                      Please document need(s) addressed by the Residential Setting

                                                     29

Facility Information (cont.’d)
4. If shared partnership or shared ownership of ACH facilities
                    Y      N       Are all ACHs controlled by one owner or governing body?
                    Y      N       Are any medical staff or direct care staff shared by the ACHs?
                    Y      N       Do the ACHs share administrative functions, such as lawn care, laundry,
                                   billing/finance, food service, transportation?
                                   If yes, please list functions.
                    Y      N       Do the ACHs share any licenses or accreditations?
                                   If yes, please list.
                    Y      N       Are the ACHs organized and geographically close, making it feasible to
                                   operate as one facility?
                    Y      N       Are any of the ACHs able to operate independently (e.g. no shared staff
                                   or shared administrative services)?

5. Is the ACH licensed or accredited? Collect hard copy of each license or accreditation.
                    Y      N       Licensed as a psychiatric facility
                    Y      N       Accredited as a psychiatric facility
                    Y      N       Other state licenses
                          Provider Questionnaire
                       Please document need(s) addressed by the Residential Setting

                                                       30

Facility Information (cont.’d):
6.  The facility is under the jurisdiction of the North Carolina Division of Mental Health,
    Developmental Disabilities and Substance Abuse Services (DMH/DD/SAS).
                      Y     N
7. How many licensed beds are in the facility?
           #_____
8. How many physical beds are in the facility?
           #_____

9. How many residents currently reside at this facility?
           #_____
10. What is the average length of stay for residents in this facility?
           #_____ months

11. Do you accept residents under the age of 21?
              Y      N

12. Does this facility have a policy to only admit residents with a mental disease diagnosis?
               Y       N
                         Provider Questionnaire
                         Please document need(s) addressed by the Residential Setting
                                                       31

Facility Information:
13. Does this facility advertise itself as specializing in the care and treatment of individuals with mental
    disease?
                      Y     N
14. Does this facility have a pharmacy on-site?
                      Y     N
15. Does this facility have access to medications other than those specifically prescribed for each resident?
                      Y     N
16. Does this facility employ or have a contractual arrangement with any licensed mental health
    professionals
    to provide mental health treatment to residents?
                      Y     N If yes, how many? _____
                               If yes, provide licensure and title of these professionals.

17. Does this facility employ staff with specialized psychiatric/psychological training, other than on-the-
    job training or experience?
                     Y     N If yes, how many have specialized psychiatric/psychological training?
                              If yes, describe the nature of specialized training.
                          Provider Questionnaire
                          Please document need(s) addressed by the Residential Setting
Facility Information (cont.’d):                         32
18. Does this facility contain any locked or secured areas?
               Y      N If yes describe the nature and purpose of the secured areas.

19. Does this facility have a restraint room or utilize a four-point or greater restraint? [physical restraints
    and/or chemical restraints?]
              Y       N If yes, do you have a P&P regarding seclusion and restraints? If yes,
                        reviewer to obtain a hard copy of their P&P.
                        If yes, describe the nature and purpose of these restraints, as well as the facility’s
                        authority to utilize them.

20. Are there any limitations, other than those imposed by a court or guardian, placed on a resident’s
    ability to permanently leave the facility?
               Y     N If yes, describe the nature and purpose of those restrictions.

21. How many residents terminated their residency since Jan 1, 2012, through the date of the interview?
            Y     N If yes, how many? _____

22. Does this facility provide assistance to residents who need assistance with ADLs and/or IADLs?
                         If yes, describe the nature of these services.

23. Does this facility have any contractual arrangements with state mental facilities to accept patients?
              Y       N If yes, describe the nature of this contractual arrangement.
                                              33

 DMA determines IMD designation through

    Review of data collected and other medical records
    Facility questionnaire completed by provider
    Any additional information sent by provider at time of on site or At Risk notification

        THE PROVIDER MAY SEND OR WHILE ON SITE ANY INFORMATION
         FROM ANY SOURCE, THAT WOULD INDICATE THAT MH/SA IS NOT
         THE PRIMARY DIAGNOSIS OR THE REASON FOR FACILITY
         PLACEMENT.

    Signed physician note from MD does not necessarily guarantee that
     the review will agree with primary reason for living in the facility
        The physician may not be knowledgeable of the rules, regulations or appropriate
         clinical alternatives
        Medical conditions alone do not override the MH/SA reason for placement or care


    Discussion of examples
  What Does This Mean for North Carolina?
  Phase II IMD Determination Process – Communication Process
                                                 34

 The purpose of the at risk notification is to let the local community know up front of the
  possible designation so that local resources can begin to plan and to assure that DMA
  has full and accurate information needed to render the IMD determination.
 Send At Risk Notification to Providers
  •   Stating reasons for At Risk Letter
      •   Specific reasons why DMA believes the provider could be an IMD
      •   List of recipients who are designated as MH/SA placement (confidential/PHI
          attachment)
  •   Implications if designated as an IMD
         Instructions to provide additional information within 10 business days
         DMA contact information will be in the letter

 Send At Risk Notification to Recipients (and to Guardian/legal rep if needed)
  •   Stating implications if facility is designated an IMD
  •   Who to contact for housing alternatives
 County DSS Directors (county of Medicaid eligibility and county where facility is
  located)
 County LME Directors
 What Can a Facility Do If Deemed “at risk”?
                                               35


 First, the facility should be continuously looking to see if they could be at risk
  and taking steps to make sure that they are addressing the criteria – this is
  prior to ever receiving an at risk letter
 Once the at risk notification is received the facility may wish to:

     Gather additional information to submit to DMA such as:
         supports that placement is not related to MH/SA,
         facilities are not shared or
         % calculation is in error
     Closely review census % with MH/SA

     Work with families and recipients around discharge planning such as
         alternative residential options
         locating other facilities, and
         discussing options about other wrap around supports and services
     Collaborating with the DSS and LME
   What Does This Mean for North Carolina?
            Phase II IMD Results
                                            36


 If not designated as an IMD at point in time
     Owner notified of results of review

 The provider will continue to submit annual attestation to DMA


 Subject to onsite reviews and monitoring by DMA at any point in time for
  any reason

 After phase II reviews are completed, compliance to IMD regulations are
  the responsibility of the facility

 Failure to comply with IMD regulations or failure to submit attestation may
  result in termination from the Medicaid program and financial recoupment
  of payments made to the provider.
  What Does This Mean for North Carolina?
            Phase II IMD Results- Designated an IMD Providers
                                                 37




 Providers who are IMDs
     Suspension/Termination letter sent via trackable mail
     DMA will contact provider by all forms of communication on file such as email address
      and fax –make sure that correct information is collected at time of onsite review.
     The local DSSs and LMEs will be notified (all DSS and LME counties of recipients based
      upon county of eligibility that reside in the facility and location) and county of location
      of the facility
     Payment to the provider is suspended on the effective date stated in the IMD
      notification letter. Termination of the provider will be outlined in following slides
     Providers will be contacted by LME and DSS to assist with transition. The provider may
      also initiate contact with the DSS and/or LME
     Providers deemed IMD may bill after IMD determination for Date of Service (dos) prior
      to IMD determination effective date. All routine edits/audits/rules apply

 (*) unless Business continuity is interrupted
                     Getting Suspension Lifted
                                                   38

       Provider remains in suspended status for 60 days to achieve IMD compliance
            Providers send IMD Compliance Attestation to DMA within 60 calendar days of date
             of IMD Determination

       If the attestation is submitted, DMA will lift suspension of payments effective
        the date of the attestation
            Suspension will be lifted within 1 State Business Day(*) of DMA receipt of attestation
            Submission of attestation that facility is no longer an IMD when the facility is may be
             considered fraud and appropriate referrals will be made

       DMA will conduct on site review (within 30 days) to confirm IMD Attestation
        and compliance

       If compliance is NOT confirmed, Provider Payment is recouped back to the
        date of the attestation and provider is Terminated in Medicaid. New provider
        Application is required in accordance to § 455.416

       If Attestation is confirmed, Provider will submit annual attestation and
        conduct ongoing IMD compliance self reviews
   *unless business continuity is interrupted
           What Does This Mean for North Carolina?

                                                            39




 If Provider fails to send IMD Attestation within 60 calendar days?

             Provider will be terminated from Medicaid in accordance to (§ 455. 416) on 61st calendar day or
              next state business day(*) whichever comes last


             Provider will be required to submit new provider enrollment application § 455.420

             Providers applications will be processed according to routine procedures

             Fees for re-enrollment will apply unless exempt per federal regulations



  (*) unless Business continuity is interrupted
40
                 Recipient Notification
                                       41




 Nothing happens to the recipient’s Medicaid coverage during the AT RISK
  process. Medicaid remains active.

 Recipients will receive written notification that the provider is NOT an
  IMD.

 Due to delays in mailing, the provider will know before the recipients of
  NON-IMD facility determination. Please notify recipients so that families
  and recipients will know their Medicaid is still active.
       What Does This Mean for North Carolina?
                                                   42

 Recipients ( or Guardian, if applicable)
   Recipient and legal guardian/responsible person as listed on file with DMA will Receive
    Notice that Medicaid payments will stop while residing in an IMD

      Date benefit payments affected is the date stated in the letter, not at the end of the month

      ALL payments for ANY covered Medicaid service will be denied

      Responsible county (eligibility) of DSS will receive copy of letter

      Responsible LME will be notified of recipients if they have MH/SA diagnosis

      LME and DSS of county of eligibility can assist with housing options and other service access

      On the date that the provider IMD designation is lifted, the Medicaid benefits payments will
       resume for the recipients who remain in residency of the facility, assuming that they remain
       otherwise Medicaid eligible.

      If the recipient moves to another facility that is NOT an IMD at any point in the process,
       Medicaid benefit payments may be immediately re-instated as long as they remain otherwise
       eligible for Medicaid. DMA and the Division of Aging and Adult Services (DAAS) will provide
       guidance to the local DSSs regarding the process and procedures.
                                                     43


                          North Carolina DMA IMD Determination


                  DMA notifies NC Adult Care Home providers, Supervised Living, Family Care
                           Homes that IMD reviews being conducted (Public Notice)



                 DMA analyzes data for any billed Mental Health Services, NPI, EIN to identify all
               facilities that meet Federal guidelines (>16 beds and 50% of residents have a MI/SA
                                                      diagnosis

                                                                                        Provider letter sent
                 Conducts phone interviews with owners to identify shared ownership/functions in
                                 accordance to State Medicaid Manual (4390)


           Send Providers the Facility
      Questionnaire, Provider Questionnaire,                                           Schedule onsite reviews
      and Medical Documentation Checklist
                                     Review findings against medical records
                                                       &
                                          Determine At Risk Facilities
                           NOT AT RISK                                  YES AT RISK


                Notify owner of status of
               review explaining Facility                                   Provider At Risk Letter
               is NOT an IMD Status at                                         Sent to Owner &
                  this time. Subject to            Send Alert Status          Recipients At Risk
                Annual Attestation and              to County DSS                Notification
                  monitoring by DMA.                   and LME



                                                                           Provider May Send Additional Information
                                                                               to DMA Within 10 Business Days
                                                                                   Addressing At Risk Status




                                                              Additional information                  Additional
                                                              does not impact DMA                information clarifies
                                                                   designation                       at risk status



July 2, 2012
                                                      DMA designates facility an             Facility is NOT an IMD
                                                               IMD                                 at this time
                               North Carolina DMA IMD Determination (page 2)

                                             Facility Designated IMD

                                                                                                                Internal
                                                    Communication/                                               DHHS
                                                   Notification process                                        notification
                                                                                        Provider Suspension/Termination
               Recipient Letter
                                                                                       Letter Sent via Trackable process &
           (Or Applicable Guardian)
                                                                                       contact by all other available contact
             Sent Trackable Mail
                                                                                                    information


                EIS Changes                                                               Payment Suspended to
                   Occur                                                                       Provider


                                                      Attestation Process Begins: Provider Must Attest Within 60
                  Recipient                                                 Calendar Days
                  Transition
                   Occurs                                                                                DMA lifts Provider
                                                                                 Yes                      suspension and
                                                                                                         Recipient Benefits
                                                                                                         back in effect from
                                                       No                                                date of Attestation


                                                                               DMA Verifies Attestation with
                            Provider Terminated (§455.416)                           Onsite Review
                             on 61st Calendar Day or Next
                                 State Business Day *
                           (Standard Operating Procedure)                     Attestation not           Attestation
                                                                                confirmed               confirmed

                          New Application                                 Provider Terminated
                             Required                                          (§455.416)                DMA Submits Non-
                            (§455. 420)                                                              Exception Form to CSC for
                                                                                                     High Priority Action Within
                                                                    Recoupment Process                 1 State Business Day*
                                                                         initiated


                                                                                                     CSC Implements
                                             New Application
                                                Required
                                               (§455. 420)
                                                                                CSC Contacts Provider Services Via Email
                                                                                         that Action Complete


                                                               Provider Services Verifies CSC System that Action Taken
July 2, 2012
                                    *Unless Business
                                  Continiuity Is Interrupted
                                                                      2




                                                                                                                                   44
                                    Appeals
                                            45


 There are no Medicaid appeal rights for recipients for two reasons
     The adverse action was taken against the provider, not the recipient.
     Since the recipient resides in a non-covered Medicaid facility, appeal rights do
      not apply because the Medicaid is not active

 Providers may appeal to in accordance to NC appeal procedures to Office of
  Administrative Hearing (OAH)

     CMS guidance is that federal funding will cease during the pendency of the
      appeals.
     If the appeal decision is in favor of the facility, the facility is not an IMD then
      payment will be made back to the date of the IMD determination finding as long
      as all other Medicaid rules and regulations were followed
     If the appeal decision is upheld then the process described early for becoming
      incompliance is in play.
  Tracking Recipients Who Were in IMD Facilities
                                            46




 DHHS will track recipients who move from facility to determine
     Were discharge procedures followed in accordance to 131D or 122C licensure
      regulations. All licensure rules still apply. For example, discharge rules for
      ACH’s, 10A NCAC 13F.0702 must be followed
     Where were the recipients moved to
     What services or resources were required and by whom


 For those recipients who remained in the facility


     How were the needs of the recipients met?
     What resources were used?
         IMD Report
ACLS – Admission and Discharge
              47
48
  What Does This Mean for North Carolina?
   IMD Annual Attestation Expectations
                    49


 Provider submits an Annual Attestation attesting that the
  facility is not an IMD
 Subject to onsite reviews by DMA/designee
 DHHS is exploring
    DHSR and other regulatory agencies reviewing for IMD as part of their
     routine or existing regulatory practices. For example, when DHSR
     conducts the licensure review, they will review for IMD compliance.
    More information will be shared about this process in the future
    Sampling of attestation rather than all facilities - possibly
      Random
      Identified through analytics

 Even if other agencies gather the information, the State
 Medicaid Agency (DMA) may not delegate the designation
 to another entity.
QUESTIONS?
    50

								
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