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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
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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?
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