Kansas
Department of Social and Rehabilitation
Services
Gary
Daniels, Acting Secretary
Integrated
Service Delivery - Candy
Shively, Deputy Secretary (785)
296-3271
Economic
and Employment Support -
Bobbi Mariani, Director (785) 296-3349
....Enriching
lives today and tomorrow
MEMORANDUM
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To:
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EES
Program Administrators CFS
Program Administrators HealthWave Clearinghouse
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Date:
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March
14, 2005
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From:
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Bobbi
Mariani, EES Director
Sandra
Hazlett, CFS Director
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RE:
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Implementation
of Level of Care/Patient Liability for Level
VI and Head Injury Rehabilitation Facilities
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The purpose of this memo
is to provide implementation instructions for two new beneficiary
level of care (LOC) coding combinations related to institutional
expenses. The new levels of care are necessary to assign a patient
liability for residents of these
specific types of institutions. The new
policy will impact both EES and CFS staff and is effective for all claims processed
on or after March 21, 2005
- General
LOC and Patient Liability Process:
When
an individual enters an institutional living arrangement and
is determined eligible for Medicaid, a patient liability is established.
The patient liability is the beneficiary’s monthly share
of the cost of institutional care and is based on income. Any
Medicaid payments made to the institution are reduced by the
amount of the patient liability. The facility is responsible
for collecting the patient liability from the resident. More
information about patient liability can be found in KEESM 8172
and subsections.
To
ensure Medicaid is paying only for those who truly need long
term care services, a level of care screening or assessment is
required prior to payment of most institutional costs. There
are many different types of speciality facilities and each has
a different screening mechanism. The eligibility worker ensures
the proper level of care criteria have been met before approving
Medicaid payment. Persons who do not meet the necessary level
of care are not eligible for Medicaid reimbursement of LTC/institutional
expenses. More information about level of care/screening requirements
can be found in KEESM 8112 and 8114.
Before
paying a Medicaid claim to any institution, the MMIS must
have a way to confirm a patient liability has been determined
and the level of care has been confirmed. This is done through
the KAECSES LOTC screen. The LOTC screen captures both living
arrangement and level of care codes and then converts them
to a
special Beneficiary LOC code for the MMIS, which can be viewed
on the ‘Level of Care’ window in the MMIS. When an
institutional provider bills for services, a check is done to
determine if the beneficiary is authorized to receive the level
of care provided by the facility. This will prevent payment for
an individual who does not need long term care services or for
someone who needs a different type of services.
Federal
Medicaid rules require consideration of both patient liability
and level of care prior to paying long term care expenses. Although
these elements are new to both Level VI and Head Injury/Rehab
facilities, policies have been in place for most nursing facilities
for many years to provide for these situations. Specific instructions
for each facility type are provided below.
- Level
VI Facilities:
Level VI
facilities provide behavioral health care in an institutional
environment. These facilities offer a highly structured
setting to youth with behaviors such as severe emotional
or mental disturbance, sexual acting out, substance abuse
and combative behavior. For purposes of Medicaid eligibility,
these arrangements are considered medical institutions.
Level V and Level IV facilities are NOT considered medical
institutions for Medicaid purposes and these policies do
not apply to residents of those facilities. A list of all
Level VI facilities recognized by the Medicaid program is
included with this material.
With
the full implementation
of this policy, payment is dependent on an appropriate beneficiary
level of care. If the LOC is present, patient liability will
be considered. A monthly patient liability must be determined
for each beneficiary ($00 when there is no patient liability).
Payment to the facility is reduced by the amount of patient liability.
- FFS
vs Contracted Care: This policy will be implemented
in two phases. This is necessary to accommodate
the separate payment mechanisms that are currently used to reimburse
Level VI facilities, as follows:
- Children
in SRS Custody under a FC (Foster Care) Medical Program
- Level VI services provided to children served under
the
private child welfare contracts are provided under the terms
of the contract. The facility does not bill the MMIS for
payment at this time.
Note
the change in the terms of the foster care contracts effective
07-01-05 will also require a change in the payment process for
Level VI placements, as addressed below.
- Children
in JJA Custody under a FC (Foster Care) Medical
Program and Other Medicaid Eligible Children - Services for these youth are paid on a fee for
service basis after a separate Medicaid claim is filed.
Before paying
the claim, a prior authorization (PA) must be obtained from
the Mental Health Consortium. If the PA is in
place, payment is made for eligible children.
- Processing
Instructions: The following general process is to
be used for all individuals residing in a Level VI facility:
- All
Level VI placements are initiated when the CMHC, JJA Local
Agency or the CFS worker contacts the Mental Health Consortium
to request a screening. The Consortium is responsible for
coordinating the process. See the Behavior Management Provider
Manual for more information regarding the screening process.
- If
approved, a prior authorization (PA) is then entered on
the MMIS by the Consortium. The Level VI facility will not
be paid without a current PA on file.
- Following
placement of a youth in SRS custody, the facility will initially
contact CFS for payment. For JJA youth, the facility shall
continue to submit claims directly to Medicaid through MMIS.
If the child is in custody and eligible for Medicaid through
a foster care program (SRS or JJA custody), CFS will process
the request. If the child is not in custody, CFS will refer
to the case to EES for Medicaid determination. A Medicaid
application for coverage is necessary.
- Determine
Medicaid status.
- Persons
covered under a Foster Care Medicaid or SSI Medicaid program
at the time of placement remain in the FC or SI Medicaid
group throughout the stay as long as requirements continue
to be met.
- Persons
covered under another Medicaid program at the time
of placement may remain covered under the same Medicaid
program if the
stay will not exceed 30 days. If the stay exceeds 30
days, eligibility is redetermined under a CI program.
Eligibility
is never determined under a CI program until the youth
is actually a resident of the facility.
- Persons
who are not Medicaid-covered upon entrance may apply for
Medicaid. For stays exceeding 30 days, a CI program is used.
For stays under 30 days, another Medicaid program may be
established considering the child’s prior living arrangement.
For example, a child living with his parents could be considered
under the MP or MA program.
- There
is no payment for services if eligible under HealthWave
21. It will be necessary to determine eligibility
for Medicaid for any HealthWave 21 child who
enters a Level VI facility.
- For
individuals who are Medicaid eligible, determine the patient
liability. Generally, only the individual’s own income
is used.
- Complete
the KAECSES LOTC Screen. See the KAECSES User Manual for
instructions. For Level VI facilities, use the following
guide for coding.
Living Arrangement : |
BF |
Level of Care: |
MH |
LA/LOC Payment Date: |
Use month, day and year Level VI payment begins,
usually the date of entrance into the facility |
Patient Liability: |
Use amount computed. Use $0 if none. |
Patient Liability Eff Date: |
Month and Year of Patient Liability |
Date Screen Completed: |
Same date as LA/LOC date above |
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The
example below reflects how to complete
LOTC for an individual who entered a Level VI facility
on 02-08-05, where payment
is to begin immediately. Becky
has a patient liability of $225.00 for the month
of April. The patient liability will
remain this amount each month unless
a change in income occurs. The eligibility worker
must tell the resident/responsible
person and the facility about any change in
patient liability.
LOTC LONG TERM CARE 022505
14:48 JEANINE
S |
CASE NAME: BENE, BECKY B |
CASE NUMBER: 00000001 |
POS ON APP/NAME: 01 |
BECKY B |
LIVING ARRANGEMENT: |
BF |
LEVEL OF CARE: |
MH |
LA/LOC PAYMENT EFF DATE: |
020805 |
PATIENT LIABILITY: |
225.00 |
PAT LIABILITY EFF DATE: |
0405 |
DATE SCREEN COMPLETED: |
020105 |
PEND DATE |
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- Send
notices to both the beneficiary and the facility
informing them the status of the case (approved/denied)
and any amount
of patient
liability, along with effective dates .
- As
changes occur, adjust the patient liability accordingly.
Notify the resident/responsible person and the facility
giving timely and adequate notice as required.
- When
the individual is discharged, discontinue the LOTC living
arrangement and level of care codes by changing the combination
to LA of IL and an LOC of NA.
It
is the responsibility
of the facility to inform SRS of discharge.
Because a notice
will be sent
to the facility
telling them
about payment,
the facility will have the name of the assigned
worker on the case.
The communication
will typically
come
to this worker.
However, if the facility is unsure who the
individual is, or if
they have never received
a notice,
communication will
come through the CFS worker. The CFS worker
shall communicate
the information to others that
also need to know the information.
C. Implementation
Instructions: Follow the instructions
below for all individuals
residing in a level VI facility, depending on
the case type. Failure to follow the proper procedures
will
result in payment denial for the facility.
- Children
in SRS Custody under a FC (Foster Care) Medical
Program: Because payment of this expense is the responsibility
of the
contractor,
neither the LOC or patient liability are
necessary until July 1, 2005. Prior to 07-01-05, the
KAECSES LOTC
screen must be completed for all Level VI placements.
This must
be completed by close of business on 06-17-2005.
Patient
liability must be determined and included
on the LOTC screen. Detailed instructions for determining
the patient
liability
for foster care situations will be sent under separate
cover.
- Children
in JJA Custody under a FC (Foster Care) Medical
Program: Unlike SRS custody situations, payment
is made on a fee
for service basis for these residents. This means
the appropriate Living Arrangement and Level of
Care codes must be in place.
The LA/LOC effective date is the first date of
payment in the Level VI facility, usually the
date of entrance. This
is true regardless of the length of time that
has passed since the individual was placed. LOTC
must be completed by close of business 03-18-05.
A
patient liability will not be computed at this
time. A patient liability of ‘00.00' is
to be entered for each eligible resident. Implementation
of the patient liability for the
JJA custody youth will be implemented with the
regular FC population and will be in place no
later than 06-17-05.
Separate instructions will be issued.
- Children
in other Medicaid programs (including CI and SI): LOTC must be completed with appropriate codes by close of
business 03-18-05. The LA/LOC effective date is the first
date of payment in the Level VI facility, usually the date
of entrance. This is true regardless of the length of time
that has passed since the individual was placed. Because
of timely notice, patient liability cannot be implemented
prior to 04-01-05.
Again,
it is critical to stress the coding must be in place
on the LOTC screen, as bills processed on or after 03-21-2005
will not be
paid if proper coding isn’t present.
- Level
VI Beneficiary Printout: To assist with
identifying current Level VI residents, a printout
of all
individuals where a Level VI billing was made in the last
60 days
to the MMIS is being sent to the regional program contacts
(CFS and EES). This list should be used as a guide
for identifying current residents whose payment may be impacted
by the new
policy.
The
list is sorted by worker and includes both the
case number and the client ID number. The list
also includes
a JJA custody
indicator. This indicator is set to ‘Y’ if
the MMIS indicates the youth was in a JJA custody
situation in the month of March, 2005. For all
other youth, the
indicator
is not present.
The
facility name if not included. If the worker was not aware
of the Level VI placement, an MMIS claim inquiry may be
completed to determine which facility has made a claim for
payment. Contact with the facility may be required to determine
the date of entrance and the date of discharge, if applicable.
Because the policy applies to all claims processed on or
after 03-21-05, LOTC should be completed even for those
youth who are no longer living in the facility as additional
bills may be submitted. Check with the facility to determine
the date of placement, if unknown as well as any potential
date of discharge.
All
new Level VI approvals made after receipt of this memo must
include proper LOTC coding.
- Head
Injury Rehabilitation Facilities (aka Traumatic Brain
Injury Rehabilitation Facilities) :
Head
Injury facilities provide health and rehabilitation related
care to persons who have experienced severe brain injury
and are in need of active treatment programming for retraining
in independent living skills. Residents receive professional
services on a 24-hour basis due to their cognitive and physical
condition. For purposes of Medicaid eligibility, these arrangements
are considered medical institutions. A list of all Head
Injury Rehab Facilities recognized by the Medicaid program
is included with this material.
Like
Level VI facilities, with the implementation of this policy,
payment to the facility is dependent upon an appropriate
beneficiary level of care. If the LOC is present, patient
liability will then be considered. A monthly patient liability
must be determined for each resident ($00 when there is
no patient liability). Payment to the facility is reduced
by the amount of patient liability.
- Processing
Instructions: Prior to
approving payment for a HI facility
stay, the eligibility worker
must ensure
the individual meets appropriate
level of care through a functional
assessment. The Independent
Living Center
has responsibility for the function
assessment. When a request for
payment is received, a request
is to
be generated to the appropriate
ILC for level of care/payment approval
information. For out of
state placements,
permission of the HI Manager in
HCP-Community Supports and Services
is required. In addition,
the MMIS required
all out of state placements be
prior authorized. If approved,
eligibility is determined per KEESM
8112.
The KAECSES LOTC screen must be
completed
as well. The information described above
under Level VI is also
appropriate for Head Injury Rehab
facilities, with the followi
ng exceptions:
Living Arrangement: |
NF |
Level of Care: |
HI |
The
example below shows an appropriate LOTC screen
for an individual who entered the facility on 02-08-05 and
payment begins
that day:
LOTC LONG TERM CARE 022505
14:48 JEANINE
S |
CASE NAME: KAT, KATY K |
CASE NUMBER: 00000002 |
POS ON APP/NAME: 01 |
KATY K |
LIVING ARRANGEMENT: |
NF |
LEVEL OF CARE: |
HI |
LA/LOC PAYMENT EFF DATE: |
020805 |
PATIENT LIABILITY: |
123.00 |
PAT LIABILITY EFF DATE: |
0405 |
DATE SCREEN COMPLETED: |
020105 |
PEND DATE |
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Appropriate
notices, as required with any NF situation must be sent
to notify the resident/responsible party and the facility
of any approval, suspension or termination in payment as
well as any patient liability change.
- Implementation
Instructions: As with level VI facility payments,
appropriate LOTC coding must in place for all current
residents prior to 03-21-05 for the provider to receive
Medicaid payment.
Because
of timely notice issues, patient liability will not be effective
prior to 04-01-05, unless the resident and facility have
been previously notified about the patient liability.
To
assist with implementation a list of Medicaid beneficiaries
with a HIR billing within the past 60 days is included with
this material. The list, sorted by worker number also includes
the case number and Medicaid ID number. If the eligibility
worker is not aware of the placement, contact with the facility
is required to determine admission date, etc. Contact with
the ILC is required to ensure LOC has been met prior to
approving payment.
Please
note that approval for payment of individuals residing in
a Head Injury Rehab facility is a distinct process different
from approval for the HI HCBS waiver. Although short term
care may be paid while the individual is on the HI waiver,
such situations must be approved through the HI HCBS Case
Manager and are allowable if the length of stay will not
exceed the month of entrance and two following months (see
KEESM 8113. This will be communicated to the eligibility
worker through the ES-3161. Appropriate KAECSES LOTC codes
are Living Arrangement - TC; Level of Care - HI.
Your cooperation and
effort meeting the implementation deadlines defined above is
very much appreciated. If you have any questions about the material,
please contact Jeanine Schieferecke, Medical Assistance Manager
in EES, at (785) 296-8866. Please report any system problems
to SRSTSC.
BM:SH:JS:jmm
Attachment |