Current through September 17, 2024
008.01
Legal Basis
The Nebraska Medical Assistance Program (NMAP) covers IMD
services, for clients 65 and over, under
42
CFR 431.620(b),
435.1009;
440.140;
440.160;
Part 441, Subparts C and D; Part 447, Subparts B and C; Part 456, Subparts D
and I; and Part 482. The Department provides IMD services under the Family
Policy Act, Sections 43-532 through 534, Reissue Revised Statute of
Nebraska, 1943.
008.02
Definition of an
IMD
42 CFR
435.1009 defines an IMD as "an institution
that is primarily engaged in providing diagnosis, treatment or care of persons
with mental diseases, including medical attention, nursing care and related
services. Whether an institution is an institution for mental diseases is
determined by its overall character as 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 institution for mental diseases." This is limited
to free-standing facilities which are not excluded units of acute care
hospitals.
008.03
Standards for Participation
To participate in the NMAP, the IMD must -
1. Be in conformity with all applicable
federal, state, and local laws;
2.
Be licensed as a hospital by the Nebraska Department of Health and Human
Services, Division of Public Health or the licensing agency in the state where
the IMD is located;
3. Be certified
as meeting the conditions of participation for hospitals in 42 CFR Part
482;
4. Be accredited by the Joint
Commission of Accreditation of Healthcare Organizations (JCAHO) or the American
Osteopathic Association (AOA), and submit a copy of the most recent
accreditation survey with Form MC-20;
5. Meet the definition of an IMD as stated in
471 NAC 20-008.02 (above);
6. Meet
the program and operational definitions and criteria contained in the Nebraska
Department of Health and Human Services Manual;
7. Meet the current JCAHO or AOA standards of
care; and
8. Meet all requirements
in 471 NAC
20-001 except active treatment.
20-008.03A
Provider
Agreement: The provider shall complete Form MC-20 and submit the
form, along with a copy of its current JCAHO or AOA accreditation survey,
program, policies, and procedures to the Department to enroll in NMAP as a
provider. If approved, the Department notifies the IMD of its provider
number.
20-008.03B
Annual Update: With the annual cost report, the
provider shall submit a copy of all program information, their most recent
license and accreditation certificates, and any other information specifically
requested by the Department. Claims will not be paid if this has not been
received and approved. This information must be submitted with a new copy of
Form MC-20.
20-008.03C
Monthly Reports: The IMD shall submit a monthly report
to the Division of Medicaid and Long-Term Care. The report must contain -
1. The names of all Medicaid clients admitted
or discharged during the month; and
2. The date of each Medicaid client's
admission or discharge.
The report must be submitted by the 15th of the following
month.
20-008.03D
Record
Requirements: The regional center (or the local office for a
client in a private facility) shall enter the Form MC-9H document number in
Form Locator 63 on each Form CMS-1450 or standard electronic Health Care Claim:
Institutional transaction that is submitted to the Department.
Transfer to another IMD or readmission constitutes a new
admission for the receiving facility.
20-008.03D1
An Individual Who
Applies For NMAP While in the IMD: For an individual who applies
for NMAP while in the IMD, the certification must be -
1. Made by the team that develops the
individual plan of care (see 471 NAC 20-008.10);
2. Cover any period before application for
which claims are made.
When Medicaid eligibility is determined, authorization for
previous and continued care must be obtained from the Department contracted
peer review organization or management designee.
008.04
General Definitions
The following definitions are used in this section:
Interdisciplinary Team: The team
responsible for developing each client's individual plan of care. The team must
include a board-eligible or board-certified psychiatrist. The team must also
include at least two of the following:
1. A Licensed Mental Health
Practitioner;
2. A registered nurse
with specialized training or one year's experience in treating individuals with
mental illness;
3. An occupational
therapist who is licensed, if required by state law, and who has specialized
training or one year's experience in treating mentally ill individuals;
or
4. A licensed psychologist.
Inpatient Hospital Services for Individuals Age
65 or Older in Institutions for Mental Disease (IMD's): Services
provided under the direction of a psychiatrist for the care and treatment of
clients age 65 and older in an institution for mental disease that meets the
requirements of
42
CFR 440.140.
Inspection of Care Team: The
Department's inspection of care team, consisting of a psychiatrist
knowledgeable about mental institutions, a qualified registered nurse, and
other appropriate personnel as necessary who conduct inspection of care reviews
under 42 CFR 456.600-614 and 471 NAC 20-001.20.
Medical Review Organization: A
review body contracted by the Department, responsible for preadmission
certification and concurrent and retrospective reviews of
care.
008.05
Admission Criteria
See 471 NAC 20-007.05.
008.06
Signs and
Symptoms
In addition to the admission criteria, one or more of the
following signs or symptoms of the problem must be present:
1. A suicide attempt that requires acute
medical intervention or suicidal ideation with a lethal plan and the means to
carry out this plan;
2. Psychiatric
decompensation to a level in which the client is not able to communicate or
perform life-sustaining activities of daily living;
3. Delusions or hallucinations that
significantly impair the client's ability to communicate or perform
life-sustaining activities of daily living;
4. Catatonia;
5. The presence of combined illnesses where
neurological or other disease process coexists with a psychiatric disturbance,
demanding special diagnostic or treatment interventions, which exceed
non-hospital capacity;
6.
Aggression to others causing physical injury or homicidal ideation with a
lethal plan and the means to carry out the plan, that is the result of a severe
emotional psychiatric decompensation; and
7. Medication initiation or change when the
client has a documented history of reactions to psychotropic medications that
have resulted in the need for acute medical care in a hospital or an emergency
room.
008.07
Prior Authorization and Initial Certification
Procedures
IMD services for clients age 65 or older must be
prior-authorized as follows:
1.
Admissions must be prior-authorized by the Department's contracted peer review
organization or management designee. Providers should follow the Department
contracted peer review organization or management designee guidelines on
facilitating prior authorization. The MC-14 received from the peer review
organization or management designee must be maintained in the client's medical
record;
2. A psychiatrist shall
pre-certify, at the time of admission, that the client requires inpatient
services in a psychiatric hospital.
The psychiatrist shall complete, sign, and date Form MC-14
within 48 hours after admission or at the time of application for medical
assistance if this date is later than the date of admission. The 48-hour period
does not include weekends or holidays. Copies of the admission notes and plan
of care may be attached to the signed and dated Form MC-14 to certify that
inpatient services are or were needed;
3. The facility shall contact the client's
local office for determination of medical eligibility. The local office shall
respond to the facility with -
a. The medical
eligibility effective date; and
b.
The date eligibility was determined, if this date is later than the date of
admission;
4. The
facility shall complete Form MC-9H, attach a copy of
the completed Form MC-14, and forward to the Division of Medicaid and Long-Term
Care. The facility shall retain the original copy of Form MC-14 in the client's
medical record;
5. The Division of
Medicaid and Long-Term Care shall review Form MC-14 and approve or reject the
Form MC-14 findings within 15 days;
6. If rejected, the Division of Medicaid and
Long-Term Care shall return all forms to the facility with an explanation of
the rejection;
7. If approved, the
Division of Medicaid and Long-Term Care shall complete Block #11 and the
signature Block #18 of Form MC-9H. The white copy is retained in Central
Office. The Division of Medicaid and Long-Term Care shall send the pink and
gold copies to the facility and the yellow copy to the local office;
8. The document number on Form MC-9H must be
entered in Form Locator 63 on each Form CMS-1450 or standard electronic Health
Care Claim: Institutional transaction submitted to the Department;
and
9. When the client is
discharged or expires, the facility shall complete Form MC-10 to close the
authorization. The facility shall forward the white copy to the Division of
Medicaid and Long-Term Care and the yellow copy to the local office, and retain
the pink and gold copies. Within 48 hours after a client is discharged or
expires, the facility shall notify the local office in the client's county of
finance.
008.08
Transfers
Transfer to another IMD or a readmission constitutes a new
admission for the receiving facility. This procedure must be followed for each
transfer or readmission.
008.09
Sixty-Day
Recertification
A psychiatrist shall recertify, in the client's record, the
client's need for continued care in a mental hospital or need for alternative
arrangements at least every 60 days after the initial
certification.
008.10
Interdisciplinary Plan of Care
The psychiatrist and the facility interdisciplinary team
shall develop and implement an individual written plan of care for each client
within 48 hours after the client's admission. This plan of care must be placed
in the client's chart when completed. The written plan of care must include
-
1. Diagnoses, symptoms, complaints,
and complications indicating the need for admission;
2. A description of the client's functional
level;
3. Objectives;
4. Any orders for -
a. Medications;
b. Treatments;
c. Restorative and rehabilitative
services;
d. Activities;
e. Therapies;
f. Social services;
g. Diet; and
h. Special procedures recommended for the
client's health and safety.
5. Plans for continuing care, including
review and modification of the plan of care;
6. Appropriate medical treatment in the IMD
every 60 days;
7. Appropriate
social services every 60 days;
8.
Family involvement; and
9. Plans
for discharge, including referrals for outpatient follow-up care.
This requirement is met by completion of Form MC-14, which is
retained in the client's record.
008.11
Facility Interdisciplinary
Plan of Care Team Review
The attending or staff psychiatrist and other personnel
involved in the client's care shall review each plan of care at least every 90
days. The client's record must contain documentation of the 90-day
interdisciplinary team review.
008.12
Admission
Evaluation
IMD staff shall develop an admission evaluation for each
client within 30 days after the client's admission. This evaluation must be
placed in the client's record when completed. The admission evaluation must
include -
1. The Form MC-14;
2. A medical evaluation, including -
a. Diagnosis;
b. Summary of current medical
findings;
c. Medical
history;
d. Mental and physical
functional capacity;
e.
Prognosis;
f. The psychiatrist's
recommendation concerning the client's admission to the mental hospital or the
client's need for continued care in the mental hospital, if the client applies
for NMAP while in the mental hospital;
3. A psychiatric evaluation;
4. A social evaluation;
5. An initial plan of care sufficient to meet
the client's needs until the facility interdisciplinary team has developed the
individual written plan of care.
008.13
Discharge
Planning
The IMD shall make available to the psychiatrist current
information on resources available for continued out-of-hospital care of
patients and shall arrange for prompt transfer of appropriate medical and
nursing information to ensure continuity of care upon the client's discharge.
Under
42 CFR
441.102, when the client is approved for an
alternate plan of care, the IMD is responsible for discharge planning. In
cooperation with community regional mental health programs, the IMD shall
-
1. Initiate alternate care
arrangements;
2. Assist in client
transfer; and
3. Follow-up on the
client's alternate care arrangements.
When the client is being transferred to a long term care
facility (NF or ICF/MR), the facility's staff must be included in the discharge
process and must receive appropriate and adequate medical and nursing
information to ensure continuity of care. The IMD shall also contact the
client's local office.
008.14
Payment for IMD
Services
See 471 NAC 10-010.03 ff.
20-008.14A
Therapeutic Passes
from IMD Settings: For some psychiatric clients, therapeutic
passes are an essential part of treatment. For those clients, documentation of
the client's continued need for psychiatric care must follow the overnight
therapeutic passes. Payment for hospitalization beyond a second pass is not
available due to medical necessity.
20-008.14B
Unplanned Leaves of
Absence from IMD Settings: Payment for hospitalization during an
unplanned leave of absence is not available. The Department contracted peer
review organization or management designee must be notified immediately when
the client returns. Admission criteria will be applied. If approved, a new
validation number will be issued to cover the days beginning with the day of
return.
