Inpatient mental health services in an Institution for
Mental Disease (IMD's) are available to clients age 20 and younger when the
client participates in a HEALTH CHECK (EPSDT) screen, and the treatment is
medically necessary. Inpatient mental health services in an IMD must be family
centered and community based culturally competent, and developmentally
appropriate.
Services for wards of the Department must be prior-authorized
by and consent for treatment must be obtained from the ward's case manager or
the case manager's supervisor.
009.01
Legal Basis
The Nebraska Medical Assistance Program (NMAP) covers IMD
services 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.
009.02 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.
009.03 Covered
Services
Under
42 CFR
440.160, NMAP covers services in IMD's for
individuals age 20 and younger.
009.04 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 32-009.02 (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
32-001 and 471 NAC
32-008.
32-009.04A
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.
32-009.04B
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.
32-009.04C
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.
32-009.04D
Record
Requirements: Transfer to another IMD or readmission constitutes a
new admission for the receiving facility.
The psychiatrist shall complete, sign, and date Form MC-14
within 48 hours after admission. If an individual applies for assistance while
in the facility, copies of the admission notes and plan of care must be
attached to the signed Form MC-14 to certify that inpatient services are or
were needed.
32-009.04D1
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 32-009.09F);
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.
009.05
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-certified psychiatrist. The team must also include at least two
of the following:
1. 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 clinical
psychologist.
Inpatient Hospital Services for Individuals Age
20 or Younger in Institutions for Mental Disease (IMD's): Services
provided under the direction of a psychiatrist for the care and treatment of
clients age 20 and younger in an institution for mental disease that meets the
requirements of
42 CFR
440.160.
Inspection of Care Team: The
Department or designee'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 32-009.07 ff.
Medical Review Organization: A
review body contracted by the Department, responsible for preadmission
certification and concurrent and retrospective reviews of
care.
009.06
Payment for IMD Services
See 471 NAC 10-010.03 ff.
32-009.06A
Therapeutic Passes
from Institution for Mental Disease 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.
32-009.06B
Unplanned Leaves of
Absence from Institution for Mental Disease Settings: Payment for
hospitalization during an unplanned leave of absence from inpatient settings is
not available. If a client returns to a hospital after an unplanned absence,
the readmission must be approved by the Department contracted peer review
organization or management designee.
009.07 Inspections of Care
Under 42 CFR 456, Subpart I, the Department or designee's
inspection of care team shall periodically inspect the care and services
provided to clients in each IMD under the following policies and
procedures.
32-009.07A
Inspection of Care Team: The inspection of care team
must meet the following requirements:
1. The
inspection of care team must have a psychiatrist who is knowledgeable about
mental institutions and other appropriate mental health and social service
personnel;
2. The team must be
supervised by a physician, but coordination of the team's activities remains
the responsibility of the Division of Medicaid and Long-Term Care or their
designee;
3. A member of the
inspection of care team may not have a financial interest in any institution of
the same type in which s/he is reviewing care but may have a financial interest
in other facilities or institutions. A member of the inspection of care team
may not review care in an institution where s/he is employed, but may review
care in any other facility or institution.
4. A physician member of the team may not
inspect the care of a client for whom s/he is the attending
physician.
5. There must be a
sufficient number of teams so located within the state that on-site inspections
can be made at appropriate intervals in each facility caring for clients.
32-009.07B
Frequency of Inspections: The inspection of care team
and the Department shall determine, based on the quality of care and services
being provided in a facility and the condition of clients in the facility, at
what intervals inspections will be made. However, the inspection of care team
shall inspect the care and services provided to each client at least annually,
and/or more frequently as determined by the Inspection of Care team.
32-009.07C
Notification Before
Inspection: No facility may be notified of the time of inspection
more than 48 hours before the scheduled arrival of the inspection of care team.
The review team may make unannounced inspections at their discretion.
32-009.07D
Personal Contact With
and Observation of Recipients and Review of Records: For clients
age 20 and younger, the team's inspection must include -
1. Personal contact with and observation of
each client;
2. Review of each
client's medical record; and
3.
Review of the facility's policies as they pertain to direct patient care for
each client being reviewed in the inspection of care, in accordance with
42 CFR
456.611(b)(1).
32-009.07E
Determinations by the Team: The inspection of care
team shall determine in its inspection whether -
1. The services available in the IMD are
adequate to -
a. Meet the health needs of
each client; and
b. Promote his/her
maximum physical, mental, and psychosocial functioning;
2. It is necessary and desirable for the
client to remain in the IMD;
3. It
is feasible to meet the client's health needs through alternative institutional
or noninstitutional services; and
4. Each client age 20 or younger in a
psychiatric facility is receiving active treatment as defined in
42 CFR 441.154
and 471 NAC 32-009.05.
If, after an inspection of care is complete, the inspection
of care team determines that a follow-up visit is required to ensure adequate
care, a follow-up visit may be initiated by the team. This will be determined
by the inspection of care team and will be noted in the inspection of care
report.
32-009.07F
Basis for
Determinations: Under
42 CFR
456.610, in making the determinations by the
team on the adequacy of services and other related matters, the team will
determine what items will be considered in the review. This will include, but
is not limited to, items such as whether -
1.
The psychiatric and medical evaluation, any required social and psychological
evaluations, and the plan of care are complete and current; the plan of care,
and when required, the plan of rehabilitation are followed; and all ordered
services, including dietary orders, are provided and properly
recorded.;
2. The attending
physician reviews prescribed medications at least every 30 days;
3. Test or observations of each client
indicated by his/her medication regimen are made at appropriate times and
properly recorded;
4. Physician,
nurse, and other professional progress notes are made as required and appear to
be consistent with the observed condition of the client;
5. The client receives adequate services,
based on such observations as -
a.
Cleanliness;
b. General physical
condition and grooming;
c. Mental
status;
d. Apparent maintenance of
maximum physical, mental, and psychosocial function;
6. The client receives adequate
rehabilitative services, as evidenced by -
a.
A planned program of activities to prevent regression; and
b. Progress toward meeting objectives of the
plan of care;
7. The
client needs any services that are not furnished through the IMD or through
arrangements with others;
8. The
client needs continued placement in the IMD or there is an appropriate plan to
transfer the client to an alternate method of care, which is the least
restrictive, most appropriate environment that will still meet the client's
needs.
9. Involvement of families
and/or legal guardians (see 471 NAC
32-001); and
10. The facility's standards of care and
policy and procedure meets the requirements for adequacy, appropriateness, and
quality of services as they relate to individual Medicaid clients, as required
by
42 CFR
456.611(b)(1).
32-009.07G
Reports on
Inspections: The inspection of care team shall submit a report to
the Administrator of the Medicaid Division on each inspection. The report must
contain the observations, conclusions, and recommendations of the team
concerning -
1. The adequacy,
appropriateness, and quality of all services provided in the IMD or through
other arrangements, including physician services to clients; and
2. Specific findings about individual clients
in the IMD.
The report must include the dates of the inspection and the
names and qualifications of the team members. The report must not contain the
names of clients; codes must be used. The facility will receive a copy of the
codes.
32-009.07H
Copies of
Reports: Under
42 CFR 456.612,
the Department shall send a copy of each inspection report to -
1. The facility inspected;
2. The IMD's utilization review
committee;
3. The Nebraska
Department of Health and Human Services, Division of Public Health;
and
4. The Nebraska Department of
Health and Human Services, Division of Behavioral Health.
If abuse or neglect is suspected, Medicaid staff shall make a
referral to the appropriate investigative body.
32-009.07J
Facility
Response: Within 15 days following the receipt of the inspection
of care team's report, the IMD shall respond to the Central Office in writing,
and shall include the following information in the response:
1. A reply to any inaccuracies in the report.
Written documentation to substantiate the inaccuracies must be sent with the
reply. The Department will take appropriate action to note this in a follow-up
response to the facility;
2. A
complete plan of correction for all identified Findings and
Recommendations;
3. Changes in
level of care or discharge of individual clients;
4. Action to individual client
recommendations; and
5. Projected
dates of completion on each of the above.
If additional time is needed, the facility may request an
extension.
At the facility's request, copies of the facility's response
will be sent to all parties who received a copy of the inspection report in 471
NAC 32-009.07H.
A return site visit may occur after the written response is
received to determine if changes have completely addressed the review team's
concerns from the IOC report.
The Department will take appropriate action based on
confirmed documentation on inaccuracies.
32-009.07K
Department Action on
Reports: The Department will take corrective action as needed
based on the report and recommendations of the team submitted under this
subpart.
32-009.07L
Appeals: See 471 NAC
2-003 ff. and 465 NAC 2-001.02 ff. and
2-006 ff.
32-009.07M
Failure to
Respond: If the IMD fails to submit a timely and/or appropriate
response, the Department may take administrative sanctions (see 471 NAC
2-002 ff.) or may suspend NMAP payment
for an individual client or the entire payment to the facility.
009.08 Inpatient Mental Health
Services for Individuals Age 20 and Younger in an IMD
NMAP covers inpatient mental health services in an IMD for
individuals age 20 and younger under
42 CFR
440.160. The following requirements must be
met to receive NMAP payment for these services.
32-009.08A
Admission
Criteria: See 471 NAC 32-008.05.
32-009.08B
Admission
Evaluation: A psychiatrist shall make an admission evaluation when
the client is admitted to the hospital. The admission evaluation must include -
1. An initial assessment, within 24 working
hours of the admission, of the health status and related psychological,
medical, social, and educational needs of each individual client;
2. A determination of the range and kind of
services required; and
3. If all
admission criteria have been met, this evaluation must include an initial
treatment plan.
32-009.08C
Treatment Plan
Requirements:
1. The treatment
plan must meet the guidelines in 471 NAC
32-001 and in
42 CFR
441.155 and
441.156;
and
2. The treatment plan must be
developed by the psychiatrist and the Interdisciplinary Team defined in 471 NAC
32-009.08H.
32-009.08C1
Review of Plan of Care: Under
42 CFR
441.155(c), the facility
interdisciplinary team shall review the plan of care every 30 days to -
1. Determine that services being provided are
or were required on an inpatient basis; and
2. Recommend changes in the plan of care as
indicated by the client's overall adjustment as an inpatient.
This review also serves as the recertification of need for
services.
The individual plan of care must be developed by the facility
interdisciplinary team.
32-009.08D
Prior Authorization
Procedures: IMD services for clients age 20 and younger must be
prior-authorized as follows:
1. The
psychiatrist/physician 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.
2. 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.
3. 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.
4. 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.
5. If
rejected, the Division of Medicaid and Long-Term Care shall return all forms to
the facility with an explanation of the rejection.
6. 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 Central Office shall
send the pink and gold copies to the facility and the yellow copy to the local
office.
7. 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. One carbon copy of Form MC-9H may be attached to the first claim
submitted.
8. 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 Central Office
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 client's local office.
32-009.08D1
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.
32-009.08E
Certification of Need
for Services: For persons becoming Medicaid eligible after
admission, in accordance with
42 CFR
441.152, the facility interdisciplinary team
shall certify that -
1. Ambulatory care
resources available in the community do not meet the treatment needs of the
client;
2. Proper treatment of the
client's psychiatric conditions requires services on an inpatient basis under
the direction of a psychiatrist; and
3. The services can reasonably be expected to
improve the client's condition or prevent further regression so that the
services will no longer be needed.
The certification must be made at the time of admission, or
if the individual applies for the NMAP while in the IMD, before the Department
authorizes payment. This is accomplished by completion of Form MC-14. The form
must be signed by the team physician/psychiatrist making the determination. A
copy of the physician referral must accompany the completed MC-14.
32-009.08F
Initial Certification: A psychiatrist shall
pre-certify, at the time of admission, that the client requires inpatient
services in a psychiatric hospital. The psychiatrist shall complete Form MC-14
at the time of admission or within 48 hours of admission. If the individual
applies for NMAP while in a psychiatric hospital, the psychiatrist shall
certify the client's needs before the Department authorizes payment.
32-009.08G
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.
32-009.08H
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; and
8. Plans for discharge, including referrals
for outpatient follow-up care.
Care plans must address family involvement.
This requirement may be met by completion of Form MC-14,
which is retained in the client's record.
32-009.08J
Required Psychiatrist
Services: The client must be treated by a psychiatrist at least
six out of seven days, or frequently as medically necessary and the interaction
must be documented in the client's medical record.
32-009.08K
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 30 days. The client's record must contain
documentation of the 30-day interdisciplinary team review.
32-009.08L
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 (see 471 NAC
32-009.08E).
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.
32-009.08M
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.
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.
009.09 Payment for Inpatient Mental Health
Services in an Institution for Mental Disease
See 471 NAC 10-010.03 ff., 32-008.09, and
32-008.12.
009.10 Other
Regulations
In addition to the policies regarding mental health
services, all regulations in the Nebraska Department of Health and Human
Services Manual apply, unless stated differently in this
section.
