1. health and fitness

NEVADA CHECK UP MANUAL
TRANSMITTAL LETTER
August 14, 2014
TO:
CUSTODIANS OF NEVADA CHECK UP MANUAL
FROM:
LAURIE SQUARTSOFF, ADMINISTRATOR
SUBJECT:
NEVADA CHECK UP MANUAL CHANGES
CHAPTER 1000 – NEVADA CHECK UP PROGRAM
BACKGROUND AND EXPLANATION
Revisions to Nevada Check Up (NCU) Manual, Chapter 1000, are being proposed to remove all
references to eligibility. As of July 2013, NCU eligibility was transferred to the Division of
Welfare and Supportive Services (DWSS).
Throughout the chapter, grammar, punctuation, and capitalization changes were made,
duplications removed, acronyms used and standardized, and language reworded for clarity.
Renumbering and re-arranging of sections was necessary.
These policy changes are effective September 1, 2014.
MATERIAL TRANSMITTED
CL 27949
NCU CHAPTER 1000 – NEVADA CHECK
UP PROGRAM
MATERIAL SUPERSEDED
MTL 01/08, 37/10, 13/11
NCU CHAPTER 1000 – NEVADA CHECK
UP PROGRAM
Background and Explanation of Policy Changes,
Clarifications and Updates
Manual Section
Section Title
1001
Authority
Added verbiage indicating the Nevada Check Up
program is a combination program.
1002
Definitions
Definitions removed: Applicant, Disenrollment,
Enrollment, Household, Income, Redeterminations
and Re-Evaluation.
1003.1A
Coverage and
Limitations
Removed language pertaining to a circumstantial
exception to the start of NCU coverage for a
newborn.
Removed verbiage pertaining to coverage of the
Division of Child and Family Services (DCFS),
Page 1 of 3
Manual Section
Section Title
Background and Explanation of Policy Changes,
Clarifications and Updates
reunification and eligibility.
Added verbiage regarding child welfare cases.
Removed language pertaining to redetermination.
1003.1B
Closed Enrollment/
Enrollment Cap
Removed “terminate the HIFA waiver” and
language relating to income.
1003.1C
Premiums
Removed language related to when premiums are
due.
Added language regarding how premiums are
charged.
1003.1E
Participant
Responsibility
Removed language
eligibility.
relating
to
establishing
Added language relating to the agency and its
representatives.
Removed
eligibility.
language
regarding
approval
of
Added language referring to MSM Chapter 100 for
information regarding participant responsibility.
1003.1F
Medical Care
Payments
Removed the whole section and replaced with
“Refer to MSM Chapter 100.”
1003.2
Choice of Provider
Removed the whole section and replaced with
“Refer to MSM Chapter 100.”
1003.3
Eligibility
Removed whole section and replaced with
information regarding eligibility functions now
being provided by DWSS.
1003.4
Income Types
Removed whole section.
1003.5
Income Verification
Removed whole section.
1003.6
NCU Referral to
Medicaid
Removed whole section.
Page 2 of 3
Background and Explanation of Policy Changes,
Clarifications and Updates
Manual Section
Section Title
1003.7
Medicaid Referral to
Nevada Check Up
Removed whole section.
1003.8
Crowd Out
Removed whole section.
1003.9
Outreach
Removed whole section.
1003.10
Disenrollment for
Non-Payment of
Premium
Removed whole section.
1003.11
Debt Collection/
Overpayments
Replaced NCU with the Division of Health Care
Financing and Policy (DHCFP) or the DWSS.
Added language referring to the DWSS Eligibility
and Payments (E&P) Manual.
1003.13
Notification of
Adverse Action
1003.14.c
Differences Between
Nevada Check Up
and Medicaid
1003.15
Confidentiality
1003.16
Investigation
1003.17
Hearing Preparation
Meeting (HPM)
1003.18
Health Service
Matters
1004
Hearings
Removed whole section.
Removed verbiage regarding newborns.
Removed whole section and replaced with “Refer to
MSM Chapter 100.”
Replaced NCU with the DHCFP.
Removed whole section.
Removed reference to MSM Chapter 3100.
Added language referring to DWSS for eligibility
determination issues.
Added language to reference MSM Chapter 3100
regarding hearings information.
1005.1
Fiscal Agent Contact
Information
Added contact information for Fiscal Agent and
Managed Care Organizations (MCO).
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1000
INTRODUCTION
INTRODUCTION
The Nevada Check Up (NCU) Program is Nevada’s version of the federal Children’s Health
Insurance Program (CHIP). It serves children ages 0zero through 18 years. The program is
designed for families who do not qualify for Medicaid and whose incomes are at or below 200%
of the Federal Poverty Level (FPL).
NCU insurance is comprehensive health insurance covering medical, dental, vision, mental health
services, therapies and hospitalization. All Medicaid policies and requirements (such as prior
authorization, etc.) except for those listed in section 1003.141003.6 are the same for NCU.
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AUTHORITY
AUTHORITY
Title XXI of the Social Security Act authorizes the states to design and operate children’s health
insurance programs. The 1997 Nevada Legislature enacted legislation, Nevada Revised Statute
(NRS) 422.021 “Children’s Health Insurance Program”, enabling the Division of Health Care
Financing and Policy (DHCFP) to prepare and submit a state plan for the operation of a standalone children’s health insurance program. In September of 2012 the Nevada Title XXI State Plan
was amended and Nevada now operates a combination program including a separate child health
program and an expanded Medicaid plan program.
The program was established pursuant to the federal regulations at 42 United States Code
(U.S.C.) §§ 1397aa to 1397jj and under the Code of Federal Regulations (CFR) at 42 CFR §
457.10-1190, inclusive, to provide health insurance for uninsured children from low-income
families in this state.
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1002
DEFINITIONS
1002.1
APPLICANT
DEFINITIONS
Is the adult person who signs a Nevada Check Up (NCU) application on behalf of the household
and is then designated as the Head of Household (HOH).
1002.21002.1 COVERED SERVICES
Those services for which Nevada Check Up (NCU) reimburses providers.
1002.3
DISENROLLMENT
Is the process of terminating individuals from enrollment in the NCU program.
1002.4
ENROLLMENT
Is the process of approving eligibility for participants to receive health care related services in the
NCU program.
FEE FOR SERVICE (FFS)
1002.51002.2
See Chapter 100, sSection 109 of the Medicaid Services Manual (MSM) for the definition.
1002.6
HOUSEHOLD
Includes the applicant, children, stepchildren, adopted children, grandchildren, stepgrandchildren, parents, step-parents, parents-in-law, grandparents, brothers, sisters, step-brothers,
step-sisters, sisters-in-law, brothers-in-law, sons-in-law, daughters-in-law, and/or any person who
is financially responsible for the applying children. A person living with the applicant is included
as another adult in the household and their income is counted toward the household income. Also,
any related person who appears as a dependant on the family’s income tax return may be counted
as a member of the household as long as that person also resides with the HOH.
1002.7
INCOME
Means gross income as defined by the U.S. Internal Revenue Code, and the following items: taxfree interest; the untaxed portion of pensions and/or annuities; railroad retirement benefits;
veterans’ pensions and compensations; payments received under the Social Security Act,
including supplemental security income (but excluding hospital and medical insurance benefits
for the aged and disabled); public welfare payments (including shelter allowances);
unemployment insurance benefits; all “loss of time” and disability insurance payments; disability
payments under workers’ compensation laws; alimony; support payments; allowances received by
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DEFINITIONS
dependents of servicemen; the amount of recognized capital gains excluded from adjusted gross
income; life insurance proceeds in excess of $5,000; bequests and inheritances; cash gifts over
$300 (not between household members) and such other kinds of cash flow into a household as
specified by the department.
1002.81002.3
MANAGED CARE
See Chapter 100, Section 109 of the MSM for the definition.
1002.91002.4
MANAGED CARE ORGANIZATION (MCO)
See Chapter 100, Section 109 for the definition of Health Maintenance Organization (HMO) or
Managed Care Organization (MCO) of the MSM.
1002.101002.5
NATIVE AMERICANS
Are members of federally recognized Tribes or Alaska Native families who can provide
verification of affiliation. Native Americans are exempt from premium payments in NCU.
1002.111002.6
NEVADA CHECK UP (NCU)
The appellation adopted for the Children’s Health Insurance Program (CHIP) in Nevada.
1002.121002.7
NEVADA CHECK UP CARD
The program verification card that is issued to each child. The card includes the name, and billing
number of each child. The card is mailed to the Head of Household (HOH) for each enrolled child
in a family.
1002.131002.8
OUT OF NETWORK SERVICES
Are those services received from a provider who is neither FFS Medicaid nor MCO contracted
provider. Participants are instructed that they must seek care with a contract provider, or they may
be liable for the cost.
1002.141002.9
PARTICIPANT
Is a NCU enrolled child receiving services through either a contracted Managed Care
Organization or the FFS program.
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1002.151002.10
DEFINITIONS
PREMIUMS
Are payments that constitute cost sharing for insurance. They are based on the family’s gross
income and the calculated percent of the current federal poverty level.
1002.161002.11
PRIMARY CARE PHYSICIAN (PCP)
Is a physician who practices general medicine, family medicine, general internal medicine,
general pediatrics or osteopathic medicine. Physicians who practice obstetrics and gynecology
may function as PCPs at the discretion of the contractor within their policy guidelines. MCO
participants are required to designate a PCP. The PCP is responsible for referring to specialists
and getting prior authorizations.
1002.171002.12
PROVIDER
See Chapter 100, Section 109 of the MSM for definition.
1002.18
REDETERMINATIONS (RD)
An annual review of a participant’s eligibility for NCU is required by federal regulation and is
completed in conjunction with the redetermination of all eligible members in the household.
1002.19
RE-EVALUATION
A Re-evaluation may be the result of a participant’s request for an eligibility review or change,
such as added or subtracted family members, income increases or decreases, etc., or may be the
result of information received/discovered by the DHCFP or their designated agent which indicates
that the household data was incorrect at the time of the last eligibility decision or that the
eligibility determination may not be accurate. Eligibility is determined based on new information
received for the case and appropriate notification is sent to the participant.
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1003.1
GOAL
POLICY
Nevada Check Up’s (NCU) primary focus is to provide affordable health care to children in
families who have incomes at or below 200% of the Federal Poverty Level (FPL). Our goal is to
ensure that, within the limits of the budget, every eligible child is enrolled and receiving care.
1003.1A
COVERAGE AND LIMITATIONS
Participants are covered for most medical care benefits established in the Nevada Medicaid plan.
If a family wishes to receive services not included in the Medicaid plan, the entire cost of the
service must be paid by the family. Such services must be agreed upon, in writing, between the
provider and the responsible adult seeking services for a NCU participant.
NCU does not offer retroactive coverage. Unlike Medicaid, services in NCU always begin the
first of the administrative month following approval and enrollment. The first of two exceptions
to this rule is a newborn whose family is already enrolled with NCU or whose mother received
prenatal care through the Health Insurance Flexibility and Accountability (HIFA) Waiver
Program and whose family has notified NCU of the child’s birth within 14 days following
delivery. See Section 1003.14.C. The second An exception to this rule is when a child returns to
NCU after being placed in the custody of an agency which provides child welfare services
pursuant to the provisions of Nevada Revised Statute (NRS) 62A.380 or 432.010 to 432.085. The
child will be re-enrolled if the return falls within the annual redetermination cycle that was
previously established for the case.
Child(ren) who are placed in the custody of an agency which provides child welfare services will
be terminated from NCU and referred to Medicaid, as the child(ren) would be Medicaid eligible
through the Division of Child and Family Services (DCFS). pursuant to the provisions of NRS
62A.380 or 432.010 to 432.085 will continue to be included as part of the household as long as
there is a reunification plan in place. Per NRS 432.085 the parents are liable for any expense
occurred by the agency that provides child welfare services while the child is in the custody of an
agency which provides child welfare services pursuant to the provisions of NRS 62A.380 or
432.010 to 432.085. Once the reunification plan is terminated, the child will be removed from the
household count at the time of the annual redetermination, unless the child has returned to the
household.
NCU accepts children with pre-existing conditions for enrollment into the insurance program.
There is no penalty or other distinction imposed on children who have medical or emotional
conditions prior to the family’s application to NCU.
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NCU is required by federal law to process all completed applications within 45 days of receipt.
An application must have a hand written signature or an electronic signature in order to be
processed.
Once determined eligible and enrolled, the family child(ren) is entitled to one year of insurance
coverage, as long as quarterly premiums are paid and the child(ren) continue to meet eligibility
requirements does not lose eligibility due to one of the following conditions. A child will lose
eligibility at any time under the following conditions: child dies; obtains other insurance; leaves
the home; leaves the state; or is incarcerated for a period more than 30 days; the child turns 19;
gets married or emancipated; voluntarily withdraws from NCU; enrolls in Medicaid, or additional
information is received that indicates the information NCU used at the time of the original
decision, to make the original decision, was incomplete or inaccurate and that negates the original
decision.
Redeterminations are scheduled annually, at which time documentation is required for new
income and previously unreported information on changes in family composition are required.
1003.1B
CLOSED ENROLLMENT/ENROLLMENT CAP
NCU will monitor the status of available State and Federal Children’s Health Insurance Program
(CHIP) funds. A period of closed enrollment and/or enrollment cap will be placed on the number
of new enrollees if it is necessary for the program to stay within available funds. Prior to
implementation of a period of closed enrollment and/or cap and waiting list, the state will:
1.
provide 30 days of public notice; and
2.
provide notification to Center for Medicare and Medicaid Services (CMS); and.
3.
terminate the HIFA waiver.
Once closed enrollment is in place or the enrollment cap is reached, new applications will
continue to be accepted through the normal processes. NCU eligibility would be run on all
applications. The application of individuals that appear to be eligible for Medicaid would be
forwarded to Medicaid for eligibility determination. Those applicants not eligible for NCU will be
denied with the appropriate reason. The applicants that are eligible for NCU but are not able to be
enrolled due to the closed enrollment/enrollment cap will be put on the wait list with a wait list
date equal to the date when NCU received the completed application. These applicants will be
notified of the closed enrollment/enrollment cap and entry onto the wait list.
On a monthly basis, NCU will make an assessment of the number of enrollees against the
appropriated funds for the program. As additional funds become available (either through attrition
of enrollees or more funding is identified) a determination will be made as to the number of new
enrollees that can be accommodated with the identified funds. The applicants on the wait list
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will be notified of the availability of coverage. Notifications will go out first to those applicants
with the earliest waitlist date; thus a first come, first served process. To update eligibility, if the
update is within the 12 month continuous coverage period, applicants would attest that there have
not been any changes to their family circumstances (e.g. number in household, income, insurance
status, and the like). If changes have occurred, the new information would be added into the NCU
database and eligibility re-determined.
Enrollees determined eligible prior to any closed enrollment period will not be impacted by this
particular change so long as they continue to pay premiums timely and comply with any requests
for information., including income, household, and citizenship verification. Enrollees who are
disenrolled from the program for failure to timely pay premiums or for failure to timely complete
their redetermination process or provide requested information will be precluded from
reenrollment during any closed enrollment period and will be added to the wait list.
1003.1C
PREMIUMS
Premium levels are broken out by <36% FPL, 36% through 150% FPL, 151% through 175% FPL
and 176% to 200% FPL. Premiums are due on the first day of each calendar quarter (January,
April, July and October), with the exception of newly enrolled participants, who are required to
pay their prorated quarterly premium within 10 days from the date of the enrollment notice.
Families are notified at the time of enrollment of the amount and due dates of their premium
payments and are billed quarterly. NCU allows a two month grace period beginning the first day
of any covered month in which the premium is intended. Premiums are charged per family and
not per child. Quarterly invoices are sent approximately three weeks prior to the premium due
date. If payment is not received by the due date, a late notice will be sent approximately one
month after the due date. If payment is not received, the children will be disenrolled at the end of
the two month grace period.Premiums are charged for participation in Nevada Check Up.
Premiums are charged per family not per child. NCU allows a two month grace period beginning
the first day of any covered month in which the premium is intended. The entity responsible for
premium payments will send premium reminders, late notices and final notices to inform eligible
families of their responsibility for payment. If payment is not received, the children will be
disenrolled at the end of the two month grace period.
By federal regulation, NCU is permitted to charge up to five percent of participating families’
income for cost sharing.
1003.1D
PROVIDER RESPONSIBILITY
A provider must be an active Nevada Medicaid service provider in order to use NCU insurance
for children enrolled in NCU. If the child is a member of one of the Managed Care Organization
(MCO) plans, the provider must be on the MCO’s panel or be an out-of-network provider who
has negotiated a contract with the MCO to furnish covered services.
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NCU providers must be as diligent in verifying participant eligibility as they would be if serving a
Medicaid recipient. See Medicaid Services Manual (MSM) Chapter 100., Section 103 of the
Medicaid Services Manual (MSM). Possession of a NCU card does not guarantee that the child is
still enrolled.
Providers are required to keep any records necessary to disclose the extent of services furnished to
participants and produce these records, upon request, to authorized personnel of the State.
If prior authorization is required for a service, the provider must request it and receive approval
before beginning the services.
Note: Prior authorizations for the MCO’s are established by each plan and enrollees are informed
of them through their Member Handbooks.
1003.1E
PARTICIPANT RESPONSIBILITY
Applicants or participants must cooperate in establishing eligibility with NCU staff in by
providing information related to family size, income, citizenship and other facts pertinent to
eligibility. Applicants or participants authorize the agency and its representatives NCU to make
any investigation concerning information supplied on the application or re-determination that is
necessary to determine eligibility. Applicants or participants consent to the release of such
information and must cooperate with the agency NCU staff and Medicaid/NCU investigators.
Failure to provide facts material to determining eligibility or to cooperate with investigation can
result in administrative actions, including but not limited to, disenrollment, and/or referral for
criminal prosecution.
Upon approval of eligibility for NCU, the family is enrolled for the next administrative month.
The NCU Application allows the applicant to choose an MCO in areas where managed care is
available. If no MCO is chosen, the family is auto-assigned to an MCO. NCU enrollees may
request disenrollment from the MCO without cause during the first 90 days of enrollment and are
required to contact the NCU office if they request disenrollment from the MCO and if he/she is a
mandatory recipient, must select another MCO. After the first 90 days of enrollment, the enrollee
will be locked into an MCO for 12 months. There will be one open enrollment period annually. If
the enrollee wishes to disenroll at any time during the 12 month lock-in period, they must contact
the appropriate MCO and provide good cause. The MCO will determine if it is good cause as
defined in 42 CFR 438.56. MCO changes will be effective the next administrative month. All
newly enrolled families are billed for the first quarterly premium.
Participants in NCU must receive care only from providers contracted by their MCO if enrolled in
an MCO plan or a Nevada Medicaid Provider if enrolled in a Fee For Service (FFS) plan. Parents
may be responsible for the cost of medical services received from out-of-network providers unless
the service is prior authorized.
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Parents or guardians of children participating in NCU must present the children’s insurance cards
when seeking services for the children. The provider may choose not to see the child if the parent
cannot produce a card to assist in determining current enrollment.
Parents or guardians of NCU insured children must be responsible to the medical providers in
keeping appointments and/or giving adequate notice of cancellation or rescheduling. Most
providers require 24-hour notice for cancellation or rescheduling of appointments.
Parents or guardians of NCU children may not allow any other individual to use their children’s
insurance card.Refer to MSM Chapter 100 for additional information regarding participant
responsibility.
1003.1F
MEDICAL CARE PAYMENTS
NCU’s Quality Improvement Organization (QIO)-like vendor or the participant’s MCO will
approve payment for NCU covered services determined to be medically necessary.
No payments will be made when a parent/guardian requests non-covered services. The provider is
not permitted to increase the level of service, bill insurance for the approved amount and allow
the parent to pay the difference. If a service or appliance is not approved, the entire cost is not
approved.
Claims for payment must be sent to NCU’s fiscal agent within 180 days of service. Out-of-state
providers are allowed up to one year to bill for their services.
NCU participants who reside in areas that have Division of Health Care Financing and Policy
(DHCFP) contracted MCO’s are enrolled in managed care plans. Their in-network medical care
claims are submitted to, and paid by, the MCO.Refer to MSM Chapter 100.
1003.2
CHOICE OF PROVIDER
Individuals eligible for, and enrolled in NCU who are in a FFS Plan have free choice of providers
from among those who have signed Nevada Medicaid provider contracts. Such choice is a matter
of mutual agreement between the patient and the provider and in no way abrogates the right of the
professional to accept or reject a given individual as his private patient or to limit his practice as
he chooses.
If participants are enrolled with an MCO, they must choose their provider from the panel
established by the MCO and must follow the MCO’s guidelines for medical care.Refer to MSM
Chapter 100.
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1003.3
POLICY
ELIGIBILITY
Families who apply for children’s health insurance coverage through NCU must:
a.
not be eligible for Medicaid;
b.
not have any other health insurance coverage for their children;
c.
have incomes of 200% or less of the FPL;
d.
have a child who is a citizen or Lawful Permanent Resident (LPR) who has met the 5-year
bar and can provide proof of legal status;
1.
e.
Exceptions to the 5-year bar are Iraqi and Afghan Special Immigrants who are
granted temporary eligibility during their initial 8 months (Iraqis) or 6 months
(Afghans), of Special Immigrant status. This time frame begins from their date of
U.S. entry as Special Immigrants or the date of their conversion to Special
Immigrant status. Once the 8 or 6 month period has been met, NCU eligibility will
cease, regardless of other program criteria. Eligibility for this population may
resume once the 5-year bar, citizenship or alien eligibility criteria are met. Special
Immigrants and family members who claim Special Immigrant status must provide
verification that they have been converted to this status or admitted under section
101(a)(27) of the Immigration and Nationality ACT (INA);
submit a family application which includes at least one child and at least one parent or
adult with responsibility for the child (Head of Household – HOH); and
f.
not be employed and not eligible for the plan from an organization that provides health
care coverage through a State health benefits plan (Public Employee Benefits Systems –
PEBS).
All eligibility functions for the Nevada Check Up program are now provided by the Division of
Welfare and Supportive Services (DWSS). Information regarding eligibility can be found in the
DWSS Eligibility and Payments (E&P) Manual.
1003.4
INCOME TYPES
The following income types are the common methods of calculating income. However in
determining income, each circumstance will vary and other methods of determining annual
income may be used to reflect accurate gross income.
a.
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Alimony – The regularity and timeliness of the payment is considered. Generally,
payments are considered irregular if three or more consecutive months are missed or if the
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amounts vary. In these situations, longer periods of time may be used to calculate the
income.
b.
Income from employment – Determine by using the gross weekly, bi-weekly, semimonthly, or monthly income, or averaging the year to date income based on number of
weeks paid. Bonus payments received during the year are to be included in the eligibility
calculations. If the nature of the employment is deemed seasonal/not regular, proof is
required from the employer stating the circumstance that exists.
Child Support – The regularity and timeliness of the payment is considered. Generally,
payments are considered irregular if three or more consecutive months are missed or if the
amounts vary. In these situations, longer periods of time may be used to calculate the
income. NCU will use the state automated system to verify child support being received as
the primary source of verification, whenever possible. Bank statements showing deposits,
copies of checks received or a notarized letter from a parent, caretaker, relative or legal
guardian paying support may also be used.
c.
Disability Income – NCU will request a copy of the current year’s award letter, or other
documentation that will confirm the current amount and frequency of the gross income.
Please note bank statements show net amount paid and are not acceptable forms of proof
for this income.
d.
Education Assistance – Any financial aid for vocational or educational courses from an
organization or a government program or agency must be considered in an eligibility
determination. Most educational assistance programs are administered through the U.S.
Office of Education under Title IV of the Higher Education Act. An Award Letter from
the educational source is an acceptable form of verification. Examples of the most
common Title IV educational assistance grants include the following:
e.
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1.
Stafford Loan Program;
2.
Parent Loans for Students (PLUS Loans);
3.
Supplemental Educational Opportunity Grants;
4.
College Work Study; and
5.
Carl D. Perkins Loans (Title IV, Part E) (formerly National Direct Student Loans).
Self Employment – A copy of the most recently filed federal income tax return is required
to determine self employment, capital gain, farm income, pensions, interest, royalties, etc.
The eligibility worker will determine the most accurate estimate of annual income. An
expense that is not validated and itemized will not be allowed. If the eligibility worker is
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not able to determine income based on the tax return provided, an SE-4 Monthly Expense
Form will be required to determine minimum monthly expenses and/or requirements. The
SE-4 Monthly Expense Form will also be requested if the most recent tax forms did not
include the self employment income (For example, a new business that was not in
business the previous year). Additional information may still be requested to determine
gross income.
f.
Unearned Income – This can consist of Social Security Income, Retirement Survivors
Disability Income, Retirement Pension, Veterans Benefits, Workers Compensation, etc.
All proof required for these sources of unearned income must be in the form of the current
year’s award letter or another acceptable document that shows gross amounts paid. Bank
statements or copies of disability checks show net amount paid and are not acceptable
forms of proof for this income.
g.
In-Kind Money – This can include but is not limited to Flexible Fringe Benefits such as
car payments, pastoral housing, and insurance payments etc., received by the applicant
from any source. Housing and Urban Development (HUD) Housing assistance is not
considered In-Kind Money.
h.
Cash Gifts/Contributions – Cash, gifts and/or contributions are considered income
received and used to assist in supporting the household, whether or not it is considered a
loan.
i.
Stipends – These will usually appear as lump sum amounts added to estimated annual
income and may be generated from a variety of sources and are usually a one-time
payment but can also be annual.
j.
Unemployment Compensation – A copy of the current award letter stating the weekly
benefit amount is an acceptable form of verification of unemployment compensation
received.
The above list is not all inclusive but is a fair representation of income sources used by NCU. In
certain circumstances, when stated sources are not available, other sources may be used at
management staff discretion.
1003.5
INCOME VERIFICATION
The following are examples of acceptable income verification documents that NCU may use:
a.
October 13, 2010
Tax Return – A complete copy of the most recent year’s tax return may be used.
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b.
Letter from Employer – In some circumstances, a current letter from the applicant’s
employer may be substituted for cash-paid employees, newly hired employees, to verify a
change in income, or any other circumstance that needs verification by the employer such
as elimination or reduction of overtime, reduction in regular hours, etc. The letter must
include the employee’s gross income per payroll period and the frequency of pay (weekly,
bi-weekly, etc.). If the letter states the employee’s hourly wage, it must also include the
average number of hours or expected number of hours worked in a pay period. If the
nature of employment is deemed seasonal, the employer can provide proof for accurate
adjustment. The letter must be on company letterhead and signed with the following
statement: “I declare under penalty of perjury under the laws of the State of Nevada that
the foregoing information is true and correct (NRS 199.120 through NRS 199.200 and
NRS 41.365).”
c.
Pay Stubs – Request copies of the two most current consecutive pay stubs at the date of
application to estimate the individual’s annual income. If the pay stubs provided are
current but not consecutive, the eligibility worker will calculate the missing pay stub,
should sufficient information be available to do so, and use that calculation in place of the
missing pay stub. If the pay amounts vary, the year-to-date or other period of time may be
used to determine the best estimate. At NCUs discretion, additional pay stubs or other
additional information may be requested on a case-to-case basis.
d.
SE-4 Monthly Budget Form – NCU uses this form to determine the minimum monthly
income of the household. This form is provided to the participant for completion to
itemize monthly bills and expenses when current documents (i.e., current tax return) are
not sufficient to determine gross income. NCU considers this the minimum amount
required to support the household each month.
e.
Financial Documents – Independent collateral information used in obtaining a loan may
be required. Financial documents may be used when current documents (i.e., current tax
return) are not sufficient to determine gross income. NCU may require such documents be
provided directly from the financial institution by which a recent purchase of a house, car
or financial loan was approved.
f.
Automated Government Databases – The automated State Child Support system is used to
verify child support payments made through the District Attorney’s office.
g.
Bank Statements – These documents are used to determine monthly cash deposits for
anyone receiving cash contributions, tips, income from sale of property, etc. They may not
be used to determine monthly payments from Social Security, Disability, Unemployment
Compensation or any other monthly income that may have deductions included, as the
bank statement shows only net amount paid.
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h.
POLICY
SE-11 Earnings Verification Information Necessary for a Federal Review of Federal Fund
Use – This form is sent directly to employers from NCU when all other means of
verification have failed. The SE-11 requests information on start and end dates of
employment; hours per week; rate of pay; pay periods; whether insurance is available
through the employer; the name of the carrier and dependants insured; and the employer
name, address, telephone number, and contact person.
The above list is not all inclusive but is a fair representation of income sources used by
NCU. In certain circumstances, when stated sources are not available, other sources may
be used at management staff discretion.
1003.6
NCU REFERRAL TO MEDICAID
If initial screening of the application indicates the family appears to meet eligibility criteria for
Medicaid, NCU enrollment is denied and a Medicaid referral letter is sent to the family. The case
is referred to the Division of Welfare and Supportive Services (DWSS) for eligibility
determination. Eligibility requirements are found in Chapter 100 of the MSM.
1003.7
MEDICAID REFERRAL TO NEVADA CHECK UP
Applications for Medicaid that have been processed by the DWSS and found to be ineligible for
Medicaid are referred to NCU. On a monthly basis, NCU electronically receives and evaluates
these referrals to determine if the applicant is eligible for NCU. NCU considers information in
these referrals to be verified by DWSS and will not require the applicants to verify information
again unless deemed questionable or the information is older than 90 days.
1003.8
CROWD OUT
If a family has had creditable private insurance coverage at the time of, or within six months of,
applying for NCU, the application must be denied. There are a few exceptions to this regulation.
These include insurance coverage that was terminated due to the following reasons:
a.
Loss of employment other than voluntary termination;
b.
Death of the parent who was responsible for insurance coverage;
c.
Change to new employment that does not provide an option for dependant coverage;
d.
Change of address that results in no employer-sponsored coverage;
e.
Discontinuation of health benefits to all employees of the applicant’s employer;
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f.
Expiration of coverage periods established by the Consolidated Omnibus Reconciliation
Act of 1985 (COBRA);
g.
Self-employment;
h.
Termination of health benefits due to a long-term disability;
i.
Termination of dependant coverage due to an extreme economic hardship on the part of
either the employee or the employer.
j.
Extreme financial hardship related to the cost of premiums, deductible payments, and/or
co-payments.
OUTREACH
NCU applications are available in many places. Doctors’ offices, emergency rooms, Family
Resource Centers, schools and other state agencies carry supplies of applications. The program
website, http://nevadacheckup.nv.gov includes both a printable and electronic application each
available in Spanish and English.
1003.10
DISENROLLMENT FOR NON-PAYMENT OF PREMIUM
Families will be disenrolled if they are past due on their premium payment. Prior to disenrollment
the Division will provide notice to the families that their payments are past due and they will be
disenrolled if payment is not received. The Division will make reasonable efforts to notify the
affected family of the disenrollment decision prior to disenrollment. The notice will include
written correspondence to the family's last known address. The notice of disenrollment includes
the date of disenrollment. The family may have the right to contest the Division's action. (See
section 1003.1D).
1003.111003.4
DEBT COLLECTION/ OVERPAYMENTS
Per NRS 422.410, NCUthe DHCFP or the DWSS will collect all debt owed by the participant for
any reason, including but not limited to the following:
a.
Agency error;
b.
Participant failure to pay insurance premiums; or
c.
Ineligibility of participant – including attempts to defraud the program.
To the extent allowable by law, NCU will pursue all available avenues to collect overpayment, up
to and including referral to a collection agency and/or referral to prosecutorial agency. In addition,
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if an enrollee has a prior outstanding bad debt with NCU, they will be deemed to be ineligible
until such bad debt is either paid, or sufficient payment arrangements are made with NCU.
Also refer to the DWSS Eligibility and Payments (E&P) Manual B900 Program
Violation/Sanctions.
1003.121003.5
IMMUNIZATIONS/WELL CHILD CARE
NCU encourages families to immunize their children at appropriate times. The program also
encourages families to seek preventive care through Well Child Visits to their primary care
providers.
1003.13
NOTIFICATION OF ADVERSE ACTION
Families of NCU enrolled children are provided written notice of any adverse action regarding
eligibility and enrollment. The notice includes instructions on how to request a review and
information on accessing the fair hearing process. Families are also informed that they have the
right to request continuation of services pending the outcome of the review and hearing process.
NCU complies with the requirements of Chapter 3100 of the MSM.
1003.141003.6
DIFFERENCES BETWEEN NEVADA CHECK UP AND MEDICAID
Below are major areas where Medicaid policy and NCU policy differ.
a.
Residential Treatment Centers (RTC) – In NCU, for participants enrolled in an MCO, it
remains the MCO’s responsibility to provide reimbursement for all medical care
(physician, optometry, laboratory, dental and x-ray services, etc.) for participants who are
receiving services in an RTC. The RTC bed day rate is covered by FFS.
In Medicaid, those who are admitted to ana RTC are disenrolled from the MCO and
receive all Medicaid-covered services as FFS recipients.
b.
Severely Emotionally Disturbed (SED)/Severely Mentally Ill (SMI) – In NCU, for
participants enrolled in an MCO, it remains the MCO’s responsibility to provide
evaluation and medically appropriate services.
In Medicaid, once a diagnosis of SED or SMI is confirmed through evaluation, a recipient
may elect to disenroll from the MCO and the MCO must notify the DHCFP of such
election.
c.
August 24, 2011
Newborns – In NCU, if a family is expecting a child, whether the pregnant female is an
adult or one of the enrolled children, NCU must be notified within 14 days of the birth.
When the child is born and NCU is notified, the newborn will be eligible to receive
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services as of the date of birth and will be immediately assigned to the family’s previously
designated MCO if residing in a mandatory MCO coverage area. Exception: if the mother
has other health insurance coverage that provides for 30 days of coverage for the newborn,
the newborn will be enrolled as of the first day of the next administrative month following
the date of birth. If the notification criterion is not met, the child will be added the next
administrative month following notification. A newborn cannot be enrolled before a
family’s start date.
d.c.
1003.151003.7
Non-Emergency Transportation (NET) – NCU does not cover NET.
CONFIDENTIALITY
A.
All information related to a family’s application for NCU is private and will not be shared
with any person other than a person to whom the family has provided written permission
to receive such information. NCU complies with the Health Insurance Portability and
Accountability Act (HIPAA) requirements in relation to the privacy of medical
informationRefer to MSM Chapter 100.
B.
Medical information received on a participant will not be shared with anyone, including
the participant and designated representative. If the participant and/or representative
requests information regarding a medical condition, the physician providing such care is
the one who must be consulted.
C.
Medical information, regardless of the source, may be shared within the Department of
Health and Human Services (DHHS) without a formal release. However, any other agency
wishing copies of medical information must submit a release, signed by the legal guardian
of the participant, stating what information is requested.
D.
The exception to this policy is in the case of a hearing. NCU information, presented at a
hearing and constituting the basis of a decision, will be open to examination by the
participant’s guardian and/or designated representative.
E.
Medical providers will not disclose information concerning the care or services given to
participants except as specifically allowed by state and federal laws and regulations.
1003.161003.8
INVESTIGATIONS
NCUThe DHCFP is required to investigate reports of possible fraud or abuse within the NCU
program. Investigation results substantiating fraud or abuse will be used for determination of
imposition of administrative actions or referral to appropriate law enforcement officials (42 CFR
§ 457.915). Administrative actions include denial of eligibility, termination of enrollment or debt
collection.
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1003.17
POLICY
HEARING PREPARATION MEETING (HPM)
A.
Notification of the Right to a Fair Hearing
B.
Applicants and participants must be informed, in writing, of their right to a Fair Hearing at
the time of application and at any time an action is taken that adversely affects their NCU
coverage. As part of the Fair Hearing process, an HPM will be conducted. An HPM is an
informal mediation between the appointed HPM designee and the applicant or participant
to review the applicant or participant’s case and make every effort to reconcile the
disagreement without the necessity of a Fair Hearing.
Hearing Preparation Meeting Designee Responsibilities
C.
D.
1.
HPM designees are assigned on a case to case basis;
2.
The HPM designee is an impartial individual who may be an employee of the
DHCFP but shall not have been associated with the decision in question;
3.
It is the HPM designee’s responsibility to:
a.
b.
hear verbal testimony and document evidence from all parties involved;
document the HPM proceedings;
c.
limit the inclusion of any unnecessary information;
d.
ensure the agency took appropriate action based on program policy and
evidence presented; and
e.
if the HPM designee determines the action to be appropriate, he/she will
advise the applicant/participant of the subsequent proceedings.
Agency Responsibilities
1.
It is the agency’s responsibility to contact the client to schedule a conference
within ten (10) calendar days following the receipt of a Fair Hearing request; and
2.
Conduct the HPM within twenty-one (21) business days following receipt of the
Fair Hearing request and provide an explanation and supporting policy to
substantiate the agency’s decision.
Client Responsibilities
It is the client’s responsibility to timely provide testimony and documentation to support
their position.
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1003.18
POLICY
HEALTH SERVICE MATTERS
Please refer to Chapter 3100, MSM, for hearings information for health service matters.
October 13, 2010
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1004
HEARINGS
HEARINGS
A.
Please refer to the Division of Welfare and Supportive Services (DWSS) Administrative
Manual Section B100 Chapter 3100, Medicaid Services Manual for hearings information
for eligibility determination issues.
B.
Please refer to Medicaid Service Manual (MSM) Chapter 3100, for hearings information
for health care service matters.
January 18, 2008
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1005
1005
REFERENCES AND CROSS REFERENCES
Policy Resources - Medicaid Service Manuals (MSM) as follows:
100
200
300
400
500
600
700
800
900
1000
1100
1200
1300
1400
1500
1600
1700
1800
1900
2000
2100
Medicaid Program
Hospital Services
Radiology Services
Mental Health & Alcohol/Substance Abuse Services
Nursing Facilities
Physician Services
Rates and Cost Containment
Laboratory Services
Private Duty Nursing
Dental
Ocular Services
Prescribed Drugs (Rx)
Durable Medical Equipment (DME)
Home Health Agency
Healthy Kids Program (EPSDT)
Intermediate Care for the Mentally Retarded
Therapy
Adult Day Health Care
Transportation
Audiology Services
Home and Community Based Waiver (HCBW) for Persons with Mental Retardation and
Related Conditions
2200 Home and Community Based Waiver (HCBW) for the Frail Elderly
2300 Home and Community Based Waiver (HCBW) for Persons with Physical Disabilities
2400 Comprehensive Outpatient Rehabilitation (COR) Services
2500 Case Management
2600 Intermediary Service Organization
2800 School Based Child Health Services
3100 Hearings
3200 Hospice Services
3300 Program Integrity
3400 Telehealth
3500 Personal Care Aid Program (PCA)Services (PCS) Program
3600 Managed Care Program (MCO)
3900 Home and Community Based Waiver (HCBW) for Assisted Living
Addendum
MSM Definitions
October 13, 2010
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1005.1
1005
MAGELLAN MEDICAID ADMINISTRATION, INCORPORATED
PROVIDER RELATIONS UNITS
Provider Relations Department
Magellan Medicaid Administration, Inc.
PO Box 30026
Reno, NV 89520-3026
Toll Free within Nevada (877) NEV-FHSC (638-3472)
PRIOR AUTHORIZATION DEPARTMENTS
Magellan Medicaid Administration, Inc.
Nevada Medicaid and Nevada Check Up
HCM
4300 Cox Road
Glen Allen, VA 23060
(800) 525-2395
PHARMACY POINT-OF-SALE DEPARTMENT
Magellan Medicaid Administration, Inc.
Nevada Medicaid Paper Claims Processing Unit
PO Box C-85042
Richmond, VA 23261-5042
(800) 884-3238
FISCAL AGENT CONTACT INFORMATION
PROVIDER RELATIONS UNITS (Enrollment/Claims Issues/Questions)
Hewlett Packard Enterprise Services (HPES)
PO Box 30042
Reno, NV 89520-3042
Toll Free within Nevada (877) 638-3472
ELECTRONIC BILLING
HPES
EDI Coordinator
P.O. Box 30042
Reno, NV 89520-3042
Telephone: (877) 638-3472 (select option for "Electronic Billing")
Fax: (775) 335-8594
E-mail: http://medicaid.nv.gov
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PRIOR AUTHORIZATION FOR DENTAL AND PERSONAL CARE AIDE
Mailing Address:
"Dental PA" or "PCA PA"
P.O. Box 30042
Reno, NV 89520-3042
Telephone: (800) 648-7593
Fax: (775) 784-7935
PRIOR AUTHORIZATION FOR ALL OTHER SERVICE TYPES (except Pharmacy)
Telephone: (800) 525-2395
Fax: (866) 480-9903
PHARMACY
Clinical Call Center
Pharmacy prior authorization requests
Telephone: (877) 638-3472
Fax: (855) 455-3303
Technical Call Center
General pharmacy inquiries
Telephone: (866) 244-8554
THIRD PARTY LIABILITY (TPL) UNIT
Emdeon TPL Unit
P.O. Box 148850
Nashville, TN 37214
Phone: (855) 528-2596
Fax (855) 650-5753
Email: [email protected]
MANAGED CARE ORGANIZATIONS
AMERIGROUP Community Care
Physician Contracting
Phone: (702) 228-1308, ext. 59840
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Provider Inquiry Line
(for eligibility, claims and pre-certification)
Phone: (800) 454-3730
Notification/Pre-certification
Phone: (800) 454-3730
Fax: (800) 964-3627
Claims Address:
AMERIGROUP Community Care
Attn: Nevada Claims
P.O. Box 61010
Virginia Beach, VA 23466-1010
HEALTH PLAN OF NEVADA (HPN)
Phone: (800) 962-8074
Fax: (702) 242-9124
Claims Address:
Health Plan of Nevada
P.O. Box 15645
Las Vegas, NV 89114
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MEDICAID SERVICES MANUAL
TRANSMITTAL LETTER
August 14, 2014
TO:
CUSTODIANS OF MEDICAID SERVICES MANUAL
FROM:
LAURIE SQUARTSOFF, ADMINISTRATOR
SUBJECT:
MEDICAID SERVICES MANUAL CHANGES
CHAPTER 400 – MENTAL HEALTH AND ALCOHOL/SUBSTANCE
ABUSE SERVICES
BACKGROUND AND EXPLANATION
Changes are being proposed to the Medicaid Services Manual (MSM) Chapter 400 to allow for
coverage of prior authorized (PA), medically necessary inpatient detoxification and treatment
services beyond the current five day limit for recipients age 21 years and older. This revision is
being made to comply with the Mental Health Parity and Addiction Equity Act.
Verbiage is being removed regarding provider qualifications that are duplicative language in
MSM Chapter 100. No changes to this policy are being made.
Proposed revision to Attachment C include removing the prior authorization requirement from
crisis intervention and screening services and to add crisis intervention services as a service
option as a Level 1 outpatient services.
These changes are effective September 1, 2014.
MATERIAL TRANSMITTED
CL 27959
MENTAL HEALTH AND ALCOHOL/
SUBSTANCE ABUSE SERVICES
Manual Section
Section Title
403.6A.1.d
Rehabilitation
Mental Health
(RMH) Services
MATERIAL SUPERSEDED
MTL 06/11, MTL 13/13
MENTAL HEALTH AND ALCOHOL/
SUBSTANCE ABUSE SERVICES
Background and Explanation of Policy Changes,
Clarifications and Updates
Deleted
language
regarding
felonies
and
misdemeanors within seven years to align with MSM
Chapter 100. Added language referencing MSM
Chapter 100, Conditions of Participation for All
Providers.
Page 1 of 2
Manual Section
Section Title
403.10A.1.a.2
Inpatient
Alcohol/Substance
Abuse
Detoxification and
Treatment Services
Added language that Medicaid covers Medicaid
covers stays beyond five days only if additional
detoxification services are deemed medically
necessary the QIO-like vendor.
Added language that Medicaid covers Medicaid
covers stays beyond 21 days are covered only if the
additional treatment services are deemed medically
necessary by the QIO-like vendor.
403.10A.1.b.2
Attachment C
Background and Explanation of Policy Changes,
Clarifications and Updates
Substance Abuse
Agency Model
Level of Care Grid
Added policy allowing 24 hour crisis intervention
services in all levels of service.
Clarified language that prior authorization is
required on services, except for; Behavioral
Health/Substance Abuse Screens and 24 hour crisis
intervention screens.
Clarified language that post authorization that is not
required for 24 hour crisis intervention.
Page 2 of 2
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Subject:
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4.
POLICY
Interns/Psychological Assistants
The following are also considered QMHPs:
a.
Licensed Clinical Social Worker (LCSW) Interns meet the requirements
under a program of internship and are licensed as an intern pursuant to the
State of Nevada, Board of Examiners for Social Workers (Nevada
Administrative Code (NAC) 641B).
b.
Licensed Marriage and Family Therapist (LMFT) and Licensed Clinical
Professional Counselor Interns who meet the requirements under a program
of internship and are licensed as an intern pursuant to the State of Nevada
Board of Examiners for Marriage and Family Therapists and Clinical
Professional Counselors.
c.
Psychological Assistants who hold a doctorate degree in psychology, is
registered with the State of Nevada Board of Psychological Examiners
(NAC 641.151) and is an applicant for licensure as a Licensed Clinical
Psychologist who has not yet completed the required supervised
postdoctoral experience approved by the Board.
Reimbursement for Interns/Psychological Assistants is based upon the rate
of a QMHP, which includes the clinical and direct supervision of services
by a licensed supervisor.
403.4
OUTPATIENT MENTAL HEALTH SERVICES
These services include assessment and diagnosis, testing, basic medical and therapeutic services,
crisis intervention, therapy, partial and intensive outpatient hospitalization, medication
management and case management services.
a.
September 1, 2013
Assessments are covered for problem identification (diagnosis) and to establish
measurable treatment goals and objectives by a QMHP or designated QMHA in the case
of a Mental Health Screen.
1.
Mental Health Screen – A behavioral health screen to determine eligibility for
admission to treatment program.
2.
Comprehensive Assessment – A comprehensive, evaluation of a recipient’s history
and functioning which, combined with clinical judgment, is to conclude with a
DSM 5-axial diagnosis or DC:0-3 and a summary of identified rehabilitative
treatment needs.
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3.
Health and Behavior Assessment – Used to identify the psychological, behavioral,
emotional, cognitive and social factors important to the prevention, treatment or
management of physical health needs. The focus of the assessment is not on the
mental health needs, but on the biopsychosocial factors important to physical
health needs and treatments. The focus of the intervention is to improve the
recipient’s health and well-being utilizing cognitive, behavioral, social and/or
psycho-physiological procedures designed to ameliorate specific disease related
needs. This type of assessment is covered on an individual basis, family with the
recipient present or family without the recipient present.
4.
Psychiatric Diagnostic Interview – Covered once per calendar year without prior
authorization. If there is a substantial change in condition, subsequent assessments
may be requested through a prior-authorization from the QIO-like vendor for
Nevada Medicaid. A psychiatric diagnostic interview may consist of a clinical
interview, a medical and mental history, a mental status examination, behavioral
observations, medication evaluation and/or prescription by a licensed psychiatrist.
The psychiatric diagnostic interview is to conclude with a written report which
contains a DSM 5-axial diagnosis and treatment recommendations.
5.
Psychological Assessment – Covered once per calendar year without prior
authorization. If there is a substantial change in condition, subsequent assessments
may be requested through a prior-authorization from the QIO-like vendor for
Nevada Medicaid. A psychological assessment may consist of a clinical interview,
a biopsychosocial history, a mental status examination and behavioral
observations. The psychological assessment is to conclude with a written report
which contains a DSM 5-axial diagnosis and treatment recommendations.
6.
Functional Assessment - Used to comprehensively evaluate the recipient’s skills,
strengths and needs in relation to the skill demands and supports required in the
particular environment in which the recipient wants or needs to function; as such,
environment is consistent with the goals listed in the recipient’s individualized
Treatment Plan. A functional assessment is used to assess the presence of
functional strengths and needs in the following domains: vocational, education,
self-maintenance, managing illness and wellness, relationships and social.
A person-centered conference is covered as part of the functional assessment to
collaboratively develop and communicate the goals and objectives of the
individualized Treatment Plan. The conference must include the recipient, a
QMHP, family or legal representative, significant others and case manager(s). The
case manager(s) or lead case manager, if there are multiple case managers shall
provide advocacy for the recipient’s goals and independence, supporting the
recipient’s participation in the meeting and affirming the recipient’s dignity and
rights in the service planning process.
September 1, 2013
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September 1, 2013
POLICY
7.
Intensity of Needs Determination - A standardized mechanism to determine the
intensity of services needed based upon the severity of the recipient’s condition.
The intensity of needs determination is to be utilized in conjunction with the
clinical judgment of the QMHP and/or trained QMHA. This assessment was
previously known as a level of care assessment. Currently, the DHCFP recognizes
the Level of Care Utilization System (LOCUS) for adults and the Child and
Adolescent Screening Intensity Instrument (CASII) for children and adolescents.
There is no level of care assessment tool recognized by the DHCFP for children
below age six, however, providers must utilize a tool comparable to the CASII and
recognized as a standard of practice in determining the intensity of needs for this
age group.
8.
Severe Emotional Disturbance (SED) Assessment - Covered annually or if there is
a significant change in functioning. The SED assessment is a tool utilized to
determine a recipient’s eligibility for higher levels of care and Medicaid service
categories.
9.
Serious Mental Illness (SMI) Assessment - Covered annually or if there is a
significant change in functioning. The SMI assessment is a tool utilized to
determine a recipient’s eligibility for higher levels of care and Medicaid service
categories.
10.
Global Assessment of Functioning (GAF) Scale: GAF ratings are based on clinical
judgment; GAF ratings measure overall psychological functioning and psychiatric
disturbances; and are used to collaborate Intensity of Needs Determinations. The
GAF scale is located in DSM-IV.
Neuro-Cognitive, Psychological and Mental Status Testing
1.
Neuropsychological Testing with interpretation and report involves assessment and
evaluation of brain behavioral relationships by a neuropsychologist. The
evaluation consists of qualitative and quantitative measurement that consider
factors such as the interaction of psychosocial, personality/emotional, intellectual,
environmental, neurocognitive, biogenetic, and neurochemical aspects of
behaviors in an effort to understand more fully the relationship between
physiological and psychological systems. This service requires prior authorization
from the QIO-like vendor.
2.
Neurobehavioral Testing with interpretation and report involves the clinical
assessment of thinking, reasoning and judgment, acquired knowledge, attention,
memory, visual spatial abilities, language functions and planning. This service
requires prior authorization.
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Prior Authorization may be requested from the QIO-like vendor for additional
assessment and therapy services for Level III and above only.
D.
a.
Service provision is based on the calendar year beginning on January 1.
b.
Sessions indicates billable codes for this service may include occurrence
based codes, time-based, or a combination of both. Session = each time this
service occurs regardless of the duration of the service.
Non-Covered OMH Services
The following services are not covered under the OMH program for Nevada Medicaid and
NCU:
1.
Services under this chapter for a recipient who does not have a DSM or DC:0-3
diagnosis;
2.
Therapy for marital problems without a DSM diagnosis;
3.
Therapy for parenting skills without a DSM diagnosis;
4.
Therapy for gambling disorders without a DSM diagnosis;
5.
Custodial services, including room and board;
6.
Support group services other than Peer Support Services;
7.
More than one provider seeing the recipient in the same therapy session;
8.
Services not authorized by the QIO-like vendor if an authorization is required
according to policy; and
9.
Respite.
403.6
PROVIDER QUALIFICATIONS
403.6A
REHABILITATION MENTAL HEALTH (RMH) SERVICES
RMH services may be provided by specific providers who meet the following qualifications for
an authorized service:
1.
July 22, 2011
QBA - Is a person who has an educational background of a high-school diploma or
General Education Development (GED) equivalent and has been determined competent by
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the overseeing Clinical Supervisor, to provide RMH services. These services must be
provided under direct contract with a BHCN or Independent RMH provider. A QBA must
have the documented competencies to assist in the provision of individual and group
rehabilitative services under the Clinical Supervision of a QMHP and the Direct
Supervision of a QMHP or QMHA.
a.
b.
QBAs must also have experience and/or training in service provision to people
diagnosed with mental and/or behavioral health disorders and the ability to:
1.
read, write and follow written and oral instructions;
2.
perform RMH services as prescribed on the Rehabilitation Plan;
3.
identify emergency situations and respond accordingly;
4.
communicate effectively;
5.
document services provided; and
6.
maintain recipient confidentiality.
Competency and In-services Training
1.
July 22, 2011
Before QBAs can enroll as Medicaid providers, they are required to
successfully complete an initial 16-hour training program. This training
must be interactive, not solely based on self-study guides or videotapes, and
should ensure that a QBA will be able to interact appropriately with
individuals with mental health disorders. At a minimum, this training must
include the following core competencies:
a.
Case file documentation;
b.
Recipient's rights;
c.
Client confidentiality pursuant to state and federal regulations;
d.
Communication skills;
e.
Problem solving and conflict resolution skills;
f.
Communication techniques for individuals with communication or
sensory impairments;
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2.
3.
July 22, 2011
POLICY
g.
Cardio Pulmonary Resuscitation (CPR) certification (certification
may be obtained outside the agency); and
h.
Understanding the components of a Rehabilitation Plan.
QBAs must also receive, at a minimum, 2 hours of quarterly in-service
training. At a minimum, this training must include any combination (or
single competency) of the following competencies:
a.
Basic living and self-care skills: The ability to help recipients learn
how to manage their daily lives, recipients learn safe and
appropriate behaviors;
b.
Social skills: The ability to help recipients learn how to identify and
comprehend the physical, emotional and interpersonal needs of
others - recipients learn how to interact with others;
c.
Communication skills: The ability to help recipients learn how to
communicate their physical, emotional and interpersonal needs to
others – recipients learn how to listen and identify the needs of
others;
d.
Parental training: The ability to facilitate parents’ abilities to
continue the recipient’s (child’s) RMH care in home and
community-based settings.
e.
Organization and time management skills: The ability to help
recipients learn how to manage and prioritize their daily activities;
and/or
f.
Transitional living skills: The ability to help recipients learn
necessary skills to begin partial-independent and/or fully
independent lives.
For QBAs whom will also function as Peer-to-Peer Supporters, their
quarterly in-service training must also include, at a minimum, any
combination (or single competency) of the following competencies:
a.
The ability to help stabilize the recipient;
b.
The ability to help the recipient access community based mental
and/or behavioral health services;
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c.
The ability to assist during crisis situations and interventions;
d.
The ability to provide preventative care assistance; and/or
e.
The ability to provide personal encouragement, self-advocacy, selfdirection training and peer mentoring.
c.
Applicants must have a FBI criminal background check before they can enroll with
Nevada Medicaid as QBAs. Applicants must submit the results of their criminal
background checks to the overseeing BHCN and/or the Individual RMH provider
(who must also be a Clinical Supervisor). The BHCN and/or the Individual RMH
provider must maintain both the requests and the results with the applicant’s
personnel records. Upon request, the BHCN and/or the Individual RMH provider
must make the criminal background request and results available to the Nevada
Medicaid (DHCFP) for review.
d.
Individuals who have been convicted of any of the following felonies or
misdemeanors under federal or state law within the last 7 years for which DHCFP
has determined to be inconsistent with the best interests of recipients are excluded
from eligibility for qualification as a provider of services covered in this chapter.
Refer to Medicaid Services Manual (MSM) Chapter 100 under Conditions of
Participation for All Providers. In addition, the following criteria will exclude
applicants from becoming an eligible provider:
The applicant or contractor has been convicted of:
September 1, 2013
1.
murder, voluntary manslaughter or mayhem;
2.
assault with intent to kill or to commit sexual assault or mayhem;
3.
sexual assault, statutory sexual seduction, incest, lewdness, indecent
exposure or any other sexually related crime;
4.
abuse or neglect of a child or contributory delinquency;
5.
a violation of any federal or state law regulating the possession, distribution
or use of any controlled substance or any dangerous drug as defined in
chapter 454 of Nevada Revised Statutes (NRS);
6.
a violation of any provision of NRS 200.700 though 200.760;
7.
criminal neglect of a patient as defined in NRS 200.495;
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8.
any offense involving fraud, theft, embezzlement, burglary, robbery,
fraudulent conversion or misappropriation of property;
9.
any felony involving the use of a firearm or other deadly weapon;
10.
abuse, neglect, exploitation or isolation of older persons;
11.
kidnapping, false imprisonment or involuntary servitude;
12.
any offense involving assault or battery, domestic or otherwise;
13.
conduct inimical to the public health, morals, welfare and safety of the
people of the State of Nevada in the maintenance and operation of the
premises for which a provider contract is issued
14.1.
Cconduct or practice detrimental to the health or safety of the occupants or
employees of the facility or agency;
15.2.
Aany other offense determined by DHCFP to be inconsistent with the best
interest of all recipients.
The BHCN or Independent RMH provider upon receiving information resulting
from the FBI criminal background check, or from any other source, may not
continue to employ a person who has been convicted of an offense as listed above.,
and as cited within MSM Chapter 100. If an applicant believes that the information
provided as a result of the FBI criminal background check is incorrect, he or she
must immediately inform the BHCN or Independent RMH provider, or DHCFP
(respectively) in writing. The BHCN or Independent RMH provider or DHCFP,
that is so informed within 5 days, may give the employee or independent
contractor a reasonable amount of time, but not more than 60 days, to provide
corrected information before denying an application, or terminating the
employment or contract of the person pursuant to this section.
September 1, 2013
e.
Have had tuberculosis (TB) tests with negative results documented or medical
clearance as outlined in NAC 441.A375 prior to the initiation of service delivery.
Documentation of TB testing and results must be maintained in the BHCN or
Independent RMH provider personnel record. TB testing must be completed
initially and annually thereafter. Testing and surveillance shall be followed as
outlined in NAC 441A.375.3.
f.
The purpose of the annual training is to facilitate the development of specialized
skills or knowledge not included in the basic training and /or to review or expand
skills or knowledge included in the basic training. Consideration must be given to
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Inpatient freestanding psychiatric and/or alcohol/substance abuse hospitals and general
acute hospitals with a psychiatric and/or substance abuse unit are reimbursed a per diem,
all inclusive prospective daily rate determined and developed by the Nevada DHCFP’s
Rate Development and Cost Containment Unit. (Days certified as administrative are paid
at the all-inclusive prospective administrative day rate.)
For claims involving Medicare crossover, Medicaid payment is the lower of the Medicare
deductible amount or the difference between the Medicare payment and the Medicaid per
diem prospective payment. (Medicare crossover claims involving recipient’s ages 21 to 64
in freestanding psychiatric hospitals are reimbursable only if the recipient is a QMB.)
Also, additional Medicaid reimbursement is not made when the Medicare payment
exceeds the Medicaid prospective rate. Service claims denied by Medicare are also denied
by Medicaid.
403.10
INPATIENT ALCOHOL/SUBSTANCE ABUSE DETOXIFICATION AND TREATMENT
SERVICES POLICY
Inpatient substance abuse services are those services delivered in freestanding substance abuse
treatment hospitals or general hospitals with a specialized substance abuse treatment unit which
includes a secure, structured environment, 24-hour observation and supervision by mental health
substance abuse professionals and a structured multidisciplinary clinical approach to treatment.
These hospitals provide medical detoxification and treatment services for individuals suffering
from acute alcohol and substance abuse conditions.
403.10A
COVERAGE AND LIMITATIONS
1.
Hospital inpatient days may be considered a Medicaid benefit when detoxification and
treatment for acute alcohol and/or other substance abuse necessitates the constant
availability of physicians and/or medical services found in the acute hospital setting.
Medicaid reimburses for admissions to substance abuse units of general hospitals
(regardless of age), or freestanding psychiatric and substance abuse hospitals for recipients
age 65 and older, or those under age 21. The QIO-like vendor must prior authorize and
certify all hospital admissions for both detoxification and treatment services to verify
appropriateness of placement and justify treatment and length of stay.
Prior authorization is required for all Medicaid and pending Medicaid recipients, and
Medicaid recipients covered through primary insurance, except Medicare Part A. If
this is the case then authorization may need to be sent through Medicare.
Medicaid reimburses only for the following hospital alcohol/substance abuse
detoxification and treatment services:
July 22, 2011
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a.
b.
POLICY
Detoxification
1.
Recipients (under age 21) - Medicaid reimburses for up to five (5) hospital
inpatient detoxification days with unlimited lifetime admission services
(Medicaid covers stays beyond five days only if additional detoxification
services are deemed medically necessary by the QIO-like vendor).
2.
Recipients age 21 years and older - Medicaid reimburses for up to five (5)
hospital inpatient detoxification days with unlimited lifetime admission
services. (Medicaid covers stays beyond five days only if additional
detoxification services are deemed medically necessary by the QIO-like
vendor).
3.
For recipients of all ages, results of a urine drug screen or blood alcohol
test must be provided at the time of the initial request for authorization.
Treatment
1.
Recipients (under age 21) - Medicaid reimburses for up to 21 hospital
inpatient treatment days with unlimited lifetime admission services until
the recipient reaches age 21 (stays beyond 21 days are covered only if
additional treatment services are deemed medically necessary by the QIOlike vendor).
2.
Recipients age 21 years and older - Medicaid reimburses for up to 21
hospital treatment days with unlimited lifetime admissions only if the
recipient is deemed amenable for treatment, and has the potential to remain
sober, and as determined by the physician. (Stays beyond 21 days are
covered only if the additional treatment services are deemed medically
necessary by the QIO-like vendor).
To measure the recipient's ability to be amenable to treatment and the
potential to remain sober, he/she must:
July 22, 2011
a.
Be currently attending, or willing to attend during treatment and
upon discharge, and actively participate in Alcoholics Anonymous
(AA) and/or Narcotics Anonymous (NA) meetings.
b.
Develop, over the duration of treatment, a support system to assist
sobriety efforts and a substance abuse-free lifestyle.
MENTAL HEALTH AND ALCOHOL/SUBSTANCE
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ATTACHMENT C
SUBSTANCE ABUSE AGENCY MODEL LEVEL OF CARE GRID
Level of Care
Level 0.5
Early
Intervention/
Prevention
Covered Services
Description of Treatment Level
Prevention
1. Screening services recommended by the A. DEPRESSION SCREENING
U.S. Preventive Services Task Force:
Adults: Many formal screening tools are
a. Depression screening in adults and
available, including instruments designed
adolescents.
specifically for older adults. (See Policy,
page 4) Asking two simple questions
b. Alcohol
screening
in
adults,
about mood and anhedonia ("Over the
including pregnant women.
past two weeks, have you felt down,
depressed, or hopeless?" and "Over the
past two weeks, have you felt little
c. Tobacco
use
counseling
and
interest or pleasure in doing things?") may
interventions for pregnant women.
be as effective as using more formal
2. Must be direct visualization. Self-screens
instruments (2). There is little evidence to
recommend one screening method over
and over the phone are non-covered.
another; therefore, clinicians may choose
the method most consistent with their
personal preference, the patient population
being served, and the practice setting.
Utilization Management
No prior
required.
authorization
Limited to one screen per
90 days per disorder.
All positive screening tests should trigger
full diagnostic interviews that use
standard diagnostic criteria (that is, those
from the updated Diagnostic and
Statistical Manual of Mental Disorders,
Fourth Edition) to determine the presence
or absence of specific depressive
disorders, such as MDD or dysthymia.
The severity of depression and comorbid
psychological problems (for example,
anxiety, panic attacks, or substance abuse)
should be addressed.
January 10, 2014
BEHAVIORAL HEALTH AND SUBSTANCE ABUSE SERVICES
Attachment C Page 1
ATTACHMENT C
SUBSTANCE ABUSE AGENCY MODEL LEVEL OF CARE GRID
Level of Care
Covered Services
Level 0.5
Early
Intervention/
Prevention
(Continued)
Description of Treatment Level
Utilization Management
Prevention
Adolescents: Instruments developed for
primary
care
(Patient
Health
Questionnaire for Adolescents [PHQ-A]
and the Beck Depression InventoryPrimary Care Version [BDI-PC]) have
been used successfully in adolescents.
There are limited data describing the
accuracy of using MDD screening
instruments in younger children (7-11
years of age).
B. ALCOHOL SCREENING
Adults/Pregnant Women: The USPSTF
considers three tools as the instruments of
choice for screening for alcohol misuse in
the primary care setting: the Alcohol Use
Disorders Identification Test (AUDIT),
the abbreviated AUDIT-consumption
(AUDIT-C), and single question screening
(for example, the NIAAA recommends
asking, “How many times in the past year
have you had five [for men] or four [for
women and all adults older than 65 years]
or more drinks in a day?”). Of available
screening tools, AUDIT is the most
widely studied for detecting alcohol
misuse in primary care settings; both
AUDIT and the abbreviated AUDIT-C
have good sensitivity and specificity for
detecting the full spectrum of alcohol
misuse across multiple populations.
January 10, 2014
BEHAVIORAL HEALTH AND SUBSTANCE ABUSE SERVICES
Attachment C Page 2
ATTACHMENT C
SUBSTANCE ABUSE AGENCY MODEL LEVEL OF CARE GRID
Level of Care
Covered Services
Level 0.5
Early
Intervention/
Prevention
(Continued)
Description of Treatment Level
Utilization Management
Prevention
AUDIT comprises ten questions and
requires approximately two to five minutes
to administer. AUDIT-C comprises three
questions and takes one to two minutes to
complete. Single-question screening also
has adequate sensitivity and specificity
across the alcohol-misuse spectrum and
requires less than one minute to administer.
C. TOBACCO
Pregnant Women
Various primary care clinicians may
deliver effective interventions. There is a
dose-response relationship between quit
rates and the intensity of counseling (that
is, more or longer sessions improve quit
rates). Quit rates seem to plateau after 90
minutes of total counseling contact time.
Helpful components of counseling include
problem-solving guidance for smokers (to
help them develop a plan to quit and
overcome common barriers to quitting) and
the provision of social support as part of
treatment. Complementary practices that
improve
cessation
rates
include
motivational
interviewing,
assessing
readiness to change, offering more
intensive counseling or referrals, and using
telephone "quit lines."
January 10, 2014
BEHAVIORAL HEALTH AND SUBSTANCE ABUSE SERVICES
Attachment C Page 3
ATTACHMENT C
SUBSTANCE ABUSE AGENCY MODEL LEVEL OF CARE GRID
Level 1
Outpatient
Services
Outpatient Services
A clinic model that meets the certification
1. Medication management
1.2. 24 hour crisis intervention services face requirement NAC 458.103 for alcohol and
to face or telephonically available seven
drug abuse programs.
days per week
2.3.Behavioral Health/Substance Abuse
The entity will provide medical, psychiatric,
Covered Screens
psychological, services, which are available
3.4.Comprehensive biopsychosocial
onsite or through consultation or referral.
Assessment
Medical and psychiatric consultations are
4.5.Individual and group counseling
available within 24 hours by telephone or in
5.6.Individual, group, family psychotherapy person, within a time frame appropriate to the
6.7.Peer Support Services
severity and urgency of the consultation.
Emergency services available by telephone 24
hours a day, 7 days a week. Recovery and selfhelp groups are a part of the overall milieu. All
other services are individually billed.
January 10, 2014
BEHAVIORAL HEALTH AND SUBSTANCE ABUSE SERVICES
Prior authorization
required
Prior authorization is
required on services,
except for: Behavioral
Health/Substance Abuse
Screens and 24 hour crisis
intervention.
Post authorization is not
required for 24 hour crisis
intervention.
Attachment C Page 4
ATTACHMENT C
SUBSTANCE ABUSE AGENCY MODEL LEVEL OF CARE GRID
Level of Care
Covered Services
Description of Treatment Level
Level 2
2.1 Intensive
Outpatient
Treatment
An evidenced-based/best practice model
providing a minimum amount of skilled
structured programming hours per week.
During the day, before or after work setting,
evening, and/or weekend. Provides a milieu
“real world” environment. The milieu is a
combination of skilled treatment services.
Frequencies and intensity are appropriate to Prior authorization
the objectives of the treatment plan.
required
Prior authorization is
Requires a comprehensive interdisciplinary required on services,
program team approach of appropriately except for: Behavioral
credentialed addiction treatment professionals, Health/Substance Abuse
including addiction – credentialed physicians Screens and 24 hour crisis
who assess and treat substance-related intervention.
disorders. Some staff are cross trained to
understand the signs and symptoms of mental Post authorization is not
disorders and to understand and explain the required for 24 hour crisis
uses of psychotropic medications and intervention.
interactions with substance-related disorders.
1.
2.
3.
4.
5.
6.
7.
8.
9.
2.5 Partial
Hospitalization
Medical and psychiatric consultation
Psychopharmacological consultation
Medication management
24 hour crisis management intervention
services face to face or telephonically
available seven days per week
Comprehensive biopsychosocial
assessments
Behavioral Health/Substance Abuse
Covered Screens
Individual and group counseling
Individual, group, family psychotherapy
Self-help/recovery groups
1. Outpatient hospital setting.
Same as above, in addition psychiatric and
2. All level 2.1 services in addition need the medical management.
direct access to psychiatric, medical
and/or laboratory services.
Intensity of service required is higher than can
be provided in Intensive Outpatient Treatment.
Utilization Management
Prior authorization
Prior authorization is
required on services,
except for: Behavioral
Health/Substance Abuse
Screens and 24 hour crisis
intervention.
Post authorization is not
required for 24 hour crisis
intervention.
January 10, 2014
BEHAVIORAL HEALTH AND SUBSTANCE ABUSE SERVICES
Attachment C Page 5
ATTACHMENT C
SUBSTANCE ABUSE AGENCY MODEL LEVEL OF CARE GRID
Level of Care
Covered Services
Description of Treatment Level
Level 3
Residential
3.3-.5 Managed
Residential
Medical, psychiatric, psychological, services,
which are available onsite or through
consultation or referral. Medical and
psychiatric consultations are available within
24 hours by telephone or in person, within a
time frame appropriate to the severity and
urgency of the consultation.
A clinic model that meets the certification
requirement NAC 458.103 for alcohol and
drug abuse programs. Room and board is not a
reimbursable service through the Division of
Health Care Financing and Policy (DHCFP)
outpatient program.
1. 24 hour crisis management intervention
services face to face or telephonically
available seven days per week
2. Medication management
3. Emergency services available by
telephone 24 hours a day, 7 days a week
4.3.Behavioral Health/Substance Abuse
Covered Screens
5.4.Comprehensive biopsychosocial
Assessment
6.5.Individual and group counseling
7.6.Individual, group, family psychotherapy
8.7.Peer Support Services
January 10, 2014
Utilization Management
Prior authorization
required
Prior authorization is
required on services,
except for: Behavioral
Health/Substance Abuse
Screens and 24 hour crisis
The entity will provide medical, psychiatric, intervention.
psychological, services, which are available
onsite or through consultation or referral. Post authorization is not
Medical and psychiatric consultations are required for 24 hour crisis
available within 24 hours by telephone or in intervention.
person, within a time frame appropriate to the
severity and urgency of the consultation. Intensity of service is
Emergency services available by telephone 24 dependent upon individual
hours a day, seven days a week. Recovery and and presenting symptoms.
self-help groups are a part of the overall
milieu. All other services are individually
billed.
BEHAVIORAL HEALTH AND SUBSTANCE ABUSE SERVICES
Attachment C Page 6