1. health and fitness
2. therapy

MEDICAID SERVICES MANUAL
TRANSMITTAL LETTER
April 10, 2014
TO:
CUSTODIANS OF MEDICAID SERVICES MANUAL
FROM:
MARTA E. STAGLIANO, CHIEF OF PROGRAM INTEGRITY
SUBJECT:
MEDICAID SERVICES MANUAL CHANGES
CHAPTER 1700 - THERAPY
BACKGROUND AND EXPLANATION
Revisions to Medicaid Services Manual (MSM) Chapter 1700 were made to clarify therapy
services covered as a component of the Early and Periodic Screening, Diagnosis and Treatment
(EPSDT) benefit. This change in verbiage clarifies therapy services for individuals ordered under
an EPSDT referral by a physician, physician’s assistant or an Advanced Practitioner of Nursing
(APN). These services do not have to be rehabilitative or restorative in nature.
Throughout the chapter, grammar, punctuation, and capitalization changes were made, duplications
removed, acronyms used and standardized, and language reworded for clarity.
These changes are effective upon approval at public hearing, but based on guidance received from
the Centers for Medicare and Medicaid Services were implemented through procedure memo
distributed to Hewlett Packard Enterprises, Health Plan of Nevada and Amerigroup on January 22,
2014.
MATERIAL TRANSMITTED
CL 27919
CHAPTER 1700 - THERAPY
MATERIAL SUPERSEDED
MTL16/11, 28/12, 22/13
CHAPTER 1700 - THERAPY
Manual Section
Section Title
Background and Explanation of Policy Changes,
Clarifications and Updates
1700
Introduction
Added policy language to include EPSDT.
1703.2A.2
Covered Services
Changed language to “Therapy services may be
ordered under an EPSDT referral by a physician,
physician’s assistant or an APN. The examination
must identify a functional limitation to either acquire
or correct/ameliorate a functional deficit/condition
based upon medical necessity, which includes
realistic and attainable therapy goals.”
1703.5C
Prior
Authorization
Requirements
Added language to exempt EPSDT from service
limitations.
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1700
INTRODUCTION
INTRODUCTION
Nevada Medicaid reimbursement for outpatient Physical Therapy (PT), Occupational Therapy
(OT), Speech/Communication Therapy (ST) and Respiratory Therapy/Care (RT) is based on the
provision of medically necessary therapy services for an illness or injury resulting in functional
limitations which can respond or improve as a result of the prescribed therapy treatment plan in a
reasonable, predictable period of time. Therapy services must be prescribed by a physician,
physician’s assistant or an aAdvanced pPractitioner of nNursing (APN).
Services related to activities for the general health and welfare of patients, e.g., general exercises
to promote overall fitness and flexibility and activities to provide diversion or general motivation,
do not constitute restorative or rehabilitative therapy services for Medicaid purposes.
Outpatient Physical, Occupational and Speech therapy under 42 Code of Federal Regulations
(CFR) 440.110 is an optional service under State Medicaid Programs.
Therapy services provided by the Home Health Agency (HHA) Program is a mandatory home
health care benefit provided to recipients in his/her residence. See Medicaid Service Manual
(MSM), Chapter 1400 for HHA Therapy coverage.
Nevada Medicaid provides therapy services for most Medicaid-eligible individuals under the age
of 21 as a mandated service, a required component of Early and Periodic Screening, Diagnosis
and Treatment (EPSDT) benefit.
Therapy services provided by an outpatient hospital under 42 CFR 440.20 is a mandatory service
under State Medicaid Programs.
All Medicaid policies and requirements are the same for Nevada Check Up (NCU), with the
exception of those listed in the NCU Manual, Chapter 1000.
January 1, 2014
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1703
POLICY
1703.1
Medicaid will reimburse physical, occupational, speech therapy services rendered to eligible
Medicaid recipients and eligible participants in the Nevada Check Up (NCU) Program. Therapy
must be medically necessary (reference Medicaid Services Manual (MSM) Chapter 100; sSection
103.1) to restore or ameliorate functional limitations that are the result of an illness or injury
which can respond or improve as a result of the prescribed therapy treatment plan in a reasonable,
predictable period of time. It must be rendered according to the written orders of the physician,
physician’s assistant or an Advanced Practitioner of Nursing (APN) and be directly related to the
active treatment regimen designed by the therapist and approved by the professional who wrote
the order.
Requests for therapy must specify the functional deficits present and include a detailed
description assessing the measurable degree of interference with muscle and/or joint mobility of
persons having congenital or acquired disabilities, measurable deficits in skills for daily living,
deficits of cognitive and perceptual motor skills and integration of sensory functions. Identify
measurable speech and/or communication deficits through testing, identification, prediction of
normal and abnormal development, disorders and problems, deficiencies concerning the ability to
communicate and sensorimotor functions of a person’s mouth, pharynx and larynx.
A written individualized plan addressing the documented disabilities needs to include the therapy
frequency, modalities and/or therapeutic procedures and goals of the planned treatment. The
primary diagnosis must identify the functional deficit which requires therapeutic intervention for
the related illness or injury diagnosis.
Therapy services provided in the community-based and/or hospital outpatient setting are subject
to the same coverage and therapy limitations.
Services that are provided within the School Based Child Health Services (SBCHS) Program are
covered under MSM Chapter 2800.
1703.2
COVERAGE AND LIMITATIONS
1703.2A
COVERED SERVICES
1.
Medicaid covers outpatient therapy for individual and/or group therapy services
administered by the professional therapist within the scope of their license for the
following:
a.
January 1, 2013
An individual therapy session may be covered up to a max of one hour when
service is provided to the same recipient by the same therapist on the same day.
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b.
POLICY
Group therapy (comprised of no more than 2-4 two to four individuals) may be
covered up to a max of ninety 90 minutes per session when the service is provided
to the same recipient by the same therapist on the same day. The leader of the
group must be a Medicaid provider. Documentation in the medical record is
expected to be available on each Medicaid recipient in the group.
2.
Therapy services may be ordered as a result of a comprehensive Healthy Kids evaluation
under an EPSDT referral by a physician, physician’s assistant or an APN. The
examination must identify the a functional deficits limitation to either acquire or
correct/ameliorate a functional deficit/condition based upon and establish medical
necessity, which includes realistic rehabilitative/restorative and attainable therapy goals.
3.
The application of a modality that does not require direct (one-on-one) patient contact by
the licensed therapist may be provided by a licensed therapy assistant under the
supervision of the licensed Medicaid therapist.
4.
Evaluations administered per therapy discipline within the scope of their license and meets
the following criteria:
5.
January 1, 2013
a.
Initial evaluations.
b.
Re-evaluations may be covered when there is a break in service greater than 90
days.
To be considered reasonable and medically necessary all of the following conditions must
be met:
a.
Meet the definition of medical necessity in MSM Chapter 100.
b.
The service must be considered under accepted standards of medical practice to be
a specific and effective treatment for the patient’s functional deficit/condition.
c.
The services must be of such a level of complexity and sophistication, or the
condition of the patient must be such, that the services required can be safely and
effectively performed only by a qualified therapist or qualified assistant under the
therapist’s supervision.
d.
There must be an expectation that the functional deficit/condition will improve in a
reasonable, and generally predictable, period of time based on the assessment
made by the physician of the patient’s realistic rehabilitative/restorative potential
in consultation with the qualified therapist.
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e.
1703.2B
POLICY
The amount, frequency, and duration for restorative therapy services must be
appropriate and reasonable based on best practice standards for the illness or injury
being treated.
6.
Cochlear Implant Therapy: Speech and Language Pathologist (SLP) services are covered
under cochlear implantation protocol for speech evaluation and therapy services. Codes
used by speech therapists will require the appropriate therapy modifier. (Refer to MSM
Chapter 2000 for comprehensive cochlear policy.)
7.
Therapy for Development Delay disorders may be covered for speech and language, fine
motor and/or gross motor skills development when the functional deficit(s), identified by
ICD-9-CM diagnosis code(s) meet all medical necessity requirements.
8.
Respiratory therapy is considered reasonable and necessary for the diagnosis and/or
treatment of an individual’s illness or injury when it is:
a.
Consistent with the nature and severity of the recipient’s medical symptoms and
diagnosis;
b.
Reasonable in terms of modality, amount, frequency and duration of the treatment;
or
c.
Generally accepted by the professional community as being safe and effective
treatment for the purpose used.
9.
In certain circumstances the specialized knowledge and judgment of a qualified therapist
may be covered when medically necessary to establish a safe and effective home
maintenance therapy program in connection with a specific disease state.
10.
SLP evaluations may be covered according to MSM Chapter 1300, Appendix B for a
dedicated speech generating device evaluation and therapeutic services.
PRIOR AUTHORIZATION REQUIREMENTS
1.
With the exception of initial therapy evaluations and re-evaluations, all therapy services
must be prior authorized by the Quality Improvement Organization (QIO-like) vendor.
2.
Initial and re-evaluations do not require prior authorization. Appropriate therapy
evaluations must be accomplished and submitted with prior authorization requests.
3.
To obtain prior authorization for therapy services, all Ccoverage and Llimitations
requirements must be met (MSM Section 1703.2A).
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1703.2C
1703.2D
1703.2E
POLICY
NON-COVERED SERVICES
1.
Services which do not meet Nevada Medicaid medical necessity requirements.
2.
Personal comfort items, which do not contribute meaningfully to the treatment of an
illness or injury or the functioning of a malformed body part.
3.
Services that do not require the performance or supervision of a licensed therapist, even if
they are performed or supervised by a licensed therapist.
4.
Wound care requested by a therapist or a hospital based therapy department unless it is
part of a comprehensive therapy treatment plan, (e.g., whirlpool with debridement &
ROM exercises etc.).
5.
Reimbursement for licensed nurses when wound care is ordered as a Physical Therapy
(PT) or Occupational Therapy (OT) service.
6.
Outpatient therapy provided to patients admitted in an acute or rehabilitation hospital.
7.
Reimbursement for an all inclusive Respiratory Rehabilitation Program.
8.
Medicaid does not reimburse or require re-evaluations to update other third party payer
plans of progress for outpatient rehabilitation.
PROVIDER RESPONSIBILITY
1.
Providers must comply with prior authorization requirements set forth in the Medicaid
Services Manual (MSM), Chapter 100 (Medicaid Program), Section 103.2 (Authorization).
2.
The provider will allow, upon request of proper representatives of the Division of Health
Care Financing and Policy (DHCFP), access to all records which pertain to Medicaid
recipients for regular review, audit or utilization review.
3.
Once an approved prior authorization request has been received, providers are required to
notify the recipient in a timely manner of the approved service units and service period
dates.
4.
For Provider Responsibilities refer to MSM Chapter 100.
RECIPIENT RESPONSIBILITY
For Recipient Responsibilities refer to MSM Chapter 100.
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1703.3
POLICY
LYMPHEDEMA THERAPY POLICY
Nevada Medicaid will reimburse a qualified lymphatic therapist (OT or PT) for a combination of
therapy techniques recommended by the American Cancer Society and the National Lymphedema
Network for primary and secondary lymphedema.
1703.3A
COVERAGE AND LIMITATIONS
1.
2.
1703.3B
1703.3C
Complete or Combined Decongestive Physiotherapy (CDP) therapy is covered by
Medicaid for ICD-9 codes 457.0, 457.1, and 757.0 when all of the following conditions
are met:
a.
A treating or consulting practitioner (MD, DO, DPM, APN, and PA), within their
scope of practice, documents a diagnosis of lymphedema due to a low output cause
and specifically orders CDP therapy;
b.
The lymphedema causes a limitation of function related to self-care, mobility,
and/or safety;
c.
The recipient or recipient caregiver has the ability to understand and provide
home-based CDP;
d.
CDP services must be performed by a health care professional who has received
CDP training;
e.
The frequency and duration of the services must be necessary and reasonable; and
f.
Lymphedema in the affected area is not reversible by exercise or elevation.
A CDP course of treatment by either OT or PT is considered a once in a lifetime benefit
consisting of 90 minutes (6 six units) per session, 3-5 three to five times per week for a
maximum of 3 three consecutive weeks with prior authorization.
PRIOR AUTHORIZATION REQUIREMENTS
1.
All lymphedema therapy services must be prior authorized by the QIO-like vendor.
2.
To obtain prior authorization for therapy services, all Ccoverage and Llimitations
requirements must be met (MSM Section 1703.2A).
NON-COVERED SERVICES
1.
January 1, 2013
Non-covered services include the following:
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1703.3D
POLICY
a.
Therapy limited to exercise or elevation of the affected area;
b.
Other services such as skin care and the supplies associated with the compressions
wrapping. (they are included in the services and are not paid separately);
c.
OT and PT services performed concurrently for the therapeutic exercise portion of
the session is duplicative (Only one service type per therapeutic session is
allowed); and
d.
Therapy designed principally for temporary benefit/without ongoing patient
education.
PROVIDER RESPONSIBILITIES
For Provider Responsibilities, refer to MSM Chapter 100.
1703.3E
RECIPIENT RESPONSIBILITIES
For Recipient Responsibilities, refer to MSM Chapter 100.
1703.4
RESPIRATORY THERAPY POLICY
1703.4A
COVERAGE AND LIMITATIONS
Medicaid will reimburse contracted practitioners of respiratory care for individual services
provided in the outpatient setting. See MSM Chapter 600 for outpatient services general
limitations. The term “respiratory care” includes inhalation and respiratory therapy, diagnostic
testing, control and care of persons with deficiencies and abnormalities associated with the
cardiopulmonary system.
1703.4B
1703.4C
PRIOR AUTHORIZATION REQUIREMENTS:
1.
Respiratory therapy services must be prior authorized by the QIO-like vendor.
2.
To obtain prior authorization for respiratory therapy services, all Ccoverage and
Llimitations requirements must be met. (MSM Section 1703.2A).
NON-COVERED SERVICES:
1.
Reimbursement for an all inclusive Respiratory Rehabilitation Program is not a Medicaid
covered benefit, which may include the following:
a.
January 1, 2013
Psychological monitoring.
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3.
4.
5.
6.
1703.5C
POLICY
Maintenance therapy must meet at least one of the following:
a.
Prevent decline of function;
b.
Provide interventions, in the case of a chronic or progressive limitation, to
improve the likelihood of independent living and quality of life; or
c.
Provide treatment interventions for recipients who are making progress, but not at
a rate comparable to the expectations of restorative care.
Maintenance therapy must have expected outcomes that are:
a.
Functional;
b.
Realistic;
c.
Relevant;
d.
Transferable to the recipients current or anticipated environment; and
e.
Consistent with best practice standards and accepted by the professional
community as being safe and effective treatment for the purpose used.
Documentation requirements
a.
Plan of care must address a condition for which therapy is an accepted method of
treatment as defined by standards of medical practice.
b.
Plan of care must be for a condition that establishes a safe and effective skilled
maintenance program.
Management of a maintenance program is covered only when provided by a skilled
therapist (reference MSM Section 1701.2).
PRIOR AUTHORIZATION REQUIREMENTS
1.
All Maintenance therapy services require prior authorization.
2.
Services are limited to ten sessions every three years per each recipient, from the date of
initial visit. EPSDT is exempt from service limitations.
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HEARINGS
1704
HEARINGS
1704.1
Please reference Medicaid Services Manual (MSM) Chapter 3100, for hearings procedures.
August 24, 2011
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MEDICAID OPERATIONS MANUAL
TRANSMITTAL LETTER
April 10, 2014
TO:
CUSTODIANS OF MEDICAID OPERATIONS MANUAL
FROM:
MARTA E. STAGLIANO, CHIEF OF PROGRAM INTEGRITY
SUBJECT:
MEDICAID OPERATIONS MANUAL CHANGES
CHAPTER 600 – KATIE BECKETT ELIGIBILITY OPTION
BACKGROUND AND EXPLANATION
Revisions to Medicaid Operations Manual (MOM) Chapter 600 are being made to incorporate
the definition of parental responsibility in the assessment process for Level of Care (LOC)
determinations for Katie Beckett children. The LOC determination for children must include age
appropriate assessments based on the child’s functional abilities in relationship to developmental
milestones for the age of a child being assessed. This chapter revision incorporates additional
definitions taken from the Medicaid Services Manual (MSM) Addendum which further clarify
parental responsibility.
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 changes are effective May 1, 2014.
MATERIAL TRANSMITTED
CL 27782
KATIE BECKETT ELIGIBILITY OPTION
Manual Section
Section Title
602
Definitions
MATERIAL SUPERSEDED
MTL 21/12
KATIE BECKETT ELIGIBILITY OPTION
Background and Explanation of Policy Changes,
Clarifications and Updates
Added Definitions for the following terms:
ABLE – Copied from the MSM Addendum.
ACTIVITIES OF DAILY LIVING (ADLs) –
Copied from the MSM Addendum.
AGE APPROPRIATE – This is a new definition
derived from the Centers for Disease Control and
Prevention.
Page 1 of 2
Manual Section
Section Title
Background and Explanation of Policy Changes,
Clarifications and Updates
CAPABLE – Copied from the MSM Addendum.
CARE COORDINATION – Revised definition to
mirror that of the MSM Addendum.
DEVELOPMENTAL MILESTONE – This is a
new definition derived from the Centers for Disease
Control and Prevention.
FUNCTIONAL ABILITY – Copied from the MSM
Addendum.
FUNCTIONAL IMPAIRMENT – Copied from the
MSM Addendum.
INSTRUMENTAL ACTIVITIES OF DAILY
LIVING (IADLs) – Copied from the MSM
Addendum.
LEGALLY RESPONSIBLE INDIVIDUAL (LRI)
– Copied from the MSM Addendum.
PARENT – Copied from the MSM Addendum.
PARENTAL RESPONSIBILITY – Copied from
MSM Chapter 3500.
SKILLED NURSING (SN) – Copied from the
MSM Addendum.
603.3
Policy – Coverage
and Limitations –
Parental
Responsibility
Policy section was added to clearly define that
parents will not be paid for routine care, supervision
or services normally provided for the child without
charge as a matter of course in the usual
relationship among family members.
603.5
Policy – Level of
Care
Previously number 603.4. Added policy indicating
LOC assessments must be age appropriate and take
into consideration the diagnoses, developmental
milestones, and functional abilities of the child.
ADLs and IADLs may be looked at as tasks, but
must be developmentally appropriate in relationship
to the child’s age and that a child should be able to
perform independently.
603.5a
Policy – Level of
Care
Revised Nursing Facility Standard policy to clarify
the criteria for LOC determinations for children.
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602
DEFINITIONS
DEFINITIONS
ABLE
An able parent and/or legal guardian of a minor child, is a Legally Responsible Individual (LRI)
who has the option to be present in the home during the time of carrying out necessary
maintenance, health/medical care, education, supervision, support services and/or the provision of
Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) as
needed.
ACTIVITIES of DAILY LIVING (ADLs)
ADLs are self care activities routinely preformed on a daily basis, such as bathing, dressing,
grooming, toileting, transferring, mobility continence and eating.
For the purpose of evaluation, the ADLs are defined as:
•
Bathing/Dressing/Grooming: Includes bathing (washing oneself in a bathtub or shower, or
by sponge bath. It also includes the individual’s ability to get into and out of the shower or
tub), dressing and undressing and personal hygiene.
•
Toileting: Includes getting to and from the toilet, getting on and off the toilet and
performing associated personal hygiene. Also includes the routine maintenance of
incontinence.
•
Transferring: Includes moving into or out of a chair, bed or wheelchair.
•
Mobility: Includes walking and getting around with the use of assistive devices or with
assistance.
•
Eating: Putting food into the body from a cup, plate, feeding tube or intravenously. Does
not include the preparation of food which is an IADL.
AGE APPROPRIATE
A developmental concept whereby certain activities may be deemed appropriate or inappropriate
to the child’s “stage” or level of development (developmental milestones).
CAPABLE
A capable parent and/or legal guardian of a minor child, is an LRI who is physically and
cognitively capable of carrying out necessary maintenance, health/medical care, education,
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DEFINITIONS
supervision, support services and/or the provision of needed ADLs and IADLs.
CARE COORDINATION
Links persons who have complex personal circumstances or health needs that place them at risk
of not receiving appropriate services to those services.A formal process that ensures ongoing
coordination of efforts on behalf of Medicaid-eligible recipients who meet the care criteria for a
higher intensity of needs. Care coordination includes: facilitating communication and enrollment
between the recipient and providers and providing for continuity of care by creating linkages to
and monitoring transitions between intensities of services. Care coordination is a required
component of case management services and is not a separate reimbursable service.
COST EFFECTIVENESS
The method by which the Division of Health Care Financing and Policy (DHCFP) monitors and
tracks reimbursement for medical services to ensure that the established Level of Care (LOC) cost
limitations are not exceeded.
DEVELOPMENTAL MILESTONE
A functional ability that is achieved by most children at a certain age. Developmental milestones
can include physical, social, emotional, cognitive and communication skills.
DIAGNOSIS
The determination of the nature or cause of physical or mental disease or abnormality through the
combined use of health history, physical developmental examination, and laboratory tests.
DIARY or DIARY DATE
Specific to the Katie Beckett Eligibility Option, the diary date drives the physician consultant’s
disability reevaluation date. The disability reevaluation date can be established for one, two or
three years from the initial disability determination date.
DISABILITY DETERMINATION
The DHCFP’s physician consultant and professional staff make up the disability determination
team. The team reviews medical documentation and determines if the applicant qualifies based on
Social Security Disability Standards. Those standards outlined by Social Security Disability are:
a.
September 12, 2012
The child/participant must have a physical or mental condition(s) that seriously limits his
or her life activities; and
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b.
DEFINITIONS
The condition(s) must have lasted, or be expected to last, at least one year or the condition
is expected to be terminal.
ELIGIBILITY
References a person’s status to receive Medicaid program benefits. Eligibility is determined by
the Division of Welfare and Supportive Services (DWSS) based upon specific criteria for the
Katie Beckett Eligibility Option.
FUNCTIONAL ABILITY
Functional ability is defined as a measurement of the ability to perform ADLs progressing from
dependence to independence. This includes, but may not be limited to: personal care, grooming,
self feeding, transferring from bed to chair, ambulation or wheelchair mobility, functional use of
extremities with or without the use of adaptive equipment, effective speech or communication,
and adequate functioning of the respiratory system for ventilation and gas exchange to supply the
individual’s usual activity level.
FUNCTIONAL IMPAIRMENT
Functional impairment is a temporary or permanent disability (resulting from an injury or sudden
trauma, aging, disease or congenital condition) which limits a person’s ability to perform one or
more ADLs or IADLs including but not limited to: dressing, bathing, grooming, mobility, eating,
meal preparation, shopping, cleaning, communication, and performing cognitive tasks such as
problem solving, processing information and learning.
HEALTH EDUCATION
The guidance (including anticipatory) offered to assist in understanding what to expect in terms of
a child’s development and to provide information about the benefits of healthy lifestyles and
practices as well as accident and disease prevention.
INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADLs)
IADLs are activities related to independent living including preparing meals, shopping for
groceries or personal items, performing light or heavy housework, communication and money
management.
INTERMEDIATE CARE FACILITY FOR THE MENTALLY RETARDED (ICF/MR)
An institution (or distinct part of an institution) which is primarily used for the diagnosis,
treatment, or rehabilitation for persons with mental retardation or a related condition. In a
protected residential setting, an ICF/MR facility provides ongoing evaluation, planning, 24-hour
September 12, 2012
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DEFINITIONS
supervision, coordination, and integration for health and rehabilitative services to help individuals
function if or when they are able to return home.
INTERMEDIATE CARE SERVICES FOR THE MENTALLY RETARDED
Health and rehabilitative services provided to a mentally retarded person or person with a related
condition. The services are certified as needed and provided in a licensed inpatient facility.
LEGALLY RESPONSIBLE INDIVIDUAL (LRI)
Individuals who are legally responsible to provide medical support including: spouses of
recipients, legal guardians, and parents of minor recipients, including: stepparents, foster parents
and adoptive parents.
LEVEL OF CARE (LOC) ASSESSMENT
A screening assessment to determine if an applicant’s or participant’s condition requires the level
of services provided in a hospital, Nursing Facility (NF), or ICF/MR.
NOTICE OF DECISION (NOD)
The method by which the DWSS advises the participant of his or her Medicaid eligibility status.
PARENT
a.
natural, adoptive, or foster parent of a child (unless a foster parent is prohibited by State
Law from serving as a parent);
b.
a guardian, but not the State if a child is a ward of the State;
c.
an individual acting in the place of a natural or adoptive parent (including a grandparent,
stepparent or other relative) with whom the child lives; or
d.
an individual who is legally responsible for the child’s welfare.
PARENTAL RESPONSIBILITY
An able or capable parent and/or legal guardian of a minor child, has a duty/obligation to provide
the necessary maintenance, health/medical care, education, supervision and support. Necessary
maintenance includes, but is not limited to, the provision of ADLs and IADLs.
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DEFINITIONS
PARENTAL FINANCIAL RESPONSIBILITY (PFR)
The cost-sharing portion that enables a child to receive Medicaid coverage under the Katie
Beckett Eligibility Option. PFR is based on evaluation of parental income and resources by the
DWSS with the PFR amount determined based upon a sliding fee schedule.
PERIODIC
Intervals established for screening by medical, dental, and other health care providers to detect
disease or disability that meet reasonable standards of medical practice. The procedures
performed and their frequency depend upon the child’s age and health history.
SCREENING
A methodical examination performed to determine a child’s health status and to make appropriate
diagnosis and treatment referrals.
SKILLED NURSING (SN)
SN means the assessments, judgments, interventions, and evaluations of intervention, which
require the training and experience of a licensed nurse. SN care includes, but is not limited to:
a.
performing assessments to determine the basis for action or the need for action;
b.
monitoring fluid and electrolyte balance;
c.
suctioning of the airway;
d.
central venous catheter care;
e.
mechanical ventilation, and
f.
tracheotomy care.
TREATMENT
One or more medically necessary services or care options provided to prevent, correct or improve
disease or abnormalities detected by screening and diagnostic procedures.
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a.
b.
The DHCFP staff in the District Offices facilitate the processing of Katie Beckett
Eligibility Option applications for Medicaid eligibility. Upon receipt of applicant
information from the DWSS, the DHCFP District Office staff:
1.
Complete a face-to-face interview and conduct a formal assessment of the child in
the home setting to determine if an LOC exists.
2.
Facilitate the collection of medical records to forward to the DHCFP’s Physician
Consultant and review team at the DHCFP Central Office for disability
determination and redeterminations.
3.
If a child does not meet a NF LOC, but medical records provide information
indicating there is either a mental retardation or related condition diagnosis, the
parent(s) or guardian(s) is referred to MHDS for further assessment.
The MHDS staff are responsible for the evaluation and determination of an ICF/MR LOC
for mental retardation or related conditions.
1.
d.
603.3
POLICY
The DHCFP requires that the individual determining an ICF/MR LOC must be at
least a Developmental Specialist III (DSIII) or a Qualified Mental Retardation
Professional (QMRP).
Third Party Liability (TPL)
1.
Refer to Medicaid Services Manual (MSM) Chapter 100.
2.
Participants eligible for Medicaid are required to pursue and/or maintain other
health coverage if it is available at no cost to the recipient, parent, and/or legal
guardian.
COVERAGE AND LIMITATIONS
Parental Responsibility
An able and/or capable parent or Legally Responsible Individual (LRI) of a minor child has a
duty/obligation to provide the necessary maintenance, health/medical care, education, supervision
and support. Necessary maintenance includes but not limited to, the provision of Activities of
Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs). Payment will not be
made for the routine care, supervision or services normally provided for the child without charge
as a matter of course in the usual relationship among members of a family.
September 12, 2012
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603.4
POLICY
CARE COORDINATION
Care Coordination is a component of the services provided by the District Office staff in the
Continuum of CareLong Term Support Services Unit which assists the participant to remain in his
or her home. The role of the Katie Beckett Eligibility Option Health Care Coordinator is to:
603.45
a.
facilitate access to medical, social, educational, and other needed services regardless of the
funding source.
b.
monitor quarterly calendar costs incurred to ensure that expenditures are not exceeded for
the allowable cost limits and assist the family in prioritizing services.
c.
prepare parent or guardian for transition to other services when Medicaid eligibility is no
longer met under the Katie Beckett Eligibility Option (i.e. SSI eligibility, age 19) and or
assist with any ongoing or unmet needs.
1.
Coordinate with the DWSS caseworker to change eligibility category;
2.
Refer to Medicaid Waiver programs as appropriate; and
3.
Refer to community resources.
c.
make at least quarterly contact with parent or guardian by phone, letter or in person to
ensure that all necessary services are accessed and identify any significant change in the
child’s condition or unmet needs, making referrals as necessary.
d.
conduct in-home visits with the child and parent or guardian for determination of a LOC,
making appropriate referrals as necessary. The number of visits per year is driven by the
LOC, but home visits are conducted at least annually.
LEVEL OF CARE (LOC)
LOC assessments must be age appropriate and take into consideration the diagnoses,
developmental milestones and functional abilities of the child. ADLs may be looked at as tasks
but must be developmentally appropriate in relationship to the child’s age and that a child should
be able to perform independently.
An NF andor ICF/MR LOC is assigned for a one-year period of time after the initial assessment
and evaluation. There is a home visit conducted at least annually to reassess the LOC.
Nursing Facility Pediatric Specialty Care I and Pediatric Specialty Care II (Mechanical Ventilator
Dependent) LOC’s are assigned for a six (6) month period, and a reassessment of the LOC occurs
every six (6) months.
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POLICY
Service levels determine the monthly cost allowance available for services and supplies for the
child.
a.
b.
Nursing Facility Standard. A child’s condition requires the level of service provided by
either a Skilled Nursing Facility (SNF) or an ICF. Age appropriate consideration must be
incorporated into the assessment. Children are not normally considered to meet a LOC
unless the diagnosis and symptoms require medical treatment, intervention or oversight
seven days per week. Nursing Facility Standard is appropriate when the child requires
skilled nursing care or comprehensive rehabilitative interventions throughout the day
which may include:
1.
The child’s diagnoses require specialized professional training and monitoring
beyond those normally expected of parents.
2.
The child requires skilled observation and assessment several times daily due to
significant health needs.
3.
The child has unstable health, functional limitations, complicating conditions,
cognitive or behavioral conditions, or is medically fragile such that there is a need
for active care management.
4.
The child’s impairment substantially interferes with the ability to engage in
everyday activities and perform age appropriate activities of daily living at home
and in the community, including but not limited to bathing, dressing, toileting,
feeding, and walking/mobility.
5.
The child’s daily routine is substantially altered by the need to complete these
specialized, complex and time consuming treatments and medical interventions or
self-care activities.
6.
The child needs complex care management and/or hands on care that substantially
exceeds age appropriate assistance.
7.
The child needs restorative and rehabilitative or other special treatment.
Nursing Facility Pediatric Specialty Care I and Pediatric Specialty Care II (Mechanical
Ventilator Dependent). Limited to participants from birth to 19 years of age, who are
medically fragile and require specialized, intensive, licensed skilled nursing care beyond
the scope of services than what is generally provided to the majority of NF participants.
To qualify for this LOC, a participant must be receiving highly skilled services which
require special training and oversight. Pediatric Specialty Care rates are approved for a
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POLICY
maximum of six (6) months at a time. Each Pediatric Specialty Care I or II child’s LOC
must be reevaluated every six (6) months.
c.
603.56
Intermediate Care Facility for the Mentally Retarded (ICF/MR). MHDS determines the
ICF/MR LOC.
RATE METHODOLOGY AND COST EFFECTIVENESS
A.
The DHCFP uses the average daily NF rates established by the DHCFP Rates & Cost
Containment Unit. Rates for ICF/MR are also established by the DHCFP Rates and Cost
Containment Unit.
B.
The rates for the ICF/MR facilities are averaged. This amount is then used when
determining the allowable ICF/MR rate for each participant who meets an ICF/MR LOC.
C.
At the end of each calendar quarter, a list of approved Katie Beckett Eligibility Option
cases is generated by the DHCFP staff. The list shows the total Medicaid expenditure
amount incurred for that quarter for each eligible child under the Katie Beckett Eligibility
Option.
The purpose is to ensure that the costs incurred by Medicaid for each child does not
exceed the projected costs of institutional care. There are services and supplies that are not
included in the Facility Rate and are excluded from the child’s Institutional LOC overall
costs.
If the adjusted incurred amount exceeds the maximum allowable amount, the eligibility
worker at the appropriate DWSS office is notified by the DHCFP staff. The DWSS staff
will contact the participant’s parent or legal guardian and advise him/her:
1.
of the requirement to keep costs at or below the maximum allowable amount; and
2.
that failure to keep costs at or below the maximum allowable amount for a second
consecutive quarter will result in termination of Medicaid eligibility under the
Katie Beckett Eligibility Option.
If the participant’s incurred costs exceed the maximum allowable amount for two
consecutive quarters, he/she will be terminated from the Katie Beckett Eligibility Option
and consequently from Medicaid services, effective the first day of the month following
the date of determination of non-compliance with program requirements.
An exception to this requirement occurs when a participant is re-evaluated by the DHCFP
and determined to require a higher LOC (thereby increasing the maximum allowable
amount).
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603.67
POLICY
AUTHORIZATION PROCESS
Medicaid eligibility does not guarantee payment for services. Medical services must be authorized
based on medical necessity, specific program policy and limitations. Out of state medical care
will not be paid unless the service is prior-authorized or an emergency. Services are authorized by
the Quality Improvement Organization (QIO)-like vendor.
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604
HEARINGS
HEARINGS
Refer to Medicaid OperationsServices Manual (MOSM) Chapter 3100 for information regarding
Hearing Procedures.
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605
605
Subject:
REFERENCES AND CROSS
REFERENCES
REFERENCES AND CROSS REFERENCES
Please consult chapters of the Medicaid Services Manual (MSM) which may correlate with this
chapter.
Chapter 100
Chapter 200
Chapter 300
Chapter 400
Chapter 500
Chapter 600
Chapter 700
Chapter 800
Chapter 900
Chapter 1000
Chapter 1100
Chapter 1200
Chapter 1300
Chapter 1400
Chapter 1500
Chapter 1600
Chapter 1700
Chapter 1900
Chapter 2800
Chapter 3100
Chapter 3300
Chapter 3500
Chapter 3600
September 12, 2012
Medicaid Program
Hospital Services
Radiology Services
Mental Health and Alcohol/Substance Abuse Services
Nursing Facilities
Physician Services
Rates and Cost Containment
Laboratory Services
Private Duty Nursing
Dental Services
Ocular Services
Prescribed Drugs
DME, Disposable Supplies and Supplements
Home Health Agency
Healthy Kids Program (EPSDT)
Intermediate Care for the Mentally Retarded
Therapy
Transportation Services
School Based Child Health Services
Hearings
Program Integrity
Personal Care Services (PCS) Program
Managed Care Organization
KATIE BECKETT ELIGIBILITY OPTION
Section 605 Page 1
MEDICAID OPERATIONS MANUAL
TRANSMITTAL LETTER
April 10, 2014
TO:
CUSTODIANS OF MEDICAID OPERATIONS MANUAL
FROM:
MARTA E. STAGLIANO, CHIEF OF PROGRAM INTEGRITY
SUBJECT:
MEDICAID OPERATIONS MANUAL CHANGES
CHAPTER 1200 – COST BASED REIMBURSEMENT RATES
BACKGROUND AND EXPLANATION
This new chapter is to outline the process for Cost Based Reimbursement Rates for a state or
local governmental entity/provider that provide medical services. The Division of Health Care
Financing and Policy (DHCFP) may require the non-federal share of expenditures to be paid by
the provider using Inter-governmental transfer of funds or Certified Public Expenditures (CPEs).
These policy changes are effective April 11, 2014.
MATERIAL TRANSMITTED
CL 24682
CHAPTER 1200 – COST BASED
REIMBURSEMENT RATES
Manual Section
Section Title
1200
Whole Chapter
MATERIAL SUPERSEDED
MTL - NEW
CHAPTER 1200 - COST BASED
REIMBURSEMENT RATES
Background and Explanation of Policy Changes,
Clarifications and Updates
Development of a new chapter
authority, definitions, and policy.
Page 1 of 1
identifying
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1200
Subject:
MEDICAID OPERATIONS MANUAL
1200
INTRODUCTION
INTRODUCTION
Attachment 4.19-B of the Nevada Medicaid State Plan allows for state and local government
entities to be reimbursed for their costs of providing certain Medicaid services such as Targeted
Case Management (TCM) services and Non-emergency Paratransit Transportation services.
Office of Management and Budget (OMB) Circular A-87, Attachment A, Circular No. A-87
establishes principles for determining the allowable costs incurred by state and local
governments (government units) under grants, cost reimbursement contracts, and other
agreements with the Federal Government. The principles are for the purpose of cost
determination and are designed to provide that Federal awards bear their fair share of cost
recognized under the principles except where restricted or prohibited by law.
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1201
Subject:
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1201
AUTHORITY
1201.1
NON-EMERGENCY TRANSPORTATION
AUTHORITY
42 Code of Federal Regulations (CFR) Part 431.53, pursuant to the Social Security Act (SSA)
1902(a), requires Medicaid agencies to ensure that beneficiaries are provided with necessary
transportation to and from Medicaid providers. Nevada Medicaid State Plan, Attachment 4.19-B,
page 4, 18.b.2, provides Nevada Medicaid will reimburse paratransit services the Regional
Transportation Commission (RTC) operated by local government agencies at the lower of billed
charges or a cost-based rate.
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Subject:
MEDICAID OPERATIONS MANUAL
1202
DEFINITIONS
DEFINITIONS
ANNUAL CALCULATION OF RATES
Cost-based rates are determined based on either a calendar year, State Fiscal Year (SFY) or
Federal Fiscal Year (FFY) depending on what is agreed upon with the provider or defined in the
Nevada Medicaid State Plan.
ANNUAL OPERATING BUDGET
The annual operating budget used to estimate expenditures for the rate period is the actual
yearend closing budget (actual revenues and expenditures) for the prior fiscal year.
COST ALLOCATION PLAN (CAP)
A CAP demonstrates how the provider allocates allowable direct and indirect costs to different
benefiting cost pools or objectives. If staff do not spend 100% of their time on one benefiting
program and/or service a time study is most likely required. The time study must be approved by
the Centers for Medicare and Medicaid Services (CMS) when the CAP is used to reimburse the
provider for Medicaid expenditures when using a cost based reimbursement methodology. If the
provider has implemented a CAP, generally an indirect cost rate would not be used in addition to
the CAP (see indirect cost rate below).
COST-BASED RATE
The cost-based rate is the amount per service unit Medicaid reimburses. Another example of a
service unit is ridership, or the number of rides provided, by the Regional Transportation
Commission (RTC) for non-emergency paratransit services. The cost rate is determined by
dividing net allowable costs by the service utilization forecast.
COST REPORT
The cost report is a form provided by the Division of Health Care Financing and Policy
(DHCFP) that state or local government entities use to submit costs and utilization data for
determining the cost-based rate.
DIRECT COSTS
Direct costs are those allowable expenditures that can be directly traced to the provision of
services.
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1202
Subject:
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DEFINITIONS
INDIRECT COST RATE
Indirect cost rate is defined by the Nevada Medicaid State Plan, in most cases, at ten percent
(10%) of the net allowable direct costs. The indirect cost rate reimburses the provider for costs
that benefit services provided in one or more cost objective(s).
NET ALLOWABLE COSTS
Net allowable cost is defined by the Nevada Medicaid State Plan as the sum of net allowable
direct costs and indirect costs.
NET ALLOWABLE DIRECT COSTS
Net allowable direct costs are the direct costs minus any federal grant funds received for services
minus any reimbursement outside the cost-based rate. For example in the case of non-emergency
transportation provided by the RTC, payments from the Medicaid non-emergency transportation
broker that the RTC has received during the period of the cost report will be deducted from the
total cost to provide the service.
SERVICE UTILIZATION FORECAST
The service utilization forecast, or in the case of non-emergency transportation services,
transportation utilization forecast, is the actual number of Medicaid units of service in the prior
fiscal year, as verified by authorizations provided by the Nevada Medicaid agency or its
designated vendor.
SUBCONTRACTOR
A subcontractor is a vendor who provides services or products to the servicing provider/vendor
of Medicaid through a written contract between the Medicaid servicing provider/vendor and the
subcontractor.
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POLICY
1203
POLICY
1203.1
SUBMISSION OF THE COST REPORT FOR THE REGIONAL TRANSPORTATION
COMMISSION (RTC)
By October 31 of each year, each RTC will submit a cost report to determine the cost-based rate
that will be effective from January 1 through December 31 of the coming calendar year.
Financial and ridership data will be provided for the fiscal year beginning on July 1 and ending
on June 30 immediately prior to the October 31 cost report submission deadline. Financial data
will be actual revenues and expenditures in the RTC’s closing budget for the fiscal year reported.
Total ridership data will be the actual number of total paratransit rides provided by RTC from
July 1 to June 30 of the reporting period. Medicaid ridership will be the actual number of
authorized Medicaid rides as verified by the Medicaid non-emergency transportation broker for
the reporting period.
Where the RTC incurs direct costs for paratransit through use of subcontractors, the RTC must
provide one copy of the contract to the Division of Health Care Financing and Policy (DHCFP)
no later than the date that the cost report is submitted, on or prior to October 31. Where the RTC
compiles direct costs separately for paratransit, fixed route, and any other service, this will be
noted in the appropriate box on the cost report. The RTC will maintain records demonstrating
that costs are compiled separately and that the costs entered on the cost report are accurate.
Where the RTC does not compile costs for services essential to providing paratransit services
separately from fixed route or other services, costs may be allocated by vehicle mile, vehicle
hour, or another reasonable methodology approved by the DHCFP Administrator. Where costs
are allocated, the RTC will maintain records of actual costs and data supporting the allocation.
The RTC will use the cost report form provided by the DHCFP. The cost report must be
complete when submitted. The RTC shall provide any documentation requested by the DHCFP
as it reviews the cost report to approve the RTC’s rate.
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MEDICAID OPERATIONS MANUAL
1204
1204
Subject:
DETERMINATON OF THE COSTBASED RATE
DETERMINATION OF THE COST-BASED RATE
The cost-based rate is the net allowable costs divided by the total number of rides or service
units. The rate is generally set for a year period normally specified in the Nevada Medicaid State
Plan Amendment (SPA). If the fiscal year is not specified in the SPA, then the fiscal year can be
whatever is agreed upon by the Division of Health Care Financing and Policy (DHCFP) and the
provider. Nevada Medicaid pays the federal share of the cost-based rate, and in most cases the
servicing or billing provider provides the non-federal share of rate through an Intergovernmental
Transfer payment. The Nevada Medicaid State Plan allows the DHCFP to set a single cost-based
rate annually. The rates are effective at the beginning of the fiscal year designated, such as
January 1 through December 31 of each year for the Regional Transportation Commission
(RTC). The Medicaid State Plan makes no provision for adjusting the rate during the year. The
DHCFP will not receive adjustments to cost or utilization data to increase the cost-based rate
after the annual rate becomes effective. Federal regulation prohibits overpayment for Medicaid
services. Therefore, corrections to financial or statistical data that demonstrate reimbursement
should be decreased and must be submitted to the DHCFP as soon as these corrections are
known to the provider. The DHCFP will arrange with the provider to recoup any
overpayment(s).
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1205
1205
Subject:
PAYMENTS FOR SERVICES
PAYMENTS FOR SERVICES
Payments for services can be made when billed as a medical claim through the Medicaid
Management Information System (MMIS) or made on a quarterly basis as a non-claims financial
transaction. If the payment is made as a non-claims financial transaction the payment is based on
the cost-based rate effective for the designated fiscal year and the actual units of service or rides
provided during the quarter. For non-claims financial transactions the provider submits a
quarterly cost report within 60 days of the end of the quarter. The Division of Health Care
Financing and Policy (DHCFP) remits payment following audit of the quarterly cost report. A
monthly payment may be considered for non-claim based payments. The terms and method of
payment for the individual providers are outlined in the provider’s inter-local agreement.
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1206
1206
Subject:
INTERGOVERNMENTAL
TRANSFER PAYMENTS
INTERGOVERNMENTAL TRANSFER PAYMENTS
In most cases, unless otherwise specified in the contract or inter-local agreement, the provider is
responsible for payment of the state share of costs for services. The provider remits payment
through an Intergovernmental Transfer made prior to the 30th day of the first month of the
current quarter. For instance, the Intergovernmental Transfer payment providing the state share
of costs for the quarter January through March is due by January 30 of that quarter. The Division
of Health Care Financing and Policy (DHCFP) invoices the provider for the Intergovernmental
Transfer payment by the tenth day of the month the payment is due.
The Intergovernmental Transfer payment is based on the actual utilization or ridership of the
prior quarter plus any adjustment for underpayment or overpayment of the state share in prior
quarters. The amount of the Intergovernmental Transfer is calculated by the following formula:
Actual service units or Ridership Prior Quarter X Current Rate = Estimated Total Current
Quarter
Estimated Total Current Quarter + Prior Quarter Adjustments = Total Payment
Total Payment X State Share (100% - FMAP) = Intergovernmental Transfer Payment
COST BASED REIMBURSEMENT RATES
Section 1206 Page 1