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DSL Memo Series 2003-04

February 11, 2003

STATE OF WISCONSIN
Department of Health and Family Services
Division of Supportive Living

To:
Area Administrators/Assistant Area Administrators
Bureau Directors
County Departments of Community Programs Directors
County Departments of Developmental Disabilities Services Directors
County Departments of Human Services Directors
County Departments of Social Services Directors
County Corporation Counsels
County Economic Support Workers
County Judges
County Mental Health/AODA Coordinators
County Sheriffs
Medicaid HMOs
Mendota Mental Health Institute /Winnebago Mental Health Institute Directors
Licensing Chiefs/Section Chiefs
Tribal Chairpersons/Human Services Facilitators

From: 
Sinikka McCabe, Administrator

Re: Admission and Billing Procedures for Medicaid-Covered Children Admitted to Mendota Mental Health Institute and Winnebago Mental Health Institute

Background
Children under the age of 21 years admitted to one of the two state mental health institutes, Mendota Mental Health Institute (MMHI) or Winnebago Mental Health Institute (WMHI), are funded primarily by Title XIX, Medicaid fee-for-service (FFS), Medicaid managed care, or other third party insurance. Since the beginning of Medicaid managed care in 1984, the Department has contracted with Health Maintenance Organizations (HMO) to manage the health care needs, including mental health, of Medicaid recipients who are enrolled in an HMO. Medicaid managed care is a way of delivering medically necessary services in a cost-effective manner.

For those children enrolled in a Medicaid HMO at the time of admission, the HMO must authorize medically necessary inpatient mental health care prior to the provision of service, except in the case of emergencies. This includes services provided by MMHI and WMHI. For those children not enrolled in a Medicaid HMO at the time of admission the cost of medically necessary care at MMHI and WMHI is covered by Medicaid FFS or other third party benefits through family insurance. Medicaid fee-for-service remains the payer if the child enters MMHI or WMHI under fee-for-service system and is subsequently enrolled in the HMO during his or her stay at the institute.

Addendum II of the contract between the Department and the HMO outlines the HMO’s responsibilities for the provision of mental health and substance abuse services. The HMO is required to make a good faith effort to develop MOUs or contracts with each of the county agencies responsible for these services in their catchment area. It is important for counties and the HMOs to coordinate and work together to ensure necessary and appropriate services are provided to children and families enrolled in Medicaid HMOs.

County departments of community programs/human services are responsible for providing the necessary mental health, developmental disability, and alcohol and other drug abuse services as required in s.51.42, Wis. Stats. This includes voluntary and involuntary inpatient psychiatric services, such as the care and treatment provided by MMHI and WMHI.

Whether a child remains at a state institute with funding from a Medicaid HMO or Medicaid FFS, with or without other insurance, it is important to note that medical reviews will be done on all children admitted to MMHI or WMHI on a regular basis. HMOs perform concurrent reviews; Medicaid FFS reviews are retrospective. The review process can result in a determination that the placement is no longer required due to a lack of medical necessity (see HFS 101 (96m) for the definition of medical necessity) at the hospital level. If this determination is made, further payments from Medicaid HMOs are denied, and Medicaid FFS recoupments are made retrospectively.

Problem Statement
Since the beginning of CY 2001 county departments of human services and community programs have been billed for some services/care provided to children admitted to MMHI or WMHI. Some county agencies are questioning why children eligible for Medicaid are becoming their responsibility for payment when in the past services at these facilities were paid by Medicaid. The Wisconsin County Human Services Association (WCHSA) brought this issue to the attention of DHFS staff and requested assistance.

Solution
A Workgroup of state and county staff was formed to identify the issues and determine solutions. Members of the workgroup included county fiscal staff, mental health coordinators, and state staff from the Office of Strategic Finance, Office of Legal Counsel, several divisions in the Department, and MMHI and WMHI. The workgroup reviewed the requirements of Medicaid HMOs contained in Addendum II of the contract between the Department and the Medicaid HMOs, as well as the admission and billing procedures of WMHI and MMHI. The workgroup concluded that procedures between the county, state, and institute staff need to be clarified to assure timely notification and involvement of the Medicaid HMOs in planning and authorizing medically necessary treatment.

Below are the procedures for voluntary and involuntary admissions of children to the state institutes.

1. Voluntary admissions include children under 14 years old that requires parental/guardian approval and children over 14 years old that requires the child as well as the parent/guardian to approve of the placement.
   
2. Federal Medicaid regulations (42CFR 441.150-441.182) requires that the need for inpatient hospitalizations of Medicaid recipients under the age of 21 years to psychiatric facilities be certified by knowledgeable teams, as specified in 42 CFR 441.150-441.182. The Certificate of Need (CON) form developed by DHCF is the manner in which the state meets this federal regulation. The CON requirement is separate from the Medical Necessity requirement. Federal law states that a certification of need must be made by an independent team that includes a physician; has competence in diagnosis and treatment of mental illness, preferably in child psychiatry; and, has knowledge of the individual’s situation. The independent team certifies that ambulatory care resources available in the community do not meet the treatment needs of the recipient; proper treatment of the recipient’s psychiatric condition requires services on an inpatient basis under the direction of a physician; and, the services can reasonably be expected to improve the recipient’s condition or prevent further regression so that the services will no longer be needed. For voluntary admissions, the independent team may use the Certification of Need (CON) for Elective/Urgent Psychiatric/Substance Abuse Admissions to Hospital Institutions for Mental Disease (IMD) for Recipients Under Age 21 form (attachment 1) or a form developed by the IMD that contains all the required elements. The admitting hospital is responsible for the correct completion of the CON, but the hospital cannot provide the independent team, so will need the assistance of the referring agency for its completion.
   
3. Before a county agency staff person pursues a voluntary admission of a child to MMHI or WMHI, the staff person must determine if the child has Medicaid and whether the child is enrolled in a Medicaid HMO or is Medicaid fee-for-service (FFS). This may be done by contacting the county economic support (ES) worker or calling the Medicaid Automated Voice Response System at 1-800-947-3544, which provides Medicaid eligibility and HMO enrollment information and is available 24 hours a day, seven days a week.
   
4. If the child is enrolled in a Medicaid HMO, the HMO is responsible for ensuring that all medically necessary treatment is made available. The HMO determines whether to provide the treatment within their network of providers or outside their network, such as at MMHI or WMHI. For these children, the county staff person must contact the HMO to determine whether the HMO will authorize inpatient mental health services. If the HMO does not approve inpatient treatment, the HMO must take responsibility for ensuring that medically necessary treatment is provided. Staff can find the mental health contact number for each HMO on the Medicaid managed care website at http://www.dhfs.state.wi.us/medicaid7. HMOs may authorize and pay for less restrictive care and counties should work with the HMOs to determine what treatment is in the best interest of the child. Counties are liable for the cost of care if they do not follow the authorized treatment plan.
   
5. If the HMO approves inpatient treatment, they may use one of their own facilities, rather than MMHI or WMHI. According to State Statute, MMHI and WMHI may not contract with the Medicaid HMOs. The HMO will only pay for a voluntary admission to MMHI or WMHI under the following conditions: 1) the HMO does not have an in-plan facility bed available that will meet the child’s needs; 2) the HMO determines that MMHI or WMHI is the best placement for the child; or, 3) until it is possible and clinically appropriate to transfer the child to an in-plan facility.
   
6. If after admission to MMHI or WMHI, the HMO determines further inpatient treatment lacks medical necessity, staff at the institute will notify the county contact person immediately. The county and the HMO must communicate and work together regarding discharge planning and follow-up treatment. The HMO is responsible for all medically necessary follow-up treatment.
   
7. If the child is eligible for Medicaid FFS, the child can be admitted to any Medicaid-certified inpatient psychiatric facility, including MMHI and WMHI. Hospitalizations of all children admitted to MMHI or WMHI who have Medicaid FFS undergo a retrospective review of medical necessity on a regular basis. This review is known as an external review. There are two parts of the external review process: 1) a telephone pre-admission review, in which Medicaid does not pay a hospital claim without a control number obtained as a result of this telephone review, and 2) a retrospective inpatient IMD Medical Review, in which Medicaid recoups payment after a claim is paid if the stay did not meet medical necessity requirements. If Medicaid recoupment is made from the state institutes, the counties will not be billed for the services provided to the child.
   
8. If the child has other third party insurance that covers inpatient psychiatric services, it is still important for the county staff to determine what the policy covers. If possible, county staff should pre-determine if the third party insurance will cover the cost of treatment and if not, the county may make application for Institutional Medicaid. If third party insurance denies payment or the benefits are exhausted, or the child has no benefits, the county or the institute may then choose to apply for institutional Medicaid as a potential payment source for the child’s care. Medicaid FFS and Medicaid HMOs will cover only those services that are determined to be medically necessary.

1. A child may be placed at MMHI or WMHI under an Emergency Detention (ED) through a three-party petition or through a detention by a law enforcement official.
   
2. If a child is admitted to MMHI or WMHI under an ED, staff at the institute will contact the county agency (DHS or DCP) contact person within 24 hours, exclusive of weekends or legal holidays. The county agency is responsible to inform MMHI and WMHI of the name of their contact person to be notified in these situations. See attachment 3 for sharing this information.
   
3. Staff at the institutes, during admission process, are expected to attempt to determine the potential funding source for the child; i.e. Medicaid FFS, Medicaid HMO, third party insurance, etc. They are required to provide this information to the county contact person when they notify the county of the admission.
   
4. The county agency is expected to verify the funding source. If it appears the child is eligible for MA, the county agency staff person should contact either the county economic support (ES) worker or EDS to verify whether the child is Medicaid FFS or Medicaid HMO.
   
5. For emergency situations only, the interdisciplinary team responsible for the plan of care at MMHI or WMHI will fill out the Certification of Need (CON) form to certify that ambulatory care resources available in the community do not meet the treatment needs of the recipient; proper treatment of the recipient’s psychiatric condition requires services on an inpatient basis under the direction of a physician; and, the services can reasonably be expected to improve the recipient’s condition or prevent further regression so that the services will no longer be needed. This certification must be made within 14 days after admission. If the condition of the child in an emergency detention meets the federal definition for an emergency hospital service (that is, the hospitalization is necessary to prevent the death or serious impairment of the health of the recipient), the Certification of Need (CON) Form for Emergency Psychiatric/Substance Abuse Admissions to Hospital Institution for Mental Disease (IMD) for Recipients Under Age 21 and in Cases of Medicaid Determination After Admission form (Attachment 2) may be used, or the IMD may develop it’s own form which must contain all the required elements. If the condition of the child in an emergency detention does not meet this federal definition, the CON for Elective/Urgent Admissions to Hospital IMD form (attachment 1) should be used.
   
6. If the parents of a child admitted to MMHI or WMHI are not cooperative in providing the necessary information for DHFS to bill private insurance or MA, the county of residence will be responsible for payment of the bill.
   
7. If the child is enrolled in a Medicaid HMO, the county worker must contact the Medicaid HMO as soon as possible or within the time frame agreed upon in the county/HMO MOU. The mental health contact number for each HMO is located on the Medicaid managed care website at http://www.dhfs.state.wi.us/medicaid7. The HMO is only responsible for treatment after Probable Cause has been determined when they are given the opportunity to provide the care through their own network, or if the HMO has approved the Institute stay. The county agency worker is expected to find out where the HMO would like the child placed if continued hospitalization is needed after the Probable Cause Hearing. The county worker must contact the HMO to authorize care within 3 business days or the county is liable for the cost of care beyond the probable cause hearing.
   
8. The county agency worker should then inform the county corporation counsel of the placement facility in the HMO provider network that should be used if the Court at the Probable Cause Hearing finds probable cause. The corporation counsel and/or the county agency are responsible for informing the judge of the placement recommendation. The Court should be informed of all placement recommendations at the Probable Cause Hearing.
   
9. If probable cause is found and the Medicaid HMO has not agreed to have the child remain in MMHI or WMHI, the child should be transferred to the in-plan facility the HMO has designated.
   
10. If the child requires secure medical transportation, the county will arrange and pay for transportation from the state institute to the Medicaid HMO provider facility. Non-secure medical transportation will be arranged and paid for by the Medicaid HMO as specified in their contract with the Department. Medical transportation in the contract means specialized medical vehicle (SMV) or ambulance. When common carrier transportation is appropriate the county will arrange and pay for this service, and then the Medicaid program reimburses the county. In Milwaukee County the HMO arranges for common carrier transportation and then the Medicaid program reimburses the HMO.

1. When a separate department of social services and community programs exist in a county, it is critical that the DSS staff communicate with the DCP staff when they are working with a child and his/her family and the child is ordered or voluntarily admitted to WMHI or MMHI. The reason for this is that often the case manager working at DSS is the responsible staff person to assist the child and his/her family with the admission and is the central contact point at the county level to monitor the placement and work with the institute staff on discharge planning.

However, it is the responsibility of the DCP to pay for the care and treatment at the state institutes if there are no other funding sources. Therefore, it is very important for the DSS worker to keep the DCP informed of any placement plans of children at the state institutes. It is suggested that the two county agencies develop a Memorandum of Understanding (MOU) detailing the responsibilities of both agencies regarding these types of situations.

2. For any voluntary admission of a child that is being considered, the county agency responsible needs to determine if the child is enrolled in a Medicaid HMO and to contact that HMO for authorization and planning prior to admitting the child. As part of their case management responsibilities, the HMO may suggest alternate care options. County agency staff and HMO staff should work together to ensure the most appropriate placement and services are provided to the child and his/her family. Counties are liable for the cost of care if they do not follow the authorized treatment plan for the child. It is suggested that county agencies and HMOs include language in their MOU on how the two agencies will work together on voluntary admissions.
   
3. When a child is placed at one of the state institutes under an Emergency Detention (ED), the county department or the corporation counsel must determine if the child is covered by private health insurance, Medicaid FFS or an HMO, and which HMO, prior to a Probable Cause Hearing. Staff can do this by contacting the county economic support (ES) worker or by calling the Medicaid Automated Voice Response System at 1-800-947-3544. The county department or the corporation counsel must also determine placement options in the HMO provider network before a Probable Cause Hearing and inform the Court of the treatment options available at which the HMO would authorize payment. The county agency should meet with their corporation counsel to establish a policy on how they will inform the Court of all necessary information.
   
4. Counties are requested to submit to MMHI and WMHI the names of their contact person for admission notification, who is responsible for coordinating with the HMO, and who the case manager is for treatment and discharge planning. The person responsible for case management and discharge planning could change with each child admitted so the county department must inform the facility within 24 hours, exclusive of weekends and holidays, of who this person is for each admission. The contact person for admission notification and the person responsible for coordinating with the HMO should be submitted to MMHI and WMHI using the form on Attachment 3 by February 28, 2003 and then updated as needed.
   
5. County departments should make an effort to negotiate an MOU with the HMOs who serve their county and be familiar with what the Medicaid HMOs are required to cover. If counties have general questions regarding HMO contract requirements, they may contact Mary Laughlin, Division of Health Care Financing, Bureau of Managed Health Care Programs at (608) 267-7927. In addition, counties may seek assistance from the HMO’s Medicaid Contract Administrator listed on Attachment 4.
   
6. County department staff need to inform the county judge that the county will be liable for the cost of placement if the Court is given the HMO provider network information, with placement recommendations, and the Court orders placement at another facility.
   
7. County staff needs to promptly review the monthly HSRS report submitted by MMHI and WMHI. Any discrepancies will be resolved by contacting the admission office at MMHI and WMHI. The HSRS report and the monthly County Board billing use the same INSIGHT database.
   
8. If a child is under an involuntary status at either MMHI or WMHI and must be transported to another facility in the HMOs provider network, it is the responsibility of the county to arrange and pay for secure medical transportation as well as common carrier transportation. However if common carrier transportation is used the county will be reimbursed by the Medicaid program for the cost of this service.

1. MMHI and WMHI are responsible for the correct completion of a Certification of Need (CON). The facility may request/require a county agency or outside provider to complete the form for non-emergency admissions. For an individual who applies for Medicaid while in the facility, the certification must be made by the team responsible for the plan of care and must cover any period before application for which claims are made.
   
2. For Emergency Detentions, staff at MMHI and WMHI will determine upon admission if a child is Medicaid HMO, Medicaid FFS or private pay and will provide verbal notification to the county contact and the HMO, if applicable, on all admissions within 24 hours, exclusive of weekends and legal holidays.
   
3. If the child is enrolled in a Medicaid HMO, staff at MMHI and WMHI will communicate necessary clinical information to the Medicaid HMO to support medical necessity as soon as possible and on an on-going basis.
   
4. Staff at MMHI and WMHI will notify the county contact verbally, as soon as possible, when an HMO refuses payment because they have determined the services are not medically necessary.
   
5. Staff at MMHI and WMHI will enter the appropriate State Board Code. The State Board Code will determine whether or not the county will be billed for the services. In the event the Medicaid HMO does not authorize services, the State Board Code will be changed to a Billable Status and BFS will be notified to bill the county.
   
6. Staff at MMHI and WMHI will submit monthly HSRS reports to the appropriate county contact. The report includes all county clients grouped as Billable or Unbillable depending upon the State Board Code.

1. The Medicaid HMO is responsible for making a "good faith" effort to negotiate a Memorandum of Understanding (MOU) or a contract with the county agencies in their service area.
   
2. Medicaid HMOs are responsible for funding the first three business days, plus any intervening weekend days and/or holidays, if a child is placed in a facility under an emergency detention (ED) through a three-party petition or a detention by a law enforcement official.
   
3. If the court does not order the child held after the probable cause hearing, it is the HMO’s responsibility to work with the county to recommend follow-up care and provide the treatment within the HMO network.
   
4. HMOs are responsible for court-ordered treatment beyond the mandatory three working days and any intervening weekend days or holidays if they are involved in the discharge planning at a facility not in their provider network or provide the additional care in one of their facilities for the period of time they receive a capitation payment.
   
5. If a child is in need of non-secure transportation from a treatment facility not in an HMO provider network to a facility that is in the HMO provider network, the HMO is responsible for arranging and paying the transportation as specified in their contract with the Department. Medical transportation in the contract means specialized medical vehicle (SMV) or ambulance. When common carrier transportation is appropriate the county is responsible for arranging and paying, but is reimbursed by the Medicaid program for this service. In Milwaukee County, the HMO is responsible for arranging and paying for common carrier transportation and then the Medicaid program reimburses the HMO for this service.

When state institute providers are denied payment for services provided to an HMO enrollee, the Department's Division of Care and Treatment Facilities will assist in an appeal to the HMO. The appeal must first be made directly to the HMO within 60 days of the denial of payment. Contact the HMO for the name of the specific person or department handling provider appeals. See attachment 4 for the listing of HMO Contract Administrators.

If the HMO fails to respond to the provider within 45 days, or the provider is not satisfied with the HMO's response, an appeal can be made to the Department for a final decision. This appeal must be made within 60 days of the notification of the HMO's decision. The address for this appeal is:

Managed Care Program
Provider Appeals
P. O. Box 6470
Madison, WI 53716-0470

County staff having general Medicaid HMO contract questions may contact Mary Laughlin, in the Bureau of Managed Health Care Programs at (608) 267-7927.

DHFS staff will discuss and answer questions on the contents of this memo during early in 2003. At the videoconference, participants will be able to ask specific questions regarding the admission and billing procedures for Medicaid-covered children admitted or seeking admission to one of the state mental health institutes. Additional information will be shared in the near future, with all stakeholder groups, indicating the time, dates and locations of the meeting. If you have questions before the meeting, contact the individuals listed below.

REGIONAL OFFICE CONTACT:
Area and Assistant Area Administrators

CENTRAL OFFICE CONTACT:
MMHI: Janice Krall (608-301-1357)

WMHI: Beverly Pezewski (920-235-4910)

DHCF: Mary Laughlin (608-267-7927)

Attachments