Division of Mental Health and Addiction 1915(i) Adult Home and Community Based Service (HCBS) Programs: Adult Mental Health Habilitation (AMHH) and Behavioral and Primary Healthcare Coordination (BPHC) 1915(i) State Evaluation Team Jocelyn Piechocki and Marsha Williams October 18, 2017
Adult Mental Health Habilitation (AMHH) and Behavioral and Primary Health Care Coordination (BPHC) Marsha Williams
1915(i) Adult Programs AMHH Members • May have AMHH and BPHC • May NOT have AMHH and Medicaid Rehabilitation Option (MRO) o AMHH and MRO are mutually exclusive BPHC Members • May have BPHC and AMHH • May have BPHC and Medicaid Rehabilitation Option (MRO) • May NOT have BPHC, AMHH and Medicaid Rehabilitation Option (MRO) o Since AMHH and MRO are mutually exclusive
1915(i) Adult Programs Referral and Application Processing Referrals • For both programs, refer individuals to one of the 25 state-certified Community Mental Health Centers (CMHCs) o CMHCs are the exclusive providers for both programs o Listing of all providers for the programs may be found at: http://www.in.gov/fssa/dmha/4446.htm Application Processing • CMHCs are responsible for: o Evaluations, assessments, and application completion for each individual o Submission of completed application and Individual Integrated Care Plan with supporting documentation to the 1915(i) State Evaluation Team (SET) for clinical eligibility review o Provision of services to approved members for each program • 1915(i) State Evaluation Team (SET) is responsible for review of each application o AMHH SET: Determines eligibility for each member Submission of approved application and service authorization to DXC for prior authorization for AMHH service(s) o BPHC SET: Determines clinical eligibility for each member Submission of BPHC clinical approval to Division of Family Resources (DFR) DFR determines eligibility for Medicaid Submission of approved application and service authorization to DXC for prior authorization for BPHC service
Adult Mental Health Habilitation (AMHH) Marsha Williams 1915(i) Adult State Evaluation Team
AMHH Habilitation vs. MRO Rehabilitation • The distinction of whether a service is habilitative vs. rehabilitative is often more rooted in an individual’s level of functioning and needs than in the actual service provided o Habilitative service “… means activities that are designed to assist members in acquiring, retaining, and improving… skills necessary to reside successfully in home and community setting:” 405 IAC 5-21.6-2(g) o Rehabilitative service focuses on “restoring function” • Many of the AMHH services are similar to MRO but the member’s treatment goals, along with their treatment approach and objectives, have a habilitative focus o AMHH expectation is the individual’s goals address reinforcement, management, adaptation, and/or retention of a level of functioning (habilitative goals) activities that are designed to assist individuals in acquiring, retaining, and improving the skills necessary to reside successfully in community settings o MRO has an expectation that the individual will steadily improve their level of functioning over time (rehabilitative goals) for maximum reduction of physical or mental disability and restoration of a recipient to their best possible functional level
Adult Mental Health Habilitation (AMHH) • Adults that have reached maximum benefit from a rehabilitative treatment approach • Individuals who want habilitation services to help them maintain the gains made from rehabilitation • Individuals who are at risk of institutionalization without intense home and community based services • May NOT be enrolled in AMHH and MRO at the same time.
AMHH Eligibility • DMHA Adult 1915(i) State Evaluation Team determines AMHH program eligibility • Maximum 360 day eligibility period • May apply to renew eligibility within 60 days of the end date of the currently approved AMHH eligibility period
AMHH Eligibility Criteria • At least age 35 at time of application • Enrolled in an eligible IHCP Medicaid program • Resides in a Home and Community Based Service (HCBS) compliant setting • AMHH eligible primary mental health diagnosis • Have recommendation for intensive community based care on the Adult Needs and Strengths Assessment (ANSA) by scoring level of need (LON) of 4 or higher • Meets needs based criteria as evidenced by the ANSA algorithm which is calculated from a combination of scores of applicant’s strengths and risk factors
AMHH Services Individuals may apply for each of the following AMHH services: • Adult day services • Home and community-based habilitation and support • Respite care • Therapy and behavior support services • Addiction counseling • Peer support services • Supported community engagement services • Care coordination • Medication training and support
Behavioral and Primary Healthcare Coordination (BPHC) Marsha Williams 1915(i) Adult State Evaluation Team
Behavioral and Primary Healthcare Coordination (BPHC) Assists individuals in managing physical health issues due to barriers or impairment as a result of a mental health disorder • Any physical health issue that the consumer has difficulty managing and/or coordinating • A formal medical diagnosis for the physical health issue is not required
BPHC Eligibility Criteria Needs-Based Criteria Targeting Criteria • Demonstrated health need which requires assistance and support in coordinating behavioral health and physical health treatment • At least age 19 • Demonstrated need related to management of behavioral and physical health • Demonstrated impairment in self- management of physical and behavioral • health services BPHC eligible primary mental health diagnosis • Have recommendation for intensive community based care on the Adult Needs and Strengths Assessment (ANSA) by scoring level of need of 3 or higher • Meets an algorithm based on answers to health questions used to assess applicant’s strengths and risk factors
BPHC Eligibility • 1915(i) Adult State Evaluation Team determines clinical eligibility o If determined to be clinically eligible for BPHC, information is transmitted to DFR • DFR determines non-clinical/financial Medicaid eligibility o Individuals determined to be clinically eligible for BPHC have a Special Income Level (SIL) consideration that is 300% or below the Federal Poverty Level (FPL) which may be applied during Medicaid eligibility review • Maximum 180 day BPHC clinical eligibility period • May apply to renew eligibility within 60 days of the end date of the currently approved BPHC eligibility period
BPHC Service Activities BPHC service has one (1) service which includes the following activities: Coordination of healthcare services o Direct assistance in gaining access to services o Coordination of care within & across systems o Oversight of the entire case o Linkage to services • Assistance in utilizing the healthcare system o Logistical support o Advocacy o Education • Referral & linkage to medical provider s • Coordination of services across systems o Physician consults o Communication conduit o Notification of changes in medication regimens & health status o Coaching for more effective communication with providers
Home and Community Based Service (HCBS) Jocelyn Piechocki 1915(i) Adult State Evaluation Team
CMS HCBS Background • CMS HCBS Final Rule published January 2014, with an effective date of March 17, 2014 • Addressed HCBS setting requirements across: 1915(i) State Plan Amendment programs: AMHH and BPHC 1915(c) waiver programs 1915(k) Community First Choice programs
What is a Home and Community-Based Service (HCBS) Compliant Setting? Per CMS, an HCBS setting can be any of the following: 1) Member owned/leased 1) Residential Provider owned/operated/controlled 1) Third-party owned/operated/controlled
What is not an HCBS Compliant Setting? • The following settings are identified by CMS as institutional, and are NOT considered home and community-based: 1) Nursing facilities 2) Institutes for Mental Disease (IMD) 3) Intermediate Care Facilities for Individuals with Intellectual Disability (ICF/IID) 4) Hospitals • Federal requirements apply to all settings in which a member may reside and/or receive services
Qualities of an HCBS Compliant Setting: The “Big 5” CMS established five qualities (the “Big 5”) that apply to ALL settings 1) The setting is integrated in and supports full access of individuals receiving Medicaid HCBS to the greater community, 2) The setting is selected by the individual from among setting options, 3) The setting ensures an individual’s rights of privacy, dignity, and respect, and freedom from coercion and restraint 4) The setting optimizes, but does not regiment, individual initiative, autonomy, and independence in making life choices, including but not limited to daily activities, physical environment, and with whom to interact 5) The setting facilitates individual choice regarding services and supports, and who provides them
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