1915(i) Adult Home and Community Based Service (HCBS) Programs: - - PowerPoint PPT Presentation

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)

• 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)

• 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)

• CMHCs are the exclusive providers for both programs
• 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:
• Evaluations, assessments, and application completion for each individual
• Submission of completed application and Individual Integrated Care Plan with supporting documentation to the

1915(i) State Evaluation Team (SET) for clinical eligibility review

• Provision of services to approved members for each program
• 1915(i) State Evaluation Team (SET) is responsible for review of each application
• AMHH SET: Determines eligibility for each member
• Submission of approved application and service authorization to DXC for prior authorization for AMHH

service(s)

• 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
• ften more rooted in an individual’s level of functioning and needs

than in the actual service provided

• 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)

• 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

• 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

• 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

• f 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
• f 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

• At least age 19
• BPHC eligible primary mental

health diagnosis

• Demonstrated health need which requires

assistance and support in coordinating behavioral health and physical health treatment

• Demonstrated need related to management of

behavioral and physical health

• Demonstrated impairment in self-

management of physical and behavioral health services

• 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

Targeting Criteria Needs-Based Criteria

BPHC Eligibility

• 1915(i) Adult State Evaluation Team determines clinical eligibility
• If determined to be clinically eligible for BPHC, information is

transmitted to DFR

• DFR determines non-clinical/financial Medicaid eligibility
• 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

• Direct assistance in gaining access to services
• Coordination of care within & across systems
• Oversight of the entire case
• Linkage to services
• Assistance in utilizing the healthcare system
• Logistical support
• Advocacy
• Education
• Referral & linkage to medical providers
• Coordination of services across systems
• Physician consults
• Communication conduit
• Notification of changes in medication regimens & health status
• 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

POCO Residential Settings

• POCO (Provider Owned, Controlled and/or Operated)

residential settings, as defined by CMS, are those settings in which an individual resides that are specific physical places that are owned, co-owned, and/or operated by a provider of HCBS

• Indiana has four types of DMHA-certified residential facilities

for adults:

1) alternative family homes for adults (AFA) 2) transitional residential living facility (TRS) 3) semi-independent living facilities (SILP) 4) supervised group living (SGL)

• Each of these DMHA-certified residential facilities meets the definition of a POCO

residential setting

Additional Required Qualities of POCO Residential Settings: The “POCO 5”

POCO residential settings must meet additional conditions in order to be fully HCBS compliant:

1) Member signs a lease or resident agreement that provides the same protections from evictions under the landlord/tenant law of the state, county, city 2) Each individual has privacy in their sleeping or living unit: 3) Individuals have the freedom and support to control their own schedules and activities, and have access to food any time 4) Individuals are able to have visitors of their choosing at any time 5) The setting is physically accessible to the individual

“Presumed Institutional”

The HCBS Final Rule states that any setting that has any of the following three qualities of an institution does not meet the federal HCBS requirements:

1. Any setting that is located in a building that is also a publicly or privately

• perated facility that provides inpatient institutional care (that is, a

hospital, IMD, ICF/IID, or nursing facility) 2. Any setting in a building on the grounds of, or immediately adjacent to, a public institution (defined by CMS as an institution that is the responsibility

• f a governmental unit or over which a governmental unit exercises

administrative control) 3. Any other setting that has the effect of isolating individuals receiving Medicaid HCBS from the broader community of individuals not receiving Medicaid HCBS

1915(i) Adult Programs Summary

• 35 years and older
• LON 4 or above
• No longer able to rehab
• AMHH eligible primary

mental health diagnosis

• Maximum 360 day approved

eligibility period (can renew eligibility)

• Can be enrolled in AMHH

and BPHC

• Cannot be on enrolled in

both AMHH and MRO; programs are mutually exclusive

• 19 years and older
• LON 3 or above
• Mental health impedes

ability to manage and/or coordinate physical health issue(s)

• MRO eligible primary

mental health diagnosis

• Maximum 180 days

approved eligibility period (can renew eligibility)

• Can be enrolled in BPHC

and AMHH

• Can be enrolled in BPHC

and MRO

• Individuals must live in

an HCBS compliant setting to be eligible for AMHH/BPHC services

• Private/Independent

homes must meet all of the Big 5 Requirements

• POCO settings must

meet both the “Big 5” and the “POCO 5” requirements

• HCBS services are

prohibited from being provided in an institutional setting

AMHH BPHC HCBS

1915(i) Adult HCBS Programs Contact Information

Division of Mental Health and Addiction: (317) 232-7800 Home and Community Based Services (HCBS) DMHAAdultHCBS@fssa.in.gov Adult Mental Health Habilitation (AMHH) AMHHservices@fssa.in.gov Behavioral and Primary Healthcare Coordination (BPHC) BPHCservice@fssa.in.gov