Mo. Code Regs. tit. 13 § 70-15.070

Current through Register Vol. 49, No. 21, November 1, 2024.

Section 13 CSR 70-15.070 - Inpatient Psychiatric Services for Individuals Under Age Twenty-One

PURPOSE: This amendment provides reimbursement to psychiatric residential treatment providers for days when the participant is temporarily away from the facility.

(1) Pursuant to provisions of section 208.161, RSMo, MO HealthNet coverage will be afforded to eligible individuals under age twenty-one (21) for inpatient psychiatric services provided under the following conditions:

(A) Under the direction of a physician; and

(B) In a psychiatric hospital facility or an inpatient psychiatric program in a hospital, either of which is accredited by a national organization whose psychiatric hospital accrediting program has been approved by Centers for Medicare & Medicaid Services (CMS) or is licensed by the hospital licensing authority of Missouri; or

(C) In a psychiatric residential treatment facility (PRTF) that is operated as a public institution by the Missouri Department of Mental Health (DMH) and is exempt from the hospital licensing law, that is accredited by the Joint Commission, and is certified as complying with the requirements at 42 CFR 441 subpart D and the condition of participation at 42 CFR 483 subpart G by the designated state agency for which such authority has been authorized; or

(D) In a privately operated PRTF that is accredited by the Joint Commission, the Council on Accreditation, the Commission on Accreditation of Rehabilitation Facilities, Det Norske Veritas (DNV), or equivalent organization, and is certified as complying with the requirements at 42 CFR 441 subpart D and the condition of participation at 42 CFR 483 subpart G by the designated state agency for which such authority has been authorized; and

(E) For claimants under the age of twenty-one (21) or, if receiving the services immediately before attaining the age of twenty-one (21), not to extend beyond the earlier of the date-

1. Services are no longer required; or

2. Individual reaches the age of twenty-two (22).

(2) Reimbursement for inpatient psychiatric services, as provided for in this rule, shall be made as follows: hospital care reimbursement at 13 CSR 70-15.010;

(A) For psychiatric hospitals and inpatient psychiatric programs within general hospitals, reimbursement will be calculated in accordance with the provisions for inpatient hospital care reimbursement at 13 CSR 70-15.010;

(B) For state operated PRTF services for individuals under the age of twenty-one (21), reimbursement will be calculated as follows:

1. The MO HealthNet Division shall reimburse state operated PRTFs for services based on the individual participant's days of care multiplied by the facility's Title XIX per diem rate less any payments made by participants;

2. The per diem for a state-operated PRTF is calculated as follows:

A. Determine the total costs from the second prior year hospital cost report (i.e. FY 2021 per diem rate is based off the hospital's 2019 cost report) for PRTF services;

B. Trend the total cost of the state operated PRTF by the Hospital Market Basket index as published in Healthcare Cost Review by Institute of Health Systems (IHS), or equivalent publication, regardless of any changes in the name of the publication or publisher;

C. Determine the total PRTF patient days from the DMH Customer Information Management, Outcomes and Reporting (CIMOR) system for the second prior year to correspond with the hospital cost report; and

D. Divide the trended cost as determined in subparagraphs (2)(B)2.A. and (2)(B)2.B. of this rule by the total patient days as determined in subparagraph (2)(B)2.C. of this rule to arrive at the State-Operated PRTF per diem; and

3. The per diem is updated each state fiscal year using the second prior year cost report;

(C) For private PRTF services for individuals under the age of twenty-one (21), reimbursement will be calculated as follows:

1. Effective for dates of service on or after September 29, 2021, the division will reimburse private PRTFs on a prospective per diem rate. The prospective Missouri Private PRTF per diem rate was created using a wage rate model which utilized data derived from cost surveys prepared and submitted by potential PRTF providers. These cost surveys were collected February, 2021 or prior. The model specifically examines potential facility, occupancy, staff to patient ratios, necessary nursing hours per patient day, direct care and behavioral health pro- fessional wage and overhead expense, and risk factors. For a detailed breakdown of these calculations, see: https://dss.mo.gov/mhd/cs/psych/pdf/mo-prtf-wage-rate-build-model.pdf. The Missouri Prospective PRTF Rate Methodology document is incorporated by reference and made a part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, on its website at https://dss.mo.gov/mhd/cs/psych/pdf/mo-prtf-wage-rate-buildmodel.pdf, October 1, 2021. This rule does not incorporate any subsequent amendments or additions. The per diem rate is included in the MO HealthNet Division (MHD) fee schedule, which is incorporated by reference and made a part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, on its website at https://dss.mo.gov/mhd/providers/pages/cptagree.htm, August 13, 2021. This rule does not incorporate any subsequent amendments or additions; and

(D) For state-operated and private PRTFs, medical leave days and therapeutic leave days will be paid to the PRTF at fifty percent (50%) of the per diem rate. Medical leave days include inpatient hospital medical/surgical stays and inpatient hospital psychiatric stays. Five (5) days of leave are allowed for medical/surgical stays per treatment episode, and five (5) days of leave are allowed for inpatient psychiatric stays per treatment episode. Therapeutic leave is for purposes of transition from the PRTF to the designated placement and must be included in the particpant's plan of care. Ten (10) days of leave are allowed for therapeutic leave per treatment episode.

(3) A written and signed certification of need for services must be completed for every admission reimbursed by Medicaid that attests to-

(A) Ambulatory care resources available in the community do not meet the treatment needs of the youth;

(B) Inpatient treatment under the direction of a physician is needed; and

(C) The services can reasonably be expected to improve the patient's condition, or prevent further regression, so that the services will no longer be needed.

(4) The certifications of need for care shall be made by different teams depending on the status of the individual patients as follows:

(A) For an individual who is receiving Medicaid at the time of admission, the certification of need shall be made by an independent team of health professionals at the time of admission. A team member cannot be employed by the admitting hospital or PRTF or be receiving payment as a consultant on a regular and frequent basis. The team must include a licensed physician who has competence in diagnosis and treatment of behavioral health disorders, preferably in child psychiatry, and has knowledge of the patient's situation and one (1) other behavioral health professional who is licensed;

(B) For an individual who applies for Medicaid while in the facility, the certification of need shall be made by the treatment facility interdisciplinary team responsible for the individual's plan of care as specified in section (5). The certification of need is to be made before submitting a Medicaid claim for payment and must cover any period for which Medicaid claims are made; or

(C) For an individual who undergoes an emergency admission, the certification of need shall be made by the treatment facility interdisciplinary team responsible for the individual's plan of care as specified in section (5) within fourteen (14) days after admission.

1. All admissions to PRTFs shall be considered non-emergent. The certification of need shall be performed by an independent review team.

(5) The treatment facility's interdisciplinary team shall be a team of physicians and other personnel who are employed by, or provide services to patients in, the facility.

(A) The team shall include, as a minimum, either:

1. A board-eligible or board-certified psychiatrist who is a licensed physician;

2. A clinical psychologist who has a doctoral degree and is licensed and a physician licensed to practice medicine or osteopathy; or

3. A physician licensed to practice medicine or osteopathy with specialized training and experience in the diagnosis and treatment of behavioral health disorders, and a psychologist who has a master's degree or doctorate in clinical psychology and is licensed.

(B) The team also shall include one (1) of the following:

1. A psychiatric social worker who is licensed;

2. A licensed registered nurse with specialized training or one (1) year's experience in treating individuals with behavioral health disorders;

3. An occupational therapist who is licensed and who has specialized training or one (1) year of experience in treating individuals with behavioral health disorders; or

4. A psychologist who has a master's degree or doctorate in clinical psychology and is licensed.

(C) The team must be capable of performing the following responsibilities:

1. Assessing the individual's immediate and long-range therapeutic needs, developmental priorities, and personal strengths and liabilities;

2. Assessing the potential resources of the individual's family;

3. Setting treatment objectives; and

4. Prescribing therapeutic modalities to achieve the plan of care objectives.

(6) Inpatient psychiatric services shall include active treatment which means implementation of a professionally developed and supervised individual plan of care, as described in section (7), that meets the following requirements:

(A) Developed and implemented no later than fourteen (14) days after admission; and

(B) Designed to achieve the participant's discharge from inpatient status at the earliest possible time.

(7) An individual plan of care is a written plan developed for each participant to improve his/her condition to the extent that inpatient care is no longer necessary. The plan of care shall-

(A) Be based on a diagnostic evaluation that includes examination of the medical, psychological, social, behavioral and developmental aspects of the participant's situation and reflects the need for inpatient psychiatric care;

(B) Be developed by a team of professionals specified under section (5) in consultation with the participant; and his/her parents, legal guardians, or others in whose care s/he will be released after discharge;

(C) State treatment objectives;

(D) Prescribe an integrated program of therapies, activities, and experiences designed to meet objectives;

(E) Include, at an appropriate time, post-discharge plans and coordination of inpatient services with partial discharge plans and related community services to ensure continuity of care with the participant's family, school, and community upon discharge; and

(F) Be reviewed every thirty (30) days by the treatment facility interdisciplinary team specified in section (5) to provide the following requirements:

1. Determine that services being provided are or were required on an inpatient basis; and

2. Recommend changes in the plan as indicated by the participant's overall adjustment as an inpatient.

(8) Before admission or before authorization for payment, the team described in section (4) of this rule must make medical, psychiatric, and social evaluations of each applicant's or participant's need for care in the hospital or PRTF. Each medical evaluation must include the following elements:

(A) Diagnoses;

(B) Summary of present medical findings;

(C) Medical history;

(D) Mental and physical functional capacity;

(E) Prognoses; and

(F) A recommendation by a licensed physician concerning admission to or continued care in the hospital or PRTF for individuals who apply for Medicaid after admission.

(9) Audits to monitor facility or program compliance shall be performed by a medical review agent as authorized by the MO HealthNet Division. Inpatient admissions of July 1, 1991, and after will be subject to audits, which may include up to one hundred percent (100%) of Medicaid admissions. Documentation of certification of need, medical/psychiatric/social evaluations, plan of care, and active treatment shall be a part of the individual's medical record. All required documentation must be a part of the medical record at the time of audit to be considered during the audit. Failure of the medical record to contain the required documents at the time of audit shall result in recoupment. The medical review agent's audit process is as follows:

(A) The facility has thirty (30) calendar days from the date of the request to furnish medical records for desk audits. At rates determined by the medical review agent, provider costs associated with submission of records will be reimbursed. Records not received within thirty (30) days will result in the services being denied and the Medicaid payment recouped;

(B) Review of the certification of need, medical/psychiatric/social evaluations, and plan of care documentation is performed to determine compliance with this rule;

(C) A sample of claims is reviewed for quality of care;

(D) An initial review of the medical record information for active treatment is performed by either a nurse who is licensed or social worker reviewer who is licensed using a nationally recognized, evidence-based clinical tool;

(E) If the medical record documentation regarding the patient's condition and planned services meet the criteria in subsection (9)(D) of this rule, the services are approved by either the nurse or social worker reviewer;

(F) If the criteria in subsection (9)(D) of this rule is not met, the nurse or social worker reviewer refers the case to a physician reviewer who is a licensed physician for a determination of documentation and medical necessity. The physician reviewer is not bound by criteria used by the nurse or social worker reviewer. The physician reviewer uses his/her medical judgment to make a determination based on the documented medical facts in the record;

(G) If the physician reviewer denies the admission or days of stay, the attending physician and facility shall be notified. The facility may request of the medical review agent a reconsideration review. The facility is notified of the medical review agent's reconsideration determination;

(H) Reconsideration determination is the final level of review by the medical review agent. The division will accept the medical review agent's decision;

(I) Facilities are notified by the MO HealthNet Division if an adjustment of Medicaid payments is required as a result of audit findings;

(J) The following Medicaid policies apply for calculation of Medicaid payments:

1. Medicaid shall reimburse nursing facility care provided in the inpatient hospital or PRTF setting in accordance with 13 CSR 7015.010;

2. No Medicaid payment shall be made on behalf of any participant who is receiving inpatient hospital care and is not in need of either inpatient or nursing facility care. No payment will be made for outpatient services rendered on an inpatient basis; or

3. Medicaid shall not pay for admissions or continued days for social situations, placement problems, court commitments or abuse/neglect without medical risk; and

(K) Overpayment determinations may be appealed in accordance with section 208.156, RSMo.

13 CSR 70-15.070

AUTHORITY: section 208.201, RSMo Supp. 1987.* This rule was previously filed as 13 CSR 40-81.053. Emergency rule filed Sept. 24, 1981, effective Oct. 4, 1981, expired Jan. 13, 1982. Original rule filed Sept. 24, 1981, effective Jan. 14, 1982. Emergency amendment filed Sept. 13, 1991, effective Oct. 2, 1991, expired Jan. 29, 1992. Amended: Filed June 18, 1991, effective Dec. 9, 1991.

Amended by Missouri Register February 15, 2022/Volume 47, Number 4, effective 3/31/2022

Amended by Missouri Register November 1, 2023/volume 48, Number 21, effective 12/31/2023.

*Original authority: 208.201, RSMo 1987.