008.01Legal Basis The Nebraska Medical Assistance Program (NMAP) covers IMD services, for clients 65 and over, under 42 CFR 431.620(b), 435.1009; 440.140; 440.160; Part 441, Subparts C and D; Part 447, Subparts B and C; Part 456, Subparts D and I; and Part 482. The Department provides IMD services under the Family Policy Act, Sections 43-532 through 534, Reissue Revised Statute of Nebraska, 1943.
008.02Definition of an IMD42 CFR 435.1009 defines an IMD as "an institution that is primarily engaged in providing diagnosis, treatment or care of persons with mental diseases, including medical attention, nursing care and related services. Whether an institution is an institution for mental diseases is determined by its overall character as that of a facility established and maintained primarily for the care and treatment of individuals with mental diseases, whether or not it is licensed as such. An institution for the mentally retarded is not an institution for mental diseases." This is limited to free-standing facilities which are not excluded units of acute care hospitals.
008.03Standards for Participation To participate in the NMAP, the IMD must -
1. Be in conformity with all applicable federal, state, and local laws;2. Be licensed as a hospital by the Nebraska Department of Health and Human Services, Division of Public Health or the licensing agency in the state where the IMD is located;3. Be certified as meeting the conditions of participation for hospitals in 42 CFR Part 482;4. Be accredited by the Joint Commission of Accreditation of Healthcare Organizations (JCAHO) or the American Osteopathic Association (AOA), and submit a copy of the most recent accreditation survey with Form MC-20;5. Meet the definition of an IMD as stated in 471 NAC 20-008.02 (above);6. Meet the program and operational definitions and criteria contained in the Nebraska Department of Health and Human Services Manual;7. Meet the current JCAHO or AOA standards of care; and8. Meet all requirements in 471 NAC 20-001 except active treatment. 20-008.03AProvider Agreement: The provider shall complete Form MC-20 and submit the form, along with a copy of its current JCAHO or AOA accreditation survey, program, policies, and procedures to the Department to enroll in NMAP as a provider. If approved, the Department notifies the IMD of its provider number.20-008.03BAnnual Update: With the annual cost report, the provider shall submit a copy of all program information, their most recent license and accreditation certificates, and any other information specifically requested by the Department. Claims will not be paid if this has not been received and approved. This information must be submitted with a new copy of Form MC-20.20-008.03CMonthly Reports: The IMD shall submit a monthly report to the Division of Medicaid and Long-Term Care. The report must contain - 1. The names of all Medicaid clients admitted or discharged during the month; and2. The date of each Medicaid client's admission or discharge. The report must be submitted by the 15th of the following month.
20-008.03DRecord Requirements: The regional center (or the local office for a client in a private facility) shall enter the Form MC-9H document number in Form Locator 63 on each Form CMS-1450 or standard electronic Health Care Claim: Institutional transaction that is submitted to the Department. Transfer to another IMD or readmission constitutes a new admission for the receiving facility.
20-008.03D1An Individual Who Applies For NMAP While in the IMD: For an individual who applies for NMAP while in the IMD, the certification must be - 1. Made by the team that develops the individual plan of care (see 471 NAC 20-008.10);2. Cover any period before application for which claims are made. When Medicaid eligibility is determined, authorization for previous and continued care must be obtained from the Department contracted peer review organization or management designee.
008.04General Definitions The following definitions are used in this section:
Interdisciplinary Team: The team responsible for developing each client's individual plan of care. The team must include a board-eligible or board-certified psychiatrist. The team must also include at least two of the following:
1. A Licensed Mental Health Practitioner;2. A registered nurse with specialized training or one year's experience in treating individuals with mental illness;3. An occupational therapist who is licensed, if required by state law, and who has specialized training or one year's experience in treating mentally ill individuals; or4. A licensed psychologist. Inpatient Hospital Services for Individuals Age 65 or Older in Institutions for Mental Disease (IMD's): Services provided under the direction of a psychiatrist for the care and treatment of clients age 65 and older in an institution for mental disease that meets the requirements of 42 CFR 440.140.
Inspection of Care Team: The Department's inspection of care team, consisting of a psychiatrist knowledgeable about mental institutions, a qualified registered nurse, and other appropriate personnel as necessary who conduct inspection of care reviews under 42 CFR 456.600-614 and 471 NAC 20-001.20.
Medical Review Organization: A review body contracted by the Department, responsible for preadmission certification and concurrent and retrospective reviews of care.
008.05Admission Criteria See 471 NAC 20-007.05.
008.06Signs and Symptoms In addition to the admission criteria, one or more of the following signs or symptoms of the problem must be present:
1. A suicide attempt that requires acute medical intervention or suicidal ideation with a lethal plan and the means to carry out this plan;2. Psychiatric decompensation to a level in which the client is not able to communicate or perform life-sustaining activities of daily living;3. Delusions or hallucinations that significantly impair the client's ability to communicate or perform life-sustaining activities of daily living;5. The presence of combined illnesses where neurological or other disease process coexists with a psychiatric disturbance, demanding special diagnostic or treatment interventions, which exceed non-hospital capacity;6. Aggression to others causing physical injury or homicidal ideation with a lethal plan and the means to carry out the plan, that is the result of a severe emotional psychiatric decompensation; and7. Medication initiation or change when the client has a documented history of reactions to psychotropic medications that have resulted in the need for acute medical care in a hospital or an emergency room.008.07Prior Authorization and Initial Certification Procedures IMD services for clients age 65 or older must be prior-authorized as follows:
1. Admissions must be prior-authorized by the Department's contracted peer review organization or management designee. Providers should follow the Department contracted peer review organization or management designee guidelines on facilitating prior authorization. The MC-14 received from the peer review organization or management designee must be maintained in the client's medical record;2. A psychiatrist shall pre-certify, at the time of admission, that the client requires inpatient services in a psychiatric hospital. The psychiatrist shall complete, sign, and date Form MC-14 within 48 hours after admission or at the time of application for medical assistance if this date is later than the date of admission. The 48-hour period does not include weekends or holidays. Copies of the admission notes and plan of care may be attached to the signed and dated Form MC-14 to certify that inpatient services are or were needed;
3. The facility shall contact the client's local office for determination of medical eligibility. The local office shall respond to the facility with - a. The medical eligibility effective date; andb. The date eligibility was determined, if this date is later than the date of admission;4. The facility shall complete Form MC-9H, attach a copy of the completed Form MC-14, and forward to the Division of Medicaid and Long-Term Care. The facility shall retain the original copy of Form MC-14 in the client's medical record;5. The Division of Medicaid and Long-Term Care shall review Form MC-14 and approve or reject the Form MC-14 findings within 15 days;6. If rejected, the Division of Medicaid and Long-Term Care shall return all forms to the facility with an explanation of the rejection;7. If approved, the Division of Medicaid and Long-Term Care shall complete Block #11 and the signature Block #18 of Form MC-9H. The white copy is retained in Central Office. The Division of Medicaid and Long-Term Care shall send the pink and gold copies to the facility and the yellow copy to the local office;8. The document number on Form MC-9H must be entered in Form Locator 63 on each Form CMS-1450 or standard electronic Health Care Claim: Institutional transaction submitted to the Department; and9. When the client is discharged or expires, the facility shall complete Form MC-10 to close the authorization. The facility shall forward the white copy to the Division of Medicaid and Long-Term Care and the yellow copy to the local office, and retain the pink and gold copies. Within 48 hours after a client is discharged or expires, the facility shall notify the local office in the client's county of finance.008.08Transfers Transfer to another IMD or a readmission constitutes a new admission for the receiving facility. This procedure must be followed for each transfer or readmission.
008.09Sixty-Day Recertification A psychiatrist shall recertify, in the client's record, the client's need for continued care in a mental hospital or need for alternative arrangements at least every 60 days after the initial certification.
008.10Interdisciplinary Plan of Care The psychiatrist and the facility interdisciplinary team shall develop and implement an individual written plan of care for each client within 48 hours after the client's admission. This plan of care must be placed in the client's chart when completed. The written plan of care must include -
1. Diagnoses, symptoms, complaints, and complications indicating the need for admission;2. A description of the client's functional level;4. Any orders for - c. Restorative and rehabilitative services;h. Special procedures recommended for the client's health and safety.5. Plans for continuing care, including review and modification of the plan of care;6. Appropriate medical treatment in the IMD every 60 days;7. Appropriate social services every 60 days;8. Family involvement; and9. Plans for discharge, including referrals for outpatient follow-up care. This requirement is met by completion of Form MC-14, which is retained in the client's record.
008.11Facility Interdisciplinary Plan of Care Team Review The attending or staff psychiatrist and other personnel involved in the client's care shall review each plan of care at least every 90 days. The client's record must contain documentation of the 90-day interdisciplinary team review.
008.12Admission Evaluation IMD staff shall develop an admission evaluation for each client within 30 days after the client's admission. This evaluation must be placed in the client's record when completed. The admission evaluation must include -
2. A medical evaluation, including - b. Summary of current medical findings;d. Mental and physical functional capacity;f. The psychiatrist's recommendation concerning the client's admission to the mental hospital or the client's need for continued care in the mental hospital, if the client applies for NMAP while in the mental hospital;3. A psychiatric evaluation;5. An initial plan of care sufficient to meet the client's needs until the facility interdisciplinary team has developed the individual written plan of care.008.13Discharge Planning The IMD shall make available to the psychiatrist current information on resources available for continued out-of-hospital care of patients and shall arrange for prompt transfer of appropriate medical and nursing information to ensure continuity of care upon the client's discharge. Under 42 CFR 441.102, when the client is approved for an alternate plan of care, the IMD is responsible for discharge planning. In cooperation with community regional mental health programs, the IMD shall -
1. Initiate alternate care arrangements;2. Assist in client transfer; and3. Follow-up on the client's alternate care arrangements. When the client is being transferred to a long term care facility (NF or ICF/MR), the facility's staff must be included in the discharge process and must receive appropriate and adequate medical and nursing information to ensure continuity of care. The IMD shall also contact the client's local office.
008.14Payment for IMD Services See 471 NAC 10-010.03 ff.
20-008.14ATherapeutic Passes from IMD Settings: For some psychiatric clients, therapeutic passes are an essential part of treatment. For those clients, documentation of the client's continued need for psychiatric care must follow the overnight therapeutic passes. Payment for hospitalization beyond a second pass is not available due to medical necessity.20-008.14BUnplanned Leaves of Absence from IMD Settings: Payment for hospitalization during an unplanned leave of absence is not available. The Department contracted peer review organization or management designee must be notified immediately when the client returns. Admission criteria will be applied. If approved, a new validation number will be issued to cover the days beginning with the day of return.471 Neb. Admin. Code, ch. 20, § 008