Inpatient mental health services in an Institution for Mental Disease (IMD's) are available to clients age 20 and younger when the client participates in a HEALTH CHECK (EPSDT) screen, and the treatment is medically necessary. Inpatient mental health services in an IMD must be family centered and community based culturally competent, and developmentally appropriate.
Services for wards of the Department must be prior-authorized by and consent for treatment must be obtained from the ward's case manager or the case manager's supervisor.
009.01 Legal Basis The Nebraska Medical Assistance Program (NMAP) covers IMD services 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.
009.02 Definition of an IMD 42 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.
009.03 Covered Services Under 42 CFR 440.160, NMAP covers services in IMD's for individuals age 20 and younger.
009.04 Standards 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 32-009.02 (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 32-001 and 471 NAC 32-008. 32-009.04AProvider 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.32-009.04BAnnual 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.32-009.04CMonthly 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.
32-009.04DRecord Requirements: Transfer to another IMD or readmission constitutes a new admission for the receiving facility. The psychiatrist shall complete, sign, and date Form MC-14 within 48 hours after admission. If an individual applies for assistance while in the facility, copies of the admission notes and plan of care must be attached to the signed Form MC-14 to certify that inpatient services are or were needed.
32-009.04D1An 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 32-009.09F);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.
009.05 General 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-certified psychiatrist. The team must also include at least two of the following:
1. 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 clinical psychologist. Inpatient Hospital Services for Individuals Age 20 or Younger in Institutions for Mental Disease (IMD's): Services provided under the direction of a psychiatrist for the care and treatment of clients age 20 and younger in an institution for mental disease that meets the requirements of 42 CFR 440.160.
Inspection of Care Team: The Department or designee'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 32-009.07 ff.
Medical Review Organization: A review body contracted by the Department, responsible for preadmission certification and concurrent and retrospective reviews of care.
009.06 Payment for IMD Services See 471 NAC 10-010.03 ff.
32-009.06ATherapeutic Passes from Institution for Mental Disease 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.32-009.06BUnplanned Leaves of Absence from Institution for Mental Disease Settings: Payment for hospitalization during an unplanned leave of absence from inpatient settings is not available. If a client returns to a hospital after an unplanned absence, the readmission must be approved by the Department contracted peer review organization or management designee.009.07 Inspections of Care Under 42 CFR 456, Subpart I, the Department or designee's inspection of care team shall periodically inspect the care and services provided to clients in each IMD under the following policies and procedures.
32-009.07AInspection of Care Team: The inspection of care team must meet the following requirements: 1. The inspection of care team must have a psychiatrist who is knowledgeable about mental institutions and other appropriate mental health and social service personnel;2. The team must be supervised by a physician, but coordination of the team's activities remains the responsibility of the Division of Medicaid and Long-Term Care or their designee;3. A member of the inspection of care team may not have a financial interest in any institution of the same type in which s/he is reviewing care but may have a financial interest in other facilities or institutions. A member of the inspection of care team may not review care in an institution where s/he is employed, but may review care in any other facility or institution.4. A physician member of the team may not inspect the care of a client for whom s/he is the attending physician.5. There must be a sufficient number of teams so located within the state that on-site inspections can be made at appropriate intervals in each facility caring for clients. 32-009.07BFrequency of Inspections: The inspection of care team and the Department shall determine, based on the quality of care and services being provided in a facility and the condition of clients in the facility, at what intervals inspections will be made. However, the inspection of care team shall inspect the care and services provided to each client at least annually, and/or more frequently as determined by the Inspection of Care team.32-009.07CNotification Before Inspection: No facility may be notified of the time of inspection more than 48 hours before the scheduled arrival of the inspection of care team. The review team may make unannounced inspections at their discretion.32-009.07DPersonal Contact With and Observation of Recipients and Review of Records: For clients age 20 and younger, the team's inspection must include - 1. Personal contact with and observation of each client;2. Review of each client's medical record; and3. Review of the facility's policies as they pertain to direct patient care for each client being reviewed in the inspection of care, in accordance with 42 CFR 456.611(b)(1). 32-009.07EDeterminations by the Team: The inspection of care team shall determine in its inspection whether - 1. The services available in the IMD are adequate to - a. Meet the health needs of each client; andb. Promote his/her maximum physical, mental, and psychosocial functioning;2. It is necessary and desirable for the client to remain in the IMD;3. It is feasible to meet the client's health needs through alternative institutional or noninstitutional services; and4. Each client age 20 or younger in a psychiatric facility is receiving active treatment as defined in 42 CFR 441.154 and 471 NAC 32-009.05. If, after an inspection of care is complete, the inspection of care team determines that a follow-up visit is required to ensure adequate care, a follow-up visit may be initiated by the team. This will be determined by the inspection of care team and will be noted in the inspection of care report.
32-009.07FBasis for Determinations: Under 42 CFR 456.610, in making the determinations by the team on the adequacy of services and other related matters, the team will determine what items will be considered in the review. This will include, but is not limited to, items such as whether -1. The psychiatric and medical evaluation, any required social and psychological evaluations, and the plan of care are complete and current; the plan of care, and when required, the plan of rehabilitation are followed; and all ordered services, including dietary orders, are provided and properly recorded.;2. The attending physician reviews prescribed medications at least every 30 days;3. Test or observations of each client indicated by his/her medication regimen are made at appropriate times and properly recorded;4. Physician, nurse, and other professional progress notes are made as required and appear to be consistent with the observed condition of the client;5. The client receives adequate services, based on such observations as - b. General physical condition and grooming;d. Apparent maintenance of maximum physical, mental, and psychosocial function;6. The client receives adequate rehabilitative services, as evidenced by -a. A planned program of activities to prevent regression; andb. Progress toward meeting objectives of the plan of care;7. The client needs any services that are not furnished through the IMD or through arrangements with others;8. The client needs continued placement in the IMD or there is an appropriate plan to transfer the client to an alternate method of care, which is the least restrictive, most appropriate environment that will still meet the client's needs.9. Involvement of families and/or legal guardians (see 471 NAC 32-001); and10. The facility's standards of care and policy and procedure meets the requirements for adequacy, appropriateness, and quality of services as they relate to individual Medicaid clients, as required by 42 CFR 456.611(b)(1). 32-009.07GReports on Inspections: The inspection of care team shall submit a report to the Administrator of the Medicaid Division on each inspection. The report must contain the observations, conclusions, and recommendations of the team concerning - 1. The adequacy, appropriateness, and quality of all services provided in the IMD or through other arrangements, including physician services to clients; and2. Specific findings about individual clients in the IMD. The report must include the dates of the inspection and the names and qualifications of the team members. The report must not contain the names of clients; codes must be used. The facility will receive a copy of the codes.
32-009.07HCopies of Reports: Under 42 CFR 456.612, the Department shall send a copy of each inspection report to - 1. The facility inspected;2. The IMD's utilization review committee;3. The Nebraska Department of Health and Human Services, Division of Public Health; and4. The Nebraska Department of Health and Human Services, Division of Behavioral Health. If abuse or neglect is suspected, Medicaid staff shall make a referral to the appropriate investigative body.
32-009.07JFacility Response: Within 15 days following the receipt of the inspection of care team's report, the IMD shall respond to the Central Office in writing, and shall include the following information in the response: 1. A reply to any inaccuracies in the report. Written documentation to substantiate the inaccuracies must be sent with the reply. The Department will take appropriate action to note this in a follow-up response to the facility;2. A complete plan of correction for all identified Findings and Recommendations;3. Changes in level of care or discharge of individual clients;4. Action to individual client recommendations; and5. Projected dates of completion on each of the above. If additional time is needed, the facility may request an extension.
At the facility's request, copies of the facility's response will be sent to all parties who received a copy of the inspection report in 471 NAC 32-009.07H.
A return site visit may occur after the written response is received to determine if changes have completely addressed the review team's concerns from the IOC report.
The Department will take appropriate action based on confirmed documentation on inaccuracies.
32-009.07KDepartment Action on Reports: The Department will take corrective action as needed based on the report and recommendations of the team submitted under this subpart.32-009.07LAppeals: See 471 NAC 2-003 ff. and 465 NAC 2-001.02 ff. and 2-006 ff.32-009.07MFailure to Respond: If the IMD fails to submit a timely and/or appropriate response, the Department may take administrative sanctions (see 471 NAC 2-002 ff.) or may suspend NMAP payment for an individual client or the entire payment to the facility.009.08 Inpatient Mental Health Services for Individuals Age 20 and Younger in an IMD NMAP covers inpatient mental health services in an IMD for individuals age 20 and younger under 42 CFR 440.160. The following requirements must be met to receive NMAP payment for these services.
32-009.08AAdmission Criteria: See 471 NAC 32-008.05.32-009.08BAdmission Evaluation: A psychiatrist shall make an admission evaluation when the client is admitted to the hospital. The admission evaluation must include - 1. An initial assessment, within 24 working hours of the admission, of the health status and related psychological, medical, social, and educational needs of each individual client;2. A determination of the range and kind of services required; and3. If all admission criteria have been met, this evaluation must include an initial treatment plan. 32-009.08CTreatment Plan Requirements: 1. The treatment plan must meet the guidelines in 471 NAC 32-001 and in 42 CFR 441.155 and 441.156; and2. The treatment plan must be developed by the psychiatrist and the Interdisciplinary Team defined in 471 NAC 32-009.08H. 32-009.08C1Review of Plan of Care: Under 42 CFR 441.155(c), the facility interdisciplinary team shall review the plan of care every 30 days to - 1. Determine that services being provided are or were required on an inpatient basis; and2. Recommend changes in the plan of care as indicated by the client's overall adjustment as an inpatient. This review also serves as the recertification of need for services.
The individual plan of care must be developed by the facility interdisciplinary team.
32-009.08DPrior Authorization Procedures: IMD services for clients age 20 and younger must be prior-authorized as follows: 1. The psychiatrist/physician 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.2. 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.3. 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.4. 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.5. If rejected, the Division of Medicaid and Long-Term Care shall return all forms to the facility with an explanation of the rejection.6. 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 Central Office shall send the pink and gold copies to the facility and the yellow copy to the local office.7. 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. One carbon copy of Form MC-9H may be attached to the first claim submitted.8. 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 Central Office 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 client's local office.32-009.08D1Transfers: 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.32-009.08ECertification of Need for Services: For persons becoming Medicaid eligible after admission, in accordance with 42 CFR 441.152, the facility interdisciplinary team shall certify that - 1. Ambulatory care resources available in the community do not meet the treatment needs of the client;2. Proper treatment of the client's psychiatric conditions requires services on an inpatient basis under the direction of a psychiatrist; and3. The services can reasonably be expected to improve the client's condition or prevent further regression so that the services will no longer be needed. The certification must be made at the time of admission, or if the individual applies for the NMAP while in the IMD, before the Department authorizes payment. This is accomplished by completion of Form MC-14. The form must be signed by the team physician/psychiatrist making the determination. A copy of the physician referral must accompany the completed MC-14.
32-009.08FInitial Certification: A psychiatrist shall pre-certify, at the time of admission, that the client requires inpatient services in a psychiatric hospital. The psychiatrist shall complete Form MC-14 at the time of admission or within 48 hours of admission. If the individual applies for NMAP while in a psychiatric hospital, the psychiatrist shall certify the client's needs before the Department authorizes payment.32-009.08GSixty-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.32-009.08HInterdisciplinary 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; and8. Plans for discharge, including referrals for outpatient follow-up care. Care plans must address family involvement.
This requirement may be met by completion of Form MC-14, which is retained in the client's record.
32-009.08JRequired Psychiatrist Services: The client must be treated by a psychiatrist at least six out of seven days, or frequently as medically necessary and the interaction must be documented in the client's medical record.32-009.08KFacility 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 30 days. The client's record must contain documentation of the 30-day interdisciplinary team review.32-009.08LAdmission 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 - 1. The Form MC-14 (see 471 NAC 32-009.08E).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. 32-009.08MDischarge 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. 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.
009.09 Payment for Inpatient Mental Health Services in an Institution for Mental Disease See 471 NAC 10-010.03 ff., 32-008.09, and 32-008.12.
009.10 Other Regulations In addition to the policies regarding mental health services, all regulations in the Nebraska Department of Health and Human Services Manual apply, unless stated differently in this section.
471 Neb. Admin. Code, ch. 32, § 009