471 NAC 32-009. INPATIENT MENTAL HEALTH SERVICES FOR BENEFICIARIES 20 AND YOUNGER IN INSTITUTIONS FOR MENTAL DISEASE (IMD)

009. INPATIENT MENTAL HEALTH SERVICES FOR BENEFICIARIES 20 AND YOUNGER IN INSTITUTIONS FOR MENTAL DISEASE (IMD). Inpatient mental health services in an institution for mental disease (IMD) are available to beneficiaries age 20 and younger when the beneficiary participates in a health check or Early and Periodic Screening, Diagnostic and Treatment (EPSDT) screen, and the treatment is medically necessary. Inpatient mental health services in an institution for mental disease (IMD) must be family centered, and community based, culturally competent, and developmentally appropriate. Services for children who are wards of the State of Nebraska must be prior-authorized by and consent for treatment must be obtained from the beneficiary’s case manager or the case manager's supervisor. 009.01 LEGAL BASIS. Nebraska Medicaid covers institution for mental disease (IMD) services according to federal regulations . Nebraska Medicaid provides institution for mental disease (IMD) services under Nebraska Statute 009.02 STANDARDS FOR PARTICIPATION. To participate in Nebraska Medicaid , the institution for mental disease (IMD) must: (A)Be in conformity with all applicable federal, state, and local laws; (B)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 institution for mental disease (IMD) is located; (C)Be certified as meeting the conditions of participation for hospitals in federal regulations ; (D)Be accredited by the Joint Commission or the American Osteopathic Association (AOA), and submit a copy of the most recent accreditation survey with the appropriate Nebraska Medicaid approved provider agreement form ; (E)Meet the definition of an institution for mental disease (IMD) as stated in this chapter; (F)Meet the current Joint Commission or American Osteopathic Association (AOA) standards of care; and (G)Meet all requirements in this chapter. 009.02(i) PROVIDER AGREEMENT. The provider must complete the appropriate Nebraska Medicaid approved provider agreement form and submit the form, along with a copy of its current Joint Commission or American Osteopathic Association (AOA) accreditation survey, program, policies, and procedures to Nebraska Medicaid to enroll in Nebraska Medicaid as a provider. If approved, Nebraska Medicaid notifies the institution for mental disease (IMD) of its provider number. 009.02(ii) ANNUAL UPDATE. With the annual cost report, the provider must submit a copy of all program information, their most recent license and accreditation certificates, and any other information specifically requested by Nebraska Medicaid. Claims will not be paid if this has not been received and approved. 009.02(iii) MONTHLY REPORTS. The institution for mental disease (IMD) must submit a monthly report to Nebraska Medicaid . The report must be submitted by the 15th of the following month. The report must contain: (1)The names of all Nebraska Medicaid beneficiaries admitted or discharged during the month; and (2)The date of each Nebraska Medicaid beneficiary’s admission or discharge. 009.02(iv) RECORD REQUIREMENTS. Transfers to another institution for mental disease (IMD) or readmission constitutes a new admission for the receiving facility. The psychiatrist must complete, sign, and date the appropriate form within 48 hours after admission. If beneficiary applies for assistance while in the facility, copies of the admission notes, and plan of care must be attached to the appropriate signed form to certify that inpatient services are or were needed. 009.02(iv)(1) AN INDIVIDUAL WHO APPLIES FOR NEBRASKA MEDICAID WHILE IN THE INSTITUTION FOR MENTAL DISEASE (IMD). For an individual who applies for Nebraska Medicaid while in the institution for mental disease (IMD), the certification must be: (a)Made by the team that develops the individual plan of care, in compliance with this chapter ; and (b)Cover any period before application for which claims are made. 009.02(iv)(2) PRIOR AND CONTINUED AUTHORIZATON. When Nebraska Medicaid eligibility is determined, authorization for previous and continued care must be obtained from the Nebraska Medicaid contracted peer review organization or management designee. 009.03 INTERDISCIPLINARY TEAM. 009.03(A) COMPOSITION. The team must include a board-certified psychiatrist. The team must also include at least two of the following: (i)Licensed mental health practitioner (LMHP); (ii)A registered nurse (RN) with specialized training or one year's experience in treating individuals with mental illness; (iii)An occupational therapist (OT) who is licensed, if required by state law, and who has specialized training or one year's experience in treating mentally ill individuals; or (iv)A clinical psychologist. -009.04 INSPECTIONS OF CARE. Inspections of care will be conducted as outlined in federal regulations. 009.05 INPATIENT MENTAL HEALTH SERVICES FOR BENEFICIARIES 20 AND YOUNGER IN AN INSTITUTION FOR MENTAL DISEASE (IMD). Nebraska Medicaid covers inpatient mental health services in an institution for mental disease (IMD) for beneficiaries age 20 and younger under federal regulations . The following requirements must be met to receive Nebraska Medicaid payment for these services. 009.05(A) ADMISSION CRITERIA. See requirements in this chapter . 009.05(B) ADMISSION EVALUATION. A psychiatrist must make an admission evaluation when the beneficiary is admitted to the hospital. The admission evaluation must include: (i)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 beneficiary; (ii)A determination of the range and kind of services required; and (iii)If all admission criteria have been met, this evaluation must include an initial treatment plan. 009.05(C) TREATMENT PLAN REQUIREMENTS. (i)The treatment plan must meet the requirements in this chapter and in federal regulations ; and (ii)The treatment plan must be developed by the psychiatrist and the interdisciplinary team defined in this chapter . 009.05(C)(1) RECERTIFICATION OF NEED. This review also serves as the recertification of need for services. The individual plan of care must be developed by the facility interdisciplinary team. 009.05(D) PRIOR AUTHORIZATION. Institution for mental disease (IMD) services for beneficiaries age 20 and younger must be prior-authorized. 009.05(D)(1) TRANSFERS. Transfers to another institution for mental disease (IMD) or readmissions constitute a new admission for the receiving facility. This procedure must be followed for each transfer or readmission. 009.05(E) CERTIFICATION OF NEED FOR SERVICES. For persons becoming eligible for Nebraska Medicaid after admission, in accordance with federal regulations , the facility interdisciplinary team must certify that: (i)Ambulatory care resources available in the community do not meet the treatment needs of the beneficiary; (ii)Proper treatment of the beneficiary's psychiatric conditions requires services on an inpatient basis under the direction of a psychiatrist; and (iii)The services can reasonably be expected to improve the beneficiary's condition or prevent further regression so that the services will no longer be needed. 009.05(E)(1) CERTIFICATION PROCEDURE. The certification must be made at the time of admission, or if the individual applies for Nebraska Medicaid while in the institution for mental disease (IMD), before Nebraska Medicaid authorizes payment. This is accomplished by completion of the appropriate Nebraska Medicaid approved confidential report form. The form must be signed by the team physician, psychiatrist, or advanced practice registered nurse (APRN) making the determination. A copy of the physician referral must accompany the completed appropriate Nebraska Medicaid approved confidential report form . 009.05(F) INITIAL CERTIFICATION. A psychiatrist must pre-certify, at the time of admission, that the individual requires inpatient services in a psychiatric hospital. The psychiatrist must complete the appropriate Nebraska Medicaid approved confidential report form at the time of admission or within 48 hours of admission. If the individual applies for Nebraska Medicaid while in a psychiatric hospital, the psychiatrist must certify the individual’s needs before Nebraska Medicaid authorizes payment. 009.05(G) SIXTY-DAY RECERTIFICATION. A psychiatrist must recertify, in the beneficiary's record, the beneficiary's need for continued care in an institution for mental disease (IMD) or need for alternative arrangements at least every 60 days after the initial certification. 009.05(H) INTERDISCIPLINARY PLAN OF CARE. The psychiatrist and the facility interdisciplinary team must develop and implement an individual written plan of care for each beneficiary within 48 hours after the beneficiary's admission. This plan of care must be placed in the beneficiary's chart when completed. Care plans must address family involvement. This requirement may be met by completion of the appropriate form, which is retained in the beneficiary's record. The written plan of care must include: (i)Diagnoses, symptoms, complaints, and complications indicating the need for admission; (ii) A description of the beneficiary's functional level; (iii)Objectives; (iv)Any orders for: (1)Medications; (2)Treatments; (3)Restorative and rehabilitative services; (4)Activities; (5)Therapies; (6)Social services; (7)Diet; and (8)Special procedures recommended for the beneficiary's health and safety; (v)Plans for continuing care, including review and modification of the plan of care; (vi)Appropriate medical treatment in the institution for mental disease (IMD) every 60 days; (vii)Appropriate social services every 60 days; and (viii)Plans for discharge, including referrals for outpatient follow-up care. 009.05(J) REQUIRED PSYCHIATRIST SERVICES. The beneficiary must be treated by a psychiatrist at least six out of seven days, or as medically necessary and the interaction must be documented in the beneficiary's medical record. 009.05(K) FACILITY INTERDISCIPLINARY PLAN OF CARE TEAM REVIEW. The attending or staff psychiatrist and other personnel involved in the beneficiary's care must review each plan of care at least every 30 days. The beneficiary's record must contain documentation of the 30-day interdisciplinary team review. 009.05(L) ADMISSION EVALUATION. Institution for mental disease (IMD) staff must develop an admission evaluation for each beneficiary within 30 days after the beneficiary's admission. This evaluation must be placed in the beneficiary's record when completed. The admission evaluation must include : (i)The appropriate Nebraska Medicaid approved confidential report form pursuant to this chapter ; (ii)A medical evaluation, including: (1)Diagnosis; (2)Summary of current medical findings; (3)Medical history; (4)Mental and physical functional capacity; (5)Prognosis; and (6)The psychiatrist's recommendation concerning the beneficiary's admission to the institution for mental disease (IMD) or the beneficiary's need for continued care in the institution for mental disease (IMD) if the beneficiary applies for Nebraska Medicaid while in the institution for mental disease (IMD) ; (iii)A psychiatric evaluation; (iv)A social evaluation; and (v)An initial plan of care sufficient to meet the beneficiary's needs until the facility interdisciplinary team has developed the individual written plan of care. 009.05(M) DISCHARGE PLANNING. The institution for mental disease (IMD) must make available to the psychiatrist current information on resources available for continued out-of-hospital care of beneficiaries and must arrange for prompt transfer of appropriate medical and nursing information to ensure continuity of care upon the beneficiary's discharge. The institution for mental disease (IMD) is responsible for discharge planning. In cooperation with community regional mental health programs, the institution for mental disease (IMD) must : (i)Initiate alternate care arrangements; (ii)Assist in beneficiary transfer; and (iii)Follow-up on the beneficiary's alternate care arrangements. 009.05(M)(1) LONG-TERM CARE (LTC) FACILITY STAFF INVOLVEMENT AND TRAINING. When the beneficiary is being transferred to a long-term care (LTC) facility , 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 institution for mental disease (IMD) must also contact Nebraska Medicaid .