dmas governor’s access plan for the seriously … · 2 department of medical assistance services...

www.dmas.virginia.gov 1

Department of Medical Assistance Services

DMAS Governor’s Access Plan for

the Seriously Mentally Ill (GAP)

GAP SMI Screening Entity Training

December 2014

http://www.dmas.virginia.gov 1




OBJECTIVES of TRAINING

• Overview of Screening Entities & Screener Credential Requirements

• Overview of Screening Entities & Screener Roles

– Assisting with GAP applications to Cover Virginia

– How to find the DMAS P-603 SMI Screening Tool

– Using the DMAS P-603 SMI Screening Tool

– SMI Screening Tool Attachments

– How to submit to Magellan

• GAP Program Sources of Information





GAP SMI Screening Entities &

Screener Credential Requirements

December 2014





GAP SMI Screening Entities

SMI screenings may be conducted by:

– Community Services Boards (CSBs);

– Federally Qualified Health Centers(FQHCs);

– Inpatient Psychiatric Hospitals; and,

– General Hospitals with an Inpatient Psychiatric Unit.



GAP SMI Screening

• One of the two screening types listed below must be completed by a DMAS approved screening entity in order to determine GAP SMI Eligibility.

– Limited Screening: Conducted for individuals who have had a diagnostic evaluation within the past 12 months and the evaluation is available to the screener. This screening may be completed by a Qualified Mental Health Professional-Adult (QMHP-A or QMHP-Eligible) or a Licensed Mental Health Professional (LMHP), including supervisees and residents.

– Full Screening: Conducted for individuals who have not had a diagnostic evaluation within the past 12 months or for whom the evaluation is not available to the screener. A diagnostic evaluation is completed at the time of the screening by an LMHP (including supervisees and residents).



Quick Definitions

• Licensed Mental Health Professional (LMHP) – means a physician, licensed clinical psychologist, licensed professional

counselor, licensed clinical social worker, licensed substance abuse treatment practitioner, licensed marriage and family therapist, or certified psychiatric clinical nurse specialist.

• LMHP Supervisee or Resident (LMHP-S; LMHP-R; LMHP-RP) – LMHP-R means the same as "resident" as defined in (i) 18VAC115-20-

10 for licensed professional counselors; (ii) 18 VAC115-50-10 for licensed marriage and family therapists; or (iii) 18 VAC115-60-10 for licensed substance abuse treatment practitioners;

– LMHP-RP means the same as an individual in a residency program as defined in 18VAC125-20-10 for clinical psychologists.

– LMHP-S means the same as "supervisee" as defined in 18 VAC140-20-10 for licensed clinical social workers.



Quick Definitions Continued

– An LMHP-Supervisee or Resident in any of the above definitions shall be in continuous compliance with the regulatory requirements for supervised practice and shall not perform the functions of the LMHP-S, LMHP-R, or LMHP-RP or be considered a "supervisee" or “resident” until the supervision for specific clinical duties at a specific site is pre-approved in writing by the appropriate Virginia Board.

• Qualified Mental Health Professional (QMHP-A or QMHP-E) – means the same as defined in 12VAC35-105-20 as a QMHP-Adult or

QMHP-Eligible. DMAS requirements for QMHP-A and QMHP-E are equivalent to the Department of Behavioral Health and Developmental Services provider requirements for Qualified Mental Health Professionals.





GAP SMI Screening Entity &

Screener Roles

December 2014





Roles

• Screening entities must schedule an appointment for the GAP SMI Screening within 7 business days of receiving a request.

• Verify that the individual receiving the GAP SMI Screening is at least age 21 and under age 65.

• Screeners may assist with submitting the GAP application to Cover Virginia if one has not already been done.

• Conduct the GAP SMI Screening using DMAS form P-603.

• Have an LMHP conduct a diagnostic evaluation if one has not been completed within the past 12 months or is not available to the screener.

• Submit the DMAS P-603 and required attachment(s) to Magellan within 3 business days of the GAP SMI screening.



Roles • Limited Screening: As a rule, these screenings should be

conducted face-to-face because the preferred process includes the screening entity assisting the individual with the application to Cover VA. SMI screenings may however be submitted on behalf of the individual when all of the following are met:

• The individual has an open and active case with the screening entity;

• The screening entity has the permission of the individual to submit a GAP SMI Screening; and

• There is a mental health diagnostic evaluation on file that was completed by an LMHP (including supervisees and residents) within the past 12 months.

• Full Screening: Must be conducted face-to-face by an LMHP for individuals who have not had a diagnostic evaluation within the past 12 months or for whom the evaluation is not available to the screener.



Roles

**All HIPAA rules apply; DMAS does NOT have the authority to waive HIPAA requirements.**



Eligibility Process

GAP eligibility is a two step process:

1. Financial/non-financial determination (Cover VA GAP app); and

2. GAP SMI determination.

Individuals may start at either step to enter the GAP Program.



Cover VA GAP Application

There are two ways to submit an application for the GAP Program to Cover Virginia:

1. Telephonically by calling 1-855-869-8190 or TDD at 1-888-221-1590

2. Through the provider assisted web application. Members may only be assisted by a GAP Screening entity or another DMAS approved organization. This is the preferred method for application.

• Applicants beginning the process through Cover Virginia will be referred to their local GAP Screening Entity for a GAP SMI Screening.



Cover VA GAP Application

• SMI Screeners who choose to assist individuals with submitting the application to Cover Virginia may do so either by phone or through the web application.

• The local Dept. of Social Services is not involved in any of the GAP Application processes.

• A training will be available in January to assist screeners in learning the details of how to assist members in submitting applications online.



GAP SMI Screening

• GAP SMI is determined via the use of the GAP Serious Mental Illness Screening Tool (DMAS P-603).

• The screening tool addresses 5 areas:

– Age

– Diagnosis

– Duration of Illness

– Level of Disability, and

– Whether due to mental illness the individual requires assistance to consistently access and utilize needed medical and/or behavioral health services/supports.



Locating the DMAS P-603 Online • Virginia Medicaid Web Portal -

https://www.virginiamedicaid.dmas.virginia.gov/wps/portal

• Provider Forms Search application - https://www.virginiamedicaid.dmas.virginia.gov/wps/portal/ProviderFormsSearch

https://www.virginiamedicaid.dmas.virginia.gov/wps/portal

https://www.virginiamedicaid.dmas.virginia.gov/wps/portal/ProviderFormsSearch



Locating The Form Continued

• Type: GAP

• Category: Screening

• Number/Name: DMAS-P603

• Title: GAP SMI Screening Form



Locating The Form Continued



DMAS Form P-603



DMAS P-603

Date SMI Screening Referral Received:

____________________________________________

Referral Source: Cover Virginia Hospital Other

Self Veteran’s Administration Community Services Board

Family Member Behavioral Health Provider Medical Care Provider/Clinic

COVER VIRGINIA

Confirm that the individual has made an application with Cover Virginia.

• COVER VIRGINIA: Place a check or X in the box to verify that the individual being screened has submitted an application with Cover Virginia.

• SMI SCREENING REFERRAL: Enter the date that the individual was referred for a GAP-SMI screening and place a check or an X in the box indicating the referral source.



DMAS P-603 Demographic Info • Name: Enter the full legal name of the individual.

• Date of Birth: Enter the date of birth of the individual.

• Gender: Enter the natal sex of the individual.

• SSN: Enter the Social Security Number of the individual.

• Street Address: Enter the physical address where the individual resides.

• City, State, and zip code: Enter the city, state, and zip code of the street address above.

Applicant Demographic Information

Name (Last, First, MI):

Date of Birth: Gender:

Male Female Social Security #:

Street Address:

City, State, and Zip code



DMAS P-603 Demographic Info • Ethnicity and Race: These sections of the screening are optional and do

not need to be completed in order for the screening to be processed. Place a check or X next to the ethnicity and race of the individual. The individual may decline to provide this information. Race and ethnicity are not to be assumed by the screener since they can be left blank.

Ethnicity Hispanic/Latino (OPTIONAL—If applicable, check all

that apply)

Mexican Mexican

American

Chicano/a Puerto

Rican

Cuban Other

Race - (OPTIONAL)

White Asian Indian Japanese Other

Asian

Samoan

Black or African American Chinese Korean Native

Hawaiian

Other

Pacific

Islander

American Indian or Alaska Native Filipino Vietnamese Guamania

n or

Chamorro

Other



DMAS P-603 Screener Information • The screening site is the location at which the screening is being

conducted. The contact information for the screening facility/site is information on who to contact should there be questions regarding the completion of the screening tool.

• Sections pertaining to the “screener” are to be answered with specific information for the individual that conducted the screening.

Name of Screening Site: Contact Name for Screening Facility: Screening Site Phone #:

Screening Site Fax #: Name of Screener:

Screener Credentials/Licensure: Screener Phone#:

Screener Zip Code#: Screening Site NPI:

Magellan Provider Identifier (MIS #): MIS

number for the site.

Screener Signature: Electronic signatures are acceptable.

Providers without electronic records must print, sign, scan, and

submit forms with original signatures.

*Date of SMI Screening: Date screening was

conducted.

*Date of Licensed Mental Health Professional Evaluation: This is

the diagnostic evaluation. Evaluation dates must be within the past

12 months.



P-603 SMI Criteria - Age

In order to be considered as having SMI for the purposes of the GAP demonstration the following SMI criteria must be met:

1. Age

The individual is at least 21 years of age and has not yet reached their 65th birthday.

Yes No Serious Mental Illness Criteria

1. Age: The person is 21-64 years of age or older.



P-603 SMI Criteria - Diagnosis 2. Diagnosis: The person has a serious mental illness

diagnosed under Axis I in the DSM. At least one of the

following diagnoses must be present. Adjustment Disorder

or V Code diagnoses do not meet this criterion.

Schizophrenia spectrum disorders & other psychotic disorders

Exception: substance/medication induced psychotic disorder

Major depressive disorder

Bipolar and related disorders

Exception: cyclothymic disorder

Post-Traumatic Stress Disorder

Other: OCD, Panic Disorder, Agoraphobia, Anorexia nervosa, Bulimia

nervosa



P-603 SMI Criteria - Duration 3. Duration of Illness: The person must meet at least one of

these criteria:

Is expected to require services of an extended duration. Answer yes if the

individual is expected to require mental health services for a period of more than 12 months.

Has undergone psychiatric treatment more intensive than

outpatient care, such as crisis response services, alternative

home care, partial hospitalization, or inpatient hospitalization,

more than once in his or her lifetime.

Has experienced an episode of continuous, supportive residential

care, other than hospitalization, for a period long enough to have

significantly disrupted the normal living situation. A disruption of a normal

living situation would mean that the individual was unable to maintain their housing or had difficulty maintaining their

housing due to being in a supportive residential facility or program that was not a hospital. This would include group

home placement as an adolescent and assisted living facilities, however it does not include independent living

situations through DSS.



P-603 SMI Criteria – Level of Disability

.

4. Level of Disability: The person must meet at least two of these criteria on a continuing

or intermittent basis. There must be evidence of severe and recurrent disability

resulting from mental illness. The disability must result in functional limitation in major

life activities. Due to the person’s mental illness:

Is unemployed; employed in a sheltered setting or a supportive work situation; has

markedly limited or reduced employment skills; or has a poor employment history.

Requires public and family financial assistance to remain in the community and may be

unable to procure such assistance without help.

Has difficulty establishing or maintaining a personal social support system.

Requires assistance in basic living skills such as personal hygiene, food preparation, or

money management.

Exhibits inappropriate behavior that often results in intervention by the mental health or

judicial system.



P-603 SMI Criteria

5. Due to mental illness, the person requires assistance to consistently access and to utilize needed medical and/or behavioral health services/supports.

This criterion must be checked YES in order for GAP SMI to be met.



DMAS P-603 Required Attachments

• Diagnostic evaluations must be performed by a Licensed Mental Health Professional (LMHP) within the 12 months leading up to the screening or at the time of the screening.

• If the diagnostic evaluation contains enough supporting information of items marked “yes” on the screening tool then the evaluation is the only required attachment to be submitted to Magellan. The more thorough the evaluation the more likely no further information will be needed.

• Additional information must be submitted by the screening entity if the diagnostic evaluation does not contain sufficient supporting documentation.



Diagnostic Evaluation

The following information is recommended to be gathered as part of the diagnostic evaluation. • Date

• Name of individual being evaluated

• Address

• Phone Number

• Date Of Birth

• Social Security Number

• Gender

• Guardian name and contact, if applicable

• Primary Language

• Does the individual agree to the screening

• Have Protected Health Information Releases been Signed

• Referral Source – Who referred for the screening

• Diagnosis: Includes DSM Code & Description

• Dated and Credentialed Signature of LMHP, LMHP-R, LMHP-S, or LMHP-RP completing the diagnostic screening.



Recommended Diagnostic Evaluation Items

• Presenting Problem/Reason for referral: Chief Complaint. Indicate duration, frequency and severity of behavioral health symptoms. Identify precipitating events/stressors, relevant history.

• Medical Concerns /Medical Profile: Significant past and present medical problems/illnesses/injuries/known allergies; current physical complaints.

• Substance Use – Drug and Alcohol Profile: Substance use / abuse by individual, type of Substance, Frequency/Duration

• Previous mental health treatment: Give details of mental health history and any mental health related hospitalizations and diagnoses, including the types of interventions that have been provided to the individual. Include the date of the mental health interventions and the name of the mental health provider if known.

• Current treatment – provider, service, diagnosis

• Medications – how many? What kind?



Recommended Diagnostic Evaluation Items

• Difficulty with accessing assistance and who helps them. Does the individual have a personal support system such as family, friends, etc.

• Employment status – Unemployed? How long? More than once in the past 12 months?

• Educational status, including vocational programs – current and highest level completed

• Residence/current living situation – Alone? Has support? Homeless? Daily routine including ADLs, current and within the past 12 months

• Legal Status: Pending charges, court hearing date, probation/parole status, past convictions, previous charges but not convicted.

• Mental Status Profile

• Resources and Strengths: Extracurricular activities, church, extended family; activities that the individual engages in or are meaningful to the individual.



Eligibility Determination Process

• The screening entity will have three business days from the date of the face-to-face screening to complete the GAP SMI Screening Tool (DMAS P-603) and required attachments and submit to Magellan.

• Magellan will have three business days to review the submission and determine whether GAP SMI criteria has been met. There will be no pending for additional information.

• Magellan will transmit the met/not met decision nightly to Cover Virginia.

• GAP SMI Screenings are effective for 12 months following the date of the screening.



Eligibility Determination Process • Cover Virginia will have 45 days from the date

they receive a signed and dated GAP application to render an eligibility determination.

• Cover Virginia will send a letter to the individual giving them their GAP ID # to use until a member card can be sent to them. They will also send the member handbook.

• GAP coverage is effective on the first day of the same month in which the individual applied to Cover Virginia and the signed, and dated, application was received.



Submitting to Magellan SMI Screeners will need to submit to Magellan by going to www.MagellanHealth.com/Provider and logging in. Select the “VA GAP Assessment” on the left hand side of the screen after logging in.

http://www.magellanhealth.com/Provider



Submitting to Magellan

This screen will assist in determining

whether the individual already has Medicaid

benefits. If not, click on Add GAP Assessment.




This screen is information

regarding the individual’s GAP SMI criteria.




The next screen with gather

demographic information

pertaining to the individual

applying for GAP benefits.




This screen allows the provider to attach

documents including the original

Screening Form DMAS P-603,

diagnostic evaluations, and other

supporting documentation if needed.




This screen offers an opportunity to

revise or submit to Magellan. This is the

opportunity to ensure that all required

information has been completed and

documents have been uploaded.



Submitting to Magellan The last screen is the submission confirmation. Providers are

strongly encouraged to print this

screen for their records.



GAP SMI Screening Reimbursement

GAP SMI Screenings will be reimbursed at the following rates:

Limited Screening for individuals who have had a diagnostic evaluation within the past 12 months and that evaluation is available to the screener: $37

Full Screening for individuals who have not had a diagnostic evaluation within the past 12 months and a diagnostic evaluation was completed at the time of the GAP SMI Screening: $75



GAP SMI Screening

• There is no set limit on the number of GAP SMI screenings an individual may receive if eligibility is denied due to not meeting SMI criteria.

• The met/not met decision is determined by Magellan and screeners are to submit the form and required attachments regardless of whether they believe that SMI criteria has been met.

• Should GAP eligibility be denied due to a GAP SMI not met decision and the individual appeals that decision, Magellan will defend the decision for the appeal hearing.

• Financial/non-financial eligibility (non-SMI) appeals will be defended by Cover Virginia.





GAP Sources of Information

December 2014





Education and Outreach

A complete GAP Overview Presentation is available on the DMAS website at www.dmas.virginia.gov. Click on GAP under the “What’s New” header on the Right side of the screen.

Magellan of Virginia will also be hosting GAP Presentations and Trainings which will be available on their website at www.magellanofvirginia.com under Trainings in the For Providers section.

http://www.dmas.virginia.gov/

http://www.magellanofvirginia.com/



Magellan Behavioral Health of VA

Questions regarding how to submit to the Screening Tool and Attachments to Magellan should be directed to Magellan toll free at 1-800-424-4046 or by visiting www.magellanofvirginia.com or submitting questions to [email protected].

Providers may also check GAP member eligibility, behavioral health claims status, behavioral health check status, behavioral health service limits, and behavioral health service authorizations by visiting www.MagellanHealth.com/Provider.

http://www.magellanofvirginia.com/

mailto:[email protected]

http://www.magellanhealth.com/Provider



DMAS Website

Information on the GAP Demonstration Waiver is also located on the Virginia DMAS website at www.dmas.virginia.gov

Questions pertaining to the GAP demonstration may also be e-mailed to [email protected]

http://www.dmas.virginia.gov/

mailto:[email protected]

dmas governor’s access plan for the seriously … · 2 department of medical assistance services...

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