Magellan Training: Medicaid Rehabilitation Option

MRO

Initial Auth

What information do I need when I call? Current diagnosis (onset) Rehabilitation Assessment

Functional Limitations Rehab Plan Licensed clinician contact

MRO Re-Auth Form

Client Name and SS# Agency Name and Contact Person Auth End Date Medications and Number of Face to Face Current Dx Program Type or Service Medicaid ID# and Service Location

MRO Re-Auth Form

Rehabilitation Need Measureable Goal Progress on Goal Crisis Plan (include something other than ER or 911) Discharge Plan and ELOS Hospitalizations or ER visits in report period Psychiatrically Stable (if not a brief description) Specific Functional Limitations R/T Major Mental Health Diagnosis

Specific Functional Limitations

Must be the result of long term mental illness Must be present for one year Must be pervasive across life skills areas Must require life skills training to improve client’s quality of life

MRO

Medicaid Chapter 35 PRR, ACT, DR, CS Active Life skill training Assessment based Client centered Realistic goals Crisis plan

Medicaid Rehab Option Guidelines

Must meet SPMI status Must have functional limitations May have other diagnosis as secondary

SPMI Guidelines

At risk of institutionalization if services not provided Seriously interferes with functioning Has had one year or will have Results in functional deficits in two of three life skills areas.

SPMI Con’t

Not primary substance abuse Not primary developmental disabilities

Major Life Skills Areas

Voc/Educational Social Skills Activities of Daily Living

Vocational/Educational

Inability to be employed Inability to pursue education Inability to carry out home management tasks (meals, laundry,

budgeting, child care)

Social Skills

Inappropriate Inadequate Participates only with extensive support History of dangerousness

Activities of Daily Living

Inability to consistently perform Hygiene, grooming, meals Personal business Transportation, care of residence Medical, legal, housing Avoidance of common dangers

MRO Authorization Considerations

Careful examination of functional limitations. Focus on where the limitations can best be addressed (home or club

house). Compensatory training not cure. Not a life time service (except ACT) Without assessment and diagnosis we cannot authorize these services.

Authorization Considerations

A major mental illness alone is not sufficient for SPMI Presence of symptoms is not sufficient Provider must link functional deficits to Axis I disorder NOS not acceptable

Considerations con’t

Brain injury Typically developmentally delayed have not met milestones Axis I typically have met milestones

Considerations con’t

Across settings Long term Requires support/intervention Medication Our case notes/hx of care Compensation not cure

Considerations con’t

Long term sub abuse and homelessness often look like SPMI, because many SPMI have both.

TBI often look like SPMI

Psychiatric Residential Rehab

SPMI These deficits require 24 hour psychiatric residential setting The need is 24 behavioral monitoring

Day Rehab

Day Rehab The need: Day structure to work on socialization/self care/pre-voc

Community Support The need: Case management

In home work on self care Household/ADL tasks

Community Support

The need: Case management and In home work on self care Household/ADL tasks

Authorization Considerations

PRR and DR are authed together for those who have both needs CS and DR are authed together for those who have high social needs

plus in home needs. CS is not authed with PRR (except 30 days in/out)

ACT

Two in Omaha One in Lincoln One in Hastings

ACT Guidelines

The need: SPMI plus high utilization of emergency/hospital services

Poor response to lower levels of care 24 hour available intervention Poor response to other treatment

General MRO Admission

Meets Admit guidelines Does not require a higher LOC A lower LOC is not indicated Likelihood of benefit from service Is making progress

General MRO Continuing Stay

Meets Admission guidelines Does not require a higher LOC A less intensive LOC is not appropriate Reasonable likelihood of benefit Is making some progress in rehabilitation goals

General MRO Exclusion

Not SPMI Primary substance abuse or DD Does not have functional deficits in two or three areas Resides in a Nursing Home or PRR Needs a higher LOC

General MRO Discharge

Maximum benefit Sustainability plan in place Supports in place Crisis relapse plan in place Or the individual requests discharge

Q & A