magellan training: medicaid rehabilitation option mro
TRANSCRIPT
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