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7.2.1
Introduction
Background
An Institution for Mental Diseases (IMD) is an inpatient treatment
facility that includes hospitals, nursing facilities or other institutions
having more than 16 beds, primarily engaged in providing diagnosis,
treatment, or care of persons with mental diseases, including medical
attention, nursing care and related services. Title XIX of the Social
Security Act provides that, except for persons under the age of
21 receiving inpatient psychiatric care, Medicaid (Title XIX) does
not cover services to persons in an IMD that are under 65 years
of age.
Effective July
5, 2000, Arizona was granted expenditure authority to provide limited
services to Title XIX persons age 21 through 64 in IMDs. Based on
current ADHS/Office of Behavioral Health Licensure standards, facilities
that meet the definition of an IMD are licensed Level I facilities
with more than 16 total treatment beds. General acute care hospitals
with psychiatric units are not considered IMDs. The following provider
types that participate in the ADHS/DBHS public behavioral health
system are considered IMDs:
- Level I
psychiatric hospital (provider type 71);
- Level I
Residential Treatment Center with more than 16 beds (provider
types B1 and B3 (NOTE 1)); and
- Level I
Sub-acute facility with more than 16 beds (provider type B6).
Limitations
A Title XIX eligible person who is 21 years through 64 years old
may receive services in an IMD for up to 30 days per admission and
60 days per contract year (July 1-June 30). A person whose stay
exceeds 30 days per admission/60 days per contract year may lose
Title XIX eligibility. There are no length of stay limitations for
persons under the age of 21 or over the age of 64.
Reporting
and tracking
Because of the limitations, it is important for IMD facilities to
assist in reporting and tracking the number of days a Title XIX
eligible person (21 years through 64 years old) receives care in
an IMD.
The intent of this section is to
describe reporting and tracking requirements for behavioral health
providers designated as IMDs (provider types 71 and B6). Thirty and
sixty day limitations do not apply to persons in residential
treatment center (RTC) IMDs, (provider types B1 and B3) which are
licensed to treat persons less than 21 years old.
Effective January 1, 2006, Medicare
eligible behavioral health recipients, including persons who are
dually eligible for Medicare (Title XVIII) and Medicaid (Title
XIX/XXI), will receive Medicare Part D prescription drug benefits
through Medicare Prescription Drug Plans (PDPs) or Medicare
Advantage Prescription Drug Plans (MA-PDs).
Medicare Part D coverage includes
co-payment requirements of all persons. The co-payments are waived
when a dual eligible person enters a medical institution, that is
Medicaid funded, for at least a full calendar month. IMDs must
notify AHCCCS when a dual eligible person is expected to be in the
IMD for at least a full calendar month to ensure co-payments for
Part D are waived. The waiver of co-payments applies for the
remainder of the calendar year, regardless of whether the person
continues to reside in a medical institution.
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7.2.2
References
The following citations can serve as additional resources for this
content area:
7.2.3
Scope
To whom does this apply?
This section
applies to all facilities designated as an IMD (provider types 71,
B1, B3 and B6).
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7.2.4
Did you know…?
- A Title XIX
eligible person (ages 21-64) who exceeds 30 inpatient days in
an IMD is considered to be in an ineligible setting and is not
entitled to receive any medical or behavioral health Medicaid
services, either inside or outside of the facility, while remaining
as a resident.
- T/RBHAs
must monitor Title XIX eligible persons’ (ages 21-64) cumulative
utilization as reimbursement for days exceeding the 30 day per
admission/60 days per contract year cannot be made with Title
XIX funds.
- The
reason that RTCs with more than 16 beds are identified as IMDs
is that the federal regulations for the KidsCare program (Title
XXI) specify that persons cannot apply for KidsCare eligibility
or have a re-determination of their eligibility if they are in
an IMD. Title XXI does not impose any length of stay limitations
for KidsCare eligible persons in an IMD. Therefore, the 30/60
day IMD limitations are not applicable to persons already Title
XXI eligible upon entering an IMD.
- Enrollees with Medicare Part D
prescription drug coverage and AHCCCS (health insurance and
Medicare Savings Programs), dual eligibles, have minimal
prescription drug co-payments. Part D co-payments will be waived
when dual eligible persons enter an institution, including an IMD,
with the intent to remain for at least a full calendar month.
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7.2.5
Objectives
To inform behavioral health providers designated as an
IMD of reporting and tracking requirements for Title XIX eligible
persons.
7.2.6
Definitions
Institution
for Mental Disease
7.2.7
Procedures
7.2.7-A.
Reporting requirements
What must be done when a Title XIX eligible person
is admitted to an IMD?
At the time of admission, IMD designated providers (provider type
71 and B6) must give written notification to Title XIX eligible
persons (ages 21-64) that their AHCCCS eligibility will end if they
remain in an IMD longer than 30 days per admission or 60 days annually
(July 1- June 30).
Notification
of admission of Gila River RBHA members to an IMD should be faxed
to the attention of the Gila River RBHA Billing Clerk at (602) 528-1374
or mailed to the following address utilizing PM
Form 7.2-GR, TITLE XIX INSTITUTION FOR MENTAL DISEASE ADMISSION/DISCHARGE
NOTIFICATION FORM:
Hu Hu Kam Memorial
Hospital
ATT: RBHA Billing Clerk
P.O. Box 38
Sacaton, AZ 85247
A person’s
clinical liaison needs to ensure that discharge planning starts
at the time of admission to an IMD. The discharge plan must address
what will happen if the person reaches the 30-day limit, such as
the person would be transferred to a psychiatric unit of a general
medical hospital or other non-IMD facility to avoid losing Title
XIX eligibility. This is especially critical for persons who may
also have a medical condition that could be jeopardized by the loss
of Title XIX medical benefits.
The Arizona
State Hospital must notify AHCCCS Division of Member Services [fax:
(602) 253-4807 or telephone: (602) 417-4063] of all admissions of
Title XIX and Title XXI eligible persons at the time of admission.
IMDs, other
than the Arizona State Hospital, must notify AHCCCS Division of
Member Services [fax: (602) 253-4807 or telephone: (602) 417-4063]
when a Title XIX eligible person (ages 21-64) has been a resident
for 30 consecutive days. IMDs must be prepared to provide the following
information:
- Provider
identification number and telephone number;
- Behavioral
health recipient’s name, date of birth, AHCCCS identification
number and social security number; and
- Date of
admission.
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What happens
if a Title XIX eligible person (ages 21-64) stays longer than 30
days?
Reimbursement for stays exceeding 30 days per admission or 60 days
per contract year (July 1-June 30) cannot be made with Title XIX
or Title XXI dollars.
What happens
when a Title XIX eligible person (ages 21-64) who has exceeded 30
days is discharged?
AHCCCS eligibility for a person whose admission has been reported
as exceeding 30 days will be suspended for the remainder of the
admission. IMD providers must notify AHCCCS Division of Member Services
when the person is discharged so that the person’s eligibility
can be restored.
Are there
tracking requirements for IMD providers?
Because of claims and encounter lags, tracking of utilization at
the state level (AHCCCS and ADHS) is not always up to date. IMD
providers are encouraged to review utilization information with
the contracted RBHA and from a person’s history, medical records
and any other resources to facilitate the tracking of Title XIX
eligible (ages 21-64) persons’ accumulated days in an IMD
setting.
Are there reporting requirements
for dual eligible persons enrolled in Medicare Part D who are
admitted to an IMD?
To ensure that dual eligible persons’ Medicare Part D co-payments
are waived when it is expected that dual eligible persons will be in
an IMD, funded by Medicaid, for at least a full calendar month,
AHCCCS must be notified immediately upon admittance. Reporting must
be done using
PM Form 3.21.1, AHCCCS Notification To Waive Medicare Part D
Co-Payments For Members In A Medical Institution That Is Funded By
Medicaid, included in
Section 3.21, Service
Prioritization for Non-Title XIX/XXI Funding.
NOTE 1: Level
I Residential Treatment Centers, Secure and Non-Secure, are certified
as IMD’s when registered with AHCCCS, but they do not carry
the limitations of the other IMDs.
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7.2 Institutions for Mental Diseases (IMD) Reporting
Last Revised: 09/12/2003
Effective Date: 01/01/2004 |
