State Identified ILS IMD Presentation
- Document is also available in Portable Document Format (PDF)
State Identified In–Lieu–of Services (ILS) Request Form Procedure for Institutions of Mental Disease (IMD)
Webinar with MMCOs
August 2019
Purpose
- To learn how to submit an application for State budget initiative → IMD ILS coverage permitted under 2016 Final Rule, 42 CFR 438.6(e)
Agenda
- Short recap on IMD
- Implement IMD as ILS under 438
- Request Form Introduction
- Request Form Procedure
- MMCOR Reporting
- Next Steps
Short Recap on IMD
- Currently, NYS covers MMC, HIV SNP, and HARP IMD stays up to 30 days per episode/60 days per year
- If the IMD stay is over 30 days per episode/60 days per year, member is disenrolled from the plan
- Coverage policy prevents unnecessary interruption of services and gap months due to short stays
- OMH utilization data shows Medicaid managed care enrollees average IMD stays of less than 15 days
State Identified ILS for IMD 42 CFR 438
- The 2016 Federal Rule 42 CFR 438.6(e) permits the State to offer IMD coverage for up to 15 days per month as an in lieu of service and obtain FFP for the plan capitation paid that month
- Applies to age 21 – 64 only and those in need of acute inpatient psychiatric care
- ILS must be cost–effective alternative service, medically appropriate, voluntary for the MMCO to provide, and voluntary for the enrollee
- DOH and OMH developed State Identified IMD ILS Request Form
Implementing IMD as an ILS in NYS
- State Identified ILS developed to cover IMD stays less than 15 days per month
- No change to IMD benefit; Benefit Package coverage remains 30 days per episode/60 days per year
- No change for coding or billing of IMD services
- No change to enrollment/disenrollment related to IMD stays
- No enrollee notice or handbook changes
Request Form Introduction
- Same request form as ILS, however, Section 2 has been completed by the State
- MMCO´s will complete Section 1 to apply for and establish the IMD ILS coverage authority
Request Form Procedure for Section One
MMCO´s should complete page 3 with specific MMCO information. Please fill in all boxes.
- Date of the request
- MMCO plan name
- Contact Person
- Title of the Contact person
- Phone number of Contact person
- Email address for the Contact person
Request Form Procedure for Section One, #1
Section one should then be filled out by the MMCO. Be sure to provide information in the grid regarding:
- 1) ILS to be Provided
- NYS Authorization Number
leave blank – State will issue - Expected start date for provision of service
10/1/2019 (Requirement) - Target area for availability of service
Entire Service Area - Related to DSRIP/VBP?
No
Request Form Procedure for Section One, #2
MMCO Monitoring Activities – Please describe in detail activities, reports, and/or analyses the MMCO will use to monitor the provision, utilization, quality, cost–benefit, and/or outcomes of the ILS.
- Monitoring Activities include:
- Current MMCO Utilization Management Process
- Current MMCO Encounter Data Review Process
Request Form Procedure Review of filled in Section 2
- IMD admission will only apply to six private IMD´s in the State: Four Winds in Westchester and Saratoga counties, Gracie Square in NYC, BryLin in Buffalo, Brunswick in LI, and South Oaks Hospital in LI
- Use appropriate procedure codes listed
- Review outcomes and objectives – private IMD services increases access to short–term acute psychiatric stays; enables mental health stabilization and prevents longer term stays for individuals needing care
State Identified ILS Request Form for IMD
- The State Identified ILS Request Form was transmitted to MMCOs via OMC Mail on 8/13/2019
- The State Identified ILS Request Form can also be downloaded from the DOH website at
https://www.health.ny.gov/health_care/managed_care/plans/docs/req_form_in_lieu_of_services.pdf
MMCO IMD ILS Request Forms
Request Forms Due Back
No later than COB on 9/6/19
Submit Completed Request Forms to ils@health.ny.gov
|top of section| |top of page|MMCO Monitoring and Reporting for ILS
- MMCOs will monitor IMD services as described in the ILS request form
- MMCOs will report expenditures for IMD stays less than 15 days per month on the MMCOR as ILS
MMCOR Reporting
Table 21–IN LIEU OF SERVICES – COST (MEDICAID & HARP)
- In Lieu of Services are defined as alternative services or settings that are not included in the State Plan but are medically appropriate, cost–effective substitutes for covered services or settings. In Lieu of Services require prior approval by DOH through an application process.
- Plans are required to type in the name of the In–Lieu of Service in column 02100 and the ILS authorization number in column 02102. An example of the authorization number is 2017–12001. The costs for each of your entered services are to be broken out by premium group.
Table 21A–IN LIEU OF SERVICES – UTILIZATION (MEDICAID & HARP)
- In Lieu of Services are defined as alternative services or settings that are not included in the State Plan but are medically appropriate, cost– effective substitutes for covered services or settings. In Lieu of Services require prior approval by DOH through an application process.
- The services and authorization numbers entered on Table 21 will carry over to Table 21A. The utilization amounts for each of your entered services are to be broken out by premium group.
Tables 6 & 7–STATEMENTS OF REVENUE AND EXPENSES – Medical Expense Line
- Line 0049 In Lieu of Services – Medicaid, HARP, HIV SNP – cost of alternative services or settings that are not included in the State Plan but are medically appropriate, cost–effective substitutes for covered services or settings. In Lieu of Services require prior approval by DOH through an application process. For the HARP line of business, the information will populate from Table 21.
Next Steps
- MMCOs submit ILS request forms by 9/6/19
- DOH approves ILS
- Appendix M executed
- MMCOs post ILS availability on their respective websites
- DOH posts ILS availability on DOH website
Questions?
Submit to: ils@health.ny.gov
