Issued: May 6, 2022
LME-MCO Joint Communication Bulletin # J408
(https://www.ncdhhs.gov/media/15051/download?attachment) has replaced previous guidance regarding changes in the Intellectual and Developmental Disabilities (I/DD) and Traumatic Brain Injury (TBI) benefit plan for the Division of Mental Health, Developmental Disabilities and Substance Abuse Services (DMH/DD/SAS) State-Funded Service Definitions. The new and revised service definitions include Residential Supports (RS) I/DD and TBI and Supported Living Periodic I/DD and TBI.
The implementation date for the policy changes has been changed from March 1, 2022 to June 1, 2022. The new service definitions and frequently asked questions (FAQ) for Residential Supports (I/DD and TBI) as well as Supported Living Periodic (I/DD and TBI) are available here: https://www.ncdhhs.gov/divisions/mental-health-developmental-disabilities-and-substance-abuse/joint-communication-bulletins
Effective November 30, 2022, the following codes will be terminated in NCTracks under the IDD/TBI Benefit Plan:
The codes indicated in the table above will be closed to new admissions effective June 1, 2022 under I/DD. New admissions must choose from Residential Supports (I/DD and TBI) Level 1-3 or another appropriate service. The transition period begins June 1, 2022. Members currently enrolled in a State-Funded residential service (Group Living, Supervised Living, Family Living) must transition to State-Funded Residential Supports (I/DD and TBI) Level 1-3 by 9/30/2022. Providers should update their documentation and submit Service Authorization Requests (SAR) to transition their members to the most appropriate service. Members who have Medicaid should pursue Long Term Community Supports (LTCS) as state funds are limited and the payor of last resort.
Family Living (Low, Moderate, High), Group Living (Low, Moderate, High) and Supervised Living (Low and Moderate) codes under Mental Health (MH) are not affected by these changes.
NEW State-Funded Residential Supports (I/DD and TBI)
Effective June 1, 2022, State-Funded Residential Supports (I/DD and TBI) Level 1-3 have been added to the state service array.
The new State-Funded Residential Supports (I/DD and TBI) codes require prior authorization. Partners will load the new State-Funded Residential Supports (I/DD and TBI) in the provider contracts as appropriate.
It is the responsibility of the provider to submit all appropriate and updated supporting documentation for the service requested. Residential Supports (I/DD and TBI) requires a NC Support Needs Assessment Profile (SNAP) of Level 2 – Level 4 or a Supports Intensity Scale (SIS) Level C – Level E requiring a moderate to high level of supervision and support in most settings.
If UM identifies a member authorized for a State-Funded residential service (Group Living, Supervised Living, Family Living), who does not meet the service criteria for Residential Supports (I/DD and TBI); Partners may reach out to the provider to request supporting documentation. Partners will also track these members and submit the waiver request form to the state by 10/7/2022.
If a member is identified during the transition to Residential Supports (I/DD and TBI) as being Medicaid eligible and possibly meeting medical necessity criteria for LTCS, Partners will follow up with the provider regarding the need to transition to LTCS as soon as possible and prior to the next service authorization request. Providers should follow up with Doug Gallion (Dgallion@partnersbhm.org) regarding LTCS transitions.
NEW State-Funded Supported Living Periodic (I/DD and TBI)
Effective June 1, 2022, State-Funded Supported Living Periodic (I/DD and TBI) has been added to the state service array. The new service definition and frequently asked questions (FAQ) document are posed on the NCDHHS website: https://www.ncdhhs.gov/divisions/mental-health-developmental-disabilities-and-substance-abuse/joint-communication-bulletins.
New Supported Living Periodic (I/DD and TBI) code effective 6/1/2022.
Supported living Periodic (I/DD and TBI)) is an individualized service that provides assistance to individuals with activities of daily living, household chores essential to the health and safety of the individual, budget management, attending appointments, and interpersonal and social skill building to enable the individual to live independently in the community.
The service is provided in the home of the individual. Training activities, supervision, and assistance may be provided to allow the individual to participate in home or community activities. Other activities include assistance with monitoring health status and physical conditions and assistance with transferring, ambulation and use of special mobility devices.
All individuals receiving Supported Living Periodic (I/DD and TBI) services who live in the same household must be on the lease unless the individual is a live-in caregiver. A Supported Living Periodic home must have no more than three residents including any live-in caregiver providing supports per S.L. 2011-202/H509. A live-in caregiver is defined as an individual unrelated to the individual and who provides services in the individual’s home through the Supported Living Periodic provider agency and is not on the lease.
The new State-Funded Supported living Periodic (I/DD and TBI) code requires prior authorization. The service may not exceed 28 hours per week.
The service requires an NC SNAP (Level 2 or lower), Supports Intensity Scale (SIS) (Level C or lower), or TBI Assessment requiring low level of supervision and support in most settings. Individuals who receive Supported Living Periodic may not receive Community Living and Support, Residential Supports, Developmental Therapy, Personal Care Services, State Plan Personal Care or Personal Assistance. Relatives may not provide Supported Living Periodic.
Providers who would like to provide this service should review the service definition (https://www.ncdhhs.gov/media/15054/download?attachment) in detail and then submit the Provider Change Request form: https://providers.partnersbhm.org/provider-enrollment-credentialing/.
Long Term Community Supports (LTCS) Therapeutic Leave
Therapeutic leave is available for members receiving LTCS level 3, 4 or 5 for up to 45 days per calendar year. Therapeutic leave should be billed using the TL modifier. No prior authorization is needed. The new codes are effective 4/1/2022. Providers who would like to provide therapeutic leave should submit the Provider Change Request form: https://providers.partnersbhm.org/provider-enrollment-credentialing/.
Research Based – Behavioral Health Treatment (RB-BHT) for Autism Spectrum Disorder
On April 19, 2022, NC Medicaid received approval from the Centers for Medicare & Medicaid Services (CMS) for Research Based – Behavioral Health Treatment (RB-BHT) for Autism Spectrum Disorder (ASD) services for beneficiaries over the age of 21, retroactively effective July 1, 2021, when the intervention provided is supported by credible scientific or clinical evidence, as appropriate for the beneficiary’s age range. Updates are being made to Clinical Coverage Policy 8F to reflect this change.
Full NCDHHS communication can be found at https://medicaid.ncdhhs.gov/blog/2022/04/19/research-based-behavioral-health-treatment-autism-spectrum-disorder.
ATTENTION INNOVATIONS PROVIDERS
Changes to Billing Practices for Specific Invoiced Services
Upcoming change: Partners will be changing the method of how the aforementioned Innovations invoiced services are requested. Currently these services are requested for 1 unit for an entire plan year. Starting June 1, 2022, these services and codes will be requested with a 1 unit = $1.00 rate. For example, Community Networking Class and Conference for a membership to an integrated community program may cost $450.00 per year. The service authorization request will be submitted reflecting 450 units for the duration of one year.
Vendors will continue to submit invoices per their existing processes.
Network providers with these codes in their contracts will be able to bill claims directly through the claims system and avoid the submission of invoice process. If a request is for $25.14 – the Service authorization request will be for 26 units. Providers will round up for all claims to an even unit.
Phasing out the old process:
- Individual Support Plans (ISP) and ISP Updates with plans Effective August 1, 2022, will transition to this new rate process. If submitted with the wrong rate/unit, UM will request correction before processing.
- Plans currently being developed and effective prior to August 1, are encouraged but not required to transition to this new rate process. These submissions will not be administratively denied for having the wrong unit/rate.
UPDATES to Clinical Coverage Policy 8P
On May 2, 2022, NC Medicaid posted Clinical Coverage Policy 8P amended May 1, 2022. A copy of the updated policy can be found here: https://medicaid.ncdhhs.gov/media/11377/open
Community Networking Class and Conference (H2015 U1):
Clarification has been received from NCDHHS regarding Community Networking Class and Conference (H2015 U1) under Clinical Coverage Policy 8-P (CCP 8P) being used to access museums and amusement parks. Please use information below for technical assistance regarding this service.
Per CCP 8P, Community Networking Services provide individualized day activities that support the waiver beneficiary’s definition of a meaningful day in an integrated community setting. The definition also defines situations/opportunities to implement Community Networking to access and engage in one’s community. Specifically, the payment for both classes/conferences and memberships is permissible when these activities are to occur in integrated settings. Payment for memberships can be covered when the beneficiary participates in an integrated class. Requests for cost of admission, when integrated classes are not available, do not meet medical necessity under this service. Per exclusions, these are activities/cost that would normally be a component of a beneficiary’s home/residential life.