2. Magellan Training: Medicaid Rehabilitation Option MRO

3. Initial Auth  What information do I need when I call?  Current diagnosis (onset)  Rehabilitation Assessment  Functional Limitations  Rehab Plan  Licensed clinician contact

4. 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

5. 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

6. 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

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

8. Medicaid Rehab Option Guidelines  Must meet SPMI status  Must have functional limitations  May have other diagnosis as secondary

9. 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.

10. SPMI Con’t  Not primary substance abuse  Not primary developmental disabilities

11. Major Life Skills Areas  Voc/Educational  Social Skills  Activities of Daily Living

12. Vocational/Educational  Inability to be employed  Inability to pursue education  Inability to carry out home management tasks (meals, laundry, budgeting, child care)

13. Social Skills  Inappropriate  Inadequate  Participates only with extensive support  History of dangerousness

14. Activities of Daily Living  Inability to consistently perform  Hygiene, grooming, meals  Personal business  Transportation, care of residence  Medical, legal, housing  Avoidance of common dangers

15. 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.

16. 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

17. Considerations con’t  Brain injury  Typically developmentally delayed have not met milestones  Axis I typically have met milestones

18. Considerations con’t  Across settings  Long term  Requires support/intervention  Medication  Our case notes/hx of care  Compensation not cure

19. Considerations con’t  Long term sub abuse and homelessness often look like SPMI, because many SPMI have both.  TBI often look like SPMI

20. Psychiatric Residential Rehab  SPMI  These deficits require 24 hour psychiatric residential setting  The need is 24 behavioral monitoring

21. 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

22. Community Support  The need: Case management and  In home work on self care  Household/ADL tasks

23. 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)

24. ACT  Two in Omaha  One in Lincoln  One in Hastings

25. 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

26. 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

27. 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

28. 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

29. General MRO Discharge  Maximum benefit  Sustainability plan in place  Supports in place  Crisis relapse plan in place  Or the individual requests discharge

30. Q & A