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DLTC INFO MEMO 2008-12

STATE OF WISCONSIN

Department of Health Services
Division of Mental Health and Substance Abuse Services

DLTC Info Memo Series 2008-12
DMHSAS Info Memo Series 2008-05

Date: December 19, 2008
Index Title: Contracting Between CSP and FC MCOs

To:
Listserv

For:
Area Administrators/Assistant Area Administrators
Bureau Directors
Program Office Directors/Section Chiefs
County Departments of Community Programs Directors
County Departments of Developmental Disabilities
Services Directors
County Departments of Human Services Directors
County Departments of Social Services Directors
County Mental Health Coordinators
CSP Directors
Tribal Chairpersons/Human Services Facilitators
Family Care Managed Care Organization Directors
Aging and Disability Resource Center Directors

From:
Sinikka Santala, Administrator, Division of Long Term Care
John Easterday, Administrator, Division of Mental Health and Substance Abuse Services

Subject:
Contracting Between Certified Community Support Programs (CSP) and Family Care
Managed Care Organizations (MCOs).

Document Summary

This memo describes how Community Support Programs (CSPs) and Family Care Managed Care Organizations (MCOs) should work together to assure access to needed mental health services for Family Care enrollees who also need CSP services. CSP services are included in the Family Care benefit package, so MCOs need to contract with certified CSPs, where they are available, to provide CSP services to their members. Certified CSPs should contract with MCOs to continue to serve individuals receiving CSP services who enroll in Family Care, unless and until an appropriate discharge plan is developed. MCOs pay both the federal and non-federal share of CSP services; counties are not responsible for the non-federal share of CSP services for Family Care enrollees. MCOs are required to pay no more than the Medicaid rate unless granted a waiver by the Department of Health Services.

Differences between Traditional Medicaid CSP's and CSP services within the Family Care Managed Care Program

The Family Care benefit package includes Community Support Program Services, with the exception of the physician (psychiatrist) services. Family Care does not include any physician services, and Family Care enrollees get their physician services through the Medicaid program, using their Forward card. A consequence of this arrangement is that, for Family Care enrollees, the MCO pays for all CSP services, except for the CSP psychiatric services which are funded by Medicaid fee for service under the outpatient services category.

Note: The Family Care Partnership benefit package is different from regular Family Care in that it does include physician services. The Partnership MCOs will pay for all CSP services, including psychiatric services.

Another change with the transition to Family Care and Family Care Partnership is the role of the primary CSP worker with the participant and the MCO interdisciplinary care management team. Family Care teams include at least a nurse and social worker; Partnership teams also include a nurse practitioner and the person's primary care physician. In the traditional home and community based waiver programs, if a consumer participates in both CSP and either the COP or CIP waiver programs, the CSP assumes primary care management. The role of the CSP is different for Family Care enrollees.

Family Care is a wrap-around model of care with many services available to each participant. The MCO is responsible for funding those services, and thus determines, with the consumer and other appropriate professionals, which services the person needs and that those services and supports are meeting the person's needs and supporting his or her personal goals or outcomes.

The comprehensive assessment and care plan is the responsibility of the MCO. The MCO needs to contract with CSP programs for their services, and CSP staff and MCO interdisciplinary teams should work collaboratively to serve the individual best. In terms of the roles of each organization, the MCO makes the funding decisions for the care plan for each member, and the CSP licensed mental health professionals, together with the consumer determine the appropriate mental health treatment plan. If there is a conflict that cannot be resolved with a facilitated meeting between the CSP and the MCO staff, then the consumer can appeal the MCO decision. (See the paragraph below on Appealing Care Plan Decisions). The CSP worker should be an important member of the consumer's interdisciplinary clinical team, but is not the lead worker as they are currently for people enrolled in both the COP/CIP waivers and a CSP. Meeting the overall needs of the individual with the array of services available within the Family Care benefit package is the responsibility of the MCO. However, very close collaboration and coordination is required to ensure that the CSP team is well informed about the member's overall health, and the MCO team is apprised of the individual's mental health status and functioning to ensure appropriate cost effective services and supports are in place for remediation of their mental health condition.

How the CSP and MCO teams work together should be very individualized depending on the person they are serving, the level of CSP involvement recommended by the CSP clinician doing the assessment, and the stability of the consumer at the time of the assessment. The portion of the Member Centered Care Plan that integrates CSP treatment into the overall Family Care plan could have multiple but always individualized goals, and services or supports to achieve those goals. Most individuals would have one or perhaps two CSP workers who provide treatment (a primary and a secondary) plus a psychiatrist. There may also be a role for CSP staff who are bachelor degreed social workers and mental health technicians (who may or may not be peer specialists) to provide daily living skills training, job skills training and community integration. The contract between the MCO and the CSP should address how communication between the CSP staff and MCO interdisciplinary team will occur, to assure continuity of care.

Funding and Contracting

The MCO is responsible for paying both the federal and non-federal share of the cost of CSP services, at the Medicaid rate for those services. For people enrolled in Family Care, the county is not responsible for the non-federal share of CSP services.

When a person enrolls in Family Care the Medicaid card can no longer be billed for CSP services, except for physician/psychiatric services. The psychiatric services provided to Family Care enrollees formerly billed through CSP must be billed through Medicaid fee for service using outpatient codes.

For people enrolled in Family Care Partnership, the MCO pays for all CSP services, including psychiatry.

Continuity of Care During Transition

For those individuals who are in both CSP and enrolled in a home and community based waiver, transition to Family Care or Partnership can be a challenging time. It is important that this transition is handled with sensitivity, that there is adequate lead time for any significant changes being made to services provided. If significant changes are going to be made, or if discharge from the CSP is contemplated, a discharge plan that meets all of the criteria in HFS 63 must be developed and implemented. The plan for discharge from the CSP is the responsibility of the discharging CSP. Discharge should not take place until appropriate discharge criteria have been met.

If there is an issue about timelines or rates in getting the contract between the MCO and CSP in place, considerations about continuity of care for the individual must be a primary concern. Even if the enrollment in Family Care has already taken place, the MCO and CSP should assure needed services stay in place for that person until there is a plan for needed treatment and services that will be effective in supporting the consumer's mental health and assure their safety and well being.

Appealing care plan decisions made by the MCO

If the MCO member does not agree with the decisions made by the MCO team about his or her mental health services, the member can file an appeal or grievance with the MCO, with the Department of Health Services, or request a state fair hearing. Others, including providers, can file an appeal on behalf of the member, as long as that is the member's wish. There are also a number of external resources to help the member with appeals or grievances, including the Family Care External Ombudsman program at: http://www.disabilityrightswi.org/
or http://www.dhs.wisconsin.gov/aging/ltcombud.htm

Information about how to file appeals and the resources to help members can be found in the "Being a Full Partner in Family Care" booklet at http://www.dhs.wisconsin.gov/ltcare/BeingAFullPartner.htm.

Referrals of individuals receiving services in CSP who appear to be eligible for Family Care, Family Care Partnership, or IRIS, the self directed support waiver program

If CSP staff believe a client may be eligible for one of the state LTC programs, CSP staff can refer the person to the local Aging and Disability Resource Center, which will offer the person a Long Term Care Functional Screen to determine their functional eligibility for those programs. If the person is eligible, the Aging and Disability Resource Center will counsel them about their options and help them enroll in the program of their choice.

Family Care, Family Care Partnership, and IRIS are all voluntary programs. If the person chooses not to enroll, he or she has the right to remain with their CSP services or other mental health services and any Medicaid card services they may be using, such as Medicaid personal care or home health. Under no circumstances can they be discharged from a mental health program such as CSP based on their refusal to accept services from another funding source such as Family Care, since this would be a violation of their client rights.

REGIONAL OFFICE CONTACT:

CENTRAL OFFICE CONTACT:
Joyce Allen, BPTR

MEMO WEB SITE: http://www.dhs.wisconsin.gov/dsl_info/

Cc: Disability Rights Wisconsin
Mental Health America
NAMI Wisconsin
Grassroots Empowerment Program
Board on Aging and Long Term Care
Division of Quality Assurance

Last Revised: July 23, 2014