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DMHSAS Memo 2009-03

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State Of Wisconsin
Department of Health Services
Division of Mental Health and Substance Abuse Services

DMHSAS Info Memo Series
Date: September 14th, 2009
Index Title: 1915 (i) State Plan Amendment Community Recovery Services for individuals with severe and persistent mental illness.

To: Listserv

Area Administrators / Human Service Area Coordinators
Bureau 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
Tribal Chairpersons / Human Services Facilitators

John Easterday Ph.D., Administrator
Division of Mental Health and Substance Abuse Services

Subject: 1915 (i) State Plan Amendment, Community Recovery Services for individuals with severe and persistent mental illness.

Document Summary
The Department of Health Services (DHS) is in the final stages of submitting a State Plan Amendment to provide 1915(i) Home and Community Based Services (HCBS) to individuals with serious and persistent mental illness. In Wisconsin, this benefit will be called Community Recovery Services (CRS). States are permitted to limit the geographic areas in which the benefit will be offered, but must specify in the application which counties and tribes will offer the benefit. This memo describes the benefit and requests counties and tribes to inform the Division of Mental Health and Substance Abuse Services (DMHSAS) of their intent to offer the benefit and the maximum number of people each county or tribes would serve.

Federal legislation has made it possible to provide home and community-based services as a Medicaid state plan option. With the submittal of a state plan amendment, counties and tribes will be able to claim Federal Financial Participation for certain services previously covered entirely with local funding. The Budget Bill (AB 75/Act 28) section 49.45(30g) established Community Recovery Services as a covered Medicaid benefit, pending approval of the State Plan Amendment. DMHSAS Memo Series 2008-07 first described this option and requested feedback from counties and tribes. Further feedback was received at a meeting with counties on April 22, 2009. A draft service description was sent out by e-mail for comment in July.

Services available
The service definitions that will be submitted in the amendment are in Attachment 1 of the memo. This document incorporates comments from counties, consumers and the Centers for Medicare and Medicaid Services (CMS). CMS could require further revisions as a part of their official review, but it is not expected that the services would change substantively. From the list of allowable services under 1915i HCBS, Wisconsin will be providing one service - psychosocial rehabilitation. Under the umbrella of psychosocial rehabilitation will be three services: Community Living Supportive Services, Supported Employment and Peer Supports. Counties and tribes electing to offer this benefit must agree to provide or contract for all three services. The services any specific individual receives is based on the individual’s needs identified under a person-centered assessment. It is important to note that state plan Mental Health and Substance Abuse services provided under psychosocial rehabilitation (Comprehensive Community Services (CCS) and Community Support Program (CSP)) have limitations related to the distinction between habilitation and rehabilitation that do not apply to this new service.

To be eligible for Community Recovery Services, individuals need to meet the following criteria:
* Eligible for medical assistance under the State plan
* Income does not exceed 150% of the Federal Poverty level
* Resides in the community
* Meets the needs based criteria as demonstrated on the MH/AODA or Children’s Long Term Support functional screen.

The needs based criteria will match the current criteria for CSP or for Comprehensive Community Services (CCS) for both adults and children. This means a functional impairment that interferes with or limits one or more major life activities and results in needs for services that are described as ongoing, comprehensive and either high intensity or low intensity. For additional information see HFS 36.14 regarding CCS.

Independent Evaluation
CMS requires an independent evaluation, defined as free from conflict of interest with providers. When counties and tribes are a provider of CRS services, they will need to arrange for this evaluation to be completed independently. The cost of the evaluation is reimbursable by Medicaid as an administrative expense with 50% FFP. It is clear that the MH/AODA functional screen will need to be completed by someone other than a provider. It is not known at this point if the final regulations will require the care plan to be equally independent or whether a county or tribal care manager could do the care plan even if the county or tribe provides services. Completion of the MH/AODA functional screen at the Aging and Disability Resource Center (ADRC) is an optional service. The ADRC can perform this function if it is funded from sources other than the ADRC contract from the Department. For additional information see ADRC Technical Assistance Informational Bulletin #19 at:

Limits on Numbers Served
As a part of Wisconsin’s application, we need to submit a projected number of persons to be served. We are also able to set a maximum level of people to receive services and to establish a waitlist. CMS requests that the limit be based on the total number of unduplicated recipients in a 12 month period. The state may also choose to place a limit on the number of individuals to receive services at any given time in the year – a slot methodology. The maximum number of people served must be a statewide maximum and a statewide registry of persons waiting for service would need to be maintained. The maximum number of individuals to be served can be adjusted, but requires a state plan amendment. We would not anticipate a submitting an amendment more frequently than once a year and would hope to amend less frequently. Since the maximum number is a statewide number, there can be some flexibility between counties and tribes. If county A is not expecting to serve the number it told us and county B would like to serve additional, we could allow that to occur. The maximum number you can serve should be based on available funding rather than the time required to complete the required paperwork to begin services.

CMS requires Wisconsin to have a consistent waitlist policy across all counties and tribes. When a county or tribe reaches its maximum in terms of numbers of people or funding available, it may establish a waitlist. The current Medicaid HCBS Waivers have developed a policy to address these CMS issues. Please refer to the following link regarding the Bureau of Long Term Support (BLTS) Waiver policy.
We will expect to have a similar policy.

CMS policy regarding provider contracts
CMS has clarified that both HCBS waiver services and 1915(i) state plan services are considered Medicaid Fee for Service (FFS) programs and as such must utilize contracts that conform with Medicaid FFS requirements. These purchase of service contracts must contain only those provisions required by Medicaid FFS and reflected in the approved 1915(i) amendment. We expect CMS to request a similar assurance from us related to CRS. Specifically, county and tribal agencies will be prohibited from adding provider qualifications or other provisions in lieu of or in addition to those imposed by the state and the approved 1915i application. For further information on how this was implemented in BLTS see the memo at:

Reimbursement methodology
CRS services will be a state plan benefit with counties and tribes providing the non-federal share. Counties and tribes, as the billing provider, will bill and be reimbursed for CRS services through the Medicaid Fiscal Agent. There will be interim rates and an annual cost settlement process. Since counties or tribes must be the billing provider, the cost settlement portion of reimbursement will be based on certified public expenses. This means counties and tribes will be required to cost report. We intend to set interim rates at the state level and use a cost reporting process. Changes to the web based cost reporting tool, including adding CRS cost reporting, are tentatively planned for spring of 2010.

County and Tribal Commitment
Counties and tribes wishing to provide CRS services need to return Attachment 2 to the Department as soon as possible, but no later than the close of business on September 25, 2009.

Regional Office Contact:
Area Administrators

Central Office Contact:
Morgan Groves
Division of Mental Health and Substance Abuse Services
1 West Wilson Street, Room 951
P.O. Box 7851
Madison, Wisconsin 53707-7851

Telephone: (608) 261-9312
FAX: (608) 266-1533


Attachment 1: Community Recovery Services Definitions Psychosocial Rehabilitation (PDF)

Attachment 2: DHS MS Word Fillable Form F-00153, Commitment to offer community recovery services
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Last Revised:  January 30, 2014