Re: APRIL 1, 2003 VIDEO CONFERENCE OF DSL NUMBERED MEMO
2003-04,ADMISSION AND BILLING PROCEDURES FOR CHILDREN ADMITTED TO MMHI/WMHI
- QUESTION AND ANSWER DOCUMENT
On February 11, 2003 the Division of Supportive Living (now the
Division of Disability and Elder Services) issued DSL Numbered Memo
2003-04, Admission and Billing Procedures for Children Admitted to MMHI/WMHI.
On April 1, 2003 DHS
staff hosted a videoconference with county and
Medicaid HMO staff to review the content of the numbered memo and to
answer questions. The following are the questions asked and the responses
to those questions.
- The Governor’s budget reduces the county allocation for Income
Maintenance (IM) Administration and therefore there will be less
economic support workers at the local level for MA application
processing and eligibility determination. Eligibility determination
will now be done centrally in Madison at EDS. How can the counties be
sure they will be able to do this quickly and correctly so the
counties will not receive bills for children at WMHI/MMHI if MA is
denied?
Answer: The Governor’s original budget request included a
provision that would have transferred 90,000 cases from counties to
state management. An alternate proposal, supported by WCHSA and the
department, would not transfer any cases from the counties to the state.
This substitute proposal has been incorporated into the state budget.
- It seems a number of the problems could be resolved if MMHI/WMHI
contracted with the HMOs. Is this a possibility?
Answer: No, state statutes prohibit the mental health institutes
from contracting with HMOs.
- What is the difference between secured transportation and medically
secure transportation?
Answer: The county sheriff’s department provides secured
transportation and is used in most cases unless medical transportation
is required. Medical transportation is by ambulance or specialized
medical vehicle (SMV).
- Who is responsible for the bill if a child is placed under a Chapter
51 Emergency Detention and MMHI/WMHI does not provide the necessary
insurance information (including the MA Fee for Service or MA HMO)
within the first 24 hours?
Answer: The county will be responsible for the cost of service if
the state is not aware of any other funding source, such as third party
insurance or Medicaid. The DSL Numbered Memo 2003-04 clearly outlines
the responsibilities of the county departments, the HMOs and the
institutes. If an agency is not following the procedures the first step
is to contact the person’s supervisor and attempt to get the issue
resolved. If this is not successful contact the Division Administrator
or the agency director.
- Who makes the arrangement for transfer to a different inpatient
facility if a child is at MMHI/WMHI under an emergency detention and
enrolled in an HMO and the judge finds probable cause for commitment?
Answer: The HMO is responsible for arranging for the transfer to
an in-plan facility. The HMO will arrange for ambulance or SMV
transportation if security is not an issue. If secure transportation or
common carrier transportation is required, the county is responsible for
the arrangements.
- What is the definition of medical necessity?
Answer: See HFS 101.03(96m) Wis. Adm. Code which states:
Medically necessary means a medical assistance service under ch. HFS 107
that is: (a) Required to prevent, identify, or treat a recipient’s
illness, injury or disability; and (b) Meets the following standards: 1.
Is consistent with recipient’s symptoms or with prevention, diagnosis
or treatment of the recipient’s illness, injury or disability; 2. Is
provided consistent with standards of acceptable quality of care
applicable to the type of service, the type of provider and the setting
in which the service is provided; 3. Is appropriate with regard to
generally accepted standards of medical practice; 4. Is not medically
contraindicated with regards to the recipients diagnoses, the recipient’s
symptoms or other medically necessary services being provided to the
recipient; 5. Is of proven medical value or usefulness and, consistent
with s. HFS 107.035, is not experimental in nature; 6. Is not
duplicative with respect to other services being provided to the
recipient; 7. Is not solely for the convenience of the recipient, the
recipient’s family or a provider; 8. With regard to prior
authorization of a service and to other prospective coverage
determinations made by the department; is cost-effective compared to an
alternative medically necessary service which is reasonably accessible
to the recipient; and 9. Is the most appropriate supply or level of
service that can safely and effectively be provided to the recipient.
- If a family has third party insurance and their child is placed at
MMHI/WMHI, who is responsible for obtaining pre-authorization from the
insurance company?
Answer: See Voluntary Admission Procedure # 8 in DSL Numbered
Memo 2003-04. It is not required to obtain pre-authorization from the
insurance company, but it is recommended that the county check with the
insurance company to determine what they will cover and for what time
period.
County/HMO Relationship
- What is a county’s course of action if an HMO will not participate
in the development and/or signing of an MOU between the county and the
HMO?
Answer: If the county is interested in assistance in negotiating
an MOU with an HMO, the county should contact their Area Administrator.
If the Area Administrators has questions or needs assistance they may
contact staff in the Division of Health care Financing, Bureau of
Managed Health Care Programs. The HMO is responsible for the provision
and payment of medically necessary services, whether or not an MOU is
place.
- Can counties obtain a listing of the Medicaid HMOs in their
respective areas?
Answer: Yes, see attachment to this document.
- Currently counties can not appeal the decisions made by the Medicaid
HMOs. Since the decisions made by the HMO can fiscally affect the
county, what can be done to change this?
Answer: In the next contract period, the Division of Health Care
Financing will work with other divisions in the Department to develop a
process for the county to use when they disagree with an HMO decision.
Counties should begin communications with HMOs early in the process to
minimize the chance of this occurring. Currently the county does not
have a basis to appeal an HMO decision.
- Can the state mandate an MOU between the counties and the HMOs?
Answer: The state requires the HMO to make a good faith effort to
develop an MOU with the county. The state can not mandate the county or
the HMO to sign an MOU that is not satisfactory to either party.
HMO Issues
- Counties have been notified that the Medical College of Wisconsin
will no longer be involved after July 1, 2003. Who will be replacing
the Medical College?
Answer: Group Practice Affiliates (GPA) will replace the Medical
College of Wisconsin as the gatekeeper for Managed Health Services and
Network Health Plan.
- If a child is in an HMO and is not getting the treatment they need,
can the child/family disenroll from the HMO and be placed on Medicaid
Fee for Service (FFS) if the county has been paying for the cost of
treatment at MMHI/WMHI for a period of time?
Answer: The HMO is responsible for providing medically necessary
services for the months in which they receive a capitation payment for
the enrollee. There are certain circumstances where the enrollee may be
granted an exemption from HMO enrollment. Exemption requests are
reviewed by medical consultants and must meet specific criteria. When
granted, exemptions are effective the first of the next possible month.
- Are there any restrictions on the HMO regarding the distance between
where an inpatient facility is located and where the parents of a
child live?
Answer: There are no restrictions regarding distance. In general,
the facility would be selected based on the availability of the specific
services required.
- Who is responsible for providing oversight of the Medicaid HMOs?
Answer: Division of Health Care Financing, Bureau of Managed
Health Care Programs
- What is the procedure if a child is court ordered for treatment, the
HMO will not fund WMHI/MMHI and the HMO inpatient provider will not
keep the child at there facility?
Answer: The county should work with the HMO to resolve the issue.
The HMO is responsible for all medically necessary care and must find a
network provider appropriate to provide services to the child. If they
do not have an appropriate network provider, the HMO must authorize
services to be provided outside the HMO network.
County Issue
- How does the county of residence find out a child has been placed
under an emergency detention at MMHI/WMHI by another county?
Answer: Either the institute or the county responsible for the ED
should notify the county of residence.
Family/Parent Issues
- What happens if the parents refuse to cooperate with the facility
designated by the HMO?
Answer: The county and the HMO should discuss the issues and
determine if there are alternatives. Then the county and the HMO should
discuss with the family what alternatives there are and try to resolve
the issues.
- If an admission is voluntary could the admission be denied if the
parents are not cooperative in providing the needed information to
bill private insurance or does provision # 6 of involuntary admissions
apply to voluntary admissions as well?
Answer: The admission would not be denied unless the county
authorizes the placement, since they would be responsible for payment of
the bill. Mental Health Institute staff will attempt to obtain insurance
information from the parents and/or responsible party. If the client
does not become eligible for Medicaid, the DHS
Billing and Collections
Unit will bill the county. The DHS
Billing and Collections Unit will
bill those parents who do not cooperate in accordance with HFS 1, the
uniform Fee System. If the county has insurance or other information
this should be forwarded to the Mental Health Institute.
- What if the parents will not cooperate in providing the necessary
financial or insurance information if their child is being placed at
MMHI/WMHI?
