8112.4 Institutions for Mental Diseases (IMD)

See Policy Memo1999-10-02 re: Law Enforcement Custody and State Psychiatric Hospital Admissions

An IMD is a hospital, nursing facility or other institution engaged in providing diagnosis, treatment or care of persons with mental diseases. Except for certain situations involving state hospitals, as noted in item (3) below, FFP is not available for a person between the ages of 21 and 64 residing in an IMD. However, state-only coverage is provided to some persons. Persons otherwise ineligible cannot obtain eligibility until release from the facility. Temporary absences to seek medical or other care, such as a general hospital admission, unless the person has been formally released from the IMD, are not covered. These individuals continue to be considered patients of the facility. Persons absent from the facility due to a trial home visit are also considered patients of the facility. However, persons who are released under the condition of outpatient treatment are not considered patients of the facility and may be eligible for medical assistance. Eligibility for medical coverage may begin the month of release from the facility. The general types of IMD arrangements and the general eligibility rules of the arrangements follow.

State Psychiatric Hospitals - Individuals age 65 or older or under age 21 (age 22 if receiving psychiatric services on their 21st birthday while they remain in the facility) may be determined eligible for medical. All other patients of a state hospital for the mentally ill are not eligible for medical assistance until release. There are currently two state hospitals with inpatient psychiatric units meeting the criteria of this item: Larned State Hospital and Osawatomie State Hospital. Persons admitted to these facilities are not eligible if they are under the jurisdiction of law enforcement. See Policy Memo 99-10-02 for a list of civil and criminal commitments. Persons in the sexual predator treatment unit at Larned State Hospital are not considered to be under the jurisdiction of law enforcement and may be eligible for medical assistance. For eligible patients, long term care procedures and guidelines are applicable, including financial eligibility in 8160 and 8170 and the spousal impoverishment provisions of 8144 . For individuals receiving coverage through CHIP who enter a state mental health hospital, CHIP coverage continues through the month of entrance and following month, regardless of anticipated length of stay. CHIP coverage terminates at the end of the period and any continuing eligibility is determined under the Medicaid program. No patient liability is determined during this period; however, any premium obligation continues. When a current Medicaid recipient between the ages of 21 and 65 is admitted to a psychiatric unit of a state hospital, eligibility shall be terminated effective the last day of the month the client was admitted and the case may be closed.

Nursing Facilities for Mental Health (NF MH) - There is no age restriction for eligibility in an NF MH. However, there is no FFP for persons residing in these facilities between the ages of 21 and 64. The Medicaid fiscal agent is responsible for separating funding sources. Long term care procedures and guidelines are applicable for persons meeting the pre admission screening criteria described in 8144 , including financial eligibility per 8172 . See 8171 for financial eligibility for person who do not the appropriate level of care. For eligible patients, long term care procedures and guidelines are applicable, including financial eligibility in 8160 and 8170 and the spousal impoverishment provisions of 8144 .

Psychiatric Residential Treatment Facilities (PRTF) - A PRTF is a facility designed to provide active treatment in a structured therapeutic environment for children and young adults with significant functional impairments resulting from an identified mental health diagnosis, substance abuse diagnosis, or a mental health diagnosis with a co-occurring disorder. A list of facilities licensed as PRTFs can be found within the Active NF & Institutions list. NOTE : A Youth Residential Center is not a PRTF and is considered a community-based placement. Independent living rules are applicable for youth living in these arrangements. Residents of a PRTF who are under age 21 (age 22 if receiving treatment in a PRTF or state hospital on their 21st birthday) are potentially eligible for Medicaid assistance. Older individuals are not eligible. Residents must be screened eligible for admittance into the PRTF by a certified individual approved by KDHE-DHCF. In limited situations, emergency admissions may be allowed. A contracted entity is responsible for entering all prescreening results in the MMIS, where payments are edited to ensure the child meets the necessary level of care. The facility is responsible for submitting a MS-2126 for each resident in which Medicaid assistance is requested. The PRTF must indicate if a screening has been completed. If it is reported a screening has been completed, then the individual is deemed to meet appropriate level of care for purposed of the eligibility determination. If they report the screening has not been completed, contact the Mental Health Consortium to determine if an exemption is applicable. If the stay is anticipated to last at least 30 days, long term care procedures and guidelines are applicable for the eligibility determination. In most instances, coverage under the LTC program (see 2663 and 8183 ) is available. If the stay is anticipated to last less than 30 days, the stay is considered temporary and independent living budgeting applies. In these cases, eligibility is determined according to the prior living arrangement. For youth entering a facility for a stay anticipated to exceed 30 days and who is receiving Medicaid prior to entering the facility, the case must be adjusted according the following rules: For youth in state custody receiving foster care or adoption support related medical assistance, coverage may continue under these categories for the duration of the stay, unless coverage ends due to other program requirements. For youth receiving medical under the SI program, coverage may continue under the SI program, if, the child remains in SSI recipient status. For youth receiving medical assistance under HCBS, the institutional protected income limit is applicable beginning the month of entrance. The eligibility worker may maintain eligibility under the Medically Needy program through the first month of the stay and establish coverage under the LTC program beginning the second month. A new application is not required. For youth receiving medical assistance under other programs, including the Caretaker Medical or poverty level program, the child must be removed from the original assistance plan beginning with the month in which the arrangement begins. A separate determination is required for the PRTF resident. Additional information may be requested, but a new application is not required. A patient liability must be determined for all residents whose stay will exceed 30 days (including all LTC eligibles). For persons eligible under the temporary care provisions, the patient liability is $0 unless the youth is part of a Medically Needy plan with an unmet spenddown. In these instances, Medically Needy rules are applicable. Example : Jana is a 15 year old Poverty level children's program recipient who receives $160.00/month in child support. She enters a PRTF for a stay not expected to exceed 30 days. Because this is a temporary stay, she remains part of the original Poverty level children's program plan. Jana's patient liability is $0, as there is no medically needy plan. If Jana's stay is expected to exceed 30, she is removed from the Poverty level children's program plan and a new application is requested to determine eligibility based on institutional rules. Jana is determined eligible under the LTC program and her patient liability is $98.00 ($160 - $62). The facility is responsible for notifying the eligibility worker of the PRTF dismissal as quickly as possible. The eligibility worker shall adjust eligibility appropriately, with independent living rules applicable beginning the month of discharge for HCBS, Poverty level Programs and Caretaker Medical determinations and the month following the month of discharge for all others. NOTE : Although the parent or caretaker with whom the child resides may “receive” child support payments, they are considered countable income for the child per 6220 (4) .

State Institutional Alternative (SIA) Facilities – A SIA facility is either an IMD or a Non-IMD facility approved by KDADS that has reserved specialized beds in their facility for the treatment of individuals who would otherwise be admitted into a state institution (such as Larned or Osawatomie). These facilities are located throughout the state and provide State Institutional coverage for these select beds. Level of CARE verification is not required in order to approve coverage, similar to state hospital admittances, as all individuals are screened and meet state hospital criteria prior to their admittance.For eligible patients, long term care procedures and guidelines are applicable, including financial eligibility in 8160 and 8170 and the spousal impoverishment provisions of 8144 . For an IMD placement, the provisions of 8112.4 (1) apply. For a Non-IMD placement, the provisions of 8112.4 (2) apply.