Provider Notice Issued 12/07/2018

1115 Waiver Pilot Program: Intensive In-Home
Billing and Service Delivery Requirements
 
1.     Basic Provisions.
This guide serves as a companion to the 1115 Demonstration Waiver and implementing rules for the purposes of providing guidance specific to the delivery and reimbursement of Intensive In-Home services provided to participants eligible to participate in the pilot program. Failure to comply with the service delivery requirements and claiming requirements outlined in the following service pages may result in claims denial.  No detail in this guide shall supplant Illinois law or administrative code in any way.
Additional information on the Intensive In-Home Pilot can be found on the HFS website.  Questions regarding the Intensive In-Home Pilot may be directed to the Bureau of Behavioral Health at 217-557-1000 or HFS.Intensive.InHome.Pilot@illinois.gov. 
2.     Enrollment Limits.
The Intensive In-Home Pilot has an annual enrollment limit as specified in the following table:
Demonstration Year
State Fiscal Year
Enrollment Limit
DY1
FY19
9,835
DY2
FY20
13,796
DY3
FY21
16,225
DY4
FY22
16,225
DY5
FY23
16,225
 
3.     Participant Eligibility.
Participants must be determined eligible for participation in the Intensive In-Home Pilot by HFS prior to receiving Intensive In-Home services.  Providers may request enrollment of a participant into the Intensive In-Home Pilot by completing and submitting a Service Request Form, along with a copy of the participant’s current IM+CANS, to HFS for review.
Effective January 1, 2019, only a participant’s Integrated Health Home provider may submit the Intensive In-Home Service Request Form to HFS for review.
 
 
3.1.         Eligibility Criteria.
To be determined eligible for participation in the Intensive In-Home Pilot, a participant must meet all the following criteria:
·       Be enrolled in one of HFS full-benefit Medical Assistance Programs;
·       Be between the ages of 3 and 21;
·       Be attributed to Tier A or Tier B of the Integrated Health Home;
·       As of January 1, 2019, be actively enrolled in an Integrated Health Home;
·       Have an IM+CANS completed and signed by a Licensed Practitioner of the Healing Arts (LPHA) within the last 180 days; and,
·       Meet either of the following:
                                                  i.     A demonstrated history of symptoms of a psychotic or other thought disorder, including evidence of hallucinations, delusions, unusual thought processes, strange thought processes, or bizarre or idiosyncratic behavior with evidence of ongoing symptomology; OR
                                                ii.      Demonstrate:
§  A treatment history of more than one psychiatric hospital admission in the preceding twelve (12) months or one or more crisis episodes within the preceding six (6) months; AND
§  Meet three or more of the clinical criteria from the IM+CANS in the following categories: Behavioral/Emotional Needs; Risk Behaviors; Caregiver Resources and Needs; and Life Functioning.
3.2     Length of Pilot Participation.
Subject to the enrollment limits, participants who are determined to meet the Intensive In-Home eligibility criteria will be enrolled in the pilot program and issued 63 days (9 weeks) of eligibility for Intensive In-Home services.
Providers may request a 28 day (4 week) extension of eligibility for Intensive In-Home services by submitting the Intensive In-Home Service Request Form, along with an updated copy of the participant’s IM+CANS and documentation of Intensive In-Home services rendered to the participant, to HFS for review.  Providers may be granted up to two extensions per participant. 
4.     Provider Participation.
Any provider seeking reimbursement for the provision of Intensive In-Home services must be enrolled for participation in the IMPACT system as a Community Mental Health Center (CMHC) or a Behavioral Health Clinic (BHC).  In order to deliver Intensive In-Home Services, providers must also be actively utilizing the Illinois Medicaid Comprehensive Assessment of Needs and Strengths (IM+CANS) in the delivery of Integrated Assessment and Treatment Planning (IATP) services.
5.     Service Definitions.
The Intensive In-Home Pilot covers two distinct but connected services: Intensive In-Home Clinical and Intensive In-Home Support.  The Intensive In-Home services together comprise a face-to-face, time-limited, focused intervention targeted to support and stabilize a child in their home or home-like setting.
Intensive In-Home Clinical is a strengths-based, individualized, and therapeutic service driven by a clinical intervention plan that is focused on symptom reduction.  Staff delivering Intensive In-Home Clinical services must minimally meet the qualifications of a Qualified Mental Health Professional (QMHP).
Intensive In-Home Support is an adjunct service that may only be provided in conjunction with Intensive In-Home Clinical services.  The goal of Intensive In-Home Support is to support the participant and family in implementing the therapeutic interventions, skills development, and behavioral techniques that are focused on symptom reduction, as outlined in the clinical intervention plan.  Staff delivering Intensive In-Home Support services must minimally meet the qualifications of a Mental Health Professional (MHP).
6.     Prohibition on Duplication of Services.
Participants participating in the Intensive In-Home Pilot shall not receive the Medicaid Rehabilitation Option – Mental Health (MRO-MH) services of Therapy/Counseling or Community Support, as defined in the Handbook for Providers of Community-Based Behavioral Services, from any provider of MRO-MH services while the participant is enrolled in the Intensive In-Home Pilot.
7.     Service Requirements.
The delivery of Intensive In-Home services requires the development and maintenance of a clinical intervention plan.  The clinical intervention plan shall be developed and signed by an LPHA based on, or incorporated into, the participant’s IM+CANS.  The clinical intervention plan shall be established in collaboration with the participant, family, and staff comprising the Intensive In-Home team, and must clearly outline the targets and goals of the Intensive In-Home services.
The first week (7 days) of a participant’s participation in the Intensive In-Home Pilot shall be considered an Engagement Week.  It is expected that the Intensive In-Home team is coordinating with the participant and family and conducting the necessary intake processes for initiating Intensive In-Home services.  Providers must conduct a minimum of one intervention, delivered either face-to-face or via phone, with the participant to receive reimbursement for the Engagement Week.
After the Engagement Week is completed, providers must conduct a minimum of two face-to-face interventions per week with the participant in the home or home-like setting to receive reimbursement for the delivery of Intensive In-Home services.  The two interventions may include the delivery of either Intensive In-Home Clinical or Intensive In-Home Support, depending on the needs of the participant and family and as supported by the clinical intervention plan.
8.     Payment and Reimbursement.
8.1    Base Payments.
Intensive In-Home services rendered to pilot participants are reimbursed on a weekly basis.  For each week that the service requirements outlined in Section 7 of this guide are met, providers of Intensive In-Home services shall submit a claim to the appropriate Medicaid payer for reimbursement.  The established weekly base rate for Intensive In-Home services is $160. 
Providers shall not submit claims and are not eligible for reimbursement for the delivery of Intensive In-Home services for weeks in which the service requirements outlined in Section 7 of this guide are not met.
8.2    Adjusted Payments.
Providers of Intensive In-Home services may qualify for an adjustment to their weekly base payment if the pilot’s outcome measures are met.  The established adjusted payment is an additional $75 per week. 
Outcome measures for Intensive In-Home shall be measured across four Adjustment Periods.  If the outcome measures are met for a particular Adjustment Period, then all of the claims paid for the participant during that Adjustment Period will receive the $75 adjusted payment.  
Adjustment Period 1: covers the first five weeks of enrollment in the Intensive In-Home Pilot (day 1 through day 35).  To qualify for the adjusted payment during this period, the participant must remain enrolled in an IHH (as applicable) and the participant must not receive any inpatient psychiatric services during the Adjustment Period.
Adjustment Period 2: covers weeks 5 through 8 of enrollment in the Intensive In-Home Pilot (day 36 through day 63).  To qualify for the adjusted payment during this period, the participant must remain enrolled in an IHH (as applicable) and the participant must not receive any inpatient psychiatric services during the Adjustment Period.
Adjustment Period 3: covers all four weeks of the first eligibility extension, if granted (day 64 through day 91).  To qualify for the adjusted payment during this period, the participant must remain enrolled in an IHH (as applicable), the participant must not receive any inpatient psychiatric services during the Adjustment Period, and the CARES line must not receive any crisis calls for the participant during the Adjustment Period.
Adjustment Period 4: covers all four weeks of the second eligibility extension, if granted (day 92 through day 119).  To qualify for the adjusted payment during this period, the participant must remain enrolled in an IHH (as applicable), the participant must not receive any inpatient psychiatric services during the Adjustment Period, and the CARES line must not receive any crisis calls for the participant during the Adjustment Period.
Table 1 below provides a detailed crosswalk of Intensive In-Home service weeks to Adjustment Periods to assist providers in better understanding the payment and claiming cycle for participants enrolled in the Intensive In-Home Pilot.
  
Table 1. Intensive In-Home Payment and Claiming Cycle
Service Week
Week
Begin
Week
End
Date of Service
on Claim
Adjusted Payment Measures
Engagement Week
Day 1
Day 7
Day 7
Adjustment Period 1:
·     No inpatient psychiatric services
·     Remain enrolled in IHH (as applicable)
Initial - Week 1
Day 8
Day 14
Day 14
Initial - Week 2
Day 15
Day 21
Day 21
Initial - Week 3
Day 22
Day 28
Day 28
Initial - Week 4
Day 29
Day 35
Day 35
Initial - Week 5
Day 36
Day 42
Day 42
Adjustment Period 2:
·     No inpatient psychiatric services
·     Remain enrolled in IHH (as applicable)
Initial - Week 6
Day 43
Day 49
Day 49
Initial - Week 7
Day 50
Day 56
Day 56
Initial - Week 8
Day 57
Day 63
Day 63
Extension 1 - Week 1
Day 64
Day 70
Day 70
Adjustment Period 3:
·     No inpatient psychiatric services
·     No crisis call through the CARES line
·     Remain enrolled in IHH (as applicable)
Extension 1 - Week 2
Day 71
Day 77
Day 77
Extension 1 - Week 3
Day 78
Day 84
Day 84
Extension 1 - Week 4
Day 85
Day 91
Day 91
Extension 2 - Week 1
Day 92
Day 98
Day 98
Adjustment Period 4:
·     No inpatient psychiatric services
·     No crisis call through the CARES line
·     Remain enrolled in IHH (as applicable)
Extension 2 - Week 2
Day 99
Day 105
Day 105
Extension 2 - Week 3
Day 106
Day 112
Day 112
Extension 2 - Week 4
Day 113
Day 119
Day 119
 
9.     Claims Submission Requirements.
Claims for Intensive In-Home services provided to participants served in the fee-for-service system must be submitted directly to HFS for reimbursement.  Claims for Intensive In-Home services provided to participants enrolled in HealthChoice Illinois must be billed to the health plan for reimbursement according to the provider’s contractual agreement with the health plan. Please refer to the policies and procedures of each individual plan.
Claims for Intensive In-Home services are to be submitted using an 837P claim form after the service requirements outlined in Section 7 have been met.  Intensive In-Home services are reimbursed on an event-based basis, with a maximum of one unit of service allowable per every seven (7) calendar days.  To ensure appropriate claims adjudication, providers shall submit claims for each week of service that qualifies for reimbursement using the date of service guidelines outlined in Table 1 of this guide.
Providers shall submit claims for Intensive In-Home services using the service coding detail outlined in Table 2 below, selecting the HCPCS/modifier combinations reflective of the two face-to-face interventions performed during the service week.
 Table 2. Service Coding Detail
 
Service Name
HCPCS
Modifier 1
Modifier
2
Unit
Max
Units
Allowable Place
of Service
Intensive In-Home Clinical
H2020
TG
TG
Event
1
04, 12, 13, 14
Intensive In-Home Support
H2020
SC
SC
Event
1
04, 12, 13, 14
Intensive In-Home Clinical
& Support
 
H2020
TG
SC
Event
1
04, 12, 13, 14

Notices

 

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