Magellan Training: Medicaid Rehabilitation Option MRO
Initial Auth § What information do I need when I call? ú Current diagnosis (onset) ú Rehabilitation Assessment Functional Limitations ú Rehab Plan ú Licensed clinician contact §
MRO Re-Auth Form § § § § Client Name and SS# Agency Name and Contact Person Auth End Date Medications and Number of Face to Face Current Dx Program Type or Service Medicaid ID# and Service Location
MRO Re-Auth Form § § § § Rehabilitation Need Measureable Goal Progress on Goal Crisis Plan (include something other than ER or 911) Discharge Plan and ELOS Hospitalizations or ER visits in report period Psychiatrically Stable (if not a brief description) Specific Functional Limitations R/T Major Mental Health Diagnosis
Specific Functional Limitations Must be the result of long term mental illness § Must be present for one year § Must be pervasive across life skills areas § Must require life skills training to improve client’s quality of life §
MRO § § § § Medicaid Chapter 35 PRR, ACT, DR, CS Active Life skill training Assessment based Client centered Realistic goals Crisis plan
Medicaid Rehab Option Guidelines Must meet SPMI status § Must have functional limitations § May have other diagnosis as secondary §
SPMI Guidelines § § At risk of institutionalization if services not provided Seriously interferes with functioning Has had one year or will have Results in functional deficits in two of three life skills areas.
SPMI Con’t Not primary substance abuse § Not primary developmental disabilities §
Major Life Skills Areas Voc/Educational § Social Skills § Activities of Daily Living §
Vocational/Educational Inability to be employed § Inability to pursue education § Inability to carry out home management tasks (meals, laundry, budgeting, child care) §
Social Skills Inappropriate § Inadequate § Participates only with extensive support § History of dangerousness §
Activities of Daily Living § Inability to consistently perform ú Hygiene, grooming, meals ú Personal business ú Transportation, care of residence ú Medical, legal, housing ú Avoidance of common dangers
MRO Authorization Considerations § § § Careful examination of functional limitations. Focus on where the limitations can best be addressed (home or club house). Compensatory training not cure. Not a life time service (except ACT) Without assessment and diagnosis we cannot authorize these services.
Authorization Considerations A major mental illness alone is not sufficient for SPMI § Presence of symptoms is not sufficient § Provider must link functional deficits to Axis I disorder § NOS not acceptable §
Considerations con’t Brain injury § Typically developmentally delayed have not met milestones § Axis I typically have met milestones §
Considerations con’t § § § Across settings Long term Requires support/intervention Medication Our case notes/hx of care Compensation not cure
Considerations con’t Long term sub abuse and homelessness often look like SPMI, because many SPMI have both. § TBI often look like SPMI §
Psychiatric Residential Rehab § § § SPMI These deficits require 24 hour psychiatric residential setting The need is 24 behavioral monitoring
Day Rehab § Day Rehab ú The need: Day structure to work on socialization/self care/pre-voc § Community Support ú The need: Case management In home work on self care § Household/ADL tasks §
Community Support ú The need: Case management and § In home work on self care § Household/ADL tasks
Authorization Considerations PRR and DR are authed together for those who have both needs § CS and DR are authed together for those who have high social needs plus in home needs. § CS is not authed with PRR (except 30 days in/out) §
ACT Two in Omaha § One in Lincoln § One in Hastings §
ACT Guidelines ú The need: SPMI plus high utilization of emergency/hospital services ú Poor response to lower levels of care ú 24 hour available intervention ú Poor response to other treatment
General MRO Admission § § § Meets Admit guidelines Does not require a higher LOC A lower LOC is not indicated Likelihood of benefit from service Is making progress
General MRO Continuing Stay § § § Meets Admission guidelines Does not require a higher LOC A less intensive LOC is not appropriate Reasonable likelihood of benefit Is making some progress in rehabilitation goals
General MRO Exclusion § § § Not SPMI Primary substance abuse or DD Does not have functional deficits in two or three areas Resides in a Nursing Home or PRR Needs a higher LOC
General MRO Discharge § § § Maximum benefit Sustainability plan in place Supports in place Crisis relapse plan in place Or the individual requests discharge
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