Medicaid Training - Questions and Answers on Psychiatric Residential Treatment Facilities

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**Stakeholder Questions and Answers – Related to PRTF Services**
Category of Stakeholder Submitting Question (if known)	Question	Response
CW Contractor	1.5.3.3: Are juvenile offenders placed in residential facilities or group homes considered incarcerated? Second Paragraph: We realize the section is titled “criminal court referrals” but want to assure that “court-ordered placement” does not extend to the CINC population.	Residential facilities or group homes are not appropriate placements for a juvenile offender in need of incarceration. This section relates to those individuals involved with the criminal justice system. It is not intended to relate to court ordered placements involved in a CINC proceeding.
CW Contractor	Page 22 – 1.5.10 – Questions: The area appears to make some necessary services optional to provide. i.e. Sex Offender, services for youth in the child welfare or juvenile justice system? Does this area close the door for other than CMHC’s to provide such services to therapeutic foster care?	All covered services are addressed in Section 1.5 of the contract (and Appendix F). This section deals with potential additional services developed over time, with perhaps some specialized focus. There is no prohibition against other licensed practitioners providing services under the scope of their license (consistent with provider network standards in the PAHP contract).
CW Contractor	Page 27-b Question: It reads as though the physician can over rule the finding of the screen team, is this so?	Page 27b - Yes.
CW Contractor	Page 27 – Question: Will consumers and providers have a place on the utilization management teams? If not, this is a large concern.	Page 27 - Any person who is adequately trained and competent to perform UM functions can be employed to do that work.
CW Contractor	Page 30 – f-g Notifying the physician of changes in medication may be difficult if the primary provider is at a distance – i.e. foster care youth/PRTF youth. Question: Will physicians be willing to be engaged at this level?	Page 30 - CMS requires coordination with primary care providers.
CW Contractor	Page 32 – Question: Need clarification on who the “contractor” responsible for transportation, etc. is?	Page 32 - "Contractor" refers to the PAHP and the PAHP is not responsible for transportation, but for coordinating with HealthWave or KHPA for transportation for TXIX members.
CW Contractor	1.5.3.6: PRTFs are included with otherinstitutions—dose this imply that “emergent” protocol with 1-3 hour response time is in effect?	1.5.3.6 - No
CW Contractor	1.5.4.i/j.: Can a youth in crisis be taken to the ER and receive immediate MH services?	1.5.4.i/j - Yes.
CW Contractor	1.5.5.c.i.: What does respond mean? Is acknowledging the receipt of such request count or does this mean approve/deny the actual pre-authorization?	1.5.5.c.i - must approve or deny. Acknowledging receipt is not adequate.
CW Contractor	1.5.5.e.: The references to a physician oversight is unclear—will this section be amenable for negotiation as was done for the IFBT agreements just recently begun?	1.5.5.e - this is federally required language, and will not be netogiated.
CW Contractor	1.5.7.b: Referral within 24 hours too long unless community based wrap around alternatives are in place—we suggest 3 hours. 1.5.8 Certification of Need: request clarification that the CBST be “lead” by the CMHC. We also assume that the “subcontractor” noted in the last paragraph on pg 19 is referencing the CMHC, not the CWCBSP	1.5.7.b - if the situation is an emergency, 3 hours will be the requirement; that is not required for the urgent situations addressed here.
CW Contractor	1.5.8 PRTF Certification of Need: Who determines if a child is in a place of safety? What are time frames to act if their placement is NOT safe?	1.5.8 - The PAHP is responsible to ensure the certification of need occurs. The PAHP, in collaboration with the referring party and knowledgeable others. If they are not in a place of safety, they bump into the emergency time frames.
CW Contractor	1.5.9, second bullet at bottom of pg 21: We assume that the community based provider for continuing MH services is the CMHC and not the CWCBSP	Yes.
CW Contractor	Page 15 – Admissions and Discharges Question: Is the contractor the entity that becomes the PAHP? Is the contractor not simply the directors of each CMHC? If so, will they have such a large technical infrastructure set up that quickly? Overall question- The document refers to many standards regarding PRTFs. However, in the definition section, it states that the PAHP will not provide for, arrange for, or is not otherwise responsible for the provision of any inpatient hospital or institutional services for its enrollees.	Page 15 - The contractor is the PAHP, and is a different functioning entity than "the directors of each CMHC." In order to meeting the contract, the required infrastructure will be in place. The Contractor has both screening and ongoing assessment responsibilities for members accessing PRTF services, and also has system management responsibilties more broadly.
	Question: Why would the contract address anything beyond the duties of the CMHC’s to screen and arrange CBST meetings? Page 15 – 1.5.8 Questions: What about an emergency admission process for PRTFs? Does it not need to line up with the new SRS policy on emergency admissions? Should the team include the physician as it could make the certification unrealistic? What is the difference between an LMHP and a QMHP? To be consistent, should it not just be LMHP? Please clarify the youth’s county of residence relative to service provided by the local CMHC. Who is the subcontractor referred to in this section?	1.5.8.a and 1.5.8.c both address the emergency related PRTF access processes. The updated language about emergency exceptions has been added into the final contract. Physician involvement is a federal requirement. QMHP is statutorially defined, with the substantive differences being the QMHP's employment in a CMHC and the specific responsibilities associated with gatekeeping for psychiatric inpatient services. Whomever is contracted with the PAHP for this responsibility.
	Page 20 –PRTF Certification of Need – Question – Would not all PRTF admissions be, at minimum, emergent if the youth are headed for a PRTF? Does the emergency screen need to be updated to fit the SRS definition/process? What does the phrase “subcontractor” mean?	Page 20 - No. The screen will need to fit the policy ongoing. See above.
	Page 21(c) Question – If a non certification is notified immediately, why does it take two days to make a notification of certification?	Page 21 - Written notice is required for either decision within 48 hours. Notice of a denial is required immediately so that the Member can pursue other options. If the decision is approval, the services will commence.
	Page 21 Question – Is it true that the PAHP does not determine eligibility, the screener does? There is confusion between the use of the terms PAHP and the CMHC’s?	Page 21 - The PAHP is responsible for certification of need.
	Page 22 Comment/Question – 30 days is way too long on medication evaluations after D/C from inpatient. The PRTFs are required to give some medication and a prescription. If the child is on a controlled substance, 30 days will not meet the need. Should the appointment not occur more quickly for success of the discharge?	Page 22 - The intention is that action take place more promptly, and we will clarify that in the contract.
	Page 32 1.8.3 –Question: Why is this section the role of the PAHP? Why would the CMHC get the courts involved? Is this section saying the PRTF provider or the CMHC provider is in charge of discharge planning? Why do the CMHC make decisions related to shelters? Seems entire section needs clarification. Page 33 –Question – Why would the CMHC’s have a say in the discharge planning for 24 hour care programs if they are not paying for them?	These value-based requirements are designed to give attention to effective discharge arrangements that will enhance the durability and success of this important transition point. The PAHP is responsible for managing the system of care related to all mental health services, including those which are "substitutable" and part of the overall system cost cap
CW Contractor	Beneficiaries are not eligible for services under this contract while they are in treatment at a PRTF. How then can the Contractor provide re-screens, discharge planning, etc. for a youth who is receiving care in a PRTF? pg. 15 1.5.3.6 Whose responsibility will it be to track admissions and discharges? Each CMCH or will there be a centralized process?	The PAHP's responsibilities are for the delivery and management of covered services, and related identified administrative functions, as well as coordinating care with other service systems. This includes the screening and ongoing assessment responsibilities for members accessing PRTF services, and also broader system management responsibilties. Page 15 The PAHP will be responsible for tracking and trending required data elements.
CW Contractor	Page 19 1.5.8 Again, how can the Contractor bill for recertification for PRTFs when children in PRTFs are excluded from this contract? Are the CMHCs recouping costs via their administrative fee? Individuals personally presenting at PRTFs…does this mean that a PRTF provider will not be paid for beneficiary care if a youth is admitted prior to Certification of Need? Is this clearly spelled out in the PRTF standards also? Are the terms “LMHP” and “QMHP” used interchangeably in this document or is there a distinction between them? Please clarify the meaning of “subcontractor” in the last paragraph on this page and throughout the document.The certification team must include a physician. This has not happened frequently in the past. Will it be a requirement for this contract?	Page 19 Certification of Need and Recertification of need in addition to ongoing coordination of community based care for individuals residing in an institution are administrative functions and will be reimbursed accordingly. Certification of Need is required to establish the medical necessity of PRTF services. Medicaid reimbursement for PRTF services cannot occur until the medical necessity of the services has been established. QMHP is statutorially defined, with the substantive differences being the QMHP's employment in a CMHC and the specific responsibilities associated with gatekeeping for psychiatric inpatient services. Subcontractor refers to any party that the PAHP as the contractor chooses to contract with. Physician involvement is a federal requirement and will therefore be a requirement of the contract.
	Page 20 1.5.8.Will the Contractor be assuming responsibility for the convening of CBSTs? The Contractor will notify the responsible subcontractor … Who would this subcontractor be? The CMHC? It is understood that a different approach to the Emergency Exception Screening Procedure was developed through committee work. Will that revised approach be incorporated into the contract? Why will notice of denial be given immediately but notice of approval take 48 hours? The Contractor shall…perform PRTF-specific eligibility functions. What eligibility, and what functions?	Page 20 The PAHP will be responsible for convening the CBST team as specified in the contract. Subcontractor refers to any party that the PAHP as the contractor chooses to contract with. See prior answers.
	Page 21 1.5.9 Coordinating and facilitating the Community Based Services Team and implementing the Community Based Service Plan appears to now be the responsibility of the Contractor, and the Contractor will be reimbursed for those services out of the administrative fee. Is this correct? The Contractor is to “schedule” necessary Med evals and treatment for post PRTF services within 30 days of discharge. There is no timeframe for when the actual services are to be received…just scheduled. This will NOT meet the needs of youth who are discharged from PRTFs.	Pg 21 Yes see previous answer.
	Page 21 1.5.9 Coordinating and facilitating the Community Based Services Team and implementing the Community Based Service Plan appears to now be the responsibility of the Contractor, and the Contractor will be reimbursed for those services out of the administrative fee. Is this correct? The Contractor is to “schedule” necessary Med evals and treatment for post PRTF services within 30 days of discharge. There is no timeframe for when the actual services are to be received…just scheduled. This will NOT meet the needs of youth who are discharged from PRTFs.	Pg 21 Yes see previous answer.
	Is the PAHP the CMHCs are the subcontractors CMHCs? What constitutes “regular” on-site presence and “regular” face to face contact with beneficiaries/members who are in institutional/facility-based settings?	CMHCs will become subcontractors to the PAHP The needs of the people receiving services, and the issues related to effective transition and aftercare planning will dictate what constitutes effective on-site and face to face contact.
Provider	Page 32 1.8.3 The PAHP shall initiate and enforce policies that require providers to initiate discharge planning [from inpatient mental health treatment]…. What providers: the PRTF providers? What authority would the PAHP have over the PRTFs? Who will they require to do what? The contract indicates that SRS does not want youth being discharged from PRTFs to shelters. Will the PAHP/CMHC be responsible for location and/or funding other preferred discharge placement? The PAHP shall be involved in and support the discharge planning of any member who is receiving twenty-four hour care, whether or not that care is being funded in whole, or in part, by the service funded in the Contract. Does this mean that the PAHP will be involve in discharge planning from JDF or the Youth Residential Centers?	Page 32 Providers refers to those providers subcontracted with the PAHP It is SRS's value-based expectation that the PAHP will be involved in assisting all members who are in need of mental health treatment with transition planning, aftercare services, and accessing community resources. This includes, for example, that the PAHP will be responsible for work on-site in joint treatment planning conferences for individual Members and in community service planning, all designed to ease transition and access for members and their families.
Provider	Why can we do with YRC’s what we were told we couldn’t do with level 5’s last year. Why aren’t YRC IMDs?	Youth Residential Care facilities (YRCs) are designed to meet the needs of youth who do not need an Institute of Mental Disease (IMD) level of care. In order to access Medicaid funding, IMD level of care services for youth can only be provided in Psychiatric Residential Treatment Facilities (PRTFs), where professional and accreditation standards are met. Youth not needing that level of care will be supported in YRCs, and the services available there, programming standards, and monitoring protocols will be structured so that these facilities do not become IMDs. Because Kansas had not consistently attended to the ground rules associated with IMDs, we were at risk of negative funding decisions by CMS and have addressed those issues by the development of separate programming and structures for PRTFs and YRCs.
Provider	What screening device will determine who gets into a PRTF and when will that screening tool be available for providers to review.	The instrument for screening each youth potentially needing PRTF services has been developed, is available on this site, and specific training for screeners and providers will be held in April.
Provider	What do we do with kids in level 5’s who do not screen into a PRTF if no one opens a YRC.	For youth who are not able to return to a home or community based setting, SRS is developing a range of options to meet their needs. We anticipate that the Youth Residential Care services of various sizes and programing will be available.
Provider	How will the transition be done July 1. Will kids be left where they are until they screen otherwise. Will the facilities be paid at the new PRTF rate? How will the transition be funded Medicaid or SGF?	PRTF rates will be effective July 1st. Each youth currently receiving Level V or VI services will receive an “informational” screening, starting in April, in order to assess current needs and connect each youth to the responsible CMHC. No youth will be denied services as a result of this screening; it is only for information purposes. In order to support a gradual and orderly transition, each youth receiving Level V or VI services as of July 1st will be served under their existing authorization and those services will continue until the end of their then-existing authorization period (either 140 or 180 days) or the youth is discharged. As of July 1st, each youth entering services, or when the authorization period ends, the new PRTF screening protocol will be applied.
Provider	When will rates be determined and providers notified?	PRTF rates will be established by the end of month (cost reports have been submitted by 19 facilities), and published to providers and others by SRS. Level V facilities had not previously met PRTF requirements, so we should anticipate a significant rate increase for them, and also expect increased costs for Level VI facilities primarily related to expenses they are already incurring above the rate.
Provider	Will rates be standard for each specified level of care in YRCs and PRTFs or will acuity be a factor.	Under the assumption that youth served in current Level VI facilities have acuity levels higher than youth served in current Level V facilities, acuity will be a factor in the PRTF rates. Each PRTF will have an individualized rate. We anticipate that the rate for YRCs will be standard across each level of care.
Juvenile Corrections	Will comprehensive planning for JJA custody youth take place to ensure evidence-based programming is provided to address criminal thinking, attitudes, values and behaviors while in residential care?	Any youth receiving PRTF services will have an individualized treatment plan to address all of the youth’s treatment needs. SRS and JJA are working collaboratively to develop effective alternatives for youth who do not need PRTF-level services but rather need some type of residential placement to meet their needs.
Juvenile Corrections	Will it be possible to develop the non-Medicaid residential system with differential levels of structure, services and funding to serve special populations such as difficult and/or more dangerous juvenile offenders (those at greater risk to reoffend)?	Yes – we certainly anticipate the need for different levels of service needs and different life needs for youth in these service settings. SRS and JJA will continue to collaborate about best ways to partner with providers to meet the array of support needs for Kansas youth. SRS and JJA anticipate funding these services at a level that does not vary by population served, but rather by the service category which the facility is operating within.
Juvenile Corrections	What outcomes are expected of PRTF services for juvenile offenders?	PRTF services are not targeted or designed specifically for juvenile offenders. However, certainly a life issue for some of the youth accessing this service will relate to issues and behaviors that may lead to law enforcement or criminal justice system involvement. For all youth receiving these services, service outcomes are being developed by SRS mental health staff as part of monitoring those services. The types of outcomes anticipated include active participation in individualized treatment planning, treatment, and discharge planning; enhanced therapeutic alliances for the youth and their families to support the durability of their improved clinical status; improved relationships between the youth and their families; and effective discharge practices that attend to effective aftercare strategies and promote improved community living or life circumstances for the youth (including that they do not reoffend).
Juvenile Corrections	Why was American Correctional Association accreditation denied as an accreditation option for PRTFs if they are to appropriately serve the juvenile offender population?	In the listing at federal regulation 42 CFR 441.151(a), American Correctional Association is not one of the identified accrediting bodies for psychiatric facility services. PRTF services are not targeted or designed specifically for juvenile offenders. It is important to the long-term stability of this critical service that it be managed and implemented as a psychiatric residential treatment service for all youth in need of this more acute and intense level of psychiatric care.
Juvenile Corrections	The move to PRTFs embraces the idea in guidelines that every eligible juvenile that screens in will be referred at $270/day. What about those youth who are eligible but could be served in a less costly setting? Will they have to be served at a PRTF? If so, why?	The comprehensive screening process associated with PRTF service access is designed to ensure that – if diversion to any less restrictive setting that can meet the youth’s needs is feasible – appropriate diversion occur. The PRTF rates will vary, and will be based upon the costs of treatment in that setting.
Juvenile Corrections	Has anyone asked the District Court judges and district attorneys what they expect when probation in the community is revoked and placement into JJA custody for out of home placement is ordered/recommended? Does the state plan meet their expectations?	Both SRS and JJA have had multiple outreach discussions with members of the judicial and criminal justice systems, to explain the required changes associated with PRTF services and how to access those (or other appropriate mental health) services.
Juvenile Corrections	In 1999 the legislature imposed a placement matrix for juvenile offender sentencing that restricted sentencing to state juvenile correctional facilities. Since then the population served in state facilities has gone down and more high risk youth are being served in the community. Do you expect more juvenile offenders to be sentenced to state juvenile correctional facilities (at even higher cost per day) if the PRTF plan does not meet the expectations of the juvenile justice system (District Court, DAs, public)?	While SRS’s primary purpose in restructuring the PRTF service model was to stabilize a critical service for youth needing intensive psychiatric treatment services, we certainly want to continue working with all youth systems to ensure effective, sensible, accessible and efficient services remain available for Kansas youth.
Juvenile Corrections	Funding correctional programs is the responsibility of the state general fund. Why are Medicaid dollars and health policy rules being used to fund juvenile offender residential services? Is it the right thing to do? Does it get the job done right?	This is the heart of the PRTF reform. It is not appropriate for Medicaid health care funding – designed to address the mental health of youth needing intensive psychiatric supports – to be accessed for any youth not needing that level of treatment. This change is a positive move forward for the system and is the right thing to do to ensure each youth’s treatment needs are being addressed. With the assessment structure and service stability features in place, we are confident that these services will be the right thing for youth needing this level of treatment.
Juvenile Services	What mental health disorders or categorization(s) specifically will qualify a youth for a PRTF? If the answer is meeting Severe Emotional Disturbance (SED) criteria with a current danger of harming self or others, we need to know what mental health disorder or cluster of disorders will qualify a juvenile offender as SED. Specifically, will a diagnosis of Conduct Disorder and Substance Abuse or Dependence qualify a youth for a PRTF? When can we expect to know these answers? It is critical for both treatment providers and community corrections agencies to know this in advance in order to appropriately plan to attempt to meet the needs of juvenile offenders.	There is no “automatic” mental health or substance abuse diagnosis or category that will “qualify” a youth for PRTF services … or “disqualify” a youth for PRTF services. A combined assessment of the youth’s mental health or substance abuse diagnosis, plus the current functional impact if the condition(s) on the youth, plus the availability of other community-based service options are all at issue. The comprehensive screening process associated with PRTF service access is designed to ensure that – if diversion to any less restrictive setting that can meet the youth’s needs is feasible – appropriate diversion occur.
Juvenile Services	What will the admission/screening process for PRTFs be? Who, what, when, where? When can we expect to know these answers? In order to minimize the length of stay for juvenile offenders in detention, it is critical that this process be immediately available, simple and for the outcome to be known within 48 hours. Screening should occur where the juvenile offender is residing (detention center, home, residential treatment center, shelter, etc.) in order to minimize safety concerns and to ensure there will be no missed appointments.	The screening tool for PRTF services, as well as the related protocol and PRTF service standards, are now available on this site. A summary of the screening process, including emergency and routine timing criteria, can be viewed at “Section 1.5.8 Certification of Need for Psychiatric Residential Treatment Facilities (PRTFs)” in the PAHP contract also available on this site. We would expect that the screening should occur where the youth can be effectively and safely seen.
Juvenile Services	What is the plan for serving juvenile offenders who do not meet criteria for admission to juvenile correctional facilities or PRTFs, but need to be removed from the community because they pose a safety risk to the community? (i.e. Highly aggressive, low level offenders. Will YRCs be able to decline admission of these types of youth? Will any of the YRCs be secure in order to ensure juvenile offenders dont just run off and continue being a menace?) When can we expect to know these answers? The first priority of the juvenile justice system must be community safety.	SRS and JJA certainly anticipate the need for different levels of service needs and different life needs for youth in residential service settings. SRS and JJA will continue to collaborate about best ways to partner with providers to meet the array of support needs for Kansas youth. YRCs will be staff secure just as the Level V’s are today. The security under the new system will not have changed. SRS also plans to have some secure care beds available for the CINC population, and the specifics of that service will be driven by the demand for that type of support.
	Is the screening tool going to be different than the current Level 6 screen? Where did the 70% figure come from for meeting Medical need?	Yes – the screening tool is different, and it is available for review on this web site. The 70% estimation is based upon informal review of some existing programs. A more comprehensive estimation will be available after informational screenings, which are currently underway, are completed.
	Will the MMIS system be in place in time for prompt payments as cash flow is critical for providers?	Yes – we have every assurance from Kansas Health Policy Authority and their MMIS Fiscal Agent that the system changes will be ready to receive and promptly pay PRTF claims.
	Will there be an chances of combinations of programs with PRTF and YRC or Shelters?	SRS’s operationalization of federal ground rules regarding co-location of programs have been discussed with providers, and are summarized as follows: in cases in which multiple components or facilities are involved, SRS will apply the following guidelines to identify the status of each component or facility. 1. Are all components controlled by one owner or one governing body? 2. Is one chief medical officer responsible for the medical staff activities in all components? 3. Does one chief executive officer control have oversight of all administrative activities in all components? OR 4. Are any of the components separately licensed? Components that are licensed as different types of providers, such as YRC’s and PRTFs, are technically considered as separate components, independent from each other. 5. Are the components so organizationally or geographically separate that it is not feasible to operate as a single entity? (Examples include separate policy and procedures for each component, separate fund accountability, administrative staff which are fully dedicated to the operation of each component independently, policies that prevent concurrent utilization of shared space, policies that prevent the sharing of staff, etc.) If the answers to items 1, 2, and 3 are "no," or the answers to items 4 and 5, are "yes," there may be a separate facility/component. If it is determined that a component is independent, the IMD criteria in subsection B are applied to that component unless the component has 16 or fewer beds.
	The daily rates are based on the 90% to 95% occupancy, what happens to facilities if they have 60 to 70% occupancy rates?	The daily rates are not based on occupancy rate, but rather on actual costs associated with service delivery.
	Please define incidental outpatient Mental Health/Sustance Abuse Treatment . Thanks	SRS’s operationalization of federal ground rules regarding this issue is as follows: For purposes of determining whether a facility is subject to the IMD exclusion, the term "mental disease" includes diseases listed as mental disorders in the International Classification of Diseases, 9th Edition, modified for clinical applications (ICD-9-CM), with the exception of mental retardation, senility, and organic brain syndrome. The Diagnostic and Statistical Manual of Mental Disorders (DSM) is a subspecification of the mental disorder chapter of the ICD and may also be used to determine whether a disorder is a mental disease. When the 50 percent guideline is being applied in a Residential Care Facility that is not licensed as PRTF, the guideline is met if more than 50 percent of the residents require specialized services for treatment of a serious mental illnesses, as defined in 42 CFR 483.102(b). It is expected that incidental mental health / substance abuse treatment will be provided to youth who require it while residing in a residential care facility; however, this treatment is of a lesser intensity than specialized services which would require inpatient psychiatric treatment. Therefore, when SRS applies the 50 percent guidelines, the review team will focus on the basis of the youth’s current need for residential care, rather than the nature of the services being provided.

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