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Covered & Uncovered Benefits

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MENTAL HEALTH MEDICAID SPECIALITY SUPPORTS AND SERVICES DESCRIPTIONS

Note: If you are a Medicaid beneficiary and have a serious mental illness, a serious emotional disturbance, a developmental disability, substance use and/ or a co-occurring disorder, you may be eligible for some of the Mental Health Medicaid  Specialty Supports and Services listed here.

Before services can be started, you will take part in an assessment to find out if you are eligible for services. The assessment process will also identify the services that can best meet your needs. Everyone who comes to us is not eligible, and not all services are available to everyone we serve. If a service cannot help you, your Community Mental Health provider will not pay for it.

Likewise, Medicaid will not pay for services that are available to you from other resources in the community.

During the person-centered-planning process, you will be assisted in figuring out which services are medically  necessary for you. The sufficient amount, scope and duration required to achieve the purpose of those services also will be determined. In addition, you will choose a service provider and receive an individual plan of service. The services listed below that are marked with an asterisk require a prescription  and must meet medically  necessary criteria.

Note: The Michigan Medicaid Provider Manual contains complete definitions of the following services as well as eligibility criteria and provider qualifications.

 

The Manual  may be accessed at: www.mdch.state.mi.us/dch-medicaid/manuals/MedicaidProviderManual.pdf

Assertive Community Treatment (ACT) provides  basic services and supports essential for people with serious mental illness to maintain independence in the community. An ACT team will provide mental health therapy and help with medications. The team may also help access community resources and

supports needed to maintain wellness and participate in social, educational and vocational activities.

Assessment includes a comprehensive psychiatric evaluation, psychological testing, substance use screening, or other assessments except  for physical health, conducted to determine a person’s level of functioning and mental health treatment needs.

Assistive Technology  includes adaptive devices and supplies that are not covered under the Medicaid Health Plan or by other community resources. These devices help individuals take better care of themselves and/or be more productive in the places where they live, work, and play.

Behavior Treatment Plan: If a person’s illness or disability involves behaviors that they or others who work with them want to change, their individualized plan of services may include a plan that talks about the behavior. This plan

is often called a “behavior treatment plan.” The behavior treatment plan is developed during person-centered planning. It is approved and reviewed regularly by a team of specialists to make sure that it is effective and dignified, and continues to meet the person’s needs.

Clubhouse Programs are programs that allow members (consumers) and staff to work side by side. Together, they operate the clubhouse and encourage participation in the greater community.  Clubhouse programs focus on fostering recovery, competency, and social supports, as well as vocational  skills and opportunities.

Community  Inpatient  Services are hospital services used to stabilize a mental health condition in the event of a significant change in symptoms, or in a mental health emergency. Community  hospital services are provided  in licensed psychiatric hospitals and in licensed psychiatric units of general hospitals.

Community  Living Supports (CLS) are activities provided by paid staff that help adults with either serious mental illness or developmental disabilities live independently and participate actively in the community. Community Living Supports may also help families who have children with special needs (such as developmental disabilities or serious emotional disturbance).

Crisis Interventions are unscheduled individual or group services aimed at reducing or eliminating  unexpected events and reducing their impact on mental health and well-being.

Crisis Residential Services are short-term alternatives to inpatient hospitalization provided in a licensed residential setting.

Enhanced Pharmacy includes doctor-ordered non-prescriptions or over-the counter items (such as vitamins or cough syrup) necessary to manage health condition(s) when a person’s Medicaid  Health Plan does not cover these items.

Environmental Modifications are physical  changes to a person’s home, car, or work environment that are of direct, medical or remedial benefit to the person. Modifications ensure access, protect health and safety, or enable greater independence for a person with physical disabilities. Note that other sources of funding must be explored first, before using Medicaid funds for environmental modifications.

Extended Observation  Beds (or 23-hour stay units) are used to stabilize a mental health emergency when a person needs to be in the hospital for only a short time. An extended observation bed allows hospital staff to observe and treat the person’s condition for up to one day before he or she is discharged to another community-based outpatient service or admitted to the hospital.

Family  Skills Training  is education and training for families who live with and or care for a family member who is eligible for specialty services or the Children’s Waiver Program.

Fiscal Intermediary  Services help individuals using a “self determination” approach to manage budgets for service and supports to pay providers.

Health  Services include assessment, treatment, and professional monitoring of health conditions that are related to or impacted by a person’s mental health condition. A person’s primary  doctor will treat any other health conditions they may have.

Home-Based Services for Children and Families are provided in the family home or in another community setting. Services are designed individually for each family, and can include things like mental health therapy, crisis intervention, service coordination, or other supports to the family.

Housing Assistance is assistance  with short-term, transitional, or one-time only expenses in an individual’s own home that his/her resources and other community resources could not cover.

Intensive Crisis Stabilization is another short-term alternative to inpatient hospitalization. Intensive crisis stabilization services are structured treatment and support activities provided by a mental health crisis team in the person’s home or in another community setting.

Intermediate Care Facility for Persons with  Mental  Retardation  (ICF/MR) provide 24-hour intensive supervision, health and rehabilitative  services and basic needs for persons with developmental disabilities.

Medication Administration takes place when a doctor, nurse, or other licensed medical provider gives an injection, or an oral medication or topical medication.

Medication Review is the evaluation and monitoring  of medicines used to treat a person’s mental health condition,  their effects, and the need for continuing or changing their medicines.

Mental Health Therapy and Counseling for Adults, Children and Families includes therapy or counseling designed to help improve functioning and relationships with other people.

Nursing Home Mental Health Assessment and Monitoring includes a review of a nursing home resident’s need for and response to mental health treatment, along with consultations with nursing home staff.

Occupational Therapy includes the evaluation  by an occupational therapist of an individual’s ability to do things in order to take care of himself or herself every day. It also includes treatments that help increase these abilities.

Partial Hospital  Services include psychiatric, psychological, social, occupational, nursing, music therapy, and therapeutic recreational services in a hospital setting, under a doctor’s supervision. Partial hospital services are provided during the day participants go home at night.

Peer-Delivered  and Peer Specialist Services Peer-delivered  services such as dropin centers are entirely run by consumers of mental health services. They offer help with food, clothing, socialization, housing, and support to begin or maintain  mental health treatment. Peer Specialist services are activities designed to help persons with serious mental illness in their individual recovery journey and are provided by individuals who are in recovery from serious mental illness.

Personal Care in Specialized Residential Settings assists an adult  with mental illness or developmental disabilities with activities of daily living, self-care and basic needs, while they are living in a specialized residential setting in the community.

Physical Therapy includes the evaluation by a physical therapist of a person’s physical abilities (such as hand, arm and overall body movement), and treatments to help improve their physical abilities.

Prevention Service Models (such as Infant Mental  Health,  School Success, etc) use both individual  and group interventions designed to reduce the likelihood that individuals will need treatment from the public mental health system.

Respite Care Services provide short-term relief to the unpaid primary caregivers of people eligible for specialty services. Respite provides temporary alternative care, either in the family home, or in another community  setting chosen by the family.

Skill-Building  Assistance includes supports, services and training to help a person participate actively at school, work, volunteer, or community  settings, or to learn social skills they may need to support themselves or to get around in the community.

Speech and Language Therapy includes the evaluation by a speech therapist of a person’s ability to use and understand language and communicate  with others or to help enhance speech, communication  or swallowing.

Substance Use Treatment  Services (descriptions follow the mental health services. See page 31).

Supports Coordination or Targeted Case Management: A Supports Coordinator or Case Manager is a staff person who helps write an individual plan of service and makes sure the services are delivered.  His or her role is to listen to a person’s goals, and to help find the services and providers inside and outside the local community mental health services program that will help achieve the goals. A supports coordinator or case manager may also connect a person to resources in the community for employment, community living, education, public benefits, and recreational activities.

Supported/Integrated Employment Services provide initial and ongoing supports, services and training, usually provided  at the job site, to help adults who are eligible for mental health services find and keep paid employment in the community.

Transportation may be provided  to and from a person’s home in order to ensure participation in a non-medical Medicaid covered service.

Treatment Planning assists the person and those of his/her choosing in the development and periodic review of the individual plan of services.

Wraparound Services for Children  and Adolescents with serious emotional disturbance and their families provide  treatment and supports necessary to maintain the child in the family home.


Services for Persons with Substance Use Disorders

The Substance Use treatment services listed below are covered by Medicaid. These services are available through Institute for Population Health(IPH) (Detroit Residents Only) at 1-800-879-7979 and Southeast Michigan Community Alliance SEMCA (residence outside of Detroit) (toll free) 1-800-686-6543 or TDD/TYY 1-800-649-3777.

Access, Assessment and Referral determines the need for substance use services and will assist an individual in finding the right services and providers.

Outpatient Treatment includes counseling for the individual, and family and group therapy in an office setting.

Intensive Outpatient Program(IOP) is a service that provides more frequent and longer counseling sessions each week and may include day or evening programs.

Methadone and Levo-Alpha Acetyl Methadol(LAAM) Treatment is provided to people who have heroin addictions. The treatment consists of opiate substitution monitored by a doctor as well as nursing services and lab tests. This treatment is usually provided along with other substance use outpatient treatment.

Sub-Acute Detoxification is in-patient medical care for people who are withdrawing from alcohol or other drugs.

Residential Treatment is intensive therapy provided in a staffed licensed facility. If you receive Medicaid, you may be entitled to other medical services not listed above. Services necessary for the maintenance of your physical health are provided or ordered by your primary care doctor. IF you receive Community Mental Health services, your local community mental health services program will work with your primary care doctor to coordinate your physical and mental health services. IF you do not have a primary care doctor, your local community mental health services program will help you find one.

Co-Occurring Disroder(COD) is abuse or dependency and a mental disorder. The disorders have one or more disorders relating to the use of alcohol and/or other drugs of abuse as well as one or more mental disorders. A diagnosis of co-occurring disorder(COD) occurs when at least one disorder of each type can be established independent of the other and is simply a cluster of symptoms resulting from the one disorder.


Children’s Home and Community-Based Services Waiver  (CWP)

The Children’s Home and Community Based Services Waiver  Program (CWP) provides services that are enhancements or additions to regular Medicaid coverage to children up to age 18 who are enrolled in the CWP. The Children’s Waiver is a fee-for-service program administered by the CMHSP. The CMHSP is responsible for assessment of potential waiver candidates.


ELIGIBILITY

The following eligibility requirements must be met:

  • The child must have a developmental disability (as defined  in Michigan state law), be less than 18 years of age and in need of habilitation services.
  • The child must have a score on the Global  Assessment of Functioning (GAF) Scale of 50 or below.
  • The child must reside with his birth or legally adoptive parent(s) or with a relative who has been named the legal guardian for that child under the laws of the State of Michigan, provided that the relative is not paid to provide foster care for that child.
  • The child is at risk of being placed into an ICF/IDD facility because of the intensity of the child’s care and the lack of needed support, or the child currently  resides in an ICF/MR facility but, with appropriate community support, could return home.
  • The child must meet, or be below, Medicaid income and asset limits when viewed  as a family of one (the parent’s income is waived).
  • The child’s intellectual or functional limitations indicate that he would be eligible for health, habilitative  and active treatment services provided  at the ICF/IDD level of care.

Habilitative services are designed to assist individuals in acquiring, retaining and improving the self-help, socialization and adaptive skills necessary to reside successfully in home and community-based settings. 

Active treatment includes aggressive, consistent implementation of a program of specialized and generic training, treatment, health services and related services.

Active treatment is directed toward the acquisition of the behaviors necessary for the beneficiary to function with as much self-determination  and independence as possible, and the prevention or deceleration of regression or loss of current optimal functional status.


COVERED WAIVER SERVICES

Covered Medicaid  services that continue to be available to CWP beneficiaries are listed in the Covered Services Section of this chapter. Refer to the Children’s Waiver Community Living Support Services Appendix  of this chapter for criteria for determining number of hours. Services covered under CWP include:

Community  Living Supports

Community  Living Supports (CLS) provides  assistance to a family in the care of their child while facilitating the child’s independence and integration into the community.

This service provides skill development related to activities of daily living, such as bathing, eating, dressing, personal hygiene, household chores and safety skills; skill development to achieve or maintain mobility, sensory-motor, communication, socialization and relationship-building skills, and participation in leisure and community activities.

Enhanced Transportation

Transportation costs may be reimbursed when separately specified in the individual plan of services and provided  by people other than staff performing  CLS, in order to enable a child served by the CWP to gain access to waiver and other community services, activities and resources. Transportation is limited to local distances, where local is defined  as within the child’s county or a bordering county Parents of children served by the waiver are not entitled to enhanced transportation reimbursement.

Environmental Accessibility Adaptations (EAAs)

Environmental Accessibility Adaptations (EAAs) include those physical adaptations to the home, specified in the individual plan of services, which are necessary to ensure the health, welfare and safety of the child, or enable him to function with greater independence in the home and without which the child would require institutionalization.

Family Training (previously called Didactic Services)

This provides for training and counseling services for the families of children served on the CWP. For purposes of this service, “family” is defined as the people who live with or provide care to a child served on the CWP, and may include a parent or siblings. Family does not include individuals who are employed to care for the child. Training includes instruction about treatment regimens and use of equipment specified in the plan of services, and must include  updates as necessary to safely maintain the child at home. Family training is also a counseling service directed to the family and designed to improve and develop the family’s skills in dealing with the life circumstances of parenting a child with special needs. All family training must be included in the child’s individual plan of services and must be provided  on a face-to-face basis.

Non-Family Training (previously called Psychological/ Behavioral Treatment)

This service provides coaching, supervision and monitoring of CLS staff by professional staff (LLP, MSW, or QMRP). The professional staff will work with parents and CLS staff to implement the plan that addresses services designed to improve the child’s social interactions and self-control by instilling positive behaviors in the place of behaviors that are socially disruptive, injurious to the child or others, or that cause property damage.

Fencing

Fencing may be approved with documentation that it is essential to achieve the outcomes specified in the child’s individual plan of services and necessary to meet a child’s health and safety needs. Authorization for fencing is for a maximum of 200 feet of standard chain link fence and one gate. If it is determined that chain link fencing will not meet the child’s health and safety needs, a standard stockade fence may be considered.

Respite Care

Respite care services are provided  to the child on an intermittent or short-term basis because of the absence or need for relief of the parent. Respite is intended to support the parent who is the primary caregiver.

This service can be provided by a qualified provider under contract with the CMHSP in the child’s home, foster home, group home, licensed respite care facility, licensed camp, or the home of a friend or relative. A parent or guardian may not be considered a provider, nor be reimbursed for this service. The maximum monthly respite allocation  is 96 hours.

Specialized Medical Equipment and Supplies

Specialized medical equipment and supplies includes durable medical equipment, environmental  safety and control devices, adaptive toys, activities of daily living (ADL) aids, and allergy control supplies that are specified in the child’s individual plan of services.

Specialty Services

Specialty Services include:

  • Music Therapies;
  • Recreation Therapies;
  • Art Therapies; and
  • Massage Therapies.

 Specialty Services may include  the following activities: Child and family training; coaching and supervision of staff; monitoring of progress related to goals and objectives; and recommending changes in the plan. This may be used in addition to the traditional professional therapy model included in Medicaid.

The Children’s Waiver is managed by the following 3 (three) Service Providers:

  • The Guidance Center 734-785-7718
  • Neighborhood  Service Organization (NSO) 313-875-7601
  • Community Living Services (CLS) 734-467-7600

Habilitation/Supports Waiver (HSW) Programs Beneficiaries with developmental disabilities may be enrolled in Michigan’s Habilitation/ Supports Waiver (HSW) and receive the supports and services as defined in this section.

HSW beneficiaries may also receive other Medicaid  state plan or additional/B3 services. A HSW beneficiary must receive at least one HSW service per month in order to retain eligibility. Medical necessity criteria should be used in determining the amount, duration, and scope of services and supports to be used.

The enrollment  process must include annual verification that the beneficiary:

  • Has a developmental disability  (as defined by Michigan law);
  • Is Medicaid-eligible;
  • Is residing in a community setting;
  • If not for HSW services, would require ICF/MR level of care services
  • Chooses to participate in the HSW in lieu of ICF/IID services.

Reimbursement for services rendered under the HSW is included  in the PIHP capitation rate.

Beneficiaries enrolled in the HSW may not be enrolled simultaneously in any other §1915(c) waiver.

 

WAIVER SUPPORTS AND SERVICES

Community  Living Supports (CLS)

Community  Living Supports (CLS) facilitate an individual’s independence, productivity, and promote inclusion and participation.

Enhanced Medical Equipment and Supplies

Enhanced medical equipment and supplies include devices, supplies, controls, or appliances that are not available under regular Medicaid coverage or through other insurances (Refer to the Medical Supplier Chapter of this manual for more information about Medicaid-covered equipment and supplies).

Enhanced Pharmacy

Physician-ordered, nonprescription “medicine chest” items as specified  in the beneficiary’s support plan.

Environmental Modifications

Physical adaptations to the home and/or workplace required by the beneficiary’s support plan that are necessary to ensure the health, safety, and welfare of the beneficiary, or enable him to function with greater independence within the environment(s) and without which the beneficiary would require institutionalization. Adaptations may include:

Family Training

Training and counseling services for the families of beneficiaries served on the waiver.

Goods and Services

The purpose of Goods and Services is to promote individual control over, and flexible use of, the individual budget by the HSW beneficiary using arrangements that support self-determination  and facilitate creative use of funds to accomplish the goals identified in the individual plan of services (IPOS) through achieving
better value or an improved outcome.

Goods and Services are available only to individuals participating in arrangements of self-determination whose individual  budget is lodged with a fiscal intermediary. This coverage may not be used to acquire goods or services that are prohibited  by federal or state laws or regulations, e.g., purchase or lease or routine maintenance of a vehicle.

Out-of-Home Nonvocational Habilitation

Assistance with acquisition, retention, or improvement in self-help, socialization, and adaptive skills; and the supports services, including  transportation to and from, incidental to the provision of that assistance that takes place in a non-residential setting, separate from the home or facility in which the beneficiary  resides. Personal Emergency Response Systems  (PERS) Electronic devices that enable beneficiaries to secure help in the event of an emergency.  PERS coverage should be limited to beneficiaries living alone (or living with a roommate who does not provide supports), or who are alone for significant parts of the day; who have no regular support or service provider for those parts of the day; and who would otherwise require extensive routine support and guidance.

Prevocational Services

Prevocational services involve the provision  of learning and work experiences where a beneficiary can develop general, non-job-task-specific strengths and skills that contribute to employability in paid employment in integrated, community settings.

Private Duty Nursing (PDN)

Private Duty Nursing (PDN) services are skilled nursing interventions provided  to individuals  age 21 and older, up to a maximum of 16 hours per day, to meet an individual’s health needs that are directly related to his developmental disability. PDN includes the provision of nursing assessment, treatment  and observation provided by licensed nurses within the scope of the State’s Nurse Practice Act, consistent with physician’s orders and in accordance with the written health care plan which is part of the beneficiary’s individual plan of services (IPOS). PDN services are for beneficiaries who require more individual and continuous care than periodic or intermittent nursing available through state plan services, e.g., Home Health. The individual receiving PDN must also require at least one of the following  habilitative  services, whether being provided by natural supports or through the waiver.

  • Community living supports
  • Out-of-home non-vocational habilitation
  • Prevocational or supported employment

Respite Care

Respite care services are provided  to a waiver eligible beneficiary on a short-term, intermittent  basis to relieve the beneficiary’s family or other primary caregiver(s) from daily stress and care demands during times when they are providing unpaid care.


Support Services

Supports Coordination

Supports coordination  works with the waiver beneficiary to assure all necessary supports and services are provided  to enable the beneficiary to achieve community inclusion and participation, productivity, and independence in home- and community  based settings. Without  the supports and services, the beneficiary would otherwise require the level of care services provided  in an ICF/IID.

Supported Employment

Supported employment is the combination of ongoing support services and paid employment that enables the beneficiary to work in the community.


Habiliitation/Supports Waiver (HSW) Providers

Community Living Services – MCPN/Service  Provider

35425 W. Michigan Ave. Wayne, MI 48184-1687 (734) 467-7600

Consumer Link Network – MCPN

1333 Brewery Park, Ste. 300

Detroit, MI 48207 (313) 656-0000


Services Providers

The Guidance Center

19275 Northline Rd. Southgate, MI 48195

(734) 785-7718 (DD Services)


NSO-Life Choices

8600 Woodward Ave. Detroit, MI 48202 (313) 875-7601


Synergy Partners, LLC – MCPN

3031 West Grand Boulevard, Ste. 555

Detroit, MI 48202 (313) 748-7400


Adult Well Being Services (AWB)

1423 Field Avenue Detroit, Mi 48214-2321 (313) 825-2419

Services to Enhance Potential (STEP)

2941 South Gulley Rd., Dearborn, MI

48124-3160 (313) 278-3040


Goodwill Industries of Greater Detroit

3111 Grand River Detroit, MI 48208-2962 (313) 964-3900

Wayne Center

7430 Second Ave., Suite #20

Detroit, MI 48202 (313) 871-2337


Services for Persons with Adult Benefit Waiver Coverage

ABW mental health and substance use coverage is limited both in scope and amount to those that are medically necessary and conform to professionally accepted standards of care consistent with the Michigan Mental Health Code. Utilization control procedures, consistent with the medical necessity criteria/ service selection guidelines specified by MDCH and in best practice standards, must be used.

Individuals should meet the following criteria for Adult Benefit Waiver Coverage:

  • Ages 19-64
  • Wayne County Resident
  • Not disabled or eligible for Medicaid or any other programs
  • Income less than 35 percent of the federal poverty level (about $200 – $250/month)

Eligibility will be determined by the Michigan Department of Human Services.

Crisis interventions for mental health-related emergency situations and/or conditions. Identification, assessment and diagnostic evaluation to determine the beneficiary’s mental health status, condition and specific needs. Inpatient hospital psychiatric care for mentally ill beneficiaries who require care in a 24- hour medically structured and supervised licensed facility.

Other medically necessary mental health services:

  • Psychotherapy or counseling (individual, family, group) when indicated,
  • Interpretation or explanation of results of psychiatric examination, other medical examinations and procedures, or other accumulated data to family or other responsible persons, or advising them how to assist the beneficiary;
  • Pharmacological management, including prescription, administration, and review of medication use and effects; or
  • Specialized community mental health clinical and rehabilitation services, including case management, psychosocial interventions and other community supports, as medically necessary, and when utilized as an approved alternative to a more restrictive care or placement.

Any beneficiary liability for the cost of covered services shall be determined by each CMHSP, according to the ability-to-pay provisions of the Michigan Mental Health Code and applicable administrative rules.42 / DWMHA Customer Service 1-888-490-9698


Services for Persons with MIChild Coverage

The Department contracts with local community mental health services programs (CMHSP) and Coordinating Agencies (CA) to provide mental health and substance use services to MIChild beneficiaries on a per eligible member per month capitation basis. Beneficiaries do NOT enroll with the CMHSP or CA to receive services, but are referred to them by the health plans. The CMHSPs and CAs are responsible for:

  • Provision of mental health services, as determined by the Department,
  • Reimbursement for direct care and subcontracted providers,
  • Maintenance of records as determined by the Department.

The CMHSP will not make initial determinations of MIChild eligibility.

DWMHA offers a comprehensive array of services. This includes specialized services for children with a serious emotional disturbance and/or developmental disability. The Access Center (1-800-241-4949) will assist you with information to contact the MIChild Program.

SUBSTANCE USE SERVICES

Substance Use Coordinating Agencies (CAs) are responsible for the following substance use services for ABW beneficiaries when medically necessary and within applicable benefit limitations:

  • Initial assessment, diagnostic evaluation, referral and patient placement;
  • Outpatient Treatment;
  • Intensive Outpatient Treatment;
  • Federal Food and Drug Administration (FDA) approved pharmacological supports for Levo-Alpha-Acetyl- Methadol (LAAM) and Methadone only; or
  • Other substance use services that may be provided, at the discretion of the CA, to enhance outcomes.