Common use of Institution for Mental Disease Clause in Contracts

Institution for Mental Disease. (IMD) The Contractor will cover short term stays in an Institution for Mental Diseases (IMD)for serious mental illness (SMI) and substance use disorder (SUD) under the State’s §1115 SMI and SUD demonstration authorities. IHCP will follow federal guidance in accordance with 42 CFR 435.1010 as well as any additional criteria established by the State’s §1115 waivers used to distinguish qualified IMD providers. In accordance with 42 CFR 457.1201(e) and 42 CFR 438.3(e)(2)(i)-(iii), the State has determined that treatment in an IMD is a medically appropriate and cost- effective substitute for the behavioral health service covered under the State Plan in other settings. Contractors may, but are not required to, use an IMD in lieu of other behavioral health services. The Contractor is prohibited from requiring an enrollee to access behavioral health services at an IMD. The State will make monthly capitation payment to the Contractor to cover short term inpatient stays for serious mental illness (SMI) in a qualified Institution for Mental Disease (IMD) for members aged 21 to 64 and is required to maintain an average length of stay not to exceed 30 days for all IMD stays for SMI. A maximum of 60 days can be approved, if medically necessary, for short term IMD stays for SMI. The Contractor will cover short term inpatient stays for SUD in a qualified Institution for Mental Diseases (IMD) for members aged 21 to 64 for up to 15 days in a calendar month as medically necessary for individuals with substance use disorder. If a member’s IMD stay exceeds 15 days in a calendar month and the member is awaiting placement in a state operated facility (SOF) for treatment, the member will be disenrolled from the plan and enrolled in fee for service. For stays exceeding 15 days in a calendar month in which the member is not awaiting placement in a SOF, the member will remain enrolled with the Contractor and the state shall recover the entire monthly capitation payment for the member. The Contractor will cover short term crisis residential stays for SUD in a qualified Institution for Mental Diseases (IMD) for members aged 21 to 64 and is required to maintain an average length of stay not to exceed 30 days for all residential IMD stays for SUD. The Contractor shall actively track and coordinate the care of members receiving care in an IMD. Anticipating and planning for a member’s successful discharge should begin immediately upon a member’s entry into an IMD. Lists of qualified IMD providers under both §1115 waivers will be provided to the Contractor. The Contractor may not require or create incentives for the member to receive services in an IMD versus a setting covered under the State Plan. In accordance with 42 CFR 435.1010, an IMD is generally defined as a “hospital, nursing facility, or other institution of more than 16 beds that is primarily engaged in providing diagnosis, treatment or care of persons with mental diseases, including medical attention, nursing care and related services. Whether an institution is an institution for mental diseases is determined by its overall character as that of a facility established and maintained primarily for the care and treatment of individuals with mental diseases, whether or not it is licensed as such. An institution for Individuals with Intellectual Disabilities is not an institution for mental diseases.” This may include a hospital providing psychiatric or substance use disorder inpatient care or a sub-acute facility providing psychiatric or substance use disorder crisis residential services. The Contractor will be responsible for reviewing and understanding all specific State criteria to distinguish qualifying IMDs under both SMI and SUD §1115 demonstrations as well as all related State guidance. The Contractor must submit data related to IMD stays as outlined in the MCE Reporting Manual. The proposed services and settings will be reimbursable and subject to the requirements contained in 42 CFR 438.6(e).

Institution for Mental Disease. (IMD) The Contractor will cover short term stays in an Institution for Mental Diseases (IMD)for IMD) for serious mental illness (SMI) and substance use disorder (SUD) under the State’s §1115 SMI and SUD demonstration authorities. IHCP will follow federal guidance in accordance with 42 CFR 435.1010 as well as any additional criteria established by the State’s §1115 waivers used to distinguish qualified IMD providers. In accordance with 42 CFR 457.1201(e) and 42 CFR 438.3(e)(2)(i)-(iii), the State has determined that treatment in an IMD is a medically appropriate and cost- cost-effective substitute for the behavioral health service covered under the State Plan in other settings. Contractors may, but are not required torequired, to use an IMD in lieu of other behavioral health services. The Contractor is prohibited from requiring an enrollee to access behavioral health services at an IMD. The State will make monthly capitation payment payments to the Contractor to cover short term inpatient stays for serious mental illness (SMI) in a qualified Institution for Mental Disease (IMD) for members aged 21 to 64 and is required to maintain an average length of stay not to exceed 30 days for all IMD stays for SMI. A maximum of 60 days can be approved, if medically necessary, for short term IMD stays for SMI. The Contractor will cover short term inpatient stays for SUD in a qualified Institution for Mental Diseases (IMD) for members aged 21 to 64 for up to 15 days in a calendar month as medically necessary for individuals with substance use disorderSUD. If a member’s IMD stay exceeds 15 days in a calendar month and the member is awaiting placement in a state operated facility (SOF) for treatment, the member will be disenrolled from the plan and enrolled in fee for service. For stays exceeding 15 days in a calendar month in which the member is not awaiting placement in a SOF, the member will remain enrolled with the Contractor and the state shall recover the entire monthly capitation payment for the member. The Contractor will cover short term crisis residential stays for SUD substance use disorder (SUD) in a qualified Institution for Mental Diseases (IMD) for members aged 21 to 64 and is required to maintain an average length of stay not to exceed 30 days for all residential IMD stays for SUD. The Contractor shall actively track and coordinate the care of members receiving care in an IMD. Anticipating and planning for a member’s successful discharge should begin immediately upon a member’s entry into an IMD. Lists of qualified IMD providers under both §1115 waivers will be provided to the Contractor. The Contractor may not require or create incentives for the member to receive services in an IMD versus a setting covered under the State Plan. In accordance with 42 CFR 435.1010, an IMD is generally defined as a “hospital, nursing facility, or other institution of more than 16 beds that is primarily engaged in providing diagnosis, treatment or care of persons with mental diseases, including medical attention, nursing care and related services. Whether an institution is an institution for mental diseases is determined by its overall character as that of a facility established and maintained primarily for the care and treatment of individuals with mental diseases, whether or not it is licensed as such. An institution for Individuals with Intellectual Disabilities is not an institution for mental diseases.” This may include a hospital providing psychiatric or substance use disorder inpatient care or a sub-acute facility providing psychiatric or substance use disorder crisis residential services. The Contractor will be responsible for reviewing and understanding all specific State criteria to distinguish qualifying IMDs under both SMI and SUD §1115 demonstrations as well as all related State guidance. The Contractor must submit data related to IMD stays as outlined in the MCE Reporting Manual. The proposed services and settings will be reimbursable and subject to the requirements contained in 42 CFR 438.6(e).