Implementation
Differentiating the 3rd Path
The CMH Residential Services Path is not considered an out-of-home placement. It is an alternative service designed to assist children with a severe emotional disturbance (SED) and their families in gaining access to residential treatment services. The CMH Residential Services Path differs from other existing paths to access services from a CRF. Existing entry paths are driven by the county or initiative tribe. For example, when the child and family have a county or tribal case manager, the lead agency determines if a child is in need of placement in an CRF based on the level of care (LOC) determination, the Diagnostic Assessment (DA) that includes the Child and Adolescent Service Intensity Instrument (CASII). The LOC determination is completed by the Mental Health Professional (MHP) and reviewed by the Juvenile Treatment Screening Team. A recommendation for placement of the child is considered, and a decision is made by the team. The lead agency (county or tribe) must adhere to the regulations outlined in the Family First Preservation Services Act (FFPSA) to receive IV-E reimbursement. The reader is asked to review the FFPSA webpage for further information regarding this process.
Conversely, the CMH Residential Services Path is an alternative, parent-driven path to accessing a residential service that does not require involvement of the county or tribe.
The key differences are:
- The family selects the level of county or initiative tribe involvement.
- The county or initiative tribe will review the DA to ensure the MHP has indicated the child has a severe emotional disturbance. The MHP must recommend the child enter a CRF within the DA.
- The CMH Residential Services Path is not a placement, rather it is considered a service. Because of this, the county or initiative tribe does not have the ability to make placement decisions.
- If the child is in a pre-paid health plan/MCO network, the health plan is responsible for the mental health treatment services as usual, and the county or initiative tribe pays for the room and board using the CMH Residential Services Path allocation.
- If the child has fee for service Medical Assistance (FFS MA), it is treated as usual. MA covers treatment costs when a child accesses a CRF through the CMH Residential Services Path. The county pays full treatment costs to the CRF and submits for reimbursement through the health care claiming process for a portion of the non-federal share of the treatment costs. Payments to counties for residential services provided by an institution for mental diseases (IMD) is equivalent to the federal share of the payment that would have been made if the residential facility was not an IMD. The portion of the payment representing what would be the non-federal share shall be paid by the county (Minn. Stat. §256B.0945, subd. 4, paragraph 2).
- A juvenile screening does not occur and subsequently a placement is not reviewed by the court.
Through this path, the child and family choose if they would like to access Rule 79 children’s mental health case management. If the family decides they would like to have a case manager, the case manager will assess for eligibility and perform the case management activities in accordance with the Children’s Mental Health Act and Minnesota Rule.
If the child is enrolled in an initiative or non-initiative tribe and would like mental health case management, the case manager must ensure compliance with the Minnesota Indian Family Preservation Act (MIFPA) and the Indian Child Welfare Act (ICWA). The tribe must be involved in all case management activities. On the other hand, if the county agency is not providing case management services, and is only utilizing the CMH Residential Service allocation funds, then ICWA and MIFPA do not apply.
Accessing Services
Two process maps have been created to provide a visual step-by-step outline for guidance to families, counties and initiative tribes: CMH Residential Services (3rd Path) Process Map and CMH Residential Services (3rd Path) – MA Fee for Service Process Map .
In order for a child to receive CMH Residential Service Path funds, a parent initiates the following steps:
1. Determine Medical Necessity: Parent seeks care for child or requests services.
1a. Request for services may also come about in the event of a crisis where a Mental Health Professional (MHP) has already been working with a child and determines a residential level of care appropriate.
2. A request for services involves an MHP completing a Diagnostic Assessment (DA) to determine Level of Care. The DA must indicate that it is medically necessary for the child to enter the CMH Residential Service. The DA will include the Child and Adolescent Service Intensity Instrument (CASII).
- - If the DA including the CASII has been completed within the previous 180 days, a new DA does not have to be completed. The exception to this occurs when the child’s MHP believes their condition has changed significantly since the prior report. In that case, a new DA would be required.
3. After the parent has obtained the DA from the MHP, the parent notifies the county, initiative tribe, or prepaid health care plan/MCO of the child’s needs, provides the DA and requests the CMH Residential Service Path funding.
For Children Enrolled in a Prepaid Medical Assistance Program (PMAP):
4. The PMAP reviews the DA to determine CRF service approval.
5. The parent brings the PMAP’s approval to the lead agency.
6. The lead agency reviews the DA to determine CMH Residential Services Path criteria have been met; that is, that the MHP has stated it is medically necessary for the child to receive CMH residential treatment service.
7. Confirm Allocation Availability: The lead agency then confirms whether CMH Residential Services Path allocation funds are available and informs parent. The county or initiative tribe is responsible for communicating the parental financial responsibility once the CMH Residential Service Path funds have been expended.
- - Collaboration between the PMAP and the lead agency is important as the county or initiative tribe will need to confirm whether CMH Residential Services Path allocation funds are available to cover the costs of room and board, while the PMAP covers the costs of the treatment.
From this point in the process there are two options:
8. The parent can locate a CRF independently, or
8a. The parent can request assistance from the agency/PMAP in locating a CRF.
9. When the parent chooses to locate a CRF independently, the parent contacts the CRF of choice to arrange admission. If there is a waitlist, the parent informs the lead agency of status. In this case, the county or initiative tribe will offer the parent resource information containing the CRF names and contact information. Example search tools: licensing look-up or FastTracker.
9a. When the lead agency locates a CRF, they contact the most appropriate CRF to arrange admission. If there is a waitlist, the lead agency informs the parent of status.
10. The CRF contacts the initiating party, either the parent or the lead agency, when a bed is available.
11. Complete Path Access: The lead agency enters the service into SSIS (Social Service Information System) or designated software.
- - The county will need to comply with MA requirements as it relates to an Institution of Mental Diseases (IMD). A resident of an IMD is eligible to receive MA services only if the member is receiving inpatient psychiatric care in an accredited psychiatric facility and is under 21 years old.
12. Lastly, the child enters the CRF service.
For children enrolled in Medical Assistance (MA) Fee for Service (FFS):
The county or initiative tribe, not the PMAP, reviews the DA to determine CMH Residential Services Path criteria are being met. PMAP approval does not apply, negating above steps 4-6.
Role of the residential treatment services provider
The chosen CRF must operate in compliance with Minnesota Statutes, Chapter 245A . The CRF must have a mental health certification. This includes out-of-state facilities if the facility is licensed by the Minnesota Department of Human Services. The selected CRF must be able to address the child's age and treatment needs. Optimally, the CRF will be in proximity to the family home.
The Goals of the CRF Service:
- Assist the child in improving their social interaction skills while supporting the child in interacting and contributing to the family functioning.
- Support the child in gaining the skills that will promote success and resiliency when they return to the community.
- Reduce or stabilize crisis hospitalization admissions.
- IMPORTANT: Involve and partner with the families in all stages of the service.
Discharge Planning and Involvement
The discharge planning process is an equally important piece of the CMH Residential Services Path. Planning for discharge and transition to the community must occur within 30 days of the date the child enters the service. The relationship built between the CRF and the family will be integral to the child’s successful return to the community. To ensure equity is preserved, both formal and informal supports within the community should be carefully examined. For example, a family may find that their child’s pastor or traditional healer may be a resource rather than other identified service providers.
To facilitate a successful return to the community, the CRFs must use a person-centered lens, involving the family and child in the identification of the appropriate resources. The child and family must inform the planning decisions. The plan will be reviewed and updated every 60 days.
Upon discharge, the CRF will assist the family in arranging for aftercare. The family will select the level of involvement they would like from their community, family, tribal and cultural representatives. Families may choose to include tribal partners and members of their community as needed to support and assist in identifying and planning for the child’s needs and subsequent services.
If the family requests case management services at any point, the CRF shall contact the case manager to ensure continuity of care.
SSIS Implications
When an agency does not have placement authority, a continuous placement is not entered into SSIS. Because the CMH Residential Services path is a service, not a placement, the county does not complete the SSIS out of home placement requirements.
For related expenditures agencies should use BRASS (Budgeting, Reporting and Accounting for Social Services):
- BRASS 480x Children’s Mental Health Residential Service Path - An optional way children with a severe emotional disturbance gain access to residential treatment services. A level of care screening conducted by a mental health professional is required. A voluntary placement agreement or court ordered placement does not occur. Child Rule 79 Case Management (490x) may run concurrently based on parental choice. The county agency will maintain payment responsibility. Services must comply with Minnesota Statutes, section 245.4885.
- BRASS 480x is “vendor-provided” only, staff cannot record their time in SSIS under this service. Payments can be created in SSIS on behalf of the client, if the agency is financially responsible for the client. If an agency chooses to not affiliate the client with a CMH workgroup within SSIS, services can still be paid in SSIS. Payments do not need to be associated with a workgroup, but should be associated with a client. If the client does not already exist in SSIS, an intake workgroup could be created (e.g., Type: Information and Referral, Problem: Mental Health, Program: Children’s Mental Health). By performing this step, a client record would be created allowing for client specific payments and billing. The intake can be screened out if no workgroup will be opened by the county. Further questions can be directed to the SSIS Help Desk.
- The initiative tribes enter child welfare cases into SSIS. This service is at the discretion of the financially responsible tribe if a workgroup and payments should be created in SSIS. Initiative tribes do not use SSIS to submit healthcare claims and should continue using the software designated by the tribal authorities for billing MA services.
- The BRASS 480x is a new BRASS code that started on January 1, 2022. BRASS Bulletin #21-32-03 can be used for reference.
The following image is a payment example in SSIS for the treatment only portion of care. The key indicator to pull the payment into a Rule 5 healthcare claiming batch for MA reimbursement on the treatment portion is the yellow highlighted area.
The image below is a payment example in SSIS of Room and Board only, if the agency chooses to do so. The key indicator that this is R&B only is the Special Cost Code (SCC – 17 Room and Board only). Having this indicator on the payment allows the agency to easily determine the R&B expenditures.
Allocation Formula
The funding allocation formula passed by the Legislature was determined by using the number of children admitted to Residential Treatment Facilities from 2018-2020, totaled for each county and tribe, then divided by the total grant fiscal year allocation to get an average cost per child. The average cost per child was then multiplied by the average number of children per county or tribe admitted to Residential Treatment Facilities over the 3-year period.
Allocations are distributed on a fiscal year basis. The SFY2022 and SFY2023 allocation amounts can be found on County Link under the “Fiscal Reporting and Accounting” tab and are distributed as a one-time lump sum payment for both fiscal years together. The SFY2022 dollar amount can be used in SFY2023. The allocations that some counties chose to decline by May 27, 2022 have been redistributed to the counties willing to accept the allocation based on the original formula used.
For revenue reporting, this is state revenue. For Social Services Expenditure and Grant Reconciliation Report (SEAGR), receipt this to SEAGR revenue code S30. Tribal allocations will be communicated on an individual basis.
Any unused portion of the FY2022 allocation may be ulitized in FY2023 (through June 30, 2023). If any portion of the allocation goes unused, DHS will invoice the counties or initiative tribes at the end of the allocation, June 30, 2023. DHS will compare expenditures reported with the allocation allotted, and send an invoice for the difference.
