Comment #2 - Areas of Draft Policy Needing Clarifying Details

Our agency has a few areas in the regulations that we feel need more detail and specification in order to eliminate potential misinterpretation or differing interpretations between MCOs and agency providers.

Questions and Unclear Policy Requirements

• Section 2.3, bottom paragraph states: "When services are delivered to younger children, the services shall be delivered with a caregiver or legally authorized representative participating with the youth as the services are delivered." What is the age range considered to be “Younger Children” that requires parental involvement at all times during services? This age range needs to be defined (or clearly written in the regulations that agencies are able to define this for themselves in policies/procedures), so that MCOs and Agencies are working from the same standard. 

• Section 5.1, #2: How quickly do assessments completed by LMHP-Types need to be approved by LMHPs? This timeframe needs to be clarified so that MCOs and Agencies are working from the same standard. 

• Please clarify the guidelines or process for recompleting the CANS assessment within the same year. For example, a youth completes a CANS that recommended MST 9 months ago, but they have since resolved their criminal concerns and are off probation, yet they still have major mental health needs. Who is responsible for recompleting the CANS - the MST agency that is discharging or the CPST agency? Does the CPST provider still have to refer to MST since the CANs recommended it? Will MCOs automatically deny CPST if we don’t make MST referrals because it is no longer recommended as part of the updated CANs? There are currently no clear guidelines on who is responsible for the CANS when an EBP ends or who will be held accountable to act on the CANS suggestions.

• There also need to be clear policies expressing how providers are able to be paid for updating or completing new CANS assessments for major changes in clinical presentation or when EBPs are no longer clinically appropriate. Some portions of the regulations require a new CANS assessment (5.1 #1, iii; 8.7), and providers are expected to continually assess clients by reviewing their CANS-lifetime. Documented Progress is considered a positive change in LON within 18 months, something that can only be determined by completing a new CANS-Lifetime assessment. However, providers are only permitted to bill for 1 CANS per year. Please consider stating clearly in the regulations that providers will be able to bill for completion of a new CANs lifetime assessment, even if this is a different CPT code. You mentioned in the recent open office hours that this could be billed as a 90791 or a direct service code; please clearly outline this in the regulations.

• Please clarify the protocols if CANS recommends more than one EBP. If the Crosswalk (eventually created) recommends multiple EBP, the regs need to clarify what providers have to do in regard to the other EBPs. If MST fails, do they have to do another EBP before beginning CPST? Who’s responsible for that decision - agencies, MCOs, clients, etc.?

• Regarding Section 10.1 Section 8, the requirement for referring to EBP and contacting MCOs about EBPs before initiating CPST will lead to a delay in all services starting (CPST, FFT, MST, etc.). Contacting MCOs and other providers about their availability is not a quick process. A recommendation is to allow CPST to start immediately for a short period of time while also pursuing if another more appropriate EBP can get established (MST, FFT, etc.). This will also allow clients to start getting clinical services and provide transitional (Stop Gap) support while waiting on potential waitlists (even short waitlists) for other EBPs to get put into place. 

  • Currently it stays that MCOs MAY provide a provisional auth to help start services while waiting to determine eligibility for CPST and EBP availability with other providers, but only if the CANS Lifetime cannot be completed. This needs to change to WILL provide a provisional auth (even if limited to low number of units) and that CPST Providers may initiate stabilizing services temporarily to give providers and clients assurance that services can start ASAP while waiting on coordination with MCO and screening EBP.

  • This recommendation would also provide reimbursement to CPST staff who are providing all of the requirements in the regulations including care coordination, “warm handoffs” to EBPs, contacting MCOs, and more to support this transition. Otherwise, private providers become responsible for anyone who is being assessed even if they are not admitted as a client, leaving no options for reimbursement. 

Crisis Support Feedback

Thank you for clarifying some of the crisis policy regarding CPST vs. external referrals! Here are some additional thoughts and concerns about the Crisis Support regulations.

• Suggestion for requirements to provide 24/7 Crisis Support (Section 5.3)

  • 24/7 coverage is a major financial liability for private providers. Please allow flexibility to bill different CPT Codes for services that occur well outside of regular business hours (For example, any CPST units billed 8pm to 8am are allowed to be billed at the Mobile or Community Stab Rates). 

  • Also, there needs to be language in the regs that providers will NOT be held accountable for any Crisis support that is not provided when units have run out -OR- the regs need to create a quick way to get provisional units added to the auth due to a crisis situation. Please also add accountability that MCOs must honor provisional units added to authorizations.

  • Section 5.3.2 Section C - For agencies with 24/7 hotlines for all programs (Outpatient, TFC, Crisis, CPST), can agencies utilize staff who are not trained in CPST to support CPST Clients if clients call their agency’s hotline? This needs to be specified in the language. For Example, if we have LPCs staffing the hotline who are not trained in CPST, and a CPST client calls the hotline, can the LPC bill for that time? Or, if it is a CPST staff member who is not on the client’s team (and has not signed their ISP), can this person provide those services?

• Section 5.5 Section C Point iii - Please Define a “Warm Handoff” and what is expected of each agency (the current provider and new provider). Also, clarify if MCOs will allow overlapping auths to help with the handoff. Please avoid language that states MCOs “May” allow overlapping auths, as MCO will then default to never allowing it (as has been our experience with Crisis services). If an MST and a CPST provider are providing services concurrently during a “Warm handoff,” this should be reimbursable to both providers.

Concerns with CANS - Lifetime

The desire to have a standardized assessment that can cross agencies is a great idea in theory! However, there are numerous questions that need to be addressed in order for this to be a successful practice. Here are some specific questions and points of feedback:

• How will agencies share the assessment? 

• How will one agency know if a CANS-Lifetime has already been completed by another agency?

• Will ROIs be required in order to share CANS between providers? This should absolutely be a requirement, and that leads to potential service delays, HIPAA violations (if ROIs are not properly obtained), miscommunication (if mistakes are made or erroneous information is included in an assessment), denials by clients to share assessments between providers, etc.

• If a client is receiving services from multiple providers, which provider will be responsible (and reimbursed) for completing the CANS at reassessment?

• What happens if 2 agencies determine different LON for the same client?

• Will insurance companies honor the LON determined by the agency, even if it is different from the initial LON at first assessment?

• Will the receiving agency be held liable for the quality of the CANS assessment done by the initial agency or for any administrative errors? 

I know you all have stated that you will be planning these components later on, but these are critical considerations for providers as we are formulating our CPST policies. Our priority is our client’s wellbeing, and we desire to provide quality services. However, reimbursement is a critical piece of service provision that agencies must consider in order to remain stable and maintain the ability to retain experienced staff and provide quality services. Please consider adding additional protections for agencies by clarifying these policies and by more clearly securing protection for agency reimbursement.