Section He-M 426.19 - Medicaid Payment for Long-Term Care Certification(a) Except for those medicaid recipients eligible to receive early and periodic screening, diagnosis and treatment (EPSDT) pursuant to He-W 546 or eligible to receive long-term care services in accordance with (b) below, the medicaid payment limit per fiscal year for all community mental health services shall be the limit established by the commissioner with approval of the US Department of Health and Human Services Centers for Medicare and Medicaid Services as an amendment to the Title XIX State Plan in accordance with He-W 520.02 and Section 1902(a) of the Social Security Act. The fiscal year runs from July 1 to June 30. Individual service limits shall still apply.(b) An individual shall qualify for services in excess of the annual medicaid payment limit if that individual has been certified for long-term care services by: (1) Determination by the CMHP that the individual is eligible to receive department funded services pursuant to He-M 401; or(2) Determination by a CMHP that a child through age 17 is eligible for services pursuant to He-M 401 unless the psychiatrist has approved the child to remain until age 21 in a children's program pursuant to He-M 401.(c) The department shall recover any medicaid payments in excess of the medicaid payment limit per state fiscal year for a recipient under each of the following circumstances: (1) The recipient's record lacks a properly completed eligibility statement which covers long-term care services billed for the period under review;(2) The eligibility period has expired and the redetermination of eligibility has not been completed;(3) Documentation in the clinical record fails to substantiate that the recipient meets the criteria for certification for long-term care; and(4) The recipient's diagnosis does not meet the criteria in He-M 401.(d) Certifications made pursuant to (b) (1) above and dated later than the service period being billed for shall be invalid.(e) For individuals eligible as adults with severe or severe and persistent mental illness with low service utilization pursuant to He-M 401.07, the commissioner shall establish a limit on the payment for services per state fiscal year. The limit shall be subject to approval by the US Department of Health and Human Services Centers for Medicare and Medicaid Services as an amendment to the Title XIX State Plan in accordance with He-W 520.02 and Section 1902(a) of the Social Security Act. The annual limit shall be waived if the standards established by He-M 426.24 are met.(f) Mental health assessment by a non-physician for the purpose of determining long-term care eligibility shall be a covered service when performed by individuals meeting the qualifications in He-M 401.04(b) .(g) Comprehensive geriatric assessment and treatment planning performed by assessment team for the purpose of determining long-term care eligibility shall be a covered service when performed by individuals meeting the qualifications in He-M 401.04(b) .N.H. Admin. Code § He-M 426.19
(See Revision Note at part heading for He-M 426) #5433, eff 7-2-92; ss and moved by #6568, eff 8-22-97 (from He-M 426.20 ); ss by #7088, eff 8-31-99; ss and moved by #8867, eff 4-13-07 (from He-M 426.18 ); ss by #9285, eff 9-30-08 (from He-M 426.18 )
Amended by Volume XXXVI Number 41, Filed October 13, 2016, Proposed by #11182, Effective 9/29/2016, Expires 3/28/2017.Amended by Volume XXXVII Number 15, Filed April 13, 2017, Proposed by #12154, Effective 3/28/2017, Expires 3/28/2027.