IPRS/State Funds Eligibility/Enrollment

As we approach the 2015-2016 fiscal year, Partners has continuously reviewed our IPRS utilization and decisions previously communicated regarding enrollment eligibility for State Funds. As part of that review, Partners wants to clarify who can be enrolled into the State Benefit Plan and IPRS services. 

 

Effective July 1, 2015, Partners will no longer automatically exclude an individual from enrolling in IPRS services because they have coverage from a third party entity. We remain committed to ensuring services are accessible to the citizens of our counties and to those in need of services. As has always been the case, we will review any request for enrollment into the State Benefit plan to ensure that limited IPRS dollars are available to meet the needs of our indigent population in the most beneficial way possible. 

 

As we indicated earlier, there is no prohibition between an individual who is Medicaid eligible also receiving third party insurance. Appropriate coordination of benefits is, as always, part of a provider's responsibility when serving those who have coverage from publicly funded and privately funded sources. 

 

Thus:

1. An individual who is eligible for Medicaid, regardless of the type of Medicaid, may also be enrolled into the State Benefit plan. The individual is able to receive IPRS funding for services as long as the service is not funded by Medicaid. The individual remains subject to all Utilization Management protocols.
2. An individual who is eligible for Medicare may also be enrolled into the State Benefit plan. The individual is able to receive IPRS funding for services as long as the service is not funded by Medicare.  The individual remains subject to all Utilization Management protocols.
3. An individual who has private insurance may be enrolled in the State Benefit Plan and may receive IPRS funding for services if that service is not included as a benefit by their insurance provider.

 

In all of the above examples, it is the expectation that Providers appropriately coordinate benefits for consumers with multiple funding sources. 

 

2015-2016 IPRS Contract Amounts Information

Additionally, over the next few days and weeks, Providers will be receiving their IPRS contracts or Medicaid renewals or both. As it relates to the funding in the IPRS contracts for the upcoming fiscal year, Partners wants to communicate the process whereby your contract amount was identified.  Partners reviewed paid claims through March 31, 2015 and then annualized the amount paid on that date to project the contract amount for the IPRS 2015-2016 contracts. As always Partners values you as providers and wants you to know this is the starting point. As we did routinely through this past fiscal year, Partners will be reviewing the utilization and claims regularly to adjust provider contract amounts as appropriate.  We ask that you review the first quarter's utilization and claims and work with your assigned Provider Network Specialist to request adjustments as appropriate. We are committed to ensuring that our network is able to serve consumers appropriately and that our utilization of our IPRS dollars are maximized. 

 

 

Therapeutic Leave
In Partners Communication Bulletin #20, we provided guidance and restrictions regarding the amount of hours for Therapeutic Leave that would be reimbursed using IPRS (State) Funds.  In this communication bulletin it was limited to 30 hours.  We have heard from providers regarding this restriction.  As such State Funds can be used for non-Medicaid eligible children and adolescents residential services Levels 2-4 and PRTF who fit CTSP requirements.  State Funds may also be used for adults in Family and Group living residential levels when the dollars are available.

 Residential providers for children and adolescents and adults in Family and Group Living residential levels shall be paid the daily residential reimbursement amount.  A consumer is allowed up to 45 days of therapeutic leave during the fiscal year, not to exceed 15 days of therapeutic leave each quarter. The leave shall follow the consumer; therefore if the consumer changes facilities, the therapeutic leave will continue to accumulate for the calendar year.

Adult Residential Providers should use the following codes for therapeutic leave:

YM755 TL -Family Living Moderate	YM755	TL
YP740 TL - Family Living Low Therp Leave	YP740	TL
YP750 TL - Family Living Moderate Ther Leave	YP750	TL
YP760TL - Grp Living Low Therapeutic Leave	YP760	TL
YP770TL - GROUP LIVING MODERATE THEREPUTIC LEAVE	YP770	TL
YP780TL - Group Living High Therapeutic Leave	YP780	TL