WAG 20-08-03-d.

The Department of Human Services (DHS) - Office of Mental Health (OMH) and Office of Developmental Disabilities (ODD) administers DHS facilities.

Only approve medical for clients in DHS facilities for services provided in a covered setting. Covered settings vary, depending on the client's age, diagnosis, and facility certification:

Psychiatric Hospital

  • Medicare certified psychiatric hospitals are covered settings for clients 65 and over with any diagnosis.
  • Facilities certified by the Joint Commission on the Accreditation of Hospitals (JCAH) are covered settings for mentally ill clients under 21.
  • Facilities certified by JCAH are covered settings for mentally ill clients up to age 22 who received services immediately before they turned 21, and whose treatment plan calls for returning to the community.

State Operated Developmental Centers - Intermediate Care Facility for the Mentally Retarded (ICF/MR)

  • Medicaid certified facilities are covered settings for clients 65 and over with any diagnosis.
  • Medicaid certified facilities are covered settings for clients 64 and under who are mentally retarded.
  • Facilities certified by JCAH, not including ICF/MR, are covered settings for clients under 21 who are mentally ill only.

HFS pays for medical care for clients temporarily discharged from a covered setting to a general hospital for medical care. HFS pays the hospital for inpatient and outpatient care for clients immediately admitted. HFS pays the attending physician for inpatient and outpatient services for a client admitted to the hospital.

However, HFS does not pay hospitals or physicians for psychiatric or physical rehabilitation services. Clients in DHS non-covered settings are ineligible for aid. DHS clients who are not eligible stay ineligible when temporarily discharged to a general hospital.

Continue eligibility for medical assistance clients temporarily moved from a covered setting to a non-covered setting. Cancel the case if the client is in the non-covered setting for more than 6 months. If the non-covered setting becomes certified within the 6 months of when the client moved, continue eligibility. Do not approve payment for services in non-covered settings.

DHS - OMH/ODD staff decide on what type of care, if any, a client needs after discharge from a DHS facility. They also arrange for the client's placement into the appropriate setting.