FROM: Theodore O. Will, Chief Executive Officer
DATE: Jul 30, 2001
SUBJECT: Kendra’s Law and the IPRO Medicaid Psychiatric Review Process
Doreen Walz, Assistant Director, Medicaid Psychiatric Review Program, ext 444
New York State enacted legislation last year that provides for assisted outpatient treatment of certain mentally ill people, who, in view of their treatment history and present circumstances, are unlikely to survive safely in the community without supervision. This law, sometimes referred to as “Kendra’s Law”, established the Assisted Outpatient Treatment Program (AOT) which has been implemented statewide by the Office of Mental Health.
In accordance with instruction from the Department of Health, Bureau of Hospital and Primary Care Services, IPRO will not deny Medicaid reimbursement for hospital stays when the patient is being evaluated for or is awaiting a court order for Assisted Outpatient Treatment, if the medical record provides the necessary documentation as set forth below.
In such cases, the hospital should document the following in the medical record:
- The patient is remaining in the hospital pursuant to seeking the necessary court order for AOT.
- That the patient meets the continued stay review criteria published by OMH and DOH in February, 1997 that discharging the patient would be a threat to self or others.
- That the patient is being evaluated for AOT or that a petition has been filed with county or supreme court for the locality seeking a court order for Assisted Outpatient Treatment.
- That continued hospitalization is necessary to meet the requirements of AOT program.
- That the treatment is being provided to the patient is in accordance with the treatment plan and is expected to be beneficial to the patient.
Likewise, IPRO will not deny hospital stays:
- When a patient is being evaluated for AOT or a court order has been obtained, but the patient is awaiting availability of the services included in the court-ordered treatment plan or
- When a patient who meets the eligibility criteria for AOT based on treatment history and/or current circumstances agrees to participate voluntarily in AOT, without a court order, but is awaiting availability of the necessary services.
Documentation in the medical record should reference either the court order or the risk history of the individual as the basis for retention in the hospital until the required services are available. Either of these situations would meet DOH/OMH Criteria C or D, as would the cases awaiting a court order.
Hospitals claiming Medicaid reimbursement for these individuals must demonstrate that active treatment was provided and documented appropriately in the medical record as required by the DOH/OMH documentation criteria promulgated in 1997.
Medical records which do not meet these documentation standards may result in denial of Medicaid reimbursement.
Should you have any questions in regard to this memorandum, please feel free to contact Doreen Walz, Assistant Director, Medicaid Psychiatric Review Program.