Purpose: The Psychiatric Indigent Inpatient (PII) program uses state dollars to fund voluntary psychiatric inpatient hospital services for those who cannot qualify for other state medical assistance or Medicaid programs.
This program only covers voluntary psychiatric inpatient hospital services that are approved through the Regional Support Networks (RSN). It does not cover people who are admitted through the Involuntary Treatment Act (ITA). ITA payments do not go through ACES. Hospitals continue to bill ITA claims as they have in the past.
The psychiatric indigent inpatient (PII) program is a state-funded, limited casualty (LCP) program specifically for mental health clients identified in need of inpatient psychiatric care by the regional support network (RSN).
The psychiatric indigent inpatient (PII) program pays only for emergent voluntary inpatient psychiatric care in community hospitals within the state of Washington. Psychiatric indigent inpatient (PII) does not cover ancillary charges for physician, transportation, pharmacy, or other costs associated with a voluntary inpatient psychiatric hospitalization.
To be eligible for the psychiatric indigent inpatient (PII) program, a client is subject to the following conditions and limitations:
The client must have a voluntary inpatient psychiatric admission authorized by a regional support network (RSN) in the month of application or within the three months immediately preceding the month of application.
Consumers applying for the psychiatric indigent inpatient (PII) program are subject to the income and resource rules for TANF and TANF-related clients in chapters 388-450 and 388-470 WAC.
If a client's income and/or resources exceed the standard for medically needy (MN), as described in WAC 388-478-0070, the client must spend down the excess amount as described in WAC 388-519-0100 for the client to be eligible for the psychiatric indigent inpatient (PII) program. Spenddown is a client financial obligation for medical expenses. The department deducts the spenddown from payments to providers (see WAC 388-502-0100 ).
A client who is voluntarily admitted must have incurred an emergency medical expense requirement (EMER) of two thousand dollars over a twelve-month period. EMER is a client financial obligation. The department deducts the EMER from payments to providers (see WAC 388-502-0100 ).
Qualifying emergency medical expense requirement (EMER) expenses are psychiatric inpatient services in a community hospital.
The emergency medical expense requirement (EMER) period lasts for twelve calendar months, beginning on the first day of the month of certification for psychiatric indigent inpatient (PII) and continuing through the last day of the twelfth month.
A client is limited to a single three-month period of psychiatric indigent inpatient (PII) eligibility per twelve-month emergency medical expense requirement (EMER) period.
Clients are not eligible for the psychiatric indigent inpatient (PII) program if they:
Are eligible for, or receiving, any other cash or medical program; or
Entered the Washington state specifically to obtain medical care; or
Are an inmate of a federal or state prison.
Are committed under the Involuntary Treatment Act (ITA).
PII requires a $2,000 EMER for voluntary inpatient psychiatric hospital services per client during a 12 calendar-month period. The 12 month period begins on the first day of the month of certification and goes through the last day of the 12th calendar month.
A client incurs the $2,000 EMER expense one time during a 12 month period. If a client is voluntarily admitted again after the 3 month certification but still during the 12 month EMER period and applies for PII, a new RSN authorization number is issued and an exception to rule will be required. If approved, the exception can waive the EMER for that client for that time period.
The client is responsible for the $2,000 EMER and any spenddown. DSHS does not cover these expenses. Hospitals may write off the EMER expenses under charity care laws. See WAC 246-453-020.
Financial eligibility for PII follows the TANF rules, including the 50% earned income disregard.
EXAMPLE
Mark admitted as a voluntary psychiatric inpatient at Harborview Hospital in Seattle on July 10. He is married with 2 children; he earns $2500 per month and his wife earns $2000 per month. They have no health insurance. The CSO receives a hospital application from Harborview for PII on July 30. Mark has incurred $10,000 in inpatient psychiatric hospital services as of July 25 and expects to remain inpatient for another two to four weeks.
Monthly Income:
$2500 + $2000
= $4500
$4500 X 50% (disregard)
= $2250
$2250
Less the MNIL standard for 4 person household (as of 7/1/06)
$742
Spenddown per month for PII
$1508
Mark's PII Liability:
$2,000
EMER
+ $4,524
Spenddown (3 month certification)
$6,524
Mark is determined eligible for PII with a certification period of July, August and September.
PII must be authorized by a Regional Support Network (RSN) in the month of application or within the preceding three months. The authorization code must be input to ACES for approval of the PII program.
Referrals to the Health and Recovery Services Administration (HRSA) Medical Consultant are not required for PII.
WORKER RESPONSIBILITIES
To open a PII assistance unit, put the RSN authorization code received with the DSHS 14-001, Application for Benefits, into ACES. (See ACES User Manual for procedures.) For a sample RSN authorization form, see Appendix A or Provider Memo 03-16 (dated June 30, 2003). The authorization approval code from the RSN is required.
If you receive an application without an RSN approval, call the hospital before denying the case.
Hospitals use award letters to bill HRSA. Please ensure the hospital providing the services receives a copy of all PII letters (award letters are 02-31, or 20-05 if spenddown is involved), by entering the hospital in ACES as an AREP (code HO).
In determining financial eligibility for PII, EMER is considered first and then spenddown, if any. Spenddown is calculated according to WAC 388-519-0110. In addition, unused voluntary psychiatric inpatient hospital expenses (left after the EMER determination) may be used to meet spenddown liability.
PII is a program administered by the Mental Health Division (MHD). Contact MHD for policy questions. Your contact is Christina Winans, Phone: (360) 902-0844, E-mail: winanca@dshs.wa.gov
