DAR File No. 27426

Health, Health Care Financing, Coverage and Reimbursement Policy

R414-25

Mental Health Clinic Services

NOTICE OF PROPOSED RULE

DAR File No.: 27426
Filed: 09/15/2004, 11:43
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

This rule needs to be repealed and will be replaced with the new rule, R414-36, that specifies community mental health center services and how these services are provided throughout the state, either under capitation or on a fee-for-service basis. (DAR NOTE: The proposed new Rule R414-36 was published in the August 15, 2004, issue of the Utah State Bulletin under DAR No. 27322.)

Summary of the rule or change:

The existing rule is repealed in its entirety and will be replaced with a new rule, R414-36, which is a companion filing. The new rule outlines community mental health center services that are currently covered, as there have been changes, and delineates the ways community mental health center services are provided. In 27 counties of the State, Medicaid recipients are automatically enrolled in the capitated Prepaid Mental Health Plan. Community mental health centers participating in this program receive premiums to serve all Medicaid recipients in their catchment areas. Exceptions to enrollment in the Prepaid Mental Health Plan are also delineated. In two counties, community mental health centers continue to be reimbursed on a fee-for-service basis rather than a prepaid capitation basis.

State statutory or constitutional authorization for this rule:

Section 26-1-5

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget associated with this repeal because policies that are included in the new rule are currently in place.

local governments:

There is no budget impact to local governments as a result of this repeal because policies that are included in the new rule are currently in place.

other persons:

There is no budget impact to other persons as a result of this repeal because policies that are included in the new rule are currently in place.

Compliance costs for affected persons:

There are no compliance costs for affected persons because policies that are included in the new rule are currently in place.

Comments by the department head on the fiscal impact the rule may have on businesses:

This outdated rule is being replaced by proposed rule R414-36. The impact on business is detailed in that filing. Scott D. Williams, MD

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Direct questions regarding this rule to:

Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at cdevashrayee@utah.gov

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

11/01/2004

This rule may become effective on:

11/02/2004

Authorized by:

Scott D. Williams, Executive Director

RULE TEXT

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

[R414-25. Mental Health Clinic Services.

R414-25-0. Policy Statement.

Mental health clinic services are preventive, diagnostic, therapeutic, rehabilitative, or palliative services provided to outpatients to meet the recipient's mental health needs, promote self-sufficiency, and systematically reduce the recipient's reliance on support systems. Services are furnished by or under the direction of a physician.

R414-25-1. Authority and Purpose.

Mental health clinic services are provided under the authority of section 1905(a)(9) of Title XIX of the Social Security Act and the 42 CFR 440.90 "Clinic Services" as an optional Medicaid service. As of January 1, 1989 mental health clinics may provide services under the "Other Diagnostic and Rehabilitative Services" option 42 CFR 440.130. Under this option, services may be provided in settings other than the mental health clinic, as appropriate, but not to include inpatient hospitals.

R414-25-2. Definitions As Used in This Chapter.

A. "Clinical team" means a group that includes at least a physician and an individual experienced in the diagnosis and treatment of mental illness who evaluates each recipient's need for mental health clinic services and develops an individual treatment plan, as appropriate. If the physician satisfies both criteria, the second team member shall be a licensed supervising professional who represents a service relevant to the client's need.

B. "Direct supervision" means the supervising professional oversees the care provided to the client. The supervising professional need not necessarily be present in the same room when the service is rendered, but shall be in the clinic and immediately available to provide assistance and guidance. Documentation shall be sufficient to reflect the active participation of the supervising professional in all aspects of the client's care and treatment.

C. "Evaluation" means identifying the existence, nature, or extent of illness, injury, or other health deviation in a recipient for the purpose of determining the need for medically necessary services by a licensed supervising professional and the reviewing and updating of the treatment plan every 90 days by the clinical team. A student intern, licensed practical nurse, or other clinic staff trained to work with psychiatric patients may obtain the intake information and prepare the evaluation report under the direct supervision of a licensed supervising professional.

D. "Group therapy" means face-to-face clinical treatment of two or more recipients or sets of families, not to exceed 10 individuals, in the same session, to improve the recipient's emotional and mental adjustment and social functioning based on measurable treatment goals identified in the individual's treatment plan. Medicaid reimbursement can be claimed only for the Medicaid recipients receiving group therapy. Therapy services shall be rendered by a licensed supervising professional or by other clinic staff trained to work with psychiatric patients, working under the direct supervision of a licensed supervising professional.

E. "Individual therapy" means face-to-face interventions with an individual recipient with focus on improving the recipient's emotional and mental adjustment and social functioning based on measurable treatment goals identified in the individual's treatment plan. Therapy services shall be rendered by a licensed supervising professional or by other clinic staff trained to work with psychiatric patients, working under the direct supervision of a licensed supervising professional.

F. "Intensive mental health day treatment" means a structured individualized psychosocial rehabilitation program provided to a group in a licensed day treatment facility to reduce or control the recipient's psychiatric symptoms so as to eliminate or decrease the need for hospitalization.

G. "Licensed supervising professional" means a licensed physician, licensed psychologist, certified or clinical social worker, registered nurse with advanced training or experience in psychiatric nursing, licensed social service worker, or licensed marriage and family therapist, as defined in Title 58 of Utah Code Annotated.

H. "Medication management" means prescribing, administering, monitoring, and reviewing the recipient's medication and medication regimen; and providing appropriate information to the recipient regarding the medication regimen. This service shall be rendered only by a physician, registered nurse, or other practitioner licensed under state law to prescribe, review, or administer medication and acting within the scope of his license.

I. "Mental health day treatment" means a structured individualized psychosocial rehabilitation program provided to a group in a licensed day treatment facility to reduce or control the recipient's psychiatric symptoms so as to prevent relapse or hospitalization and improve or maintain the recipient's level of functioning according to the individual's treatment plan. Day treatment may include individual therapy, group therapy, crisis management, recreational therapy, and other activities or treatment to restore and maintain the recipient's health and hygiene, social, interpersonal, and other daily living skills according to the individual treatment plan.

J. "Outpatient" means that a patient who is receiving professional services at an organized medical facility, or distinct part of such a facility, which is not providing him with room and board and professional services on a continuous 24-hour-a-day basis, 42 CFR 440.2. The definition of an outpatient does not exclude residents of long term care facilities from receiving clinic services. However, because of the outpatient requirement, eligibility for clinic services is limited to those patients who for the purpose of receiving necessary health care go or are brought to the clinic, or other site at which the clinic staff is available, and who on the same day leave the site at which the services are provided. State Medicaid Manual Section 4320 (D).

K. "Physician direction" means a physician directly affiliated with the clinic assumes professional responsibility for the services provided and assures that the services are medically appropriate. The physician shall oversee the patient's care, prescribe the type of care provided and periodically review the need for continued care. The physician need not be an employee of the clinic, or be utilized on a full time basis, or be present in the facility during all hours that services are provided; but the physician shall spend as much time in the facility as is necessary to assure that patients are getting services in a safe and efficient manner in accordance with accepted medical standards.

L. "Plan of care" means a written, individualized plan, developed by a clinical team, to improve the patient's condition to the point where the patient's continued participation in the program, beyond occasional maintenance visits, is no longer necessary.

M. "Prior authorization" means that degree of Medicaid agency approval for payment of services required to be obtained by a licensed provider before the service is provided.

N. "Psychological testing" means administering, evaluating, and submitting a written report of the results of psychometric, diagnostic, projective, or standardized IQ test by a licensed psychologist or physician with experience in testing. Master's level psychologists may administer psychological tests to recipients and may interpret the tests only under the direct supervision of the licensed supervising psychologist or physician. The licensed psychologist or physician shall review the tests administered, actively participate in the interpretation process, review the written report, and countersign the written report.

R414-25-3. Eligibility Requirements/Coverage.

Mental health clinic services are available to Medicaid recipients who are categorically or medically needy and in need of mental health clinic services.

R414-25-4. Program Access Requirements.

Mental health clinic services are covered benefits only when provided by or through a provider licensed by the Utah Department of Social Services as a comprehensive mental health treatment program in accordance with Utah law, Sections 62A-2-101 through 116, Utah Code Annotated 1953, as amended, who can furnish the full scope of mental health clinic services directly or by contract. In addition, the mental health treatment program shall be provided in a freestanding facility that is not part of a hospital but is organized and operated to provide mental health services to outpatients.

R414-25-5. Service Coverage.

The scope of mental health clinic services includes the following services:

A. In Clinic Services

1. Evaluation

a. If a recipient is determined to be in need of mental health clinic services, the evaluation shall include the development of an individualized, measurable treatment plan by a clinical team to improve the recipient's functioning.

b. A unit of evaluation is one hour.

c. Documentation for evaluations shall include the evaluation report, diagnosis, treatment recommendations, individual treatment plan, reevaluation report, and updated treatment plan.

1. A unit of reevaluation is one reevaluation regardless of time required to complete the reevaluation.

2. Documentation for the reevaluation shall include the reevaluation report and updated treatment plan.

2. Psychological Testing

a. A unit of psychological testing is either the level I or level II test regardless of time required to complete the testing and evaluation.

b. Level I psychological test is an examination that will give rough estimates of intellectual or personality assessments to be used as a brief screening or follow-up exam. The test or tests administered should be selected on the basis of reliability in measuring the client's intellectual and emotional functioning as indicated in the treatment plan. The test report will include a brief history, test administered, test scores, an evaluation of the test results, and current functioning of the examinee.

c. Level II psychological test is a complete measure of intelligence, aptitude, educational, and personality functioning including neuro-psychological function, as appropriate. A level II test may be utilized for treatment planning. The test report will include a brief history, tests administered, test scores, evaluation of test results, current functioning of the examinee, diagnosis and prognosis.

3. Individual Therapy

a. A unit of individual therapy is a half-hour session.

b. Documentation of individual therapy shall include clinical notes documenting progress toward treatment goals.

4. Group Therapy

a. A unit of group therapy is a half-hour session per recipient.

b. Documentation of group therapy shall include clinical notes documenting progress toward treatment goals.

5. Medication Management

a. A unit of medication management is the encounter session with the physician or registered nurse.

b. Documentation of medication management shall include the medication order or copy of the prescription signed by the prescribing practitioner and clinical notes.

6. Mental health day treatment

a. A unit of day treatment is one hour.

b. For each two hours of participation in the day treatment program, the client shall receive at least 30 minutes of direct care by a licensed supervising professional. This may be aggregated throughout the day as long as the ratio is maintained. Licensed master therapeutic recreation specialists or therapeutic recreation specialists may conduct the balance of day treatment activities and supervise other mental health staff in conducting the balance of these activities.

c. In day treatment programs for adolescents and children, a ratio of no more than 12 clients per direct staff shall be maintained during the entire day treatment program. Other clinic staff trained to work with adolescents and children may conduct the entire day treatment program if there is documentation of weekly supervision with a licensed supervising professional.

d. Documentation of day treatment shall include monthly progress notes in the clinical record; description of direct care services provided; documentation that the licensed supervising professional direct care requirement was met; documentation of number of hours client participated in day treatment program with date of attendance and type of care provided; definition of treatment plan, goals, and recipient's progress towards goals; description of the relationship between the day treatment activities attended and the recipient's individual needs and symptomatology. In day treatment programs for adolescents and children, when staff other than licensed supervising professional staff provide the direct care, documentation of weekly supervision with a licensed physician, licensed psychologist, certified or licensed clinical social worker, or registered nurse with advanced training or experience in psychiatric nursing shall be available for review.

7. Intensive mental health day treatment

a. A unit of intensive day treatment is one hour.

b. Recipients eligible for this service shall have a current Global Assessment Scale (GAS) rating or current Global Assessment of Functioning Scale (GAF) rating on Axis V of the Diagnostic and Statistical Manual of Mental Disorders, Third Edition Revised (DSM III-R) between 1 and 20. The recipient remains eligible for intensive day treatment until a rating of 21 or higher on one of the above scales is maintained for four consecutive weeks.

c. Intensive day treatment may include individual therapy, group therapy, crisis management, recreational therapy, and other activities or treatment designed to prevent hospitalization and to stabilize the recipient's condition. Intensive forms of treatment, e.g., individual therapy, group therapy, crisis services, daily living skills activities, should be emphasized.

d. There shall be documentation that the recipient participated in day treatment for at least four hours per day.

e. For each four hours of participation in the intensive day treatment program, the recipient shall receive at least 60 minutes of direct care by a licensed supervising professional. This may be aggregated throughout the day as long as the ratio is maintained. Licensed master therapeutic recreation specialists or therapeutic recreation specialists may conduct the balance of day treatment activities and supervise other mental health staff in conducting the balance of these activities. In addition, a ratio of no more than 10 recipients per licensed professional staff shall be maintained during the entire intensive day treatment program.

f. Documentation of intensive day treatment shall include weekly progress notes in the clinical record documenting medical necessity for intensive day treatment services, GAS or GAF rating, number of hours the recipient participated in intensive day treatment; the direct care services provided, by whom, and for what period of time; treatment plan goals and recipient's progress toward meeting goals.

B. Off-Clinic Site

1. The scope of mental health diagnostic and rehabilitative services includes:

a. evaluation: evaluations provided under this option should be used only when circumstances prevent the client from coming to the clinic;

b. individual therapy;

c. group therapy;

d. medication management;

e. mental health day treatment.

(1) Day treatment services must be provided in a facility that is licensed as a day treatment facility or that is licensed as part of the clinic.

(2) Day treatment provided under the diagnostic and rehabilitative services option may be conducted in a facility that is also the client's place of residence only if the facility is included under the mental health clinic license.

2. All Medicaid regulations and requirements for clinic services also apply to services provided at sites other than the clinic.

a. Services must be provided by or under the direction of a physician.

b. Supervision by the appropriate licensed supervising professional must be provided to staff who provide services off-site.

R414-25-6. Standards for Mental Health Clinics.

A. Physician direction and staff qualifications

1. Services shall be provided by or under the direction of a physician and delivered according to a plan of care approved by staff who meet appropriate professional qualifications. The physician must see the client at least once and shall prescribe the type of care to be provided. The physician's documentation and signature in the medical record shall evidence that the physician was actively involved in the establishment of a written plan of care for each recipient. The physician shall review and update the plan of care every 90 days.

2. Except as noted in Section R414-25-5, all mental health clinic services shall be rendered by a physician or a licensed supervising professional.

B. Evaluation procedures

1. An evaluation should be performed for each recipient being considered for entry into the mental health clinic treatment program. As part of the evaluation, the recipient's primary care physician should be contacted.

2. If it is determined that a recipient is in need of mental health clinic services, a clinical team shall develop an individual plan of care.

C. Plan of care

The treatment plan shall include measurable treatment objectives and the following:

1. the treatment regimen: the specific medical and remedial services, therapies, and activities that will be used to meet the treatment objectives;

2. a projected schedule for service delivery, including the expected frequency and duration of each type of planned therapeutic session or encounter;

3. the type of personnel that will be furnishing the services; and

4. a projected schedule for completing reevaluations of the patient's condition and updating of the plan of care.

D. Periodic review

The clinical team shall periodically review the recipient's plan of care in order to determine the recipient's progress toward the treatment objectives, the appropriateness of the services being furnished and the need for the recipient's continued participation in the program. The clinical team shall perform the review on a regular basis, at least every 90 days, and document the review in detail in the clinical record.

E. Documentation

1. The mental health clinic shall develop and maintain sufficient written documentation for each medical or remedial therapy, service, activity, or session for which billing is made that indicates at least the following:

a. the specific services rendered;

b. the date and actual time the services were rendered;

c. who rendered the services;

d. the setting in which the services were rendered;

e. the amount of time it took to deliver the services;

f. the relationship of the services to the treatment regimen described in the treatment plan;

g. updates describing the patient's progress.

2. The record shall be kept on file and made available as requested for state or federal assessment purposes.

3. For services that are not specifically included in the recipient's treatment regimen, a detailed explanation of how the services being billed relate to the treatment regimen and objectives contained in the plan of care should be included in the clinical record. Similarly, the record shall include a detailed explanation for a medical or remedial therapy session that departs from the plan of care in terms of need, scheduling, frequency or duration of services furnished, e.g., unscheduled emergency services furnished during an acute psychotic episode, explaining why this departure from the established treatment regimen is necessary in order to achieve the treatment objectives.

F. Quality assurance

Each mental health clinic shall have a written quality assurance program subject to review by state and federal Medicaid officials. The program shall include an interdisciplinary committee that meets at least quarterly to review quality of care and make recommendations for improvement. The quality assurance process shall include peer review procedures to appropriately assess quality of care and audit clinical records. The peer review process shall include written procedures to assess the adequacy of the treatment being delivered.

R414-25-7. Limitations.

A. Evaluation - no limits.

B. Psychological Testing - no limits.

C. Individual therapy - no limits.

D. Group therapy - no limits.

E. Medication Management - no limits.

F. Adult or child/adolescent day treatment - prior authorization is required for adult day treatment and child/adolescent day treatment that exceeds 160 units per month. See Section R414-25-8 for prior authorization criteria to grant additional units.

G. Intensive adult day treatment - prior authorization is required for intensive adult day treatment in excess of 160 units per month.

R414-25-8. Prior Authorization.

A. Prior authorization is required for service units in excess of the limits set for day treatment. The prior authorization request shall include sufficient documentation to support the need for additional units. The request shall include at least the following:

1. documentation of the course of the recipient's illness and treatment and a complete summary of the recipient's current condition including symptomalogy and behavior for which additional service units are requested;

2. documentation of initial DSM III diagnoses on Axes I-V and any change in these diagnoses;

3. an estimate of the number of additional service units required and an explanation of how additional service units will be useful in treating the recipient's condition;

4. a statement outlining other alternatives considered or utilized;

5. a copy of treatment plan and a statement of how it will serve to improve the client's condition;

6. the dates of service for which authorization is requested.

B. Criteria for Prior Authorization

Day treatment - To obtain authorization, the provider shall document the recipient meets one of the following criteria:

1. a current GAS rating or GAF rating on Axis V of the DSM III-R of 30 or under;

2. a rating of 40 or under on the GAF Scale for the last 6-12 months;

3. a history of psychiatric illness or psychiatric hospitalizations and corresponding evidence that the increased levels of day treatment requested will maintain or improve current levels of functioning.

4. Three of the following:

(a) a marked deterioration or worsening of the recipient's condition, as evidenced by an increase in symptomatology or behavior related to the diagnosis and a decrease in ability to maintain previous level of functioning;

(b) a change in diagnosis on Axis I and/or V of the DSM III-R indicating the recipient can no longer carry out activities as he had previously and that he is at increased risk for inpatient care;

(c) specific evidence of increased risk of suicide or destructive behavior toward self or others;

(d) a release from an institutional setting within the last 60 days and corresponding need for additional day treatment hours to maintain gains and make a successful transition to the community.

(e) a history of acute episodes or hospitalizations during the past year.

R414-25-9. Reimbursement Method for Clinic Services.

Payment for Clinic Services is limited to the amount paid by Medicare as specified in 42 CFR 447.321.

A. Payment for covered services will be made to qualified providers.

B. Payment for covered services will be made on a fee-for-service basis according to the following methodology:

1. Medicaid payments will be the lesser of (1) the billed usual and customary charges to the general public; or (2) the reasonable cost of providing the service; or (3) the established fee schedule.

2. The usual and customary charge is the lower of the most frequently billed gross charge prior to discounts, or the charge billed to insurance companies.

3. The cost of providing services is calculated by taking a ratio of Medicaid charges to total charges. This ratio is applied to the total allowable costs that correspond to the billable services. Reasonable costs are defined in the "Medicare Provider Reimbursement Manual," HCFA Publication 15-1 and the Utah State Plan

4. All mental health clinic services will be billed using approved HCPC codes.

5. On an annual basis, total Medicaid payments to the provider will be adjusted, as necessary, so that aggregate payments are limited to reasonable cost as determined by a fiscal audit.

KEY: medicaid

1989

Notice of Continuation December 20, 1999

26-1-4.1

26-1-5

26-18-3]

ADDITIONAL INFORMATION

PLEASE NOTE:

• Text to be deleted is struck through and surrounded by brackets (e.g., [example]). Text to be added is underlined (e.g., example). Some browsers may not depict some or any of these attributes on the screen or when the document is printed.
• Please see the DISCLAIMER regarding information available from state web pages.

For questions regarding the content or application of this rule, please contact Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at cdevashrayee@utah.gov

For questions about the rulemaking process, please contact the Division of Administrative Rules (801-538-3764). Please Note: The Division of Administrative Rules is NOT able to answer questions about the content or application of these administrative rules.