Florida Therapy Services - Mental Health Providers



COMMUNITY BEHAVIORAL HEALTH SERVICES COVERAGE AND LIMITATIONS HANDBOOKCHAPTER 1: QUALIFICATIONS, ENROLLMENT AND REQUIREMENTSPurpose and DefinitionsGENERAL COMMENT(S):The organization of the manual has changed, though not a great deal of information was removed, it is now located in different sections. The handbook stays away from any particular ICD-9/DSM diagnosis.Services for young children are outlined in their respective section, instead of the previous manual which had a separate Section (Section 5: Services for Children Ages 0-5).Language and definitions to address telemedicine have been added – Second modifier GT has been added to these codes.Staff Qualifications and professionals who can render services is more detailed to include any professional who is able to provide a service and the supervising party. Professionals rendering services to infants have been separated.STANDARD/REQUIREMENTSTATUSDESCRIPTIONADDITIONAL COMMENTSAftercare PlanningNewThe process of planning for a recipient’s transition from the current level of care. The process begins during the assessment process when the recipient’s needs and possible barriers to care are identified. The recipient and treating staff should collaborate to develop the recipient’s individualized formal aftercare plan. A formal aftercare plan should include community resources, activities, services, and supports that will be utilized to help the recipient sustain gains achieved during treatment.Bachelor’s Level Infant Mental Health PractitionerNewBachelor’s level recipients under the age of 6.Discharge CriteriaNewMeasureable criteria established at the onset of treatment that identify a recipient’s readiness to transition to a new level of care or out of care. Discharge criteria must be included on the recipient’s individualized treatment plan and are separate and apart from the recipient’s treatment plan goals and objectives. The recipient and the treating staff should collaborate to develop the individualized, measurable criteria. The recipient’s progress toward meeting the discharge criteria should be addressed throughout the course of treatment as part of the treatment plan review.Emotional DisturbanceNewUnder 21 yrs who is diagnosed with mental, emotional, or behavioral disorder of sufficient duration to meet one of the diagnostic categories specified in the most recent edition of the DSM, but who does not exhibit behaviors that substantially interfere with or limit the role or ability to function in the family, school or community. The emotional disturbance must not be considered to be a temporary response to a stressful situation.Hub SiteNewThe telecommunication distance site in Florida at which the consulting physician, dentist, or therapist is delivering telemedicine services.Infant Mental Health AidesNewA mental health aide who provides services to recipients under the age of 6 yrs.Other Responsible personModifiedA relative, legal guardian, caretaker, or other individuals and natural supports who are known to the recipient and family and are active in providing care to the recipient.Serious Emotional DisturbanceNewA person under 21 years who is all of the following:Diagnosed as having a mental, emotional or behavioral disorder that meets one of the diagnostic categories specified in the DSM.Exhibits behaviors that substantially interfere with or limit the role or ability to function in the family, school, or community, which behaviors are not considered to be a temporary response to a stressful situation.Purpose and Definitions (continued)Shelter StatusNewLegal status that begins when a recipient under the age of 18 is taken into the protective custody of DCF and ceases when one of the following occurs:Court grants custody to a parentAfter disposition of the petition for dependencyCourt orders the child to be released to a parent or placed in the temporary custody of a relative, a non- relative, or DCF.Spoke SiteNewThe provider office location in Florida where an approved service is being furnished through telemedicine.TelemedicineNewThe practice of health care delivery using telecommunication equipment by the treating provider (at the spoke site) for the provision of approved covered services (at the hub site) for the purpose of evaluation, diagnosis and treatment.Treating PractitionerModifiedA Medicaid-enrolled professional who authorizes services within the purview of that practitioner’s credentials and state law on behalf of the Medicaid group provider.Treatment TeamModifiedKey staff involved in planning and providing behavioral health services to the recipient.Staff Qualifications & EnrollmentGeneralNewCBHS staff must provide services within the scope of their professional licensure or certification, training, protocols and competence. Providers must maintain records with:Background screening resultsState mandated I-9 resultsStaff qualificationsVerification of work experienceReference checksEvidence of ongoing trainingThese records must additionally reflect adherence to human resources policies and procedures established by the provider.Specifies personnel file content requirements, standard proceduresBachelor’s Level Infant Mental Health PractitionerNewCompleted 20 hours of documented training:Early Childhood DevelopmentBehavior ObservationDevelopmental ScreeningParent and child intervention and interactionFunctional assessmentDevelopmentally appropriate practice for serving infantsYoung children and their familiesPsychosocial assessment and diagnosis of young childrenCrisis intervention trainingSupervised by a master’s level practitioner with two years of experience with recipients under the age of 6 or by a licensed practitioner of the healing arts.Staff Qualifications & Enrollment (continued)Bachelor’s Level PractitionerModifiedA Bachelor’s level practitioner must meet all of the following criteria:A Bachelor’s degree from an accredited university or college with a major in counseling, social work, psychology, nursing rehabilitation, special education, health education or a related human services field.Training in the treatment of behavioral health disorders, human growth and development, evaluations, assessments, treatment planning, basic counseling and behavior management interventions, case management, clinical record documentation, psychopharmacology, abuse regulations and recipient rights.Work under the supervision of a Master’s level practitioner.Behavioral Health TechnicianModifiedA Behavioral Health Technician must:Have a high school diploma or equivalent and in-service training in the treatment of mental health disorders, abuse regulations, recipient rights, crisis management interventions, and confidentiality.Work under the supervision of a Bachelor’s level practitioner or higher.Be certified as a Behavioral Health Technician by the Florida Certification Board (FCB).Certified Associate Behavior AnalystNewA Certified Associate Behavior Analyst must be a National Board Certified Associate Behavior Analyst or Florida Associate Behavior Analyst, who maintains active certification for a Florida Board Certified Associate Behavior Analyst.Certified Addictions ProfessionalModified & NewA CAP with a master’s degree must enroll as provider type 07 and must also be linked to a community behavioral health group (provider type 05) in order to authorize services for treatment for substance use disorders.Certified Behavior AnalystModifiedA certified Behavior Analyst must be a National Board Certified Behavior Analyst or Florida Behavior Analyst who maintains active certification for a Florida Board Certified Behavior Analyst. A Board Certified Behavior Analyst may possess a Master’s degree (BCBA) or Doctoral degree (BCBA-D).Certified Psychiatric Rehabilitation PractitionerNewA Certified Psychiatric Rehabilitation Practitioner must be certified by the Certification Commission for Psychiatric Rehabilitation, established by the United States Psychiatric Rehabilitation Association, and is working under the supervision of a Bachelor’s level practitioner or higher.Certified Recovery Peer Specialist—AdultNewA Certified Recovery Peer Specialist—Adult must be certified by the FCB and work under the supervision of a Bachelor’s level practitioner, Master’s level CAP, or higher.Certified Recovery Peer Specialist—FamilyNewA Certified Recovery Peer Specialist—Family must be certified by the FCB and work under the supervision of a Bachelor’s level practitioner, Master’s level CAP, or higher.Certified Recovery Support SpecialistNewA Certified Recovery Support Specialist must be certified by the FCB and work under the supervision of a Bachelor’s level practitioner, Master’s level CAP, or higher.Clinical Services SupervisorModifiedA Clinical Services Supervisor must have a minimum of a Master’s degree and at least two (2) years of experience working with children who have emotional or serious emotional disturbances.Clinical Social WorkerModifiedA Clinical Social Worker must be licensed in accordance with Chapter 491, F.S.Infant Mental Health AidesNewInfant mental health aides must, at a minimum, have a high school diploma or equivalent with at least two years’ experience with infants and toddlers, or hold a Child Development AideStaff Qualifications & Enrollment (continued)Licensed Practitioner of the Healing Arts (LPHA)ModifiedA treating LPHA must enroll as a provider type 07 and must also be linked to a group provider type 05 for services rendered in the capacity of a treating practitioner in order to be qualified. LPHA;s include:Clinical Social Workers licensed in accordance with Chapter 491, F.S.Mental Health Counselors licensed in accordance with Chapter 491, F.S.Marriage and Family Therapists licensed in accordance with Chapter 491, F.S.Psychologists licensed in accordance with Chapter 490, F.S.Clinical Nurse Specialists (CNS) with a subspecialty in child/adolescent psychiatric and mental health or psychiatric and mental health licensed in accordance with Chapter 496, F.S.Psychiatric Advance Registered Nurse Practitioners licensed in accordance with Chapter 464, F.S.Psychiatric Prescribing Physician Assistants licensed in accordance with Chapters 458 and 459, F.S.Marriage and Family TherapistModifiedA Marriage and Family Therapist must be licensed in accordance with Chapter 491, F.S.Master’s Level PractitionerModifiedA Master’s level practitioner must have a Master’s degree from an accredited university or college with a major in the field of counseling, social work, psychology, nursing, rehabilitation, special education, health education, or a related human services field with one of the following:Two years of professional experience in providing services to persons with behavioral health disorders.Current supervision under an LPHA as described in this section.Master’s level practitioners hired after July 1, 2014 with degrees other than social work, psychology, marriage and family therapy, or mental health counseling must have completed graduate level coursework in at least four of the following thirteen content areas: human growth and development; diagnosis and treatment of psychopathology; human sexuality; counseling theories and techniques; group theories and practice; dynamics of marriage and family systems; individual evaluation and assessment; career and lifestyle assessment; research and program evaluation; personality theories; social and cultural foundations; counseling in community settings; and substance use disorders.Medical AssistantNewA medical assistant must be registered or certified in accordance with Chapter 458, F.S.Mental Health CounselorModifiedA Mental Health Counselor must be licensed in accordance with Chapter 491, F.S.Physician’s AssistantModifiedA physician assistant must be a graduate of an approved program or its equivalent or meets standards approved by the Florida Board of Medicine and must be certified to perform medical services in accordance with Chapters 458 and 459, F.S.Psychiatric Advanced Registered Nurse Practitioner (ARNP)ModifiedA psychiatric ARNP must have education or training in psychiatry and be authorized to provide these services in accordance with Chapter 464, F.S., and protocols filed with the Florida Board of Nursing. An ARNP must enroll as a provider type 07 and must also be linked to a group provider type 05.Staff Qualifications & Enrollment (continued)Psychiatric Clinical Nurse Specialist (CNS)NewA psychiatric CNS must have a subspecialty in child/adolescent psychiatric and mental health or psychiatric and mental health and is licensed in accordance with Chapter 464, F.S., and must meet all of the following criteria: A current and active license as a registered nurse in Florida A master’s degree or higher in nursing as a CNS Provide proof of current certification in a specialty area as a CNS from one of the four certifying bodies: American Nursing Credentialing Center, American Association of Critical-Care Nurses, Oncology Nursing Certification Corporation, and National Board of Certification of Hospice and Palliative Nurses; or meet the requirements of Chapter 464, F.S. and has provided the required affidavit A certificate issued by the Florida Board of Nursing as a CNS A registered nurse currently enrolled as an LPHA must be licensed as a CNS with a subspecialty of child/adolescent psychiatric and mental health or psychiatric and mental health by January 1, 2016.Psychiatric Physician Assistant (PPA)NewA PPA must be a licensed prescribing physician assistant as defined in Chapter 458 or 459, F.S., with a Psychiatric Certificate of Added Qualification. The PPA’s supervising physician must be a provider type 25 or 26 that is linked to the community behavioral health group provider type 05.PsychologistModifiedA Mental Health Counselor must be licensed in accordance with Chapter 490, F.S.Substance Abuse TechnicianModifiedA substance abuse technician must have a high school degree or equivalent, must be under the supervision of a bachelor’s level practitioner or higher, and meet one of the following criteria: In-service training in the treatment of substance use disorders Five years of experience working directly with recipients experiencing substance use disorders in a treatment setting The substance abuse technician must be able to function as a member of a recipient’s multidisciplinary team, provide therapeutic support and recognize the signs and symptoms associated with abuse and dependence. The substance abuse technician must be familiar with substance use rules and regulations, confidentiality, twelve-step recovery concepts, clinical record documentation requirements, and patient rights; and be able to respond to special circumstances, such as emergencies, suicide, and out-of-control behavior. Treating PhysicianNewA treating physician must enroll as a provider type 25 or 26 and must also be linked to a community behavioral health group (provider type 05).Treating PractitionerModifiedTreating practitioners include: PhysicianPsychiatristPsychiatric ARNPPPALPHAMaster’s level CAP (for the authorization of substance use treatment only)A treating practitioner must be independently enrolled in the Florida Medicaid program per provider type.RequirementsIntroductionModifiedThe qualifications listed in this section apply to the following providers: Community behavioral health services (provider type 05) Treating physicians (provider types 25 and 26) Treating practitioners (provider type 07) Note: Enrollment forms may be obtained from the Medicaid fiscal agent’s Web site at mymedicaid-, select Public Information for Providers, then Provider Support, and then Enrollment, or by calling Provider Enrollment at 1-800-289-7799 and selecting Option 4. Provider QualificationsModifiedTo enroll as a Medicaid community behavioral health services provider, providers must meet all of the following: Employ or have under contract a Medicaid-enrolled psychiatrist or a physician, who is linked with the Medicaid group provider. Achieve compliance on a community behavioral health services provider pre-enrollment certification review. Hold a regular (i.e., not probationary or interim) substance abuse license in accordance with Chapter 65D-30, F.A.C., for at least one of the following components, if substance abuse services are provided: Prevention Intervention Outpatient Multiple Service Locations Within the Same Medicaid-Designated AreaModified & NewProviders who render services at more than one service address within the same Medicaid-designated area are required to submit an Application for New Location Code to identify each separate physical address where services are provided. The Application for New Location Code is an attachment to the Florida Medicaid Provider Enrollment Application. Providers must use the code assigned to the location when billing for services provided at that location. Additional service sites are subject to an on-site review by the local Medicaid area office or its designee.Multiple Service Locations in Different Medicaid-Designated AreasModified & NewProviders who render services at more than one service address in different Medicaid-designated areas are required to submit a separate Florida Medicaid Provider Enrollment Application for each Medicaid-designated area. Providers must use the code assigned to the location when billing for services provided at that location. Additional service sites are subject to an on-site review by the local Medicaid area office or its designee.SubcontractingModifiedFlorida Medicaid allows a provider to contract with an individual practitioner, but not with another agency for service delivery. As of July 1, 2014, providers are required to retain all contracts with subcontracted staff for no less than five years from the termination date of the contract. Providers must maintain subcontractor records with background screening results, staff qualifications, and verification of work experience. These records must additionally reflect adherence to human resources policies and procedures established by the provider related to subcontracting. Requirements (continued)Providers Contracted with Medicaid Health PlansNewThe service-specific Medicaid coverage and limitations handbooks provide the minimum requirements for all providers. This includes providers who contract with Florida Medicaid health plans (e.g., provider service networks and health maintenance organizations). Providers shall comply with all of the requirements outlined in this handbook, unless otherwise specified in their contract with the health plan. The provision of services to recipients enrolled in a Medicaid health plan shall not be subject to more stringent criteria or limits than specified in this handbook.Added MMA languageCHAPTER 2: COVERED, LIMITED AND EXCLUDED SERVICESGeneral Coverage InformationGENERAL COMMENT(S):NoneSTANDARD/REQUIREMENTSTATUSDESCRIPTIONADDITIONAL COMMENTSExceptions to the Limits (Special Service ) ProcessNewAs required by federal law, Florida Medicaid provides services to eligible recipients under the age of 21 years, if such services are medically necessary to correct or ameliorate a defect, a condition, or a physical or mental illness. Included are diagnostic services, treatment, equipment, supplies, and other measures described in section 1905(a) of the Social Security Act, codified in Title 42 of the United States Code 1396d(a).Services for recipients under the age of 21 years in excess of limitations described within this handbook or the associated fee schedule may be approved, if medically necessary, through the process described in the Florida Medicaid Provider General Handbook.DescriptionNewCommunity behavioral health services include mental health and substance abuse services provided to recipients with mental health, substance use, and co-occurring mental health and substance use disorders for the maximum reduction of the recipient’s disability and restoration to the best possible functional level. General RequirementModifiedRemoval of DCF district or region language. No other significant changes.Language regarding DCF district or region was removed from the previous handbook.Assessment RequirementNewPrior to the development of a tx. Plan the provider must complete and provide to the recipient an assessment or must have an assessment on file that has been conducted in the last six months. For recipients under the age of 6 years, a comprehensive behavioral health assessment completed within the past year, in accordance with the Florida Medicaid Specialized Therapeutic Services Coverage and Limitations Handbook, may satisfy the current assessment requirement for services. Prior to the authorization of services the recipient must receive an assessmentRecipient Clinical RecordModifiedProviders must maintain a clinical record for each recipient treated:Added: Consent for treatment signed by the recipient or the recipient’s legal guardian. An explanation must be provided for signatures omitted in situations of exceptions.Some components added: An evaluation or assessment that, at a minimum, contains the components of a brief behavioral health status examination conducted by a physician, psychiatrist, a licensed practitioner of the healing arts (LPHA), or master’s level certified addictions professional (CAP) for diagnostic and treatment planning purposes.General Coverage Information (continued)General Service Documentation RequirementsModifiedProviders must maintain documentation to support each service for which Medicaid reimbursement is requested; clearly distinguish and reference each separate service billed; and be authenticated with the dated signature of the individual who rendered the service. The date of a claim should be the same as the date the service was rendered. Identification of the service renderedUpdates regarding the recipient’s progress toward meeting treatment-related goals and objectives addressed during the provision of a service Dated signature of the individual who rendered the service Printed or stamped name identifying the signature of the individual who rendered the service and the credentials (e.g., licensed clinical social worker) or functional title (e.g., treating practitioner) Assessment ServicesGENERAL COMMENT(S):Psychiatric Evaluation: Trauma and Alcohol and drug use component has been added as a part of the evaluation.In-Depth Assessment: Traumatic Experience, Acute Care Treatment and Treatment and Treatment recommendations or plan have been added as Assessment components.STANDARD/REQUIREMENTSTATUSDESCRIPTIONADDITIONAL COMMENTSIn-Depth AssessmentModified & NewAddition of:Traumatic Experiences (Personal hx.)Acute Care Treatment (Hx. Of tx.)Treatment recommendations or plan.Section regarding recipients under the age of 6 added:Presenting symptoms and behaviors Developmental and medical history: history of the mother’s pregnancy and the recipient’s delivery, past and current medical conditions, and developmental milestones Family psychosocial and medical history (can be as reported or based upon collateral information) Family functioning, cultural and communication patterns, and current environmental conditions and stressors Clinical interview with the primary caretaker and observation of the caregiver–infant or –child relationship and interactive patterns Provider’s observation and assessment of the recipient, including affective, language, cognitive, motor, sensory, self-care, and social functioningA new in-depth assessment can be provided to recipients who meet one of the following criteria.New criteria: Recipients who are being admitted to treatment when it is documented that a psychosocial evaluation or bio-psychosocial evaluation was insufficient in providing a comprehensive basis for treatment planning. Criteria removed:Recipients who have been receiving intensive services for 6 months or longer and for whom the documentation supports lack of significant progressBio-psychosocial EvaluationModified & NewWhen it is consistent with the recipient’s treatment needs, bio-psychosocial evaluations can be completed using telemedicine.A bio-psychosocial evaluation must provide information on all the following components: Presenting problems Biological factors Psychological factors Social factors Mental health status examination Summary of findings Diagnostic impression Treatment recommendations or plan A bio-psychosocial evaluation completed by a Bachelor’s level practitioner must be reviewed, signed and dated by a master’s level practitioner, bachelor’s level CAP, or treating practitioner prior to completion of the treatment planning process.Limited Functional AssessmentModified & NewA limited functional assessment is restricted to administration of the Functional Assessment Rating Scale (FARS), and the Children’s Functional Assessment Rating Scale (C-FARS), the American Society of Addiction Medicine Patient Placement Criteria (ASAM PPC-2R), or any other functional assessment required by the Department of Children and Families (DCF). When it is consistent with the recipient’s treatment needs, limited functional assessments can be completed using telemedicine. As of July 1, 2014, the American Society of Addiction Medicine Patient Placement Criteria must be provided by an individual who has completed provider agency training on how to use the instrument to make accurate level of care determinationsTreatment Planning ServicesGENERAL COMMENT(S):Treatment Plan: Temporary Service Authorization (Appendix B) replaced the form Limited Service Authorization (Appendix A). The Temporary Service Authorization is a temporary increase in prescribed services; the provider must report the increase using the form. This form can be used to report the provision of crisis-oriented services that are not prescribed in the treatment plan. STANDARD/REQUIREMENTSTATUSDESCRIPTIONADDITIONAL COMMENTSIntroductionModifiedA treatment plan is an individualized, structured, and goal-oriented schedule of services with measurable objectives that promotes the maximum reduction of the recipient’s disability and restoration to the best possible functional level. Individualized recipient treatment plans must directly address the primary diagnosis(es) that is(are) consistent with the assessment. A treatment plan should directly address additional diagnoses that are consistent with assessment and that are in the range of the provider’s expertise. The provider must document efforts to coordinate services for diagnoses outside their expertise that, if treated, would assist meeting the recipient’s goals. Community behavioral health services must be prescribed on a treatment plan authorized by one of the group provider’s treating practitioners. Treatment Planning Services (continued)Treatment Plan Development and ComponentsModified, New & DeletedThe treatment plan must be jointly developed by the recipient and the treatment team. The treatment plan must be recipient-centered and consistent with the recipient’s identified strengths, abilities, needs, and preferences. The recipient’s parent, guardian, or legal custodian should be included in the development of the recipient’s individualized treatment plan, if the recipient is under the age of 18 years. Treatment planning for a recipient under the age of 18 years that does not include the recipient’s parent, guardian, or legal custodian in a situation of exception requires a documented explanation. Additional Components:Addition of individualized and strength based goalsMeasureable objectives with target completion dates that are identified for each goal. A list of services that do not need to be included: Treatment Plan Development, Treatment Plan Review, Evaluation or Assessment services provided to establish a diagnosis and to gather information for the development of the treatment plan.Signatures need to be dated: Recipient, parent, guardian, legal custodian, treating practitioner.Discharge CriteriaMedicaid will reimburse for services provided within 45 days prior to the signature of the treating practitioner.Removed:A Brief Behavioral Health Status Examination, Psychiatric Evaluation or other assessment conducted by a licensed practitioner of the healing arts must be completed prior to the development of the treatment plan. An assessment by a licensed practitioner of the healing arts completed with the past six months may be used to satisfy this requirement.Added under “Assessment RequirementAddendum and Temporary Service AuthorizationModified & NewA treatment plan addendum can be used to add additional services or to modify services prescribed on the treatment plan. Anytime there is a temporary increase in prescribed services, the provider must report the increase using the Temporary Service Authorization, found in the appendices. The Temporary Service Authorization can be used to report the provision of crisis-oriented services that are not prescribed in the treatment plan. This form may also be used for documenting the need for services already provided when a recipient leaves treatment prior to completion of the treatment plan. When used for this purpose, the form must be completed within 45 days of intake and the recipient’s file must reflect the recipient has been discharged from services. The Temporary Service Authorization must be completed, signed, and dated by a treating practitioner and placed in the recipient’s clinical record. The Temporary Service Authorization cannot be used to add ongoing services to a recipient’s treatment plan.Treatment Plan ReviewModified & NewSpecific documentation requirements:Current diagnosis code(s) and justification for any changes in diagnosis Recipient’s progress toward meeting individualized goals and objectives Recipient’s progress toward meeting individualized discharge criteria Updates to aftercare plan Findings Recommendations Dated signature of the recipient Dated signature of the recipient’s parent, guardian, or legal custodian (if the recipient is under the age of 18 years) Signatures of the treatment team members who participated in review of the plan A signed and dated statement by the treating practitioner that services are medically necessary and appropriate to the recipient’s diagnosis and needs Medical and Psychiatric ServicesGENERAL COMMENT(S):Medical and Psychiatric Services: There are slight variation in the naming of the services:Group Medical Therapy is now called Brief Group Medical TherapyBehavioral Health Screening Service is now called Behavioral Health Related Medical ScreeningBehavioral Health Services have been divided into Behavioral Health Related Services: verbal interactions and Behavioral Health Related Services: medical procedures.Methadone or Buprenorphine Administration is now called Medication Assisted Treatment.Behavioral Health Related Services: Alcohol and other Drug Testing Specimen collection has been added as a new code: H0048: $10.00 per event. Medicaid reimburses 52 behavioral health-related medical services: alcohol and other drug screening specimen collections per recipient, per state fiscal year.STANDARD/REQUIREMENTSTATUSDESCRIPTIONADDITIONAL COMMENTSIntroductionModified & NewFacilitating informed consent.Medication Management cannot be provided in a group.The following services are included under medical and psychiatric services:Medication management Brief individual medical psychotherapy Brief group medical therapyBehavioral health-related Medical screening servicesBehavioral health-related services: verbal interactions Behavioral health-related services: medical procedures Behavioral health-related services: alcohol and other drug testing specimen collection Medication assisted treatmentRefer to Handbook for specific qualifications for providers of medical servicesBehavioral Health Related Medical Services: Verbal InteractionModified & NewThis procedure covers a verbal interaction (15-minute minimum) between a qualified medical professional and a recipient. This service must be directly related to the recipient’s behavioral health disorder or to monitor side effects associated with medication.The new manual has separated Verbal Interaction and Medical Procedure.Behavioral Health Related Medical Services: Medical ProceduresModified & NewThe corresponding procedure code covers the following services: Specimen collection (for the purposes of medication management) Taking of vital signs Administering injections This service must be directly related to the recipient’s behavioral health disorder or to monitor side effects associated with psychotropic medication.Behavioral Health Medical Services: Alcohol and Other Drug Screening Specimen CollectionNewThis procedure code covers specimen collection for the purposes of alcohol and other drug testing for the treatment of substance use disorders.Many providers, including Master’s and Bachelor’s practitioners Behavioral Health Therapy ServicesGENERAL COMMENT(S):Group Therapy: Medicaid will reimburse where the group size is equal to 15 or fewer. (It was 10 with mental health diagnosis and 15 with substance abuse).Behavioral Health Day Services: Documentation requirement changed to at least a daily progress note that addresses each service provided. For ages 2-5 documentation must include a weekly summary note of the specific therapeutic activities rendered that is signed by at least a Master’s level practitionerSTANDARD/REQUIREMENTSTATUSDESCRIPTIONADDITIONAL COMMENTSIndividual and Family TherapyModifiedThe focus or primary beneficiary of individual and family therapy services must always be the recipient.Individual and family therapy services must be provided by one of the following qualified practitioners: Physician Psychiatrist PPA Psychiatric ARNP LPHA Master’s level CAP Master’s level practitioner Group TherapyModified & NewGroup therapy services include the provision of cognitive behavioral or supportive therapy interventions to an individual recipient or the recipient’s family. In addition to counseling, group therapy services to recipient families or other responsible persons include educating, the sharing of clinical information, and guidance on how to assist the recipient. Physician Psychiatrist PPA Psychiatric ARNP LPHA Master’s level CAP Master’s level practitionerCAP Bachelor’s level practitioner Medicaid will reimburse for group therapy where the total group size is equal to 15 or fewer participants.Behavioral Health Day ServicesModified & NewThese services are designed to enable recipients to function successfully in the community in the least restrictive environment and to restore or enhance ability for personal, social, and prevocational life management services. Behavioral health day services utilize an intensive therapeutic treatment approach to stabilize the symptoms of behavioral health disorders. These services should be used to provide transitional treatment after an acute episode or to reduce or eliminate the need for more intensive levels of care.. Behavioral Health Therapy Services (continued)Behavioral Health Day Services (continued)Modified & NewBehavioral health day services are appropriate early childhood therapeutic services provided to recipients ages 2 years through 5 years who are experiencing emotional problems and who meet the eligibility criteria described below. Services are designed to strengthen individual and family functioning, prevent more restrictive placement of recipients, and provide an integrated set of interventions to promote behavioral and emotional adjustments. Services must be provided in a therapeutic milieu that allows for a broad range of therapeutic activities designed for the treatment of specific social, emotional, and behavioral problems. Services must be delivered in a coordinated manner and must be appropriate for the developmental age of the recipient. Services must be individualized and directly related to the treatment plan goals and the long-term goal of returning the recipient to regular day care, preschool, or the least restrictive environment possible. Eligibility Criteria:Be age 2 or older Score in at least the moderate impairment range on a behavior and functional rating scale developed for this age group. Components:Behavioral day services are comprised of individual, group or family therapy services.Provision of insight oriented, cognitive behavioral or supportive therapy to an individual recipient or family.May involve the recipient’s family without the recipient present or a combination. Group therapy services include the provision of cognitive behavioral, supportive therapy, or counseling to individuals or family.Therapeutic care services assist the recipient in the development of the skills necessary for independent living and for symptom management.Program Requirement for Recipients Ages 2-5 Years:Services must be provided for a minimum of two to a maximum of four hours within the day. This need not be a continuous time period, but must be provided in one day. Therapeutic activities, as listed in the recipient’s treatment plan, must be interwoven throughout the recipient’s scheduled activities. The day treatment program must have a parent or caregiver component. At a minimum, there should be a monthly face-to-face contact with the parent or caregiver at the day treatment center or at the recipient’s home. If the provider is unable to involve the parent or caregiver or meet the requirement for the face-to-face contact, a telephone contact is allowable, but is not reimbursable as part of day treatment. Written justification of why the face-to-face intervention could not occur must be provided in the recipient’s clinical record. The group size during therapeutic activities must not exceed 10 recipients. The behavioral health day services staff-to-recipient ratio during therapeutic activities cannot exceed 1:5. Infant mental health aides may be used to meet these staffing requirements. Refer to CBHS Handbook for provider requirementsBehavioral Health Therapy Services (continued)Behavioral Health Day Services Certification and Specific Documentation RequirementsNewPrior to receiving behavioral health day services, a physician or a LPHA experienced in the diagnosis of mental disorders in young children must provide written certification:Recipient meets service eligibility criteria.Services can be expected to slow deterioration, or maintain or improve the recipient’s condition and functional level.Recipient’s condition or functional level cannot be improved in a less restrictive level of care.Documentation Requirements:At least a daily progress note that addressed each service provided.For ages 2-5 documentation must include a weekly summary note of the specific therapeutic activities rendered that is signed by at least a Master’s level munity Support and Rehabilitative ServicesGENERAL COMMENT(S):Psychosocial Rehabilitation: Group size restrictions equal to 12 or fewer. (It was a total group size of 12 and 15 with substance abuse diagnosis). Documentation to include at least a daily note that addresses each service provided.Clubhouse services: Medicaid will reimburse for provision of clubhouse services up to 12 participants per staff member. Specific documentation requirement: At least a daily progress note that addresses each service provided.Removal of language: In order to bill for this service, the Clubhouse program must be based upon the International Center for Clubhouse Development (ICCD) International Standard for Clubhouse Programs and must be working toward ICCD Certification.Therapeutic Behavioral On-Site Services for Recipients Under the Age of 21 Years GENERAL COMMENT(S):TBOS removed--Axis I Diagnosis, enrollment in a special education program for the seriously disturbed or the emotionally handicapped or has scored a 60 or below on the Axis V GAF within the last month. OR Axis I Diagnosis, there is adequate evidence to indicate that the child or adolescent is at risk for a more intensive, restrictive, and costly behavioral health placement. AND there is adequate evidence to indicate that the child’s or adolescent’s condition and functional level cannot be improved with a less intensive service such as individual or family therapy and group therapy.STANDARD/REQUIREMENTSTATUSDESCRIPTIONADDITIONAL COMMENTSTBOS Eligibility CriteriaModified & NewUnder the age of 2 years and meets one of the following criteria:Exhibiting symptoms of an emotional or behavioral nature that are atypical for the recipient’s age and development that interferes with social interaction and relationship development. Failure to thrive (due to emotional or psychosocial causes, not solely medical issues). Ages 2 years through 5 years and meets both of the following criteria: Exhibiting symptoms of an emotional or behavioral nature that are atypical for the recipient’s age and development. Score in at least the moderate impairment range on a behavior and functional rating scale developed for the specific age group. Ages 6 years through 17 years and meets one of the following criteria: Have an emotional disturbance. Have a serious emotional disturbance. Have a substance use disorder. Ages 18 years through 20 years, but otherwise meet the criteria for an emotional disturbance or a serious emotional disturbance.Therapeutic Behavioral On-Site Services for Recipients Under the Age of 21 Years (continued)Formal Aftercare PlanModified & NewThe recipient and the recipient’s family should collaborate with the treating staff to develop the recipient’s individualized formal aftercare plan within 45 days of admission to therapeutic behavioral on-site services. A formal aftercare plan should include community resources, activities, services, and supports that will be utilized to help the recipient sustain gains achieved during treatment. The formal aftercare plan must be placed in the recipient’s clinical record.Place of ServiceModifiedServices must be provided in community settings, including where the recipient resides and is educated. When possible, services should be provided in settings where the recipient is experiencing emotional or behavioral difficulties.Therapy ServicesModifiedTherapeutic behavioral on-site therapy services include the following: Individual and family therapy Collaborative development of the formal aftercare plan Must be provided by:Physician (added)Psychiatrist (added)LPHAMaster’s level CAP (added)Master’s level practitionerPractitioners must have training and experience in infant, toddler, and early childhood development and the observation and assessment of young children when treating recipients under the age of 6 years.Behavior Management ServicesModifiedTherapeutic behavioral on-site behavior management services must be provided by a certified behavior analyst, certified assistant behavior analyst, or by one of the following licensed practitioners who has three years of behavior analysis experience and a minimum of 10 hours of documented training every year, dedicated to behavior analysis: Clinical social worker Mental health counselor Marriage and family therapist Psychologist Practitioners must have training and experience in infant, toddler, and early childhood development and the observation and assessment of young children when treating recipients under the age of 6 years.Therapeutic Support ServicesModifiedMust be provided by:Physician (added)Psychiatrist (added)PPA (added)Psychiatric ARNP (added) LPHA (added)Master’s level CAP (added) Master’s level practitioner Bachelor’s level practitioner (added)Certified behavior analyst (added)Certified assistant behavior analyst (added) Therapeutic Support Services (continued)ModifiedCertified recovery peer specialist (added)Certified psychiatric rehabilitation practitioner (added) Certified recovery support specialist (added)Certified behavioral health technician Services for recipients under the age of 6 years must be provided by bachelor’s level infant mental health practitioners or higher. Practitioners must have training and experience in infant, toddler, and early childhood development and the observation and assessment of young children when treating recipients under the age of 6 years.Nursing Facility Residents GENERAL COMMENT(S):New section in the CBHS HandbookCommunity behavioral health services for nursing facilities residents, for whom the nursing facility is billing Medicaid on a per diem basis (not applicable for our population)Excluded ServicesGENERAL COMMENT(S):NoneSTANDARD/REQUIREMENTSTATUSDESCRIPTIONADDITIONAL COMMENTSCommunity Behavioral HealthModifiedMedicaid does not reimburse for community behavioral health services for treatment of a cognitive deficit severe enough to prohibit the service from being of benefit to the recipient. The following are services and supports not reimbursed under community behavioral health services: Services provided to a recipient on the day of admission into the Statewide Inpatient Psychiatric Program (SIPP); however, community behavioral health services are reimbursable on the day of discharge Case management services Partial hospitalization Services rendered to individuals residing in an institution for mental diseases Services rendered to institutionalized individuals, as defined in 42 CFR 435.1009 Basic childcare programs for developmental delays, preschool, or enrichment programs Travel time Activities performed to maintain and review records for facility utilization, continuous quality improvement, recipient eligibility status processing, and staff training purposes Activities (other than record reviews, services with family member or other interested persons that benefit the recipient, or services performed using telemedicine) that are not performed face-to-face with the recipient, except those defined as: ? Services rendered by a recipient’s relative ? Services rendered by unpaid interns or volunteers ? Services paid for by another funding source ? Escorting or transporting a recipient to and from a service siteCHAPTER 3: REIMBURSEMENT AND FEE SCHEDULEReimbursement InformationGENERAL COMMENT(S):NoneSTANDARD/REQUIREMENTSTATUSDESCRIPTIONADDITIONAL COMMENTSIn-Home Services for Recipients Under the Age of 6 YearsNewIn-home services with the recipient’s parent, guardian, or caregiver can be billed as part of the day services program. If provided on a day when no behavioral health day services are billed, an in-home service may be billed as individual or family therapy or therapeutic behavioral on-site therapy bination of Services that cannot be reimbursed in conjunction with Behavioral Health Day Services for Recipients Ages 2 Years through 5 YearsNewMay not be reimbursed with behavioral day services for the same recipient on the same day:PSRTBOS Therapy, Behavior Mgmt and SupportSTFC Level II, I and CrisisTBOS DJJTBOS CWSPECIALIZED THERAPEUTIC SERVICES COVERAGE AND LIMITATIONS HANDBOOKCHAPTER 1: QUALIFICATIONS, ENROLLMENT AND REQUIREMENTSDefinitionsGENERAL COMMENT(S):NoneSTANDARD/REQUIREMENTDESCRIPTIONADDITIONAL COMMENTSEmotional Disturbance under age 21diagnosed with disorder meeting DSM categorynot exhibiting symptoms significant enough to substantially interfere with functioningnot a temporary response to a stressful situationSerious Emotional Disturbanceunder age 21diagnosed with disorder meeting DSM categoryexhibiting symptoms significant enough to substantially interfere with functioningnot a temporary response to a stressful situationMultidisciplinary TeamThe role of the MDT is to assess whether the recipient is appropriate for specialized therapeutic foster care (STFC). A MDT consists of a representative from the Department of Children and Families (DCF), or its designee, the local Medicaid area office, or the Department of Juvenile Justice (when applicable). Other MDT members should include the recipient, the recipient’s case manager, a representative from the recipient’s school, the recipient’s biological or adoptive parents or relatives, the foster care parents or emergency shelter staff, assigned counselors or case managers, and the recipient’s medical health care provider.Definitions (continued)Other Responsible PersonsA relative, legal guardian, caretaker, or other individuals and natural supports who are known to the recipient and family and are active in providing care to the recipientFor services provided in the school, this may also include a child’s classroom teacher or guidance counselor. Provision of services where the family or other responsible persons are involved must clearly be directed to meeting the identified treatment needs of the recipient. Services provided to family members or other responsible persons independent of meeting the identified needs of the recipient are not reimbursable by Medicaid. Could broaden the list of those who could be seen and contacts billed under therapy categories (individual and family, group etc.)Shelter StatusThe legal status that begins when a recipient under the age of 18 years is taken into the protective custody of the Department of Children and Families (DCF) and ceases when one of the following occurs: Court grants custody to a parent. After disposition of the petition for dependency. Court orders the child to be released to a parent or placed in the temporary custody of a relative, a non-relative, or DCF.Hub SiteThe telecommunication distance site in Florida at which the consulting physician, dentist or therapist is delivering telemedicine services. Spoke SiteThe provider office location in Florida where an approved service is being furnished through telemedicine. TelemedicineThe practice of health care delivery using telecommunication equipment by the treating provider (at the spoke site) for the provision of approved covered services by the consulting provider (at the hub site) for the purpose of evaluation, diagnosis, or treatment. The following interactions do not constitute reimbursable telemedicine services: Telephone conversations Video cell phone interactions E-mail messages Facsimile transmission “Store and forward” visits and consultations, which are transmitted after the recipient or psychiatrist is no longer available Therapeutic Home AssignmentTherapeutic home assignments are overnight stays the recipient spends with the biological, adoptive, or extended family, or in a potential placement in order to practice the generalized skills learned in treatment at the recipient’s home or other natural settings. Therapeutic home assignments must be prior authorized by the primary clinician and they must be recorded in the recipient’s clinical record. Therapeutic home assignments may include time spent away overnight with friends, school, or club activities. Therapeutic home assignments are planned in conjunction with the recipient’s treatment goals and objectives. A primary clinician or a specialized therapeutic foster parent must be accessible and must maintain a level of communication during therapeutic home assignments. Replaces therapeutic visits not linked to dischargeDefinitions (continued)Treatment PlanIndividualized recipient treatment plans must directly address the primary diagnosis(es) that is(are) consistent with the assessment. The provider must document efforts to coordinate services for behavioral health diagnoses outside their expertise that, if treated, would assist meeting the recipient’s goals.Added language Staff QualificationsGENERAL COMMENT(S):There are also additions and changes to the list of staff and qualifications. The primary changes are greater specificity in required coursework. The amount of required CEUs is set at 30 hours every two years - consistent with requirements to maintain master's level licensure.STANDARD/REQUIREMENTDESCRIPTIONADDITIONAL COMMENTSMasters Level PractitionerSpecific requirement that a Master's Level Practitioner be supervised by a Licensed Practitioner of the Healing Arts.Psychiatric Advanced Registered Nurse Practitioner (ARNP)A psychiatric ARNP must have education or training in psychiatry and be authorized to provide these services in accordance with Chapter 464, F.S., and protocols filed with the Florida Board of Nursing.Psychiatric Clinical Nurse Specialist (CNS) A psychiatric CNS must have a subspecialty in child/adolescent psychiatric and mental health or psychiatric and mental health and be licensed in accordance with Chapter 464, F.S., and who must meet all of the following criteria: A current and active license as a registered nurse in Florida. A master’s degree or higher in nursing as a CNS. Provide proof of current certification in a specialty area as a CNS from one of the four certifying bodies: American Nurses Credentialing Center, American Association of Critical-Care Nurses, Oncology Nursing Certification Corporation, and National Board for Certification of Hospice and Palliative Nurses; or meets the requirements of Chapter 464, F.S and has provided the required affidavit. A certificate issued by the Florida Board of Nursing as a CNS. A registered nurse currently enrolled as an LPHA must be licensed as a CNS with a subspecialty of child/adolescent psychiatric and mental health or psychiatric and mental health by January 1, 2016.CBHA AssessorMinimum of 30 hours of documented training, dedicated to relevant child and family treatment issues, within the last two years. Master’s level practitioners must complete child and adolescent needs and strengths (CANS) recertification and a minimum of 30 hours of training, relevant to child and family issues, every two years. To be in compliance with the policy of DCF related to assessment of children in the legal custody of DCF, comprehensive behavioral health assessments completed by a non-licensed person must be reviewed and co-signed by a licensed professional to verify the assessment is accurate and complete. Prior to enrollment, an individual practitioner not currently enrolled in Florida Medicaid, must complete child and adolescent needs and strengths (CANS) assessment training, provided by a certified trainer or an approved online training course, and must obtain CANS certification.Other Requirements and General CoverageGENERAL COMMENT(S):The service-specific Medicaid coverage and limitations handbooks provide the minimum requirements for all providers. This includes providers who contract with Florida Medicaid health plans (e.g., provider service networks and health maintenance organizations). Providers shall comply with all of the requirements outlined in this handbook, unless otherwise specified in their contract with the health plan. The provision of services to recipients enrolled in a Medicaid health plan shall not be subject to more stringent criteria or limits than specified in this handbook.STANDARD/REQUIREMENTDESCRIPTIONADDITIONAL COMMENTSRecipient Clinical RecordRequires consent for treatment that is signed by the recipient or the recipient’s legal guardian.CHAPTER 2: COVERED, LIMITED AND EXCLUDED SERVICESComprehensive Behavioral Health AssessmentsGENERAL COMMENT(S):NoneCBHA Provider Self-CertificationMust have policies and procedures that address the following:Maintaining written records for every recipient (note requirement to keep files)Maintaining confidentiality and security of clinical records Credentialing, re-credentialing, and reappointing practitioners Establishing a program evaluation system to review the processes and outcomes on at least an annual basis An individual must be certified as meeting the requirements of a comprehensive behavioral health assessor, as defined in this handbook, before enrolling in Medicaid as an individual comprehensive behavioral health assessment provider. EligibilityAllows for CBHAs (annually?) up until the age of 21 years for recipients with mental health, substance use, and co-occurring mental health and substance use disorders. Recipient must be under the age of 21 years and meet all of the following criteria: Be a victim of abuse or neglect Have been determined by the Department of Children and Families (DCF) or their designee to require out-of-home care or be placed in shelter status Or the recipient must meet all of the following criteria: Have committed acts of juvenile delinquency Be suffering from an emotional disturbance or a serious emotional disturbance Be at risk for placement in a residential settingComponents of CBHAsMust include direct observation in the following settings whenever the recipient routinely participates in these settings:HomeSchool or child careWork siteCommunityFor Children under the age of 6 yearsNo longer says the CANS must be usedInstead says completion of a standardized assessment such as the CANS.For Children 6 to 20 yearsNo longer says the CANS must be usedInstead says completion of a standardized assessment such as the CANS.CHAPTER 2: COVERED, LIMITED AND EXCLUDED SERVICESComprehensive Behavioral Health Assessments (continued)AuthorizationDCF or their designee, or the recipient’s managed care plan must authorize the comprehensive behavioral health assessment services utilizing the Authorization for Comprehensive Behavioral Health Assessment form, found in the appendices. The provider must keep the authorization form on file in the recipient’s clinical record. Time Frame for CompletionRemoved the requirement for completion within 24 calendar days; however, it should be completed in a timely manner and in compliance with CFOP 155-10 and 175-40.This issue may be further addressed by Sunshine, Cenpatico, DCF and CBCIHReimbursementThe assessment is reimbursed on the date that the report is completed. The date of referral may be used as the date of service if the recipient entered the Statewide Inpatient Psychiatric Program or if the recipient loses Medicaid eligibility prior to completion of the assessment. Cleared up how to bill when coverage is lost.Specialized Therapeutic Foster Care ServicesGENERAL COMMENT(S):NoneSTANDARD/REQUIREMENTSTATUSDESCRIPTIONADDITIONAL COMMENTSIntroductionNewSpecialized therapeutic foster care services are intensive treatment services provided to recipients under the age of 21 years with emotional disturbances who reside in a state licensed foster home.IntroductionDeletedA specialized therapeutic foster parent must be available 24 hours per day to respond to crises or to provide special therapeutic interventions. DELETED: A Level II specialized therapeutic foster home must have at least one licensed parent who is not employed outside the home and is available 24 hours a day.IntroductionModifiedSpecialized therapeutic foster care levels are intended to support, promote competency, and enhance participation in normal age-appropriate activities of children who present moderate to severe emotional or behavioral management problems.Was serious in 2004 Handbook.Authorization for STFC ServicesModifiedThe multidisciplinary team must authorize specialized therapeutic foster care services. If the multidisciplinary team determines that the recipient requires specialized therapeutic foster care services, the Authorization for Therapeutic Foster Care form, found in the appendices, is completedWas child in 2004 HandbookAuthorization for STFC ServicesDeletedThe district designated multidisciplinary team must re-authorize specialized therapeutic foster care services no less than every six months. A new Authorization for Specialized Therapeutic Foster Care Form must be completed and signed by the multidisciplinary team.Authorization for STFC ServicesModifiedThe Authorization for Specialized Therapeutic Foster Care form must be forwarded to the provider agency to be placed in the recipient’s clinical record.Was child’s in 2004 Handbook.Foster Home Capacity/Exceptions for SiblingsDeletedNo more than two specialized or regular foster care children or children committed to Juvenile Justice may reside in a home being reimbursed for specialized therapeutic foster care services.Only in the case of placement of a sibling(s) of the therapeutic foster care child may the two-child limit be exceeded and only when the specialized therapeutic foster home has the licensed capacity.However: Per Statute:65C-13.030 Standards for Licensed Out-of-Home Caregivers - (c) There shall be no more than two children placed in a therapeutic family foster home unless an exception has been approved.CBCIH is modifying the Waiver Policy, which each CBC is required to currently have.Specialized Therapeutic Foster Care Services (continued)Who Can Receive – Level IAddedLevel I specialized therapeutic foster care is for recipients with a history of abuse or neglect, or delinquent behavior, and who have an emotional disturbance or serious emotional disturbance. Crisis Intervention ServicesNewFor recipients who are enrolled in managed care, the plan must authorize approval for crisis intervention services. Responsibilities of the Primary ClinicianDeletedWorking with the Department of Children & Families, community-based care lead agency or the Department of Juvenile Justice counselor to coordinate other treatment initiatives, including school performance, permanency, and reunification planning. Responsibilities of the Primary ClinicianModifiedTook wording from 2004 Manual & placed in this section: Conducting home visits at least once weekly for recipients in Level I and at least twice weekly for recipients in Level II or crisis intervention services. Caseload of Primary CliniciansNewThe maximum caseload for full-time (40-hour employment week) primary clinicians can be less than, but must not exceed: Crisis intervention—six recipients receiving specialized therapeutic foster care. The caseload of primary clinicians employed or under contract for 20 hours a week should not exceed the following: Crisis intervention—three recipients receiving specialized therapeutic foster care. Treatment Plan & Treatment Plan Review RequirementsNewA treatment plan must be developed by the primary clinician within the following number days of admission: Level I—30 days Level II—14 days Crisis intervention—14 days Treatment Plan and Treatment Plan Review Signature Exceptions NewIf the recipient’s age or clinical condition precludes participation in the development and signing of the treatment plan, an explanation must be provided on the treatment plan. Treatment Plan and Treatment Plan Review Signature ExceptionsModifiedThere are exceptions to the requirement for a signature by the recipient’s parent, guardian, or legal custodian. Documentation and justification of the exception must be provided in the recipient’s clinical record. Was medical in 2004 HandbookExceptions to the Requirement for Signature of Parent, Guardian, or Legal Custodian DeletedAs stated in Chapter 394.4784 (1 & 2), F.S., recipients age 13 years or older, experiencing an emotional crisis to such a degree that he or she perceives the need for professional assistance. The recipient has the right to request, consent to, and receive mental health diagnostic and evaluation services, outpatient crisis intervention services, including individual psychotherapy, group therapy, counseling, or other forms of verbal therapy provided by a licensed mental health professional, or in a mental health facility licensed by the state. The purpose of such services is to determine the severity of the problem and the potential for harm to the person or others if further professional services are not provided. Outpatient diagnostic and evaluative services will not include medication and other somatic methods, aversive stimuli, or substantial deprivation. Such services will not exceed two visits during any 1-week period in response to a crisis situation before parental consent is required for further services, and may include parental participation when determined to be appropriate by the mental health professional or facility.This portion was removed in the new STS Handbook.Specialized Therapeutic Foster Care Services (continued)Specialized Therapeutic Foster Care Service Reimbursement for TripsModifiedWas previously Vacations with Specialized Therapeutic Foster FamilyAppendix A – Limited Service AuthorizationDeletedNo longer in the 2014 STS Handbook.Appendix A – Procedure Codes and Fee ScheduleModifiedTook place of former Appendix AAppendix B - Authorization for CBHAModifiedChild changed to Recipient; Florida Medicaid Community Behavioral Health Services Coverage & Limitations Handbook changed to Florida Medicaid Specialized Therapeutic Services Coverage & Limitations Handbook; District Substance Abuse & Mental Health Representative signature line removed; District Family Safety Representative removed from the signature line; Managed Care Plan Representative signature line added; CBC Representative removed from DCF (or designee) signature line; and To be placed in the recipient’s clinical file changed from child’s medical file.Appendix C - Comprehensive Behavioral Health Assessment Agency and Practitioner Self-CertificationModifiedCBHA Agency & Practitioner Self-Certification; Modified FROM: has met the qualifications to be a provider of Comprehensive Behavioral Health Assessment by providing documentation to Substance Abuse and Mental Health staff who will provide this service to meet the qualifications as outlined in the Florida Medicaid Community Behavioral Health Services Coverage and Limitations handbook.; Modified TO: meets the qualifications to be a provider of comprehensive behavioral health assessment by providing documentation to the Medicaid area office staff who have verified that the agency or practitioner has met the qualifications as outlined in the Florida Medicaid Specialized Therapeutic Services Coverage and Limitations Handbook.Took off signature lines for SAMH, DCF/CBC, DJJ, and Medicaid Representatives. Appendix D - Specialized Therapeutic Foster Care Provider Agency Self – CertificationModifiedSpecialized Therapeutic Foster Care Provider Agency Self – Certification; Replaced Florida Medicaid Community Behavioral Health Services Coverage & Limitations Handbook with Florida Medicaid Specialized Therapeutic Services Coverage & Limitations Handbook; Removed the Begin and End dates of the certification; Took out listed criteria; Took off signature lies for SAMH, DCF/CBC, DJJ, and Medicaid Representatives.Appendix E - Authorization for STFCModifiedAdded: The recipient is eligible for Specialized Therapeutic Foster Care as follows: The recipient meets eligibility criteria for service. Multidisciplinary team has determined the child is in need of the service.Took out signature lines for SAMH, DCF/CBC, & DJJ Representatives; Added (or designee) after Medicaid Area Office RepresentativeAppendix F – Authorization for Crisis InterventionNew & ModifiedRecipient has been screened and recommended for Crisis Intervention by the multidisciplinary team. The recipient is eligible for Specialized Therapeutic Foster Care as follows: The recipient meets eligibility criteria for service. Multidisciplinary team has determined the child is in need of the service.Took out signature lines for SAMH, DCF/CBC, & DJJ Representatives; Added (or designee) after Medicaid Area Office RepresentativeServices will be authorized by the multidisciplinary team from: ______DateAppendices for BHOS RemovedDeletedMoved to BHOS HandbookSpecialized Therapeutic Foster Care Services (continued)Appendix G – Provider Agency Acknowledgement for TGC ServicesModifiedReplaced Florida Medicaid Community Behavioral Health Services Coverage & Limitations Handbook with Florida Medicaid Specialized Therapeutic Services Coverage & Limitations Handbook; Took out listing of the criteria;Appendix G takes the place of Appendix K – TGC Provider Agency CertificationAppendix H – Authorization for TGC ServicesModifiedTook out signature lines for SAMH & DCF/CBC; Added (or designee) after Medicaid Area Office RepresentativeQualifications of Foster ParentsMoved to DefinitionsSpecialized therapeutic foster care parents must have completed training required of all licensed foster parents and must receive 30 additional clock hours of pre-service, criterion-based training to prepare them to become treatment oriented foster care parents prior to having children placed in the home.The district Substance Abuse and Mental Health program office, along with the enrolled provider, must assure that the therapeutic foster parents meet the qualifications and training requirements before a child is placed in the home and reimbursement is received from Medicaid.Foster Parent Training RequirementsMoved to DefinitionsFoster home parents already licensed by the state must meet one of the following training requirements prior to the child being placed in the home:Have received pre-service training, orProvide documentation of having received commensurate training within the last two years.Pre-Service Training ComponentsMoved to DefinitionsSpecialized therapeutic foster parent pre-service training must be approved by the DCF or their designee, or by a managed care plan for their network providers. The specialized therapeutic foster parent pre-service training must address at least the following areas:Program orientation including the responsibilities of the treatment parent and provider agency;Normal childhood development;Emotional disturbances in children and common behavioral problems exhibited;Behavior management, theory and skills;Discipline, limit-setting, logical consequences, problem-solving, and relationship building skills;Communication skills;Permanency planning;Stress management;Crisis intervention and emergency procedures;Self-defense and passive physical restraint;Working with biological or adoptive families;Placement adjustment skills;Confidentiality;Cultural competency; andBehaviors and emotional issues of children who have been sexually abused.Specialized Therapeutic Foster Care Services (continued)Other Care ProvidersModified2004 Version: Care providers other than the specialized therapeutic foster parents (e.g., baby sitters) must have the information and training necessary to properly care for the child and must be prior approved in writing by the clinical staff person.2014 Version: A relative, legal guardian, caretaker, or other individuals and natural supports who are known to the recipient and family and are active in providing care to the recipient. For services provided in the school, this may also include a child’s classroom teacher or guidance counselor. Provision of services where the family or other responsible persons are involved must clearly be directed to meeting the identified treatment needs of the recipient. Services provided to family members or other responsible persons independent of meeting the identified needs of the recipient are not reimbursable by Medicaid.In-Service Training RequirementsModified2004 Version: Specialized therapeutic foster parents must receive ongoing in-service training from clinical staff to support, enhance, and improve their treatment skills and strengthen their abilities to work with specific children. In-service training should be provided as often as needed, but not less than:Level I - 4 clock hours per quarter; andLevel II - 6 clock hours per quarter.2014 Version: Specialized therapeutic foster parents must receive ongoing in-service training from clinical staff to support, enhance, and improve their treatment skills and strengthen their abilities to work with specific children. In-service training should be provided as often as needed, but not less than: Level I: 8 clock hours every six months Level II: 12 clock hours every six monthsTherapeutic Group Care ServicesGENERAL COMMENT(S):Sections have been moved and may lead to confusion or belief that requirement/issue is no longer in the handbookSTANDARD/REQUIREMENTSTATUSDESCRIPTIONADDITIONAL COMMENTSPurpose and DefinitionsModifiedClarity in some existing definitions and the addition of terms such as “Spoke” site and therapeutic home assignment as well as, Treatment Plan and Treatment Plan ReviewStaff QualificationsModifiedNew professionals added to this section and clarification for some positions found in the old handbookRefer to CBHS & BHOS HandbooksEnrollmentModifiedSelf-certification by STGC provider, rather than annual monitoring. EligibilityModifiedUnder 21 years of agePreviously specified under 18 years of ageSpecialized Therapeutic Group Care ServicesModified & NewSpecific language re: Treatment Plans and ReviewsExcluded ServicesModified & NewAdds language re: cognitive deficit. Adds other exclusions not reimbursable under STGC services and supportsCognitive deficit language not includedTherapeutic Group Care Services (continued)Reimbursement InformationModifiedAdds language regarding maintaining medical and dental benefits under Medicaid if in STGC for fewer than 16 days. Also clarifies TCM eligibility while in STGCTherapeutic Home AssignmentsModifiedLanguage changed to Therapeutic Home Assignments; adds clarity to usage and timeframesTherapeutic Home VisitBEHAVIORAL HEALTH OVERLAY SERVICES COVERAGE AND LIMITATIONS HANDBOOKCHAPTER 1: QUALIFICATIONS, ENROLLMENT AND REQUIREMENTSPurpose and DefinitionsGENERAL COMMENT(S):None STANDARD/REQUIREMENTSTATUSDESCRIPTIONADDITIONAL COMMENTSDischarge CriteriaNewMeasurable criteria established at the onset of treatment that identify a recipient’s readiness to transition to a new level of care or out of care. Must be included on the recipient’s Individualized Treatment Plan and is separate and apart from the treatment plan goals and objectives. The recipient and the treating staff should collaborate to develop the individualized, measurable discharge criteria. The recipient’s progress toward meeting the discharge criteria should be addressed throughout the course of treatment as part of the treatment plan review. Added separate, distinct requirement for discharge criteriaEmotional DisturbanceNew (Definition)A person under the age of 21 years who is diagnosed with a mental, emotional, or behavioral disorder of sufficient duration to meet one of the diagnostic categories specified in the most recent edition of the Diagnostic and Statistical Manual of the APA, but who does not exhibit behaviors that substantially interfere with or limit the role or ability to function in the family, school, or community. The emotional disturbance must not be considered to be a temporary response to a stressful situation.Serious Emotional DisturbanceNew (Definition)A person under the age of 21 years who is diagnosed with a mental, emotional, or behavioral disorder of sufficient duration to meet one of the diagnostic categories specified in the most recent edition of the Diagnostic and Statistical Manual of the APA.Exhibits behaviors that substantially interfere with or limit the role or ability to function in the family, school, or community. The emotional disturbance must not be considered to be a temporary response to a stressful situation.Other Responsible Persons ModifiedA relative, legal guardian, caretaker, or other individuals and natural supports who are known to the recipient and family and are active in providing care to the recipient. For services provided in the school, this may also include a child’s classroom, teacher or guidance counselor. Provision of services where the family or other responsible persons are involved must clearly be directed to meeting the identified treatment needs of the recipient. Services provided to family members or other responsible persons independent of meeting the identified needs of the recipient are not reimbursable by Medicaid.Shelter StatusNew to BHOSThe legal status that begins when a recipient under the age of 18 years is taken into the protective custody of the Department of Children and Families (DCF) and ceases when one of the following occurs:Court grants custody to a parentAfter disposition of the petition for dependencyCourt orders the child to be released to a parent or placed in the temporary custody of a relative, a non-relative or DCFDefines legal status; Child Welfare/Foster Care definition expanded to age 21Purpose and Definitions (continued)Staff AdministratorNewResponsible individual for the ongoing operations of behavioral health overlay services within the provider agency.Adds an administrative responsibilityStaff Qualifications & EnrollmentGENERAL COMMENT(S):NoneSTANDARD/REQUIREMENTSTATUSDESCRIPTIONADDITIONAL COMMENTSTreating PractitionerModifiedA Medicaid-enrolled professional who authorizes services within the purview of the treating practitioner’s credentials and state law on behalf of the Medicaid group provider (provider type 05).Treatment TeamModifiedKey staff involved in planning and providing BHOS services to the recipient.GeneralNewBehavioral Health Overlay Services staff must provide services within the scope of their professional licensure or certification, training, protocols and competence. Providers must maintain records with:Background screening resultsState mandated I-9 resultsStaff qualificationsVerification of work experienceReference checksEvidence of ongoing trainingThese records must additionally reflect adherence to human resources policies and procedures established by the provider.Specifies personnel file content requirements, standard proceduresBachelor’s Level PractitionerModifiedA Bachelor’s level practitioner must meet all of the following criteria:A Bachelor’s degree from an accredited university or college with a major in counseling, social work, psychology, nursing rehabilitation, special education, health education or a related human services field.Training in the treatment of behavioral health disorders, human growth and development, evaluations, assessments, treatment planning, basic counseling and behavior management interventions, case management, clinical record documentation, psychopharmacology, abuse regulations and recipient rights.Work under the supervision of a Master’s level practitioner.Behavioral Health Overlay CounselorModifiedA Behavioral Health Overlay Counselor must meet one of the following qualifications:Master’s level practitionerBachelor’s level practitionerBehavioral Health TechnicianModifiedA Behavioral Health Technician must:Have a high school diploma or equivalent and in-service training in the treatment of mental health disorders, abuse regulations, recipient rights, crisis management interventions, and confidentiality.Work under the supervision of a Bachelor’s level practitioner or higher.Be certified as a Behavioral Health Technician by the Florida Certification Board (FCB).Certified Associate Behavior AnalystNewA Certified Associate Behavior Analyst must be a National Board Certified Associate Behavior Analyst or Florida Associate Behavior Analyst, who maintains active certification for a Florida Board Certified Associate Behavior Analyst.Staff Qualifications & Enrollment (continued)Certified Addictions ProfessionalModified & NewA CAP with a master’s degree must enroll as provider type 07 and must also be linked to a community behavioral health group (provider type 05) in order to authorize services for treatment for substance use disorders.Certified Behavior AnalystModifiedA certified Behavior Analyst must be a National Board Certified Behavior Analyst or Florida Behavior Analyst who maintains active certification for a Florida Board Certified Behavior Analyst. A Board Certified Behavior Analyst may possess a Master’s degree (BCBA) or Doctoral degree (BCBA-D).Certified Psychiatric Rehabilitation PractitionerNewA Certified Psychiatric Rehabilitation Practitioner must be certified by the Certification Commission for Psychiatric Rehabilitation, established by the United States Psychiatric Rehabilitation Association, and is working under the supervision of a Bachelor’s level practitioner or higher.Certified Recovery Peer Specialist—AdultNewA Certified Recovery Peer Specialist—Adult must be certified by the FCB and work under the supervision of a Bachelor’s level practitioner, Master’s level CAP, or higher.Certified Recovery Peer Specialist—FamilyNewA Certified Recovery Peer Specialist—Family must be certified by the FCB and work under the supervision of a Bachelor’s level practitioner, Master’s level CAP, or higher.Certified Recovery Support SpecialistNewA Certified Recovery Support Specialist must be certified by the FCB and work under the supervision of a Bachelor’s level practitioner, Master’s level CAP, or higher.Clinical Services SupervisorModifiedA Clinical Services Supervisor must have a minimum of a Master’s degree and at least two (2) years of experience working with children who have emotional or serious emotional disturbances.Clinical Social WorkerModifiedA Clinical Social Worker must be licensed in accordance with Chapter 491, F.S.Direct Care StaffModifiedDirect Care Staff must be of age 18 years and older and have a high school diploma or General Educational Development certificate. Direct Care Staff must receive both pre-service and in-service training on the delivery of BHOS services.Licensed Practitioner of the Healing Arts (LPHA)ModifiedA treating LPHA must enroll as a provider type 07 and must also be linked to a group provider type 05 for services rendered in the capacity of a treating practitioner in order to be qualified. LPHA;s include:Clinical Social Workers licensed in accordance with Chapter 491, F.S.Mental Health Counselors licensed in accordance with Chapter 491, F.S.Marriage and Family Therapists licensed in accordance with Chapter 491, F.S.Psychologists licensed in accordance with Chapter 490, F.S.Clinical Nurse Specialists (CNS) with a subspecialty in child/adolescent psychiatric and mental health or psychiatric and mental health licensed in accordance with Chapter 496, F.S.Psychiatric Advance Registered Nurse Practitioners licensed in accordance with Chapter 464, F.S.Psychiatric Prescribing Physician Assistants licensed in accordance with Chapters 458 and 459, F.S.Marriage and Family TherapistModifiedA Marriage and Family Therapist must be licensed in accordance with Chapter 491, F.S.Master’s Level PractitionerModifiedA Master’s level practitioner must have a Master’s degree from an accredited university or college with a major in the field of counseling, social work, psychology, nursing, rehabilitation, special education, health education, or a related human services field with one of the following:Two years of professional experience in providing services to persons with behavioral health disorders.Current supervision under an LPHA as described in this section.Staff Qualifications & Enrollment (continued)Master’s Level Practitioner (continued)Modified (cont.)Master’s level practitioners hired after July 1, 2014 with degrees other than social work, psychology, marriage and family therapy, or mental health counseling must have completed graduate level coursework in at least four of the following thirteen content areas: human growth and development; diagnosis and treatment of psychopathology; human sexuality; counseling theories and techniques; group theories and practice; dynamics of marriage and family systems; individual evaluation and assessment; career and lifestyle assessment; research and program evaluation; personality theories; social and cultural foundations; counseling in community settings; and substance use disorders.Medical AssistantNewA medical assistant must be registered or certified in accordance with Chapter 458, F.S.Mental Health CounselorModifiedA Mental Health Counselor must be licensed in accordance with Chapter 491, F.S.Physician’s AssistantModifiedA physician assistant must be a graduate of an approved program or its equivalent or meets standards approved by the Florida Board of Medicine and must be certified to perform medical services in accordance with Chapters 458 and 459, F.S.Psychiatric Advanced Registered Nurse Practitioner (ARNP)ModifiedA psychiatric ARNP must have education or training in psychiatry and be authorized to provide these services in accordance with Chapter 464, F.S., and protocols filed with the Florida Board of Nursing. An ARNP must enroll as a provider type 07 and must also be linked to a group provider type 05.Psychiatric Clinical Nurse Specialist (CNS)NewA psychiatric CNS must have a subspecialty in child/adolescent psychiatric and mental health or psychiatric and mental health and is licensed in accordance with Chapter 464, F.S., and must meet all of the following criteria: A current and active license as a registered nurse in Florida A master’s degree or higher in nursing as a CNS Provide proof of current certification in a specialty area as a CNS from one of the four certifying bodies: American Nursing Credentialing Center, American Association of Critical-Care Nurses, Oncology Nursing Certification Corporation, and National Board of Certification of Hospice and Palliative Nurses; or meet the requirements of Chapter 464, F.S. and has provided the required affidavit A certificate issued by the Florida Board of Nursing as a CNS A registered nurse currently enrolled as an LPHA must be licensed as a CNS with a subspecialty of child/adolescent psychiatric and mental health or psychiatric and mental health by January 1, 2016.Psychiatric Physician Assistant (PPA)NewA PPA must be a licensed prescribing physician assistant as defined in Chapter 458 or 459, F.S., with a Psychiatric Certificate of Added Qualification. The PPA’s supervising physician must be a provider type 25 or 26 that is linked to the community behavioral health group provider type 05.PsychologistModifiedA Mental Health Counselor must be licensed in accordance with Chapter 490, F.S.Substance Abuse TechnicianModifiedA substance abuse technician must have a high school degree or equivalent, must be under the supervision of a bachelor’s level practitioner or higher, and meet one of the following criteria: In-service training in the treatment of substance use disorders Five years of experience working directly with recipients experiencing substance use disorders in a treatment setting The substance abuse technician must be able to function as a member of a recipient’s multidisciplinary team, provide therapeutic support and recognize the signs and symptoms associated with abuse and dependence. The substance abuse technician must be familiar with substance use rules and regulations, confidentiality, twelve-step recovery concepts, clinical record documentation requirements, and patient rights; and be able to respond to special circumstances, such as emergencies, suicide, and out-of-control behavior. Staff Qualifications & Enrollment (continued)Treating PhysicianNewA treating physician must enroll as a provider type 25 or 26 and must also be linked to a community behavioral health group (provider type 05).Treating PractitionerModifiedTreating practitioners include: PhysicianPsychiatristPsychiatric ARNPPPALPHAMaster’s level CAP (for the authorization of substance use treatment only)A treating practitioner must be independently enrolled in the Florida Medicaid program per provider type.CriteriaModifiedTo enroll as a Medicaid provider agency of behavioral health overlay services, a provider must meet all of the following criteria:Be enrolled as a Medicaid community mental health services provider. Be licensed by the Department of Children and Families or their designee under Chapter 65C-14, F.A.C. Be under contract with the Department of Children and Families, Child Welfare and Community-Based Care organization. Have successfully completed the behavioral health overlay services provider agency self-certification process.Certification CriteriaModified & NewTo be self-certified to provide behavioral health overlay services (Behavioral Health Overlay Services, provider type 05), a provider must comply with policy standards in the following areas:Services to be provided Crisis intervention and support Quality assurance program Required policies and procedures Clinical record and documentation requirement.Services to be ProvidedModified & NewThe provider must offer the following on-site clinical and support services: Individual, family, and group therapyIndividualized behavior management services (including design, consultation, and supervision), when indicatedTherapeutic support servicesDischarge and aftercare planning (including identification of behavioral health services needed for successful discharge from behavioral health overlay services and transition into the appropriate level of care.Further defines services provided under BHOSCrisis Intervention and SupportModifiedThe provider must demonstrate that crisis intervention and support are available 24 hours per day, 7 days per week. Crisis services include facilitating access to acute care settings or other behavioral health emergency management. Staff Qualifications & Enrollment (continued)Quality Assurance ProgramModified & NewThe provider must have a quality assurance program that evaluates the effectiveness and outcomes of all the behavioral health services it provides. The quality assurance policies and procedures must include:Monitoring behavioral health treatment planning, implementation, and outcomes. Ongoing review of behavioral health staff performance. Reviewing behavioral health medication administration and monitoring. Treatment teams that are responsible for organizing the delivery of behavioral health overlay services. Interfacing with primary caregivers. Implementing and documenting pre-service and ongoing staff training agendas that improve and support the delivery of behavioral health overlay services.Required Policies and ProceduresModified & NewThe provider agency must have policies and procedures in place that address the following: An internal review process of the recipient’s eligibility for behavioral health overlay services. Thorough screening, evaluation, and diagnosis of symptoms, risks, functional status, and co-morbidity. Therapeutic crisis intervention, including the use of time out, in compliance with the rules of the Department of Children and Families. The policies and procedures must address transfer to a restrictive level of care if a recipient displays self-injurious behavior or is a danger to others and cannot be safely managed. The use of mechanical or chemical restraint is not allowed. Medical management of recipients who require psychotropic medical intervention. An organizational chart and staff qualifications and responsibilities. Treatment teams that are responsible for organizing the delivery of behavioral health overlay services.A clinical supervision protocol that assures timely monitoring of services and modification of treatment as needed.Weekly clinical individual or group supervision protocol for behavioral health overlay services counselors with a licensed practitioner of the healing arts that requires the documentation of the date, start and end times, and the clinical topic discussed for each supervision session.Integration of behavioral health overlay services into the daily activities of recipients.Best practice guidelines for the clinical management of specific types of emotional and behavioral problems encountered within the recipient population.Formal aftercare planning that supports development of independent living skills when developmentally appropriate.Adds requirement for more specific policiesStaff RequirementsModified & NewThe provider agency must employ or contract with all of the following:A staff administratorA psychiatristA clinical services supervisorA behavior analyst (if behavior management services are offered)The counselor-to-recipient ratio must not exceed one (1) counselor to twenty (20) recipients.Specifies that the provider must employ on contract these parties.Staff Qualifications & Enrollment (continued)Multiple Service Locations Within the Same Medicaid-Designated AreaModified & NewBehavioral health overlay services agency providers who render services at more than one service address within the same Medicaid-designated area are required to submit an Application for New Location Code to identify each separate physical address where services are provided. The Application for New Location Code is an attachment to the Florida Medicaid Provider Enrollment Application. Providers must use the code assigned to the location when billing for services provided at that location. Additional service sites are subject to an on-site review by the local Medicaid area office or its designee.RequirementsGENERAL COMMENT(S):NoneSTANDARD/REQUIREMENTSTATUSDESCRIPTIONADDITIONAL COMMENTSMultiple Service Locations in Different Medicaid-Designated AreasModified & NewBehavioral health overlay agency providers who render services at more than one service address in different Medicaid-designated areas are required to submit a separate Florida Medicaid Provider Enrollment Application for each Medicaid-designated area. Providers must use the code assigned to the location when billing for services provided at that location. Additional service sites are subject to an on-site review by the local Medicaid area office or its designee.SubcontractingModifiedFlorida Medicaid allows a provider to contract with an individual practitioner, but not with another agency for service delivery. As of July 1, 2014, providers are required to retain all contracts with subcontracted staff for no less than five years from the termination date of the contract. Providers must maintain subcontractor records with background screening results, staff qualifications, and verification of work experience. These records must additionally reflect adherence to human resources policies and procedures established by the provider related to subcontracting. Providers Contracted with Medicaid Health PlansNewThe service-specific Medicaid coverage and limitations handbooks provide the minimum requirements for all providers. This includes providers who contract with Florida Medicaid health plans (e.g., provider service networks and health maintenance organizations). Providers shall comply with all of the requirements outlined in this handbook, unless otherwise specified in their contract with the health plan. The provision of services to recipients enrolled in a Medicaid health plan shall not be subject to more stringent criteria or limits than specified in this handbook.Added MMA languageCHAPTER 2: COVERED, LIMITED AND EXCLUDED SERVICESGeneral Coverage InformationGENERAL COMMENT(S):NoneSTANDARD/REQUIREMENTSTATUSDESCRIPTIONADDITIONAL COMMENTSExceptions to the Limits (Special Services) ProcessNewAs required by federal law, Florida Medicaid provides services to eligible recipients under the age of 21 years, if such services are medically necessary to correct or ameliorate a defect, a condition, or a physical or mental illness. Included are diagnostic services, treatment, equipment, supplies, and other measures described in section 1905(a) of the Social Security Act, Title 42 of the United States Code 1396d(a). Services requested for recipients under the age of 21 years in excess of limitations described within this handbook or associated fee schedule may be approved, if medically necessary, through the prior authorization process described in the Medicaid Provider General Handbook. General Coverage Information (continued)Description of BHOS ServicesModified & NewBehavioral health overlay services include mental health, substance abuse, and supportive services designed to meet the behavioral health treatment needs of recipients in the care of Medicaid enrolled, certified agencies under contract with the Department of Children and Families, Child Welfare and Community-Based Care organization. The intent of behavioral health overlay services is the maximum reduction of the recipient’s disability and restoration to the best possible functional level in order to avoid a more intensive level of care. Services must be diagnostically relevant and medically necessary. Services must be included in an individualized treatment plan that has been approved by a treating practitioner. Behavioral health overlay services include the following components: Therapy Behavior management Therapeutic supportRedefines BHOSBHOS Service EligibilityModifiedTo receive behavioral health overlay services a recipient must be:Enrolled in a Medicaid behavioral health overlay services program.Certified as meeting the clinical criteria listed below.The recipient must meet the diagnostic eligibility criterion described in Section A and also meet at least one of the risk factors in Section B. Section A: Diagnostic Criterion The recipient is under the age of 21 years and has an emotional disturbance or a serious emotional disturbance. Section B: Risk Factors The recipient must be at risk due to one of the following factors in the last 12 months: Has exhibited suicidal gestures or attempts, or self-injurious behavior or current ideation related to suicidal or self-injurious behavior, and is not currently in need of acute care. Has exhibited physical aggression or violent behavior toward people, animals, or property; this risk may also be evidenced by current threats of such aggression. Has run away from home or placements or threatened to run away on one or more occasions. Has had an occurrence of sexual aggression. Has experienced trauma. The recipient’s risk factor(s) must be documented and detailed on the Certification of Eligibility and reflected in the recipient’s treatment plan. Removed ICD-9-CM Codes; added a time limit for presence of risk factorsGeneral RequirementModifiedProviders must request reimbursement only for services that are provided by individuals employed by, under contract with, or who are compensated monetarily by the provider. Removed language that services must be rendered in the DCF district or region in which they have a current SAMH contractGeneral Coverage Information (continued)Assessment RequirementModifiedPrior to the development of a treatment plan the provider must give the recipient an assessment of mental health status, substance use concerns, functional capacity, strengths, and service needs or must have one on file that has been conducted in the last six months. The purpose of the assessment is to gather information to be used in the formulation of a diagnosis and development of a plan of care that includes the discharge criteria.Treatment Plan RequirementsModifiedThe recipient must have an individualized treatment plan developed in compliance with the Community Behavioral Health Services Coverage and Limitation Handbook policy. If the individualized treatment plan contains a behavior management component, the behavior analyst must review and sign the component. The behavior management plan must be consistent with treatment goals and objectives. Removed 30 day languageTreatment Plan Review RequirementsModifiedThe recipient’s treatment plan must be reviewed by the provider in compliance with the Community Behavioral Health Services Coverage and Limitation Handbook policy. Recipient Clinical RecordModified & NewProviders must maintain a clinical record for each recipient treated that contains all of the following: Consent for treatment that is signed by the recipient or the recipient’s legal guardian. An explanation must be provided for signatures omitted in situations of exception. An evaluation or assessment that, at a minimum, contains the components of a brief behavioral health status examination conducted by a physician, psychiatrist, a licensed practitioner of the healing arts (LPHA), or master’s level certified addictions professional (CAP) for diagnostic and treatment planning purposes. For new admissions, the evaluation or assessment by an LPHA for treatment planning purposes must have been completed within the past six months. Copies of relevant assessments, reports and tests. Service notes (progress toward treatment plans and goals). Documentation of service eligibility, if applicable. Current treatment plans (within the last six months), reviews, and addenda. Copies of all certification forms (e.g., comprehensive behavioral health assessment). The practitioner’s orders and results of diagnostic and laboratory tests. Documentation of medication assessment, prescription, and management.General Service Documentation RequirementsModifiedProviders must maintain documentation to support each service for which Medicaid reimbursement is requested; clearly distinguish and reference each separate service billed; and be authenticated with the dated signature of the individual who rendered the service. The date of a claim should be the same as the date the service was rendered. Service documentation must contain all of the following in the recipient’s clinical record: Recipient’s name Date the service was rendered Start and end times Identification of the setting in which the service was rendered General Coverage Information (continued)General Service Documentation Requirements (continued)Modified (cont.)Identification of the specific problem, behavior, or skill deficit for which the service is being provided Identification of the service rendered Updates regarding the recipient’s progress toward meeting treatment-related goals and objectives addressed during the provision of a service Dated signature of the individual who rendered the service Printed or stamped name identifying the signature of the individual who rendered the service and the credentials (e.g., licensed clinical social worker) or functional title (e.g., treating practitioner) Compliance and Quality of Care ReviewsModifiedProvider’s compliance with service eligibility determination procedures, service authorization policy, staffing requirements, and service documentation requirements can be reviewed periodically by AHCA or its designee. Providers that violate these requirements are subject to recoupments, fines, or termination in accordance with Chapter 409.913, F.S. Quality of care reviews are done periodically in conjunction with the compliance review Language changed re: penalties; corrective action plan language removedDocumentation Requirements for Daily Progress NotesModified & NewA daily progress note must be completed and signed by a qualified practitioner for each day that behavioral health overlay service is billed. Change to daily note (vs. weekly note)Aftercare PlanningModified & NewThe recipient and the treating staff should collaborate to develop the recipient’s individualized formal aftercare plan. A formal aftercare plan should include community resources, activities, services, and supports that will be utilized to help the recipient sustain gains achieved during treatment. Formalized aftercare planning processTherapy Services, Behavior Management Services, Support Services and Service LimitationsGENERAL COMMENT(S):NoneSTANDARD/REQUIREMENTSTATUSDESCRIPTIONADDITIONAL COMMENTSTherapy—Individual and FamilyModified & NewIndividual and family therapy services must be provided by one of the following qualified practitioners: Physician Psychiatrist Psychiatric physician assistant (PPA) Psychiatric advanced registered nurse practitioner (ARNP) LPHA Master’s level CAP Master’s level practitioner Individual and family therapy services include the provision of insight-oriented, cognitive-behavioral, or supportive therapy to an individual or family. Individual and family therapy can involve the recipient, the recipient’s family (without the recipient present), or a combination of therapy with the recipient and the recipient’s family.Revises language regarding who may provide and further defines the service under BHOSTherapy—GroupModified & NewGroup therapy services must be provided by one of the following qualified practitioners: Physician Psychiatrist PPA Psychiatric ARNP LPHA Revises language regarding who may provide and further defines the service under BHOS; includes limit for group size.Therapy Services, Behavior Management Services, Support Services and Service Limitations (continued)Therapy—Group (continued)Modified & New (cont.)Master’s level CAP Master’s level practitioner CAP Bachelor’s level practitioner Group therapy services include the provision of cognitive-behavioral or supportive therapy interventions to individuals or families and consultation with family or other responsible persons for sharing of clinical information. Also included is educating, counseling, or advising families or other responsible person on how to assist the recipient. The group size must not exceed 15 participants. Behavior ManagementModified & NewBehavior management services must be provided by a certified behavior analyst, or certified assistant behavior analyst, or by one of the following licensed practitioners who has three years of behavior analysis experience and a minimum of 10 hours of documented training every year dedicated to behavior analysis: Clinical social worker Mental health counselor Marriage and family therapist PsychologistBehavior management services include the following: Assessing behavioral problems, and the functions of these problems and related skill deficits and assets, including identifying primary and other important caregiver skill deficits and assets related to the recipient’s behaviors and the interactions that motivate, maintain, or improve behavior. Developing an individual behavior plan with measurable goals and objectives. Training caregivers and other involved person in the implementation of the behavior plan. Monitoring the recipient and caregiver progress and revising the plan as needed. Coordinating services on the treatment plan with the treatment team. Revises language regarding who may provide and further defines the service under BHOS and who is qualified to perform the serviceTherapeutic SupportModified & NewTherapeutic support services must be provided by one of the following qualified professionals: Physician Psychiatrist PPA Psychiatric ARNP LPHA Master’s level CAP Master’s level practitioner Bachelor’s level practitioner Certified behavior analyst Certified assistant behavior analyst Introduces these services into the BHOS service array, defines the service and formalized who can provideTherapy Services, Behavior Management Services, Support Services and Service Limitations (continued)Therapeutic Support (continued)Modified & New (cont.)Certified recovery peer specialist Certified psychiatric rehabilitation practitioner Certified recovery support specialist Certified behavioral health technician Direct care staffTherapeutic support services are direct care contacts that must be related to the recipient’s treatment plan goals and objectives and must include one or more of the following services, as medically necessary: One-to-one supervision and intervention with the recipient during therapeutic activities in accordance with the recipient’s treatment plan. Skill training of the recipient for restoration of those basic living and social skills necessary to function in the recipient’s own environment. Assistance to the recipient in implementing the behavioral goals identified through assessments, therapy, and development of the treatment plan. Therapeutic Home AssignmentsModified & NewTherapeutic home assignments are overnight stays the recipient spends with the biological, adoptive or extended family, or in a potential placement in order to practice the generalized skills learned in treatment to the recipient’s home or other natural settings. Therapeutic home assignments may include time spent away overnight with friends, school, or club activities. Therapeutic home assignments are planned in conjunction with the recipient’s treatment goals and objectives. Therapeutic home assignments must be prior authorized and must be prescribed on the recipient’s treatment plan. The provider agency must be accessible and must maintain a level of communication with the recipient during therapeutic home assignments. Telephone communication can be utilized to maintain on-going communication with the recipient during therapeutic home assignments.Further defines and expands on criteria for home visitsExcluded ServicesGENERAL COMMENT(S):NoneSTANDARD/REQUIREMENTSTATUSDESCRIPTIONADDITIONAL COMMENTSService ExclusionsModified & NewMedicaid does not reimburse for behavioral health overlay services for treatment of a cognitive deficit severe enough to prohibit the service from being of benefit to the recipient. Adds language specifically in reference to BHOS servicesBehavioral Health Overlay ExclusionsNewThe following are services and supports not reimbursed under behavioral health overlay services: Services provided to a recipient on the day of admission into a statewide inpatient psychiatric program. However, community behavioral health services are reimbursable on the day of discharge. Case management services. Partial hospitalization. Services rendered to individuals residing in an institution for mental diseases. Services rendered to institutionalized individuals, as defined in 42 CFR 435.1009. Specifies services that cannot be reimbursed under BHOSExcluded Services (continued)Behavioral Health Overlay Exclusions (continued)New (cont.)Room and board expenditures. Travel time. Education services. Activities performed to maintain and review records for facility utilization, continuous quality improvement, recipient eligibility status processing, and staff training purposes. Activities (other than record reviews, services with family member or other interested person that benefit the recipient, or services performed using telemedicine) that are not performed face-to-face with the recipient. Services rendered by a recipient’s relative. Services rendered by unpaid interns or volunteers. Services paid for by another funding source. Escorting or transporting a recipient to and from a service site.Specifies services that cannot be reimbursed under BHOSCHAPTER 3: REIMBURSEMENT AND FEE SCHEDULEReimbursement InformationGENERAL COMMENT(S):NoneSTANDARD/REQUIREMENTSTATUSDESCRIPTIONADDITIONAL COMMENTSProcedure CodesModifiedThe procedure codes and fee schedule listed in this handbook are Healthcare Common Procedure Coding System (HCPCS) Level II, which is a part of a nationally standardized code set. Level II of the HCPCS is a standardized coding system used primarily to identify products, supplies, and services not included in the CPT codes. HCPCS Level II codes are also referred to as alpha-numeric codes because they consist of a single alphabetical letter (A–V) followed by four numeric digits. Please refer to the current HCPCS Level II Expert code book for complete descriptions of the standard codes. The HCPCS Level II Expert? code book is copyrighted by Ingenix, Inc. All rights reserved. Updates language regarding codes.Effective Date of CertificationModifiedMedicaid will reimburse for behavioral health overlay services up to 72 hours prior to the Certificate of Eligibility being signed by a licensed practitioner. Clarifies the effective date of the certificationProvider Agency Staff Linked to a Community Behavioral Health GroupNewThe following provider agency staff must be reimbursed through the community behavioral health group (provider type 05) Medicaid number: Treating physician Psychiatric advanced registered nurse practitioner Psychiatric physician assistant Licensed practitioner of the healing artsUnits of ServiceSame; New for BHOSA unit of service is the number of times a procedure is performed. The definition of unit varies by service. For services defined in 15-minute increments, the total units of service for the day must be entered on the claim form. If multiple units are provided on the same day, the actual time spent must be totaled. If the minutes total ends in a 7 or less, round down to the nearest 15-minute increment. If the minutes total ends in 8 or more, round up to the nearest 15-minute increment. For example, 37 minutes is billed as two units of service while, 38 minutes is billed as three units of services. Included in BHOS Handbook…confusing, as BHOS is reimbursed per dayReimbursement Information (continued)Units of Service (continued )Same; New for BHOS (cont.)The provider may not round up each service episode to the nearest 15-minute increment before summing the total. Note: For more information on entering units of service on the claim, see the Florida Medicaid Provider Reimbursement Handbook, CMS-1500. Therapeutic Home Assignment ReimbursementModified & NewMedicaid reimburses up to 10 therapeutic home assignments per calendar quarter (three months). During the last three months of placement, and if the therapeutic home assignments are in accordance with the recipient’s aftercare plan, Medicaid can reimburse for up to 20 therapeutic home assignments. The therapeutic home assignments must be authorized in the recipient’s treatment plan. Changed title from Therapeutic Visit; revised languageService LimitsModifiedMedicaid will reimburse for behavioral health overlay services for up to 365 days per recipient, per state fiscal year (July 1 through June 30). Medicaid will not reimburse for the same procedure code twice in one day.Changed languageReimbursement RestrictionsModifiedThe following Medicaid community behavioral health services cannot be reimbursed for recipients of behavioral health overlay services: Therapeutic behavioral on-site—therapyTherapeutic behavioral on-site—behavior managementTherapeutic behavioral on-site—therapeutic supportBehavioral health day—mental healthBehavioral health day—substance abuseIndividual or family therapySpecialized therapeutic foster care Level ISpecialized therapeutic foster care Level IISpecialized therapeutic foster care crisisTherapeutic group carePsychosocial rehabilitativeClubhouse**These services may be reimbursed when provided as a part of a public school program or summer activities program. Mental health targeted case management cannot be billed in conjunction with behavioral health overlay services. ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download