HAR §17-1737-44. Rehabilitative services

(a) Rehabilitative services means those medical and remedial items or services which are prescribed by a licensed physician for the purpose of maximum reduction of a patient's physical or mental disability and restoration of the patient to the patient's best possible functional level. (b) Rehabilitative services shall be directed to restoring a disabled person toward the following goals: (1) Self-care and possible independent living; or (2) Substantial gainful employment. (c) Children through six years of age shall meet the following conditions to show rehabilitative services are reasonable and necessary: (1) The services shall be considered under accepted standards of medical practice to be a specific and effective treatment for the patient's condition. Experimental therapies are excluded from coverage; (2) An expectation that the condition will improve significantly in a reasonable and generally predictable period of time based on the assessment made by the physician of the patient's rehabilitative potential after any needed consultation with the qualified therapist or, services are necessary to establish a safe and effective maintenance program required in connection with a specific developmental or disease state; (3) The services required can be safely and effectively performed only by a qualified therapist/pathologist or under the immediate supervision of a therapist because the services are complex or because of the child's medical or physical condition; (4) The amount, frequency, and duration of the services shall be reasonable and subject to authorization by the department. UNOFFICIAL 1737-54 Additionally, the provisions and limitations pertaining to the specific rehabilitation service such as physical therapy, speech therapy, etc. addressed in this chapter and chapter 17-1739 shall apply; (5) Referrals for therapeutic services shall be made by a physician. The physician is expected to employ clinical judgment, the history and physical, testing, etc. in determining the medical necessity of rehabilitative services; and (6) Evaluation of the patient's developmental or therapeutic status shall be measured and expressed in objective, unambiguous concise language. The results of tests as well as goals, and therapeutic results shall be recorded on appropriate forms and may be reviewed by the department. (d) Medical vendor payments may be made for the following types of services whether provided on an inpatient or an outpatient basis: (1) Corrective surgery; (2) Physical therapy; (3) Speech therapy; (4) Occupational therapy; (5) Drugs, prosthetics, and durable medical equipment and supplies; and (6) Other related restorative services. [Eff 08/01/94; am 02/10/97 ] (Auth: HRS §346-14) (Imp: 42 C.F.R. §440.130) §17-1737-44.1 Community mental health rehabilitative services. (a) Medical payments to eligible providers may be made for the following types of community mental health rehabilitative services: (1) Crisis management: This service provides mobile assessment for individuals in active state of crisis (twenty-four hours per day, seven days a week). Immediate response is required. Crisis management services include referral to licensed psychiatrist, licensed psychologist, or to an inpatient acute care hospital. The presenting crisis situation may necessitate that the services be provided in the consumer’s home or natural environment setting, such as the home, school, work environment, or other community setting as well as in a health care setting. These UNOFFICIAL 1737-55 services are provided through agencies accredited by a national accreditation organization. These agencies must have staff that includes one or more qualified mental health professionals. If the services are provided by staff other than a qualified mental health professional, the staff shall be supervised at a minimum by a qualified mental health professional. (1) Crisis Residential Services: Crisis Residential Services are short-term interventions provided to individuals experiencing crisis, to address the cause of the crisis and to avert or delay the need for acute psychiatric inpatient hospitalization or inpatient hospital-based psychiatric care at levels of care below acute psychiatric inpatient. Crisis Residential Services are for individuals who are experiencing a period of acute stress that significantly impairs the capacity to cope with normal life circumstances. The program provides psychiatric services that address the psychiatric, psychological, and behavioral health needs of the individuals. Specific services are: (A) Psychiatric medical assessment; (B) Crisis stabilization and intervention; (C) Medication management and monitoring; (D) Individual, group or family counseling or all if necessary; and (E) Daily living skills training. Services are provided in a licensed residential program, licensed therapeutic group home or foster home setting. All crisis residential programs shall have less than sixteen beds. The services do not include payment for room and board. Staff providing crisis residential services shall be qualified mental health professionals. If the services are provided by staff other than a qualified mental health professional, the staff must be supervised at a minimum by a qualified mental health professional. (3) Biopsychosocial Rehabilitative Programs: This is a therapeutic day rehabilitative social skill building service which allows individuals with serious mental illness to UNOFFICIAL 1737-56 gain the necessary social and communication skills necessary to allow them to remain in or return to naturally occurring community programs. Services include group skill building activities that focus on the development of problem-solving techniques, social skills and medication education and symptom management. All services provided must be part of the individual’s plan of care. A plan of care must identify the treatment goals and the scope, amount and duration of services that will assist the individual to achieve the goals. A plan of care must be approved by a licensed physician, licensed psychologist, advanced practice registered nurse or licensed clinical social worker in behavioral health. Plans of care must be reviewed and approved every ninety calendar days. The therapeutic value of the specific therapeutic recreational activities must be clearly described and justified in the plan of care. At a minimum, the plan of care must: (A) Define the goals and objectives for the individual; (B) Educate the individual about his or her mental illness; (C) How to avoid complications and relapse; and (D) Provide opportunities for him or her to learn basic living skills and improve interpersonal skills. Services are provided by qualified mental health professionals or staff that are under the supervision of a qualified mental health professional. Provider qualifications to provide these services are ensured by provider compliance with requirements and standards of a national accreditation organization. (4) Intensive Family Intervention: These are time limited intensive interventions intended to stabilize the living arrangement, promote reunification or prevent the utilization of out of home therapeutic resources (i.e. psychiatric hospital, therapeutic foster UNOFFICIAL 1737-57 care, residential treatment facility) for children with serious emotional or behavioral disturbances or adults with serious mental illness. These services: (A) Diffuse the current crisis, evaluate its nature and intervene to reduce the likelihood of a recurrence; (B) Assess and monitor the service needs of the identified individual so that he or she can be safely maintained in the family; (C) Ensure the clinical appropriateness of services provided; and (D) Improve the individual’s ability to care for self and the family’s capacity to care for the individual. This service includes focused evaluations and assessments, crisis case management, behavior management, counseling, and other therapeutic rehabilitative mental health services toward improving the individual’s ability to function in the family. Services are directed towards the identified individual within the family. Services can be provided in-home, school or other natural environment. Services are provided by a multidisciplinary team comprised of qualified mental health professionals. If the services are provided by staff other than a qualified mental health professional, the staff shall be supervised at a minimum by a qualified mental health professional. Additionally, provider qualifications must be in compliance with requirements and standards of a national accreditation organization. (5) Therapeutic Living Supports and Therapeutic Foster Care Supports: These are services covered in settings such as group living arrangements or therapeutic foster homes. Group living arrangements usually provide services for three to six individuals, but not more than fifteen individuals, per home. Therapeutic foster homes provide services for a maximum of fifteen individuals per home. Although these group living arrangements and therapeutic foster homes may provide twenty-four hour per day of residential care, only the therapeutic services provided are UNOFFICIAL 1737-58 covered. There is no reimbursement of room and board charges. Covered therapeutic supports are only available when the identified individual resides in a licensed group living arrangement or licensed therapeutic foster home. The identified individual must be either a child with serious emotional or behavioral disturbance or an adult with a serious mental illness. Services provided in therapeutic group homes and therapeutic foster homes include supervision, monitoring and developing independence of activities of daily living and behavioral management, medication monitoring, counseling and training, directed at the amelioration of functional and behavioral deficits and based on the individual’s plan of care developed by a team of licensed and qualified mental health professionals. Services shall be provided in a licensed facility and provided by a qualified mental health professional or staff under the supervision of a qualified mental health professional with twenty-four hour on- call coverage by a licensed psychiatrist or psychologist. (6) Intensive outpatient hospital services: These are outpatient hospital services for the purpose of providing stabilization of psychiatric impairments as well as enabling the individual to reside in the community or to return to the community from a more restrictive setting. Services are provided to an individual who is either a child with serious emotional or behavioral disturbance or an adult with a serious mental illness. In addition, the adult or child shall meet at least two of the following criteria: (A) Is at high risk for acute inpatient hospitalization, homelessness or (for children) out-of-home placement because of their behavioral health condition; (B) Exhibits inappropriate behavior that generates repeated encounters with mental health professionals, educational and social agencies, or the police; or UNOFFICIAL 1737-59 (C) Are unable to recognize personal danger, inappropriate social behavior, or recognize and control behavior that presents a danger to others. The goals of service are clearly identified in an individualized plan of care. The short term and long term goals and continuing care plan are established prior to admission through a comprehensive assessment of the consumer to include a severity-adjusted rating of each clinical issue and strength. Treatment is time-limited, ambulatory and active offering intensive, coordinated clinical services provided by a multi-disciplinary team. This service includes medication administration and a medication management plan. Services are available at least twenty hours per week. All services are provided by qualified mental health professionals, or by individuals under the supervision of a qualified mental health professional. Additionally, provider qualifications must be in compliance with requirements and standards of a national accreditation organization. Registered nurses or licensed practical nurses must be available for nursing interventions and administration of medications. Licensed psychiatrists or psychologists must be actively involved in the development, monitoring, and modification of the plan of care. The services must be provided in the outpatient area or clinic of a licensed hospital certified by a national accreditation organization or other licensed facility that is Medicare certified for coverage of partial hospitalization/day treatment. These services are not provided to individuals in the inpatient hospital setting and do not include acute inpatient hospital stays. UNOFFICIAL 1737-60 (7) Assertive Community Treatment (ACT): This is an intensive community rehabilitation service for individuals who are either children with serious emotional or behavioral disturbance or adults with a serious mental illness. In addition, the adult or child must meet at least two of the following criteria: (A) At high risk for acute inpatient hospitalization, homelessness or (for children) out-of-home placement because of their behavioral health condition; (B) Exhibits inappropriate behavior that generates repeated encounters with mental health professionals, educational and social agencies, or the police; or (C) Is unable to recognize personal danger, inappropriate social behavior, and recognize and control behavior that presents a danger to others. The ACT rehabilitative treatment services are to restore and rehabilitate the individual to his or her maximum functional level. Treatment interventions include: (A) Crisis management (crisis assessment, intervention and stabilization); (B) Individual restorative interventions for the development of interpersonal, community coping and independent living skills; (C) Services to assist the individual develop symptom monitoring and management skills; (D) Medication prescription, administration and monitoring medication and self medication; and (E) Treatment for substance abuse or other co-occurring disorders. Services include twenty-four hours a day, seven days a week coverage, crisis stabilization, treatment, and counseling. Also, individuals included in ACT receive case management to assist them in obtaining needed medical and rehabilitative treatment services within their ACT treatment plan. UNOFFICIAL 1737-61 Services can be provided to individuals in their home, work or other community settings. ACT services are provided by agencies whose staffs include one or more licensed qualified mental health professionals. If the services are provided by staff other than a licensed qualified mental health professional, the staff shall be supervised by a licensed qualified mental health professional. Provider qualifications to provide these services are ensured by provider compliance with requirements and standards of a national accreditation organization. Case management is an integral part of this service and reimbursement for case management as a separate service is not allowed. If biopsychosocial rehabilitation is part of the individual’s plan of care under intensive case management, reimbursement for biopyschosocial rehabilitation as a separate service is not allowed. (b) Community mental health rehabilitative services are available to individuals eligible for medical assistance and who are medically determined to need mental health, drug abuse, or alcohol services or all three. These services must be recommended by a licensed physician, licensed psychologist, advanced practice registered nurse or a licensed clinical social worker in behavioral health to promote the maximum reduction or restoration, or both, of a recipient to their best possible functional level relevant to their diagnosis of mental illness, abuse of drugs or alcohol. (c) Individuals who are mentally retarded (MR) or developmentally disabled are not eligible for these services, including mentally retarded and developmentally disabled individuals who are in Home and Community Based Waiver programs. (d) Community mental health rehabilitative services shall be provided by the agencies certified by the department of Health, adult mental health division and child and adolescent mental health division. (e) The covered services are available only to Medicaid eligible recipients with a written plan of care developed with the participation of a licensed psychiatrist or psychologist. Services must be medically necessary. UNOFFICIAL 1737-62 (f) The statewide reimbursement rate shall be the rate negotiated by the department. The final rate will be based on the following factors: (1) Cost to provide the service; (2) Comparison to comparable Medicaid provider types; (3) Relative value to other services within the established fee schedule; (4) Rate will not exceed Medicare’s upper limit of reimbursement; and (5) Rate will be reevaluated at a minimum of once every two years for its cost basis and allowability. (g) Reimbursement shall be based of the following units of service: (1) Per contact (Crisis management services); (2) Daily (crisis residential, therapeutic support, intensive outpatient hospital services), or (2) Fifteen minute increments (assertive community treatment (ACT), biopsychosocial rehabilitative programs and intensive family intervention). [Eff 02/07/05] (Auth: HRS §346-14) (Imp: 42 C.F.R. §440.130)