Covered Services

Covered Services A. All State Plan services described in Miss. Admin. Code Part 206 and Part 223 are covered for Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)-eligible beneficiaries without regard to service limits when prior authorized by the Utilization Management/Quality Improvement Organization (UM/QIO). B. The Division of Medicaid covers neuropsychological evaluations for EPSDT-eligible beneficiaries when medically necessary, prior authorized by a UM/QIO, the Division of Medicaid or designee and conducted by a psychologist trained to administer, score and interpret neuropsychological instruments, and one (1) or more of the following apply: 1. Other interventions have been unsuccessful with the beneficiary, 2. Previous psychological evaluation indicates neuropsychological deficits and supports justification, 3. The beneficiary displays evidence of cognitive deficits or brain injury, or 4. Results are used in treatment planning and placement decisions. C. The Division of Medicaid covers developmental evaluations for EPSDT-eligible beneficiaries when medically necessary, prior authorized by a UM/QIO, the Division of Medicaid or designee, conducted by a physician or a psychologist with knowledge and expertise to administer and interpret developmental evaluation results and uses the results or the following: 1. To assist in treatment planning for a beneficiary less than three (3) years of age or a beneficiary with a severe disability, or 2. To confirm the existence of a major diagnosis. D. The Division of Medicaid covers day treatment services for EPSDT eligible beneficiaries when the service and provider meet the following requirements: 1. Service components include: a) Treatment plan development and review. b) Skill building groups such as social skills training, self-esteem building, anger control, conflict resolution and daily living skills. 2. Certified to operate by the Mississippi Department of Mental Health (DMH). 3. Included in a care plan approved by one (1) of the following: a psychiatrist, physician, psychologist, psychiatric mental health nurse practitioner (PMHNP), physician assistant (PA), licensed clinical social worker (LCSW), licensed professional counselor (LPC), licensed marriage and family therapist (LMFT), licensed master social worker (LMSW) or certified mental health therapist (CMHT). 4. Provided by a psychiatrist, physician, psychologist, PMHNP, PA, LCSW, LPC, LMFT, LMSW or CMHT. 5. Prior authorized as medically necessary by the UM/QIO. E. The Division of Medicaid covers medically necessary wraparound facilitation as part of a targeted case management benefit for EPSDT-eligible beneficiaries with a serious emotional disturbance (SED) that meet the level of care provided in a psychiatric residential treatment facility (PRTF). 1. Service components include: a) Engaging the family, b) Assembling the beneficiary and family team which includes all of the required entities and individuals as described in the DMH operational standards for wraparound facilitation. c) Facilitating the beneficiary and family team meeting, at a minimum, once every thirty (30) days, d) Facilitating the development of a wraparound service plan (WSP) through decisions made by the beneficiary and family team during the beneficiary and family team meeting, including a plan for anticipating, preventing and managing crisis, e) Working with the beneficiary and family team in identifying providers of services and other community resources to meet the family and beneficiary’s needs, f) Making necessary referrals for beneficiaries, g) Documenting and maintaining all information regarding the WSP, including revisions and beneficiary and family team meetings, h) Presenting WSP for approval to the beneficiary and family team, i) Providing copies of the WSP to the entire team including the beneficiary and family/guardian, j) Monitoring the implementation of the WSP and revising as necessary to achieve outcomes, k) Maintaining communication between all beneficiary and family team members, l) Evaluating the progress toward needs being met to ensure the referral behaviors have decreased, m) Leading the beneficiary and family team to discuss and ensure the supports and services continue to meet the caregiver and the beneficiary’s needs, n) Educating new team members about the wraparound process, o) Maintaining team cohesiveness, p) Contact with the beneficiary at least weekly, q) Meeting face-to-face with the beneficiary a minimum of twice per month in addition to family face-to-face meetings, r) Meeting face-to-face with the family a minimum of twice per month in addition to beneficiary face-to-face meetings, s) Contact with collateral contacts related to WSP implementation and/or other care coordination activities at least three (3) times a week, and t) Ensuring medication management and monitoring of beneficiaries medication(s) used in the treatment of the beneficiary’s Serious Emotional Disturbance (SED) occur at a physician visit every ninety (90) days at a minimum. 2. Wraparound services are provided by a Certified Wraparound Facilitator. 3. Prior authorized as medically necessary by the UM/QIO. F. The Division of Medicaid covers medically necessary Mississippi Youth Programs Around the Clock (MYPAC) Therapeutic Services for Early and Periodic Screening, Diagnosis and Treatment (EPSDT) eligible beneficiaries that require the level of care provided in a psychiatric residential treatment facility (PRTF). 1. In order to receive MYPAC Therapeutic Services, beneficiaries must meet DMH requirements for admission. 2. Providers of MYPAC Therapeutic Services must be certified by DMH to provide MYPAC Therapeutic Services. 3. MYPAC Therapeutic Services must be provided to beneficiaries based on the beneficiary’s needs as identified as a part of the wraparound plan of care or individual service plan. 4. MYPAC Therapeutic Services are designed to meet the clinical needs of the beneficiaries and families. Component parts of MYPAC Therapeutic Services must also be certified by DMH if applicable certification is available. Services should meet all DMH service provision requirements. These components include: a) Treatment plan development and review which is defined as the development and review of an overall plan that directs the treatment and support of the person receiving services by qualified providers. b) Medication management which includes the evaluation and monitoring of psychotropic medications, provided by a psychiatrist, or psychiatric mental health nurse practitioner. c) Intensive individual therapy defined as one-on-one therapy for the purpose of treating a mental disorder and family therapy defined as therapy for the family which is exclusively directed at the beneficiary’s needs and treatment provided in the home. d) Family therapy involves participation of non-Medicaid eligible individuals for the direct benefit of the beneficiary. The service must actively involve the beneficiary in the sense of being tailored to the beneficiary’s individual needs. There may be times when, based on clinical judgment, the beneficiary is not present during the delivery of the service, but remains the focus of the service. Must be provided by a master’s level staff. e) Peer support services defined as non-clinical activities with a rehabilitation and resiliency/recovery focus that allow a person receiving mental health services and/or substance use disorders services and their family members the opportunity to build skills for coping with and managing psychiatric symptoms, substance use issues and challenges associated with various disabilities while directing their own recovery. Must be provided by a certified Peer Support Specialist. g) Community Support Services defined as specific, measurable and individualized that focuses on the mental health needs of the beneficiary while attempting to restore beneficiary’s ability to succeed in the community. Covered community support services include: 1) Identification of strengths which aid the beneficiary in their recovery and the barriers that will challenge the development of skills necessary for independent functioning in the community. 2) Individual therapeutic interventions that directly increase the restoration of skills needed to accomplish the goals set forth in the Individual Service Plan. 3) Monitoring and evaluating the effectiveness of interventions that focus on restoring, retraining and reorienting, as evidence by symptom reduction and program toward goals. 4) Psychoeducation regarding the identification and self-management of the prescribed medication regimen and communication with the prescribing provider. 5) Direct interventions in deescalating situations to prevent crisis. 6) Relapse prevention. 7) Facilitation of the Individual Service Plan or Recovery Support Plan which includes the active involvement of the beneficiary and the people identified as important in the beneficiary's life. 5. Each beneficiary receiving MYPAC Therapeutic Services must have on file an individualized plan which describes the following: a) Services to be provided, b) Frequency of service provision, c) Who provides each service and their qualifications, d) Formal and informal supports available to the beneficiary and family, e) Plan for anticipating, preventing and managing crises, and f) A discharge or transition plan. 6. If the beneficiary participates in Targeted Case Management provided as Wraparound Facilitation, the MYPAC provider agency must be a participating team member and attend the monthly Child Family Team Meeting. 7. MYPAC Therapeutic Services must be prior authorized as medically necessary by the UM/QIO.