Non-Covered Services

Non-Covered Services A. The Division of Medicaid does not cover: 1. Educational interventions of an academic nature performed by the Department of Education, 2. Same service provided on the same date, regardless of the setting(s) in which the service was provided unless service specifically states otherwise. 3. Community-based mental health services when a beneficiary is an inpatient of a Medicaid- covered facility except for targeted case management services, including wraparound services, provided up to thirty (30) days of a covered stay in a medical institution for EPSDT-eligible beneficiaries with a serious emotional disturbance (SED) that meet the level of care provided in a psychiatric residential treatment facility (PRTF), 4. Time spent on documentation, unless completed during the session and relevant to the treatment goals, 5. Time spent completing a care plan form or prior authorization request online via web portal, 6. Staff travel time, 7. Field trips and routine recreational activities, 8. Beneficiary travel time to and from any service, or 9. Services provided to more than one (1) beneficiary at a time, unless specifically allowed in the service definition. 10. Wraparound facilitation for more than one family member at a time. 11. Case management components provided or billed as part of a direct care service, including but not limited to: a) Assisting a person in accessing needed services such as medical, social, educational, transportation, housing, substance use, personal care, employment and other services that may be identified in the Recovery Support Plan as components of Health, Home, Purpose and Community, b) Assisting the person and natural supports in implementation of therapeutic interventions outlined in the Individual Service Plan, or c) Psychoeducation and training of family, unpaid caregivers, and/or others who have a legitimate role in addressing the needs of the person. B. The Division of Medicaid does not cover the following evaluative services: 1. A neuropsychological evaluation when: a) Only administered to rule out attention deficit hyperactivity disorder (ADHD), or b) Previous evaluations did not support the suspicion of cognitive deficits or brain injury. 2. The Division of Medicaid does not cover a developmental evaluation when: a) Referral questions can be adequately answered through behavioral observation and family interviews, or b) A standardized intellectual assessment is appropriate and the beneficiary is three (3) years or older with no severe disabilities. C. The Division of Medicaid does not cover case management services that: 1. Restrict a beneficiary’s access to other services under the State Plan. 2. Require the beneficiary to receive other Medicaid services as a condition of receipt of case management services. 3. Duplicates other services provided by public agencies or private entities. 4. Authorize or deny the provision of other services under the State Plan. 5. Constitute the direct delivery of underlying medical, educational, social or other services to which a beneficiary has been referred.