471 NAC 32-004. OUTPATIENT MENTAL HEALTH AND SUBSTANCE USE DISORDER TREATMENT SERVICES

004. OUTPATIENT MENTAL HEALTH AND SUBSTANCE USE DISORDER TREATMENT SERVICES. 004.01 COVERED OUTPATIENT MENTAL HEALTH AND SUBSTANCE USE DISORDER TREATMENT SERVICES. Covered services include: (A)Crisis outpatient services; (B)The initial diagnostic interview; (C)Psychological testing; (D)Individual psychotherapy; (E)Group psychotherapy; (F)Family psychotherapy; (G)Parent child interaction therapy ; (H)Child-parent psychotherapy ; (I)Individual substance use disorder counseling; (J)Group substance use disorder counseling; (K)Family substance use disorder counseling; (L)Conferences; (M)Community treatment aide; (N)Medication management; (O)Sex offender risk assessment; (P) Annual supervision of Nebraska Medicaid eligible beneficiaries by a psychologist or a licensed independent mental health professional (LIMHP); (Q) Functional family therapy (FFT); and (R) Applied behavior analysis (ABA). 004.02 NON-COVERED TREATMENT SERVICES. Services not covered include, but are not limited to: (A)Biofeedback services; (B)Treatment that is primarily supportive, social or educational in nature; C)Treatment for prevention, maintenance, socialization, or skill building; (D)Behavior modification and planning; (E)Eye movement desensitization and reprocessing ; and (F)Art, play, or music therapy. 004.03 OUTPATIENT SERVICES PROVIDERS. Outpatient services must be provided by licensed practitioners whose scope of practice includes mental health or substance use disorder services, or both. 004.04 CRISIS OUTPATIENT SERVICES. The provider of crisis outpatient services must develop a short-term plan and must identify ongoing treatment services if services appear to be medically necessary following stabilization. If services are to continue, the provider must perform or arrange for an assessment and develop a treatment plan if one has not already been completed. 004.04(A) SESSION MAXIMUM. A beneficiary is eligible to receive crisis outpatient services of no more than five sessions per episode of crisis, or three occurrences requiring mobile crisis intervention in a 90-day time period. 004.05 INITIAL DIAGNOSTIC INTERVIEW. An initial diagnostic interview as set forth in this chapter . 004.06 PSYCHOLOGICAL TESTING. Testing services must be administered and scored by a licensed psychologist or, under the supervision of a licensed psychologist, by a provisionally licensed psychologist, a licensed psychological assistant or a licensed psychological associate. All interpretation must be done by the licensed psychologist. 004.06(A) PRIOR AUTHORIZATION. Psychological testing must be prior authorized. Before psychological testing, the beneficiary must be assessed to determine the need for and extent of the psychological testing. Testing may be authorized at the onset of treatment when it is necessary for reaching a diagnosis or helps resolve specific treatment planning questions, or both. It may also occur later in treatment if the beneficiary’s condition has not progressed and there is no clear explanation for the lack of improvement. Psychological testing that is available in schools is not covered by Nebraska Medicaid. 004.07 INDIVIDUAL PSYCHOTHERAPY. The treatment plan must identify the diagnosis that is the focus of treatment, the specific target symptoms, the goals, the frequency, and the estimated duration of the service and must be individualized according to the beneficiary’s needs and the identified symptoms experienced by the beneficiary. Services must be treatment focused and not rehabilitative or habilitative in nature. 004.08 GROUP PSYCHOTHERAPY. Group psychotherapy must be provided as an active treatment service for a primary psychiatric disorder in which identified treatment goals, frequency and duration of service are a part of the beneficiary's active treatment plan and there is reasonable expectation that group psychotherapy will improve the beneficiary's psychiatric symptoms so that therapy will no longer be needed. 004.09 FAMILY PSYCHOTHERAPY. Depending on the clinical appropriateness, it is expected that all members of the family residing in the same household as the beneficiary participate in family therapy. Others significant to the beneficiary or the family may also be in attendance at family psychotherapy if their attendance will be meaningful in improving family functioning. 004.10 PARENT-CHILD INTERACTION THERAPY (PCIT). Parent-child interaction therapy (PCIT) is used to treat clinically significant disruptive behaviors due to the child’s primary mental health disorder. 004.10(A) SERVICE IDENTIFICATION BASED ON NEED. The goals, frequency, and duration of the service must be identified in the child’s treatment plan and must vary according to the child’s individual needs and the identified symptoms experienced by the child. Services must be treatment focused and not rehabilitative or habilitative in nature. Young children should receive parent-child interaction therapy (PCIT) services only after a recent appropriate medical evaluation to rule out conditions of a general medical nature. 004.10(B) REASONABLE EXPECTATION OF IMPROVEMENT. There must be a reasonable expectation that parent-child interaction therapy (PCIT) will improve the child’s psychiatric symptoms so that the services will no longer be necessary. 004.10(C) NON-COVERED TREATMENT SERVICES. Services not following the parent-child interaction therapy (PCIT) evidence-based treatment model or performed by an individual not appropriately trained in parent-child interaction therapy (PCIT) are not covered. 004.11 CHILD-PARENT PSYCHOTHERAPY (CPP). Child-parent psychotherapy (CPP) must be designed to support and strengthen the relationship between a child and their parent or caregiver, and to improve and restore the child’s cognitive, behavioral, and social functioning. 004.11(A) SERVICE IDENTIFICATION BASED ON NEED. The goals, frequency and duration of the service must be identified in the child’s treatment plan and must vary according to the child’s individual needs and the identified symptoms experienced by the child. Services must be treatment-focused and not rehabilitative or habilitative in nature. Young children should receive child-parent psychotherapy (CPP) services only after a recent appropriate medical evaluation to rule out conditions of a general medical nature. 004.11(B) REASONABLE EXPECTATION OF IMPROVEMENT. There must be a reasonable expectation that child-parent psychotherapy (CPP) therapy will improve the child’s psychiatric symptoms so that the services will no longer be necessary. 004.11(C) NON-COVERED TREATMENT SERVICES. Services not following the child-parent psychotherapy (CPP) evidence-based treatment model or performed by an individual not appropriately trained in child-parent psychotherapy (CPP). 004.12 INDIVIDUAL SUBSTANCE USE DISORDER COUNSELING. Individual substance use disorder counseling must be designed to assist the beneficiary in achieving and maintaining abstinence from alcohol and drug use. This includes motivational enhancement and interventions . 004.12(A) REASONABLE EXPECTATION OF IMPROVEMENT. Outpatient substance use disorder counseling must reasonably be expected to improve the symptoms of the beneficiary’s substance use disorder which are identified in the beneficiary’s treatment plan. 004.12(B) SERVICE IDENTIFICATION BASED ON NEED. The treatment plan must identify the diagnosis that is the focus of treatment, the specific target symptoms, goals, the frequency and the estimated duration of the service and must be individualized according to the beneficiary’s needs and the identified symptoms experienced by the beneficiary. Services must be treatment focused and not rehabilitative or habilitative in nature. 004.13 FAMILY SUBSTANCE USE DISORDER COUNSELING. The services must focus on the beneficiary’s substance use disorder needs and the family as a system and must include a comprehensive family assessment. Depending on the clinical appropriateness, it is expected that all members of the family residing in the same household as the beneficiary participate in family substance use disorder counseling. Services must be designed to increase the functional level of the identified beneficiary and the beneficiary’s family related to substance use. 004.13(A) LEVEL OF CARE (LOC). The service must be for a beneficiary with a substance related disorder and meet the criteria of level of care (LOC) standards . 004.14 CONFERENCES. Conferences with family or other persons advising them on how to assist the beneficiary can be covered under limited circumstances. 004.14(A) DEMONSTRATION OF NEED. These circumstances must demonstrate a need for the therapeutic involvement and include: (i)Following psychiatric testing ; (ii)As required during the provision of multisystemic therapy (MST) services; or (iii)As a treatment intervention, identified in the beneficiary’s treatment plan and requiring a progress note. 004.14(B) PRIOR AUTHORIZATION. All conferences must be prior approved by Nebraska Medicaid or its designee. 004.14(C) EXCLUSIONS. Scheduling appointments and reporting beneficiary progress are not considered conferences and must not be reimbursable. Supervisory meetings or care coordination meetings are not conferences, and must not be reimbursable. 004.15 COMMUNITY TREATMENT AIDE SERVICES (CTA). The beneficiary’s community treatment aide (CTA) plan must be a part of the comprehensive treatment plan developed by the beneficiary’s outpatient psychotherapy provider and be developed in close collaboration with the therapy provider. The community treatment aide (CTA) interventions, the beneficiary’s progress and modifications to the plan must be reviewed and approved by the outpatient therapist and must be documented by the community treatment aide (CTA) and the therapist. 004.15(A) PLACE OF SERVICE. Community treatment aide (CTA) services must be provided primarily in the beneficiary’s natural environment, but may also include other appropriate community locations where the parent or caregiver are present. Community treatment aide (CTA) services must not be used in place of a school aide or other similar services not involving the parent. 004.15(B) THERAPIST DIRECTION AND SUPERVISION. Community treatment aide (CTA) services must be delivered under the direction and supervision of the therapist providing family or individual therapy, or both, on a regular basis to the beneficiary and the beneficiary’s caregiver or family. The community treatment aide (CTA) and the licensed therapist must coordinate care and document their collaboration at least every other week to ensure the community treatment aide (CTA) activities delivered to the beneficiary remain relevant to the beneficiary’s treatment plan. 004.15(C) COMMUNITY TREATMENT AIDE (CTA) ACTIVITIES. Activities designed by community treatment aide (CTA) providers may include activities related to: (i)Developing a written safety plan with input from the therapist, the beneficiary, and the parents or caregivers; (ii)Instructing the parents or caregivers in de-escalation techniques and strategies; (iii)Teaching and modeling appropriate behavioral treatment interventions and techniques and coping skills with the beneficiary and the beneficiary’s parents or caregivers; (iv)Collecting information about medication compliance and developing reminder strategies and other interventions to enhance compliance as needed; (v)Assisting parents or caregivers with reporting medication effects, side effects, concerns regarding side effects or compliance problems, and other information regarding progress and barriers to the treating therapist and the prescribing physician or advanced practice registered nurse (APRN); (vi)Teaching and modeling proper and effective parenting practices; and (vii)Providing training and rehabilitation regarding basic personal care and activities of daily living. 004.15(D) PRIOR AUTHORIZATION. Community treatment aide (CTA) services must be prior authorized by Nebraska Medicaid or its designee in order to be eligible for reimbursement. 004.15(E) PROGRAM DESCRIPTION APPROVAL. Community treatment aide (CTA) agencies must have a program description approved by Nebraska Medicaid or its designee. 004.15(F) COMMUNITY TREATMENT AIDE (CTA) PROGRAM OR CLINICAL DIRECTOR. The community treatment aide (CTA) program or clinical director may be a licensed physician who has completed a psychiatric residency or similar training program and preferably is board certified in psychiatry or addiction medicine, a psychologist, a licensed mental health practitioner (LMHP), a registered nurse (RN), an advanced practice registered nurse (APRN), or a licensed independent mental health practitioner (LIMHP). The director must have two years of professional experience in mental health or substance use disorder treatment, or both, of individuals under the age of 21. 004.15(G) COMMUNITY TREATMENT AIDE (CTA) THERAPIST. The community treatment aide (CTA) therapist must be a licensed physician who has completed a psychiatric residency or similar training program and preferably is board certified in psychiatry or addiction medicine, a psychologist, a licensed independent mental health practitioner (LIMHP), a licensed mental health practitioner (LMHP), or an advanced practice registered nurse (APRN). The community treatment aide (CTA) may be a provisionally licensed mental health practitioner (LMHP) or a provisionally licensed psychologist only if employed by an accredited organization or by exception by Nebraska Medicaid or its designee. The community treatment aide (CTA) therapist must meet all the requirements for outpatient therapy and must coordinate and collaborate with the community treatment aide (CTA) direct care staff. 004.15(H) COMMUNITY TREATMENT AIDE (CTA) DIRECT CARE STAFF. The community treatment aide (CTA) direct care staff must : (i)Have a bachelor’s degree in psychology, social work, child development or a related field and the equivalent of one year of full-time experience in direct child or adolescent services, or both, or mental health or substance use disorder services, or both. Equivalent time in graduate studies may substitute for work experience; or (ii)Have two years post-high school education in the human services or related fields and a minimum of two years’ experience in direct child or adolescent services, or both or mental health or substance use disorder services, or both. 004.15(I) BACKGROUND CHECKS AND TRAINING. Prior to allowing staff to treat beneficiaries, community treatment aide (CTA) agencies must gather information from abuse and neglect registries and conduct criminal background checks of all potential community treatment aide (CTA) workers and must assure that all workers have completed the community treatment aide (CTA) agency’s basic training program. 004.15(J) UNIT OF SERVICE. The unit of service for community treatment aide (CTA) staff persons must be 15 minutes. 004.16 MEDICATION MANAGEMENT. Medication management must include relevant history, a mental status examination, and medical decision-making regarding initiating or adjusting pharmacological agents. 004.17 SEX OFFENDER RISK ASSESSMENT. The resulting recommendations from a sex offender risk assessment should address treatment needs for medical, mental health and substance use disorder conditions that are diagnosed during the assessment. The assessment is not a forensic evaluation. 004.17(A) WRITTEN REPORT. Practitioners providing this assessment must provide a written report which includes the components listed below that support the treatment recommendations. 004.17(B) REPORT SIGNAGE. The report must be signed by the psychologist although parts of the assessment may be conducted by others who operate within the scope of their license and who are under the supervision of the signing psychologist. 004.17(C) RISK ASSESSMENT COMPONENTS. The components for a sexual offender risk assessment include demographic, biopsychosocial, psychological assessment results and treatment recommendations as follows: (i)Demographic Information: Reasons for the assessment, police reports and other relevant court documents, clinical interview of beneficiary, family members and other collateral contacts, initial diagnostic interview and review of previous mental health and substance use disorder treatment, and psychological testing records; (ii)Biopsychosocial Information: Background information, family relations and dynamics, family response to the current symptoms and problems, social functioning, school and academic history, substance use disorder history, legal history, mental health treatment history, sexual offense history, trauma and victimization history, and personal strengths; (iii)Psychological Evaluations: Level of cognitive and adaptive functioning, personal and behavior factors, sex offender risk assessment using both static and dynamic factors, sexual misconduct patterns, perception, understanding, motivation, and empathy for victim, current supervision and access to victim as well as protective factors and strengths; and (iv)Case Formulation and Treatment Recommendations: An integrated discussion of the relevant factors in determining the treatment recommendations and an assessment of the beneficiary’s current risk to reoffend. 004.18 ANNUAL SUPERVISION OF NEBRASKA MEDICAID ELIGIBLE INDIVIDUALS. The supervising practitioner must be available in person or by telephone to provide assistance as needed during the time services are being provided. The critical involvement of the supervising practitioner is to be reflected in the initial diagnostic interview, the treatment plan, and the interventions provided. 004.19 FUNCTIONAL FAMILY THERAPY (FFT). Functional family therapy (FFT) is family therapy targeted at youth. 004.19(A) INITIAL DIAGNOSTIC INTERVIEW. An initial diagnostic interview must be completed prior to the beginning of treatment and will serve as the initial treatment plan until a comprehensive treatment plan is completed. 004.19(B) STAFF NEEDS AND RESPONSIBILITIES. All staffing must be adequate to meet the individualized treatment needs of the beneficiary and meet the responsibilities of each staff position as outlined in the functional family therapy (FFT) model. 004.19(C) ASSESSMENT AND TREATMENT REQUIREMENTS. Assessments and treatment must address mental health and substance use disorder needs, and mental health and emotional issues related to medical conditions. The treatment plan must be individualized and include the specific problems, behaviors, or skills to be addressed; clear and realistic goals and objectives; services, strategies, and methods of intervention to be implemented; criteria for achievement; target dates; methods for evaluating the beneficiary’s progress; and the responsible professional. The treatment plan must be developed with the beneficiary and the identified, appropriate family members as part of the outpatient family therapy treatment planning process. The treatment plan must meet the following requirements: (i) The treating provider must consult with or refer to other providers for general medical, psychiatric, and psychological needs as indicated; (ii) It is the treating provider’s responsibility to coordinate with other treating professionals as needed; (iii) The treatment plan will be reviewed every 90 days or more often if clinically indicated; (iv) After hours crisis assistance must be available; and (v) Services must be trauma informed, culturally sensitive, age and developmentally appropriate, and incorporate evidence-based practices when appropriate. 004.19(D) PROVIDER AND TEAM REQUIREMENTS. A functional family therapy (FFT) treatment provider must have a master’s degree or greater and be a member of an active team. An active functional family therapy (FFT) team requires a functional family therapy (FFT) certified clinical supervisor and at least three functional family therapy (FFT) certified treatment providers working collaboratively with one another using the functional family therapy (FFT) model. 004.19(D)(i) TREATMENT PROVIDERS. Treatment providers may be any of the following: physicians, physician assistants (PA), advanced practice registered nurses (APRN), nurse practitioners (NP), licensed psychologists, provisionally licensed psychologists, licensed independent mental health practitioners (LIMHP), licensed mental health professionals (LMPH), or provisionally licensed mental health practitioners (LMHP) acting within their scope of practice. 004.19(D)(ii) TREATMENT CLINICAL SUPERVISORS. Treatment clinical supervisors must be physicians, physician assistants (PA), advanced practice registered nurses (APRN), licensed psychologists, or licensed independent mental health practitioners (LIMHP) certified in functional family therapy (FFT) model and with experience in the practice of psychotherapy. All psychiatric and psychotherapy services will be prescribed and provided under the supervision and direction of a supervising practitioner. Supervision is not a billable service. 004.19(D)(iii) TREATMENT ASSESSMENT PROVIDERS. Treatment assessment providers may be any of the following: physicians, psychiatric advanced practice registered nurses (APRN), nurse practitioners (NP), licensed psychologists, provisionally licensed psychologists, or licensed independent mental health practitioners (LIMHP) all acting within their scope of practice. 004.20 APPLIED BEHAVIOR ANALYSIS (ABA) SERVICES. Applied behavior analysis (ABA) must involve systematically applying interventions based upon the principles of learning theory to improve socially significant behaviors and must demonstrate that the interventions employed are responsible for the improvement in behavior for individuals with autism spectrum disorder (ASD) or developmental or intellectual disabilities. Necessity for applied behavior analysis (ABA) services must be determined based on an initial diagnostic interview (IDI) and a behavior identification assessment. Applied behavior analysis (ABA) services must meet the requirements as noted in the appropriate Medicaid service definitions.