471 NAC 35-002. DEFINITIONS

002. DEFINITIONS. The following definitions apply: 002.01 COLLATERAL CONTACT. Contacts which occur outside the provider organization without the beneficiary present and are related to the beneficiary’s individual treatment, rehabilitation, and recovery plan. 002.02 DIRECT BENEFICIARY CONTACT. Face-to-face or telehealth services between the community support worker and the beneficiary. 002.03 FAMILY THERAPY. A therapeutic service between the beneficiary and their family and a qualified licensed practitioner who provides intervention as identified by the family-focused goals of the individual treatment, rehabilitation, and recovery plan. Consent from the beneficiary must be documented prior to the involvement of the family and delivery of the service. 002.04 GROUP PSYCHOTHERAPY. Group psychotherapy service provided by a licensed clinician who is practicing within their scope of practice and provides a psychotherapy service in groups of no fewer than three and no more than twelve beneficiaries. 002.05 INDIVIDUAL PSYCHOTHERAPY. An individual treatment and rehabilitation service between an identified beneficiary and a qualified licensed practitioner who focuses upon the identified goals of the individual treatment, rehabilitation, and recovery plan. 002.06 MEDICAL NECESSITY. Nebraska Medicaid incorporates the definition of medical necessity from these regulations. Services and supplies that do not meet the definition of medical necessity in these regulations are not covered. Services may be subject to specific limitations or prior authorization requirements listed in this chapter. 002.06(A) REHABILITATIVE PSYCHIATRIC MEDICAL NECESSITY. Rehabilitative psychiatric services are medically necessary when those services can reasonably be expected to increase or maintain the level of functioning in the community of beneficiaries with severe and persistent mental illness. 002.06(A)(i) PHYSICIAN SERVICES. The fact that the physician has performed or prescribed a procedure or treatment or the fact that it may be the only treatment for a particular injury, sickness, or mental illness does not mean that it is covered by Nebraska Medicaid. Services and supplies, which do not meet the definition of medical necessity set out in this chapter are not covered. 002.07 PSYCHIATRIC RESIDENTIAL REHABILITATION. A facility-based, non-hospital or non-nursing facility program for beneficiaries disabled by severe and persistent mental illness, who are unable to reside in a less restrictive residential setting. 002.08 SECURE PSYCHIATRIC RESIDENTIAL REHABILITATION. A secure facility-based, non-hospital or non-nursing facility program for beneficiaries disabled by severe and persistent mental illness, who are unable to reside in a less restrictive setting. 002.09 SEVERE AND PERSISTENT MENTAL ILLNESS. Beneficiaries with severe and persistent mental illness must meet the following criteria: (A)The beneficiary is age 21 and over; (B)The beneficiary has a primary diagnosis of schizophrenia, major affective disorder, or other major mental illness . Developmental disorders, or psychoactive substance use disorders can be included if they co-occur with the primary mental illnesses listed above; (C)The beneficiary has a persistent mental illness as demonstrated by the presence of the disorder for the last 12 months or, which is expected to last 12 months or longer and will result in a degree of limitation that seriously interferes with the beneficiary's ability to function independently in an appropriate and effective manner in two of the three following functional areas: vocation and education, social skills, and activities of daily living; (i)Functional limitations in the area of vocation and education abilities are defined as: (1) An inability to be consistently employed or an ability to be employed only with extensive supports, except that a person who can work but is recurrently unemployed because of acute episodes of mental illness is considered vocationally impaired; (2) Deterioration or decompensation resulting in an inability to establish or pursue educational goals within a normal time frame or without extensive supports; and (3) An inability to consistently and independently carry out home management tasks, including household meal preparation, washing clothes, budgeting, and childcare tasks and responsibilities; (ii)Functional limitations in the area of social skills and abilities are defined as: (1) Repeated inappropriate or inadequate social behavior or an inability to behave appropriately or adequately without extensive or consistent support or coaching or outside of special contexts or situations; or (2) An inability to consistently participate in adult activities without extensive support or coaching or outside of limited special activities established for persons with mental illness or interpersonal impairments; or (3) A history of dangerousness to self or others; (iii)Functional limitations in the area of activities of daily living are defined as an inability to consistently perform the range of practical daily living tasks required for basic adult functioning in the community. A beneficiary may be considered to have functional limitations in this area if they are unable to perform tasks from at least three of the following five domains : (1) Grooming, hygiene, washing of clothes, and meeting nutritional needs; (2) Care of personal business affairs; (3) Transportation and care of residence; (4) Procurement of medical, legal, and housing services; or (5) Recognition and avoidance of common dangers or hazards to self and possessions; (D)The beneficiary has a significant risk of continuing to either live in a severely impaired manner or requiring institutionalization without provision of mental health services, and whose risk has persisted for one year or longer and is likely to continue for one year or longer; and (E)The beneficiary does not have a primary diagnosis of substance use disorder or developmental disability. 002.10 SUBSTANCE USE DISORDER COMMUNITY SUPPORT. A rehabilitative and supportive service for beneficiaries with primary Axis I diagnosis of substance use disorder. 002.11 SUPERVISING PROVIDER. The supervising provider must be: (A) Currently licensed and eligible to practice independently under Nebraska state law; (B) Currently enrolled with Nebraska Medicaid and eligible to provide Medicaid services; (C) Eligible to provide supervision to the supervisee under Nebraska state law; and (D) Within their scope of practice to prescribe and oversee the service being provided.