Coverage for Insureds 21 Years of Age and Younger Who Are Receiving Mental Health Services Provided by State-Sponsored Community Mental Health Providers

The State of New Hampshire Insurance Department 21 South Fruit Street, Suite 14 Concord, NH 03301 David J. Bettencourt Commissioner Keith E. Nyhan Deputy Commissioner Telephone 603-271-2261 • Fax 603-271-1406 • TDD Access: Relay NH 1-800-735-2964 nh.gov/insurance BULLETIN Docket #INS 24-016-AB TO: All Health Insurers FROM: Commissioner David J. Bettencourt DATE: March 08, 2024 RE: Coverage for Insureds 21 Years of Age and Younger Who Are Receiving Mental Health Services Provided by State-Sponsored Community Mental Health Providers As commercial health insurance coverage expands under the Affordable Care Act to ever wider segments of the New Hampshire population, and as state-sponsored community mental health services for children in the state grow under a number of state and federal initiatives, it is increasingly common that commercially covered children with severe mental illness are receiving services from community-based mental health organizations that are funded primarily through contracts with the New Hampshire Department of Health and Human Services. Some of these services are billable under the child’s commercial coverage. Despite this coverage availability, the Insurance Department’s review of the all-payer claims data indicates that these services are not commonly billed. Based on the information provided to the Department from the workgroup that the Commissioner has convened on this subject (the SB 411 Workgroup), the paucity of claims being reimbursed for these services is primarily attributable either to the fact that the organization is not in contract with the health carrier or that the organization is not sufficiently informed to properly bill under the coverage. The community-based provider organizations that provide services to children with severe mental illness include the providers of services under the “FAST Forward” program authorized under RSA 167:3-l, III and the New Hampshire Medicaid §1915(i) State Plan Amendment1 approved by CMS on July 12, 2018,2 as well as services provided by the state’s 10 Community Mental Health Centers established 1 https://www.dhhs.nh.gov/sites/g/files/ehbemt476/files/documents/2021-11/sp-3-1i.pdf 2 These agencies include: NFI North and Connected Families NH. 2 under RSA 135-C.3 The services at issue primarily include care coordination but broadly encompass: (1) crisis assessments, (2) crisis intervention services, (3) crisis stabilization services, (4) in-home services, (5) residential treatment services, (6) structured outpatient programs, (7) care coordination, (8) parent and youth peer support services, and (9) hospital-based, nonresidential treatment programs.4 Some of the services provided by these organizations are social services rather than health care services billable under commercial policies. At the same time, many of the services do qualify as health care services and are billable under specific Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes. The American Medical Association develops and owns CPT codes which cover services and procedures performed by physicians, other qualified health care professionals, hospitals, laboratories, and outpatient facilities. HCPCS codes are developed by CMS and cover a wider range of supplies and services not addressed in the CPT codes. While there is some overlap between CPT and HCPCS codes, there are certain services that are only covered by a CPT or a HCPCS code. In addition to the CPT and HCPCS codes, there are various modifiers that may need to be used to properly bill for a specific service. Modifiers may be necessary to indicate a particular treatment setting, the type of provider performing the service, whether the service is related to a social service program, or other relevant information. It is very important to understand the differences between the codes and modifiers, as well as the appropriate context for their use, to ensure accurate billing and reimbursement. The Department surveyed both the organizations providing these services and the health carriers and compiled the attached chart identifying the potentially appropriate codes for each of the service categories listed above. As a result of the growing number of commercially covered children with severe mental illness who are receiving billable services from the above-referenced community mental health organizations, it is incumbent on health carriers to take the following two actions: 1. Use best efforts to update contracts or come into contract and credential with the above-referenced organizations for all qualified providers. The parties are strongly encouraged to explore different reimbursement models as part of these contract negotiations. 3 These agencies include: 1 Northern Human Services, 2 West Central Behavioral Health, 3 Lakes Region Mental Health Center, 4 Riverbend Community Mental Health, 5 Monadnock Family Services, 6 Greater Nashua Mental Health, 7 Mental Health Center of Greater Manchester, 8 Seacoast Mental Health Center, 9 Community Partners, and 10 Center for Life Management. 4 Commercial health insurance policies in New Hampshire are required to provide benefits for mental health and substance use disorder services and the Department would generally consider these categories of services a to be included as covered services. See RSA 420-G:4-d; RA 417-E, RSA 415:18-a, and RSA 420-B:8-b. 3 2. Produce usable guidance, either in the provider contract itself or in the provider billing manual, that will allow these organizations to determine the proper billing codes and code modifiers to use in billing for services that are reimbursable under the child’s commercial coverage. 4 Code Description Who Can Bill* Dr/PA/ APRN Psy.D. MS Clinical Staff Crisis Assessments 99202 New patient office or other outpatient visit, 15-29 minutes X 99203 New patient office or other outpatient visit, 30-44 minutes X 99204 New patient office or other outpatient visit, 45-59 minutes X 99205 New patient office or other outpatient visit, 60-74 minutes X 99212 Established patient office or other outpatient visit, 10- 19 minutes X 99213 Established patient office or other outpatient visit, 20- 29 minutes X 99214 Established patient office or other outpatient visit, 30- 29 minutes X 99215 Established patient office or other outpatient visit, 40- 54 minutes X 90791 Psychiatric diagnostic evaluation X X X 90792 Psychiatric diagnostic evaluation with medical services X Crisis Intervention and Stabilization Services 90839 Psychotherapy for crisis, first 60 minutes X X X 90840 Psychotherapy for crisis, each additional 30 minutes X X X 90846 Family psychotherapy (without patient present), 50 minutes X X X 90847 Family psychotherapy (with patient present), 50 minutes X X X H2011 Crisis intervention service, per 15 minutes S9484 Crisis intervention mental health services, per hour S9485 Crisis intervention mental health services, per diem In-home Services, including individual and family therapy and behavioral interventions 99341 New Patient, home evaluation and management, 20 minutes X 99342 New Patient, home evaluation and management, 30 minutes X 99343 New Patient, home evaluation and management, 45 minutes X 99344 New Patient, home evaluation and management, 60 minutes X 99345 New Patient, home evaluation and management, 75 minutes X 99347 Established Patient, home evaluation and management, 15 minutes X 99348 Established Patient, home evaluation and management, 25 minutes X 5 99349 Established Patient, home evaluation and management, 40 minutes X 99350 Established Patient, home evaluation and management, 60 minutes X 90832 Psychotherapy, 30 minutes with patient X X X 90833 Psychotherapy when performed with evaluation and management service, 30 minutes with patient X X X 90834 Psychotherapy, 45 minutes with patient X X X 90836 Psychotherapy when performed with evaluation and management service, 45 minutes with patient X X X 90837 Psychotherapy, 60 minutes with patient X X X 90838 Psychotherapy when performed with evaluation and management service, 60 minutes with patient X X X 90846 Family psychotherapy (without patient present), 50 minutes X X X 90847 Family psychotherapy (with patient present), 50 minutes X X X H0004 Behavioral Health Counseling and Therapy, per 15 minutes H2019 Therapeutic behavioral services, per 15 minutes T1027 Family training and counseling for child development, per 15 minutes Residential Treatment Services H0004 Behavioral Health Counseling and Therapy, per 15 minutes H0017 Behavioral health; residential (hospital residential treatment program), without room and board, per diem H0018 Behavioral health; short-term residential (nonhospital residential treatment program), without room and board, per diem H0019 Behavioral health; long-term residential (nonmedical, non-acute care residential treatment program), without room and board, per diem H2019 Therapeutic behavioral services, per 15 minutes Structured Outpatient Programs 90832 Psychotherapy, 30 minutes with patient X X X 90833 Psychotherapy when performed with evaluation and management service, 30 minutes with patient X X X 90834 Psychotherapy, 45 minutes with patient X X X 90836 Psychotherapy when performed with evaluation and management service, 45 minutes with patient X X X 90837 Psychotherapy, 60 minutes with patient X X X 90838 Psychotherapy when performed with evaluation and management service, 60 minutes with patient X X X 90846 Family psychotherapy (without patient present), 50 minutes X X X 90847 Family psychotherapy (with patient present), 50 minutes X X X 6 H0004 Behavioral Health Counseling and Therapy, per 15 minutes H0015 Alcohol and/or drug services; intensive outpatient H2019 Therapeutic behavioral services, per 15 minutes S9480 Intensive outpatient psychiatric services, per diem T1027 Family training and counseling for child development, per 15 minutes Care Coordination 99490 Chronic care management by clinical staff under the direction of a physician or other qualified health professional, first 20 minutes per month X 99439 Chronic care management by clinical staff under the direction of a physician or other qualified health professional, each additional 20 minutes per month X 99491 Chronic care management by physician or other qualified health professional, 30 minutes per month X 99487 Complex chronic care management by clinical staff under the direction of a physician or other qualified health professional, first 60 minutes per month X 99489 Complex chronic care management by clinical staff under the direction of a physician or other qualified health professional, each additional 30 minutes per month X 99484 Care management services for behavioral health conditions by clinical staff under the direction of a physician or other qualified health professional, at least 20 minutes per month X G0506 Comprehensive assessment of and care planning for patients requiring chronic care management services H0006 Alcohol and/or drug services; case management H0023 Behavioral health outreach service H0034 Medication training and support, per 15 minutes H2010 Comprehensive medication services, per 15 minutes Parent and Youth Peer Support Services 90849 Multiple-family group psychotherapy X X X 90853 Group psychotherapy X X X H0038 Self-help/peer services, per 15 minutes H2019 Therapeutic behavioral services, per 15 minutes T1027 Family training and counseling for child development, per 15 minutes Partial Hospital-based, Nonresidential Treatment Programs 99221 Initial hospital care, per day typically 30 minutes X 99222 Initial hospital care, per day typically 50 minutes X 99223 Initial hospital care, per day typically 70 minutes X 99231 Subsequent hospital care, per day, typically 15 minutes X 7 99232 Subsequent hospital care, per day, typically 25 minutes X 99233 Subsequent hospital care, per day, typically 35 minutes X 90832 Psychotherapy, 30 minutes with patient X X X 90833 Psychotherapy when performed with evaluation and management service, 30 minutes with patient X X X 90834 Psychotherapy, 45 minutes with patient X X X 90836 Psychotherapy when performed with evaluation and management service, 45 minutes with patient X X X 90837 Psychotherapy, 60 minutes with patient X X X 90838 Psychotherapy when performed with evaluation and management service, 60 minutes with patient X X X 90846 Family psychotherapy (without patient present), 50 minutes X X X 90847 Family psychotherapy (with patient present), 50 minutes X X X H0004 Behavioral Health Counseling and Therapy, per 15 minutes H0035 Mental health partial hospitalization, treatment, less than 24 hours S0201 Partial hospitalization services, less than 24 hours, per diem H2001 Rehabilitation program, per 1/2 day H2019 Therapeutic behavioral services, per 15 minutes Other H0046 Mental Health Services, not otherwise specified H0045 Respite care services, not in the home, per diem H2015 Comprehensive community support services, per 15 minutes H2022 Community-based wrap-around services, per diem S9125 Respite Care, in home, per diem S9482 Family stabilization services, per 15 minutes T1027 Family training and counseling for child development, per 15 minutes How to Use the Above Chart: This chart is being offered for reference purposes only. It is not intended to cover every possible billing code that may apply, but instead seeks to identify common codes associated with the category of services. * The “Who Can Bill” column is specific to CPT (the codes that start with a number). “Dr/PA/APRN” refers to physicians, physician assistants, and advanced practice registered nurse. “Psy.D.” refers to qualified providers with a doctorate level 8 education. “MS” refers to qualified providers with a master’s degree level of education. “Clinical Staff” means clinical staff under the direction of a physician or other qualified health professional. For HCPCS codes (those codes starting with a letter), the use of the code is not limited to certain providers so the boxes have been shaded. A HCPCS code may need to include a modifier identifying the type of provider rendering the service, care setting, or other relevant information as reimbursement may vary based on the modifiers used. Questions about this bulletin should be directed to Leigh Curtis, Health Insurance Reform Coordinator at the New Hampshire Insurance Department, at Leigh.E.Curtis@ins.nh.gov.