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-IR- Database: Indiana Register

TITLE 405 OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES

Final Rule
LSA Document #13-530(F)

DIGEST

Adds 405 IAC 5-21.8 pertaining to a new program that provides behavioral and primary health care coordination services and matters related thereto, including definitions, reimbursement, eligibility criteria, program standards, and provider types. Effective 30 days after filing with the Publisher.



SECTION 1. 405 IAC 5-21.8 IS ADDED TO READ AS FOLLOWS:

Rule 21.8. Behavioral and Primary Health Care Coordination Services


405 IAC 5-21.8-1 General provisions

Authority: IC 12-8-6.5-5; IC 12-15

Sec. 1. The intent of this rule is to provide BPHC services to individuals with serious mental illness who demonstrate impairment in self-management of health services. Eligibility for services and the provision of services are based upon an individual meeting specific BPHC needs-based and targeting criteria. BPHC services will be:
(1) provided through a state plan; and
(2) delivered by service provider agencies meeting specific state-defined criteria.
(Office of the Secretary of Family and Social Services; 405 IAC 5-21.8-1; filed Apr 8, 2014, 12:41 p.m.: 20140507-IR-405130530FRA)


405 IAC 5-21.8-2 Definitions

Authority: IC 12-8-6.5-5; IC 12-15

Sec. 2. (a) The definitions in this section apply throughout this rule.

(b) "Applicant" refers to an individual who is seeking enrollment in BPHC services.

(c) "Behavioral and primary health care coordination services" or "BPHC services" refers to coordination of health care services to manage the health care needs of the recipient including direct assistance in gaining access to health services, coordination of care within and across systems, oversight of the entire case, and linkage to appropriate services.

(d) "Certified community health worker" or "CHW" refers to an individual who meets all of the following:
(1) Has completed the CHW DMHA and Indiana state department of health state-approved training program.
(2) Receives a passing score on the certification exam.
(3) Is supervised by a licensed professional or QBHP.
(4) Delivers services as defined at section 8(a) of this rule.

(e) "Certified recovery specialist" or "CRS" refers to an individual who meets all of the following:
(1) Is maintaining healthy recovery from mental illness.
(2) Has completed the CRS DMHA state-approved training program.
(3) Receives a passing score on the certification exam.
(4) Is supervised by a licensed professional or QBHP.
(5) Delivers services as defined at section 8(a) of this rule.

(f) "Division of mental health and addiction approved behavioral health assessment tool" means the state designated assessment tool administered by a qualified individual who is trained and DMHA-certified to administer the tool in order to assist in determining the level of need and functional impairment of an applicant or a recipient.

(g) "DMHA" means the division of mental health and addiction.

(h) "Health" means physical and behavioral health.

(i) "Individualized integrated care plan" or "IICP" means a treatment plan that meets all of the following:
(1) Integrates all components and aspects of care that are:
(A) deemed medically necessary;
(B) needs-based;
(C) clinically indicated; and
(D) provided in the most appropriate setting to achieve the recipient's goals.
(2) Includes all indicated medical and support services needed by the recipient in order to:
(A) remain in the community;
(B) function at the highest level of independence possible; and
(C) achieve goals identified in the IICP.
(3) Reflects the recipient's desires and choices.

(j) "Level of need" means a recommended intensity of services based on a pattern of a recipient's needs, as determined using the DMHA approved behavioral health assessment tool.

(k) "Licensed professional" means any of the following persons:
(1) A licensed psychiatrist.
(2) A licensed physician.
(3) A licensed psychologist or a psychologist endorsed as a health service provider in psychology (HSPP).
(4) A licensed clinical social worker (LCSW).
(5) A licensed mental health counselor (LMHC).
(6) A licensed marriage and family therapist (LMFT).
(7) A licensed clinical addiction counselor (LCAC), as defined under IC 25-23.6-10.5.

(l) "Medicaid rehabilitation services" means any medical or remedial service recommended by a physician or other licensed practitioner of the healing arts, within the scope of that individual's practice under state law, for:
(1) maximum reduction of physical or mental health disability; and
(2) restoration to a recipient's best possible level of functioning.

(m) "Needs-based eligibility criteria" means factors used to determine an applicant's need for BPHC services. The applicant meets the BPHC needs-based eligibility criteria when the following are demonstrated:
(1) Needs related to management of the applicant's health.
(2) Impairment in self-management of the applicant's health services.
(3) A health need that requires assistance and support in coordinating health treatment.
(4) A recommendation for intensive community based care based on the uniform DMHA approved behavioral health assessment tool as indicated by a rating of three (3) or higher.

(n) "Office" refers to the office of Medicaid policy and planning.

(o) "Other behavioral health professional" or "OBHP" means any of the following:
(1) An individual with an associate's or bachelor's degree, or equivalent behavioral health experience who:
(A) meets minimum competency standards set forth by a behavioral health service provider; and
(B) is supervised by either a licensed professional or a QBHP.
(2) A licensed addiction counselor, as defined under IC 25-23.6-10.5, who is supervised by either a licensed professional or a QBHP.

(p) "Provider agency" means any DMHA-approved agency that meets the qualifications and criteria to become a BPHC provider agency, as required by this rule.

(q) "Provider staff" means any individual working for a DMHA-approved BPHC provider agency who meets the qualifications and requirements mandated by the BPHC service being provided, as defined in this rule.

(r) "Qualified behavioral health professional" or "QBHP" means any of the following:
(1) An individual who has had at least two (2) years of clinical experience treating persons with mental illness under the supervision of a licensed professional, with such experience occurring after the completion of a master's degree or a doctoral degree, or both, in any of the following disciplines from an accredited university:
(A) Psychiatric or mental health nursing, including a license as a registered nurse in Indiana.
(B) Pastoral counseling.
(C) Rehabilitation counseling.
(2) An individual who:
(A) is supervised by a licensed professional;
(B) is eligible for and working toward professional licensure; and
(C) has completed a master's degree or a doctoral degree, or both, in any of the following disciplines from an accredited university:
(i) Social work from a university accredited by the Council on Social Work Education.
(ii) Psychology.
(iii) Mental health counseling.
(iv) Marital and family therapy.
(3) A licensed, independent practice school psychologist under the supervision of a licensed professional.
(4) An authorized health care professional (AHCP) who is either of the following:
(A) A physician assistant with the authority to prescribe, dispense, and administer drugs and medical devices or services under an agreement with a supervising physician and subject to the requirements of IC 25-27.5-5.
(B) A nurse practitioner or clinical nurse specialist, with prescriptive authority, performing duties within the scope of that person's license and under the supervision of, or under a supervisory agreement with, a licensed physician under IC 25-23-1.

(s) "Recipient" means a person receiving BPHC services.

(t) "State evaluation team" means the DMHA independent evaluation team that will review and assess all evaluation information and supporting clinical documentation collected for BPHC applicants and recipients and will be responsible for making final determinations regarding the following:
(1) Needs-based and target group eligibility of applicants for BPHC services.
(2) Authorization for BPHC services for eligible recipients.
(3) Continued eligibility determination for BPHC recipients.
(4) Appropriate service delivery to BPHC recipients as a result of conducting quality improvement reviews of BPHC service provider agencies.

(u) "Target group eligibility criteria" means factors used to determine an applicant's eligibility for BPHC services. To meet the BPHC target group criteria, an applicant must:
(1) be nineteen (19) years of age or older; and
(2) have been diagnosed with an eligible primary mental health diagnosis as defined at section 4(3) of this rule.
(Office of the Secretary of Family and Social Services; 405 IAC 5-21.8-2; filed Apr 8, 2014, 12:41 p.m.: 20140507-IR-405130530FRA)


405 IAC 5-21.8-3 Applicants and the application process

Authority: IC 12-8-6.5-5; IC 12-15

Sec. 3. (a) In order for an individual to receive services under this rule, a BPHC eligible provider agency, in collaboration with the applicant, must submit an application in the manner required by the office and the DMHA.

(b) Each applicant for BPHC services must receive a face-to-face evaluation using both the:
(1) DMHA-approved behavioral health assessment tool; and
(2) application form developed by the office and DMHA.

(c) The application form and supporting documentation should include the following information about the applicant:
(1) Health status.
(2) Current living situation.
(3) Family functioning.
(4) Vocational or employment status.
(5) Social functioning.
(6) Living skills.
(7) Self-care skills.
(8) Capacity for decision making.
(9) Potential for self-injury or harm to others.
(10) Substance use or abuse.
(11) Need for assistance managing a medical condition.
(12) Medication adherence.

(d) An application must, at a minimum, include documentation demonstrating the following:
(1) The applicant is an active participant in the planning and development of the IICP.
(2) The applicant is requesting the services listed on the proposed IICP submitted with the application.
(3) The applicant has chosen, from a randomized list of eligible BPHC service providers in the applicant's community, a provider to deliver the DMHA authorized BPHC services under this rule.

(e) Upon receipt of the application and supporting clinical documentation, the DMHA state evaluation team will assess the submitted information and determine whether or not the applicant meets the needs-based and target group eligibility criteria for receiving BPHC services.

(f) For those applicants who are not Medicaid enrolled at the time of application for BPHC services, a Medicaid application must be submitted in the manner set forth in 405 IAC 2-1.1 for a Medicaid eligibility determination.

(g) The DMHA state evaluation team retains responsibility for the following:
(1) Determining whether an applicant meets the needs-based and target group eligibility criteria for BPHC services.
(2) Approving all proposed BPHC services included in the IICP.

(h) Any approval or denial of eligibility for services under this rule will be communicated to the:
(1) applicant or the applicant's authorized representative; and
(2) referring provider agency.
(Office of the Secretary of Family and Social Services; 405 IAC 5-21.8-3; filed Apr 8, 2014, 12:41 p.m.: 20140507-IR-405130530FRA)


405 IAC 5-21.8-4 Eligibility

Authority: IC 12-8-6.5-5; IC 12-15

Sec. 4. To be eligible for services under this rule, an applicant must meet all of the following:
(1) All of the criteria set forth in 405 IAC 2-1.1-6.
(2) Be nineteen (19) years of age or older.
(3) The applicant has been diagnosed with a BPHC-eligible primary mental health diagnosis including, but not limited to:
(A) schizophrenic disorder;
(B) major depressive disorder;
(C) bipolar disorder;
(D) delusional disorder; or
(E) psychotic disorder.
(4) The applicant either:
(A) resides in a community-based setting that is not an institutional setting; or
(B) will be discharged from an institutional setting back to a community-based setting.
(5) The applicant meets all of the following needs-based eligibility criteria, as defined in section 2(m) of this rule, based on the following:
(A) Behavioral health clinical evaluation.
(B) Referral form.
(C) Supporting documentation.
(D) The DMHA behavioral health assessment tool results.
(Office of the Secretary of Family and Social Services; 405 IAC 5-21.8-4; filed Apr 8, 2014, 12:41 p.m.: 20140507-IR-405130530FRA)


405 IAC 5-21.8-5 IICP authorization period; renewal

Authority: IC 12-8-6.5-5; IC 12-15

Sec. 5. (a) A recipient approved to receive BPHC services under this rule shall be eligible for such services for up to a six (6) month period commencing from the date of service approval and authorization, as long as eligibility and needs-based eligibility criteria and other eligibility continue to be met.

(b) A reevaluation will be conducted at least every six (6) months and shall include the following:
(1) Conducting a face-to-face holistic clinical and biopsychosocial evaluation completed by a DMHA-approved BPHC service provider.
(2) Administering the DMHA approved behavioral assessment tool to determine whether the recipient still meets the level of need for intensive community-based services, as demonstrated by a rating level of three (3) or higher.
(3) Assessing the recipient's progress toward meeting treatment goals set forth in the IICP.
(4) Documenting that the recipient continues to meet BPHC target group eligibility and needs-based eligibility criteria.
(5) Completing an updated application.
(6) Completing an updated IICP documenting the recipient's choice of BPHC service providers.

(c) The DMHA evaluation team will review and assess the application and reevaluation results to determine whether the recipient continues to meet needs-based and target group eligibility criteria.

(d) Any approval or denial of eligibility and services under this rule will be communicated to the following:
(1) The applicant or the applicant's authorized representative.
(2) The referring provider agency.
(Office of the Secretary of Family and Social Services; 405 IAC 5-21.8-5; filed Apr 8, 2014, 12:41 p.m.: 20140507-IR-405130530FRA)


405 IAC 5-21.8-6 Clinical documentation requirements

Authority: IC 12-8-6.5-5; IC 12-15

Sec. 6. (a) To be reimbursable under this rule, the BPHC service must be supported by clinical documentation that is maintained in the recipient's clinical record.

(b) The documentation required to support billing for BPHC services must meet the following standards:
(1) Reflect progress toward the goals reflected in the recipient's IICP.
(2) Be updated with every recipient encounter when billing is submitted for reimbursement.
(3) Be written and signed by the agency staff rendering services.

(c) The documentation to support billing for BPHC services should:
(1) focus on recovery and habilitation or rehabilitation;
(2) support coordination or management of identified health needs and services; and
(3) emphasize consumer strengths.

(d) Clinical documentation of services provided under this section must contain the following information:
(1) The type of service being provided.
(2) The names and qualifications of the staff providing the service.
(3) The location or setting where the service was provided.
(4) The focus of the session or service delivered to or on behalf of the recipient.
(5) The recipient's symptoms, needs, goals, or issues addressed during the session.
(6) The actual time spent rendering the service.
(7) The start and end time of the service.
(8) The recipient's IICP goal being addressed during the session.
(9) The progress made toward meeting goals noted on the IICP.
(10) The date of service rendered including month, day, and year.

(e) The content of the documentation must support the amount of time billed.

(f) For BPHC services provided on behalf of the recipient without the recipient present, documentation must be provided for each encounter and must include the following information:
(1) The names of all persons attending the session and each person's relationship to the recipient.
(2) How the service:
(A) benefits the recipient; and
(B) assists the recipient in reaching the IICP goals.

(g) A provider shall maintain documentation for services provided to a BPHC services recipient in accordance with the requirements under 405 IAC 1-5-1.
(Office of the Secretary of Family and Social Services; 405 IAC 5-21.8-6; filed Apr 8, 2014, 12:41 p.m.: 20140507-IR-405130530FRA)


405 IAC 5-21.8-7 BPHC services; general provisions

Authority: IC 12-8-6.5-5; IC 12-15

Sec. 7. (a) All BPHC services provided to a recipient must meet the following requirements:
(1) Be supported by the recipient's level of need.
(2) Be documented in the recipient's IICP.

(b) Provider reimbursement for BPHC services is subject to, but not limited to, the following:
(1) The recipient's eligibility for services.
(2) The provider's qualifications and certification.
(3) The scope, limitations and exclusions of the services.
(Office of the Secretary of Family and Social Services; 405 IAC 5-21.8-7; filed Apr 8, 2014, 12:41 p.m.: 20140507-IR-405130530FRA)


405 IAC 5-21.8-8 BPHC activities

Authority: IC 12-8-6.5-5; IC 12-15

Sec. 8. (a) BPHC reimbursable activities consist of coordination of health care services to manage the health care needs of the recipient. The BPHC services include the following reimbursable activities:
(1) Logistical support.
(2) Advocacy and education to assist individuals in navigating the health care system.
(3) Activities that help recipients:
(A) gain access to needed health services; and
(B) manage their health conditions, including, but not limited to:
(i) adhering to health regimens;
(ii) scheduling and keeping medical appointments;
(iii) obtaining and maintaining a primary medical provider; and
(iv) facilitating communication across medical providers.
(4) Needs assessment.
(5) IICP development.
(6) Referral and linkage.
(7) Coordination of health services across systems.
(8) Monitoring and follow-up.
(9) Evaluation.

(b) This subsection defines the activities identified at subsection (a)(4) through (a)(9) as follows:
(1) Needs assessment consists of identifying the recipient's needs for coordination of health services. Specific assessment activities necessary to form a complete needs assessment of the recipient may include the following:
(A) Taking the recipient's history.
(B) Identifying the recipient's needs.
(C) Completing related documentation.
(D) Gathering information from other sources, such as:
(i) family members; or
(ii) medical providers.
(2) IICP development activities include the development of a written IICP based upon the information collected during the needs assessment phase. An IICP shall include recipient-driven goals for health care or lifestyle changes and identify the health activities and assistance needed to accomplish the recipient's objectives. An IICP may include activities and goals such as:
(A) referrals to medical services;
(B) education on health conditions;
(C) activities to ensure compliance with health regimens and health care provider recommendations; or
(D) activities or contacts necessary to ensure that the IICP is effectively implemented and adequately address the health needs of the individual.
(3) Referral and linkage include activities that help link the recipient with medical providers and other programs and services that are capable of providing needed health services.
(4) Coordination of health services includes, but is not limited to, the following:
(A) Physician consults, defined as facilitating linkage and communication between medical providers.
(B) The BPHC provider serving as a communication conduit between the consumer and specialty medical and behavioral health providers.
(C) Notification, with the consumer's consent, of changes in medication regimens and health status.
(D) Coaching consumers to help them interact more effectively with providers.
(5) Monitoring and follow-up include the following:
(A) Face-to-face contact with the recipient at least every ninety (90) days.
(B) Contacts and activities necessary to ensure that the IICP is effectively implemented and adequately addresses the needs of the recipient.
(C) Contacts and activities with the following individuals:
(i) The recipient.
(ii) Family members or others who have a significant relationship with the recipient.
(iii) Nonprofessional caregivers.
(iv) Providers.
(v) Other entities.
(6) Evaluation includes periodic reevaluation of the recipient's progress in order to:
(A) ensure the IICP is effectively implemented and adequately addresses the recipient's needs;
(B) determine whether the services are consistent with the IICP and any changes to the IICP;
(C) make changes or adjustments to the IICP in order to meet the recipient's ongoing needs; and
(D) evaluate the recipient's progress toward achieving the IICP's objectives.

(c) The time devoted to formal supervision between the BPHC provider and the licensed supervisor to review the recipient's care and treatment shall be:
(1) an included BPHC activity;
(2) documented in the recipient's clinical record; and
(3) billed under only one (1) provider staff member.

(d) The BPHC activities under subsection (b)(1) through (b)(3) and b(4)(A) must be delivered by provider staff who are one (1) of the following:
(1) A licensed professional.
(2) A QBHP.
(3) An OBHP.

(e) With the exception of those activities described in subsection (d), provider staff delivering services under this section must be one (1) of the following:
(1) A licensed professional.
(2) A QBHP.
(3) An OBHP.
(4) A DMHA CRS.
(5) A DMHA certified community health worker.

(f) The following are not reimbursable under this section:
(1) Activities billed under behavioral health level of need redetermination.
(2) Activities billed under Medicaid rehabilitation option case management.
(3) Activities billed under adult mental health habilitation care coordination.
(4) Direct provision of medical services or treatment, including, but not limited to, the following:
(A) Medical screening such as blood pressure screenings or weight checks.
(B) Medication training and support.
(C) Individual, group, or family therapy services.
(D) Crisis intervention services.
(5) Services provided to the recipient at the same time as another service that is the same in nature and scope, regardless of funding source.
(6) Services provided while the recipient is in an institutional or noncommunity-based setting.
(7) Services provided in a manner that is not within the scope or limitations of a BPHC service.
(8) Services not documented as covered or approved on the recipient's DMHA-approved IICP.
(9) Services not supported by documentation in the recipient's clinical record.
(10) Services provided that exceed the defined limits of the service, including service quantity, limits, duration, or frequency.
(11) Activities excluded from the service scope or definition.

(g) BPHC services are limited to a maximum of twelve (12) hours, or forty-eight (48) units, per six (6) months.
(Office of the Secretary of Family and Social Services; 405 IAC 5-21.8-8; filed Apr 8, 2014, 12:41 p.m.: 20140507-IR-405130530FRA)


405 IAC 5-21.8-9 BPHC provider agency requirements

Authority: IC 12-8-6.5-5; IC 12-15

Sec. 9. (a) In order to deliver the BPHC program under this rule, a provider must be a state-certified community mental health center approved by the DMHA as a BPHC provider agency.

(b) Any provider wishing to apply to become a BPHC provider agency must:
(1) submit a completed BPHC provider agency application to the DMHA for review and consideration; and
(2) be enrolled as a Medicaid provider.

(c) Provider agencies under this rule must attest that the staff members delivering BPHC allowable activities under this service meet the provider requirements and qualifications as defined in section 8(d) and 8(e) of this rule.

(d) Provider agencies approved to provide BPHC services under this rule are subject to the enforcement provisions in 405 IAC 1-1-6.
(Office of the Secretary of Family and Social Services; 405 IAC 5-21.8-9; filed Apr 8, 2014, 12:41 p.m.: 20140507-IR-405130530FRA)


405 IAC 5-21.8-10 Fair hearings and appeals

Authority: IC 12-8-6.5-5; IC 12-15

Sec. 10. (a) The following individuals may appeal an adverse agency action:
(1) An applicant.
(2) A recipient of services under this rule.
(3) A duly authorized representative of:
(A) an applicant; or
(B) a recipient.

(b) Administrative hearings and appeals by an applicant or recipient are governed by the procedures set forth in 405 IAC 1.1.

(c) The DMHA state evaluation team shall notify the following individuals of any such adverse agency action:
(1) The applicant or recipient.
(2) The duly authorized representative of the applicant or the recipient, if applicable.
(3) The BPHC provider agency.
(Office of the Secretary of Family and Social Services; 405 IAC 5-21.8-10; filed Apr 8, 2014, 12:41 p.m.: 20140507-IR-405130530FRA)


405 IAC 5-21.8-11 Complaints and grievances

Authority: IC 12-8-6.5-5; IC 12-15

Sec. 11. (a) The following individuals may file a written complaint or a written grievance with the state, the DMHA, or the office:
(1) An applicant.
(2) A recipient.
(3) A duly authorized representative of:
(A) an applicant; or
(B) a recipient.

(b) Upon receipt of a complaint or grievance, the DMHA shall:
(1) log the complaint or grievance; and
(2) initiate an investigation.

(c) The DMHA's decision with regard to a complaint or grievance is not appealable.

(d) The filing of a complaint or grievance is not a prerequisite to filing an appeal under section 10 of this rule.

(e) If the DMHA issues findings regarding a complaint or a grievance of an applicant or a recipient, the DMHA may require the provider agency to correct an identified deficiency within a timeline established by the DMHA. A provider agency's failure to correct the deficiency within the established timeline may result in sanctions up to and including decertification of the provider agency.
(Office of the Secretary of Family and Social Services; 405 IAC 5-21.8-11; filed Apr 8, 2014, 12:41 p.m.: 20140507-IR-405130530FRA)


LSA Document #13-530(F)
Notice of Intent: 20131120-IR-405130530NIA
Proposed Rule: 20140226-IR-405130530PRA
Hearing Held: March 20, 2014
Approved by Attorney General: March 27, 2014
Approved by Governor: April 4, 2014
Filed with Publisher: April 8, 2014, 12:41 p.m.
Documents Incorporated by Reference: None Received by Publisher
Small Business Regulatory Coordinator: Matthew P. Cesnik, FSSA Office of Medicaid Policy and Planning, Indiana Government Center South, 402 West Washington Street, Room W374, Indianapolis, IN 46204, (317) 234-3394, matthew.cesnik@fssa.in.gov

Posted: 05/07/2014 by Legislative Services Agency

DIN: 20140507-IR-405130530FRA
Composed: Oct 30,2014 11:10:32AM EDT
A PDF version of this document.