DAR File No. 38710

Health, Health Care Financing, Coverage and Reimbursement Policy

Rule R414-36

Services by Community Mental Health Centers

Notice of Proposed Rule

(Amendment)

DAR File No.: 38710
Filed: 07/22/2014 11:44:59 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to remove sections of the rule specified in the summary provided below and to consolidate Rules R414-34 and R414-35 into Rule R414-36. (DAR NOTE: The proposed repeal of Rule R414-34 is under DAR No. 38708 and the proposed repeal of Rule R414-35 is under DAR No. 38708 in this issue, August 15, 2014, of the Bulletin.)

Summary of the rule or change:

This amendment s removes sections in the rule text that specify reimbursement, eligibility, and service coverage, and defers to the scope of services found in the Rehabilitative Mental Health and Substance Use Disorder Services Utah Medicaid Provider Manual and in the Medicaid State Plan. This amendment also changes the title of the rule to "Rehabilitative Mental Health and Substance Use Disorder Services."

State statutory or constitutional authorization for this rule:

• Section 26-18-3

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget because the services provided to Medicaid recipients remain unaffected by this change.

local governments:

There is no impact to local governments because the services provided to Medicaid recipients remain unaffected by this change.

small businesses:

There is no impact to small businesses because the services provided to Medicaid recipients remain unaffected by this change.

persons other than small businesses, businesses, or local governmental entities:

There is no impact to Medicaid providers and to Medicaid recipients because the services provided to Medicaid recipients remain unaffected by this change.

Compliance costs for affected persons:

There are no compliance costs to a single Medicaid provider or to a Medicaid recipient because this change only consolidates the scope of rehabilitative mental health and substance use disorder services for Medicaid recipients.

Comments by the department head on the fiscal impact the rule may have on businesses:

No impact on business because change will not alter current practice.

David Patton, PhD, Executive Director

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Health
Health Care Financing, Coverage and Reimbursement Policy
CANNON HEALTH BLDG
288 N 1460 W
SALT LAKE CITY, UT 84116-3231

Direct questions regarding this rule to:

• Karen Ford at the above address, by phone at 801-538-6637, by FAX at 801-538-6099, or by Internet E-mail at kford@utah.gov
• Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at cdevashrayee@utah.gov
• Nina Baker at the above address, by phone at 801-538-9127, by FAX at 801-538-6412, or by Internet E-mail at nabaker@utah.gov

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

09/15/2014

This rule may become effective on:

09/22/2014

Authorized by:

David Patton, Executive Director

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

R414-36. [Services by Community Mental Health Centers.]Rehabilitative Mental Health and Substance Use Disorder Services.

R414-36-1. Introduction.

Rehabilitative mental health and substance use disorder services may be provided to Medicaid recipients in accordance with the Rehabilitative Mental Health and Substance Use Disorder Services Utah Medicaid Provider Manual and Attachment 4.19-B of the Medicaid State Plan, as incorporated into Section R414-1-5.

[R414-36-1. Introduction and Authority.

(1) This rule outlines the diagnostic and rehabilitative mental health services provided to Medicaid clients by community mental health centers.

(2) This rule is authorized under UCA 26-18-3 and governs the services allowed under 42 CFR 440.130, Oct. 2003 ed., and implements waivers authorized under federal waiver authority in subsections 1902(a)(1), 1915(b)(3) and 1915(b)(4) of the Social Security Act.

 

R414-36-2. Definitions.

In this rule:

"Diagnostic services" means any medical procedure recommended by a physician or other licensed mental health therapist to enable him to identify the existence, nature, or extent of a mental health disorder in a client.

"Prepaid Mental Health Plan" means the prepaid, capitated program through which the Department pays contracted community mental health centers to provide all needed inpatient and outpatient mental health services to residents of the community mental health center's catchment area who are enrolled in the plan.

"Rehabilitative services" means any medical or remedial services recommended by a physician or other licensed mental health therapist for maximum reduction of a client's mental health disorder and restoration of the client to his best possible functional level.

 

R414-36-3. Client Eligibility Requirements.

Diagnostic and rehabilitative mental health services are available to any Categorically or Medically Needy Medicaid client, except that

(1) Medicaid clients who reside at the Utah State Hospital and the Utah Developmental Center are not covered under the Prepaid Mental Health Plan;

(2) children in State custody are enrolled in the Prepaid Mental Health Plan only for inpatient mental health services;

(3) Medicaid clients who enroll in the UNI HOME Program are disenrolled from the Prepaid Mental Health Plan;

(4) state subsidized adoptive children who have been exempted from the Prepaid Mental Health Plan by parent request are enrolled in the Prepaid Mental Health Plan only for inpatient mental health services.

 

R414-36-4. Program Access Requirements.

(1) Diagnostic and rehabilitative mental health services must be provided by or through a community mental health center that is under contract with or directly operated by a local county mental health authority.

(2) The community mental health center must evaluate the client to determine if the client has a mental health disorder that requires mental health services.

 

R414-36-5. Service Coverage.

(1) Services must be recommended by a licensed mental health therapist.

(2) The scope of diagnostic and rehabilitative mental health services includes:

(a) psychiatric diagnostic interview examination;

(b) mental health assessment by non-physician;

(c) psychological testing;

(d) individual psychotherapy;

(e) group psychotherapy;

(f) individual psychotherapy with medical evaluation and management services;

(g) family psychotherapy with patient present;

(h) family psychotherapy without patient present;

(i) therapeutic behavioral services;

(j) pharmacologic management;

(k) individual skills training and development;

(l) psychosocial rehabilitative services; and

(m) intensive psychosocial rehabilitative services for children ages 0 through the month of their 13th birthday.

(3) Medicaid clients who reside in counties covered by a Prepaid Mental Health Plan contractor are automatically enrolled in the Prepaid Mental Health Plan for that county. A Medicaid client covered by a Prepaid Mental Health Plan may receive additional services approved by CMS under the Social Security Act section 1915(b)(3) waiver authority.

(4) Medicaid adult recipients ages 19 and over in the TANF and Medically Needy eligibility categories who are enrolled in the Non-Traditional Medicaid Plan have the following service limitations:

(a) inpatient mental health care is limited to a maximum of 30 days per year;

(b) outpatient mental health services are limited to a maximum of 30 outpatient mental health treatment services or visits per year

(c) targeted case management services under R414-33A for the chronically mentally ill also count toward the maximum of 30 outpatient mental health services.

(4) Medicaid clients enrolled in the Non-Traditional Medicaid Plan also have the following service exclusions:

(a) services for conditions without manifest psychiatric diagnoses;

(b) hypnosis, occupational, or recreational therapy; and

(c) office calls in conjunction with medication management for repetitive therapeutic injections.

(4) Psychiatric diagnosis interview examinations for legal purposes only, such as for custodial or visitation rights are excluded from coverage for all Medicaid clients.

 

R414-36-6. Qualified Providers.

Diagnostic and rehabilitative services must be provided by an individual, as limited by the scope of his license, who is:

(1) a licensed physician, a licensed psychologist, a licensed clinical social worker, a licensed certified social worker, a licensed social service worker, a licensed advanced practice registered nurse specializing in mental health nursing, a licensed registered nurse, a licensed professional counselor, or a licensed marriage and family counselor; or

(2) an individual working toward licensure in one of the professions identified in subsection (a) to the extent permitted by Utah Code Title 58; or

(3) a licensed practical nurse or other trained staff working under the supervision of one of the individuals identified in subsections (1) or (2).

 

R414-36-7. Reimbursement Methodology.

(1) Two community mental health centers are not under contract with the Department as Prepaid Mental Health Plan contractors. The Department reimburses these two community mental health centers on a fee-for-service basis. The Department pays the lower of the amount billed or the Medicaid fee schedule. The fee schedule was initially established after consultation with provider representatives. A provider shall not charge the Department a fee that exceeds the provider's usual and customary charges for the provider's private pay clients.

(2) The Department pays Prepaid Mental Health Plan contractors a capitated monthly premium to cover all inpatient and outpatient mental health services needed by Medicaid clients. The premiums are developed and certified as actuarially sound by independent actuaries who meet the qualification standards established by the American Academy of Actuaries.]

 

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: [February 1, 2005]2014

Notice of Continuation: October 21, 2009

Authorizing, and Implemented or Interpreted Law: 26-18-3