DAR File No. 38710
This rule was published in the August 15, 2014, issue (Vol. 2014, No. 16) of the Utah State Bulletin.
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:
HealthHealth 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 [email protected]
- Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at [email protected]
- Nina Baker at the above address, by phone at 801-538-9127, by FAX at 801-538-6412, or by Internet E-mail at [email protected]
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
RULE TEXT
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
Additional Information
More information about a Notice of Proposed Rule is available online.
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For questions regarding the content or application of this rule, please contact Karen Ford at the above address, by phone at 801-538-6637, by FAX at 801-538-6099, or by Internet E-mail at [email protected]; Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at [email protected]; Nina Baker at the above address, by phone at 801-538-9127, by FAX at 801-538-6412, or by Internet E-mail at [email protected]. For questions about the rulemaking process, please contact the Division of Administrative Rules.