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Ohio Administrative Code (Last Updated: January 12, 2021) |
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5160 Medicaid |
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Chapter5160-27. Community Mental Health Agency Services |
5160-27-05. [Effective 1/1/2021] Mental health intensive home based treatment service
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(A) For the purposes of medicaid reimbursement, intensive home based treatment (IHBT), is the service and activities as set forth by the Ohio department of mental health and addiction services in paragraphs (A) to (C) of rule 5122-29-28 of the Administrative Code.
(B) To be eligible for IHBT, a medicaid recipient must meet the following:
(1) The requirements as established in paragraph (E) of rule 5122-29-28 of the Administrative Code; and
(2) Score the following on the life functioning domain, child behavioral/emotional needs, and child risk behaviors dimensions of the child and adolescent needs and strengths (CANS) assessment tool available at www.medicaid.ohio.gov:
(a) A rating of "three" on one of the following life function domain items or a rating of at least "two" on two of the following life functioning domain items, and;
(i) Family;
(ii) Legal;
(iii) Social functioning;
(iv) Living situation;
(v) School behavior; or
(vi) School attendance.
(b) A rating of "two" or higher on one or more of the following items within the child behavioral/emotional needs criteria, or:
(i) Psychosis;
(ii) Impulse/hyperactivity;
(iii) Depression;
(iv) Anxiety;
(v) Oppositional;
(vi) Conduct;
(vii) Adjustment to trauma;
(viii) Anger control; or
(ix) Substance use.
(c) A rating of "two" or higher on one or more of the following items within the child risk behaviors criteria:
(i) Suicide risk;
(ii) Self-mutilation;
(iii) Other self-harm;
(iv) Danger to others;
(v) Sexual aggression;
(vi) Runaway;
(vii) Delinquency;
(viii) Judgment;
(ix) Fire setting; or
(x) Social behavior.
(3) The recipient must have at least one adult family member or other adult individual who is a part of the recipient's home who authorizes IHBT services to be provided, and actively participates in the provision of IHBT. "Home" has the same meaning as in rule 5122-29-28 of the Administrative Code.
(C) Prior authorization of IHBT services.
(1) The provider must submit a request for prior authorization and receive approval from the Ohio department of medicaid designated entity before ODM will reimburse for IHBT services. The maximum amount of IHBT service which may be prior authorized at any one time is seventy-two hours.
(2) The provider agency may request additional IHBT service to be prior authorized by the ODM designated entity.
(D) Disenrollment from IHBT
(1) A recipient or their guardian may request to end receipt of IHBT services at their discretion. The IHBT provider will notify ODM or its designee of the disenrollment. Failure to timely notify ODM or its designee may result in claims denial for other mental health services.
(2) Disenrollment of a recipient from IHBT is necessary to ensure that the recipient may obtain medicaid reimbursed behavioral health services from a provider other than the IHBT team. Upon disenrollment of an IHBT recipient, the IHBT team shall document the circumstances regarding disenrollment in the recipient's treatment plan. The provider must inform the ODM designated entity of disenrollment within three business days of the discharge date. Either the provider or the ODM designated entity shall deactivate the authorization for the IHBT service. Failure to timely disenroll the recipient from IHBT may result in claims denial for other mental health or substance use disorder services.
(E) A provider of IHBT must meet all of the following criteria:
(1) Meets the requirements found in paragraph (A)(1) or (A)(2) of rule 5160-27-01 of the Administrative Code; and
(2) Employment of one or more IHBT practitioners licensed by the counselor, social worker, and marriage and family therapist board or Ohio board of psychology working within their scope of practice, and
(3) Have documentation of completion, within the previous twelve months, of an fidelity review performed by an ODM designated entity. Information concerning fidelity standards and requirements is available at www.medicaid.ohio.gov; and
(4) Participate in a fidelity review that includes the following items and is based on the IHBT fidelity rating tool (dated September 23, 2016);
(a) Intensity of service;
(b) Strength-based assessment and treatment planning;
(c) Comprehensive system collaboration and service coordination;
(d) Cultural responsiveness;
(e) Professional training and development;
(f) Treatment partnerships and youth and family engagement;
(g) Team composition;
(h) Accessible and flexible services and scheduling:
(i) Must meet items listed in paragraphs (E)(4)(b) and (E)(4)(c) of this rule; and
(ii) Meet one additional item.
(i) Treatment durations and continuity of care: items listed in paragraphs (E) (4)(b), (E)(4)(c), and (E)(4)(d) of this rule must be met.
(5) Participate in a fidelity review that includes the following items and is based on the IHBT fidelity rating tool (dated September 23, 2016);
(a) Location of service;
(b) Caseload;
(c) Crisis response and availability;
(d) Safety planning;
(e) Outcomes monitoring and quality improvement;
(f) Fidelity monitoring.
(6) Participate in a fidelity review that includes the following items and is based on the IHBT fidelity rating tool (dated September 23, 2016);
(a) Comprehensive and integrated behavioral health treatment approach;
(b) Supervisory support and availability.
(7) Have documented evidence of fidelity compliance prior to submitting any prior authorization requests for IHBT services.
(F) ODM reserves the right to suspend or terminate the payment of IHBT services and to require subsequent review of an IHBT practitioner's fidelity performance if ODM has reason to believe that the IHBT practitioner's fidelity to the model may be in question. ODM may, at its discretion, suspend the payment of IHBT claims from the provider agency employing the IHBT practitioner until such time as ODM receives documentation from its independent validation entity that the practitioner does meet the minimum fidelity criteria described in paragraph (E) of this rule.
(G) All IHBT services must be rendered by an IHBT practitioner to the recipient or his/her family members who are participating in the treatment.
(H) Documentation requirements.
(1) Documentation in the recipient's client record of the services provided by the IHBT practitioner must meet the requirements stated in paragraph (H) of this rule as well as those stated in rules 5160-1-27 and 5160-8-05 of the Administrative Code.
(2) The IHBT practitioner must develop a specific treatment plan for each recipient receiving IHBT. The treatment plan must, at a minimum, meet the requirements stated in rule 5160-8-05 of the Administrative Code as well as the following:
(a) The treatment plan shall be individualized based on the recipient's needs, strengths, and preferences and shall set measurable long-term and short-term goals and specify approaches and interventions necessary for the recipient to achieve the individual goals. The treatment plan shall also identify who will carry out the approaches and interventions.
(b) The treatment plan shall address, at a minimum, the following key areas:
(i) Behavioral health symptom reduction.
(ii) Risk reduction and safety planning.
(iii) Family and interpersonal relationship.
(iv) Functioning in relevant life domains.
(c) The treatment plan shall be reviewed and updated by an IHBT practitioner with the recipient or guardian whenever there is a significant change in condition or at least every three months. The treatment plan update shall include a summary of the recipient's progress, goal attainment, effectiveness of the intervention and the recipient's satisfaction with the IHBT practitioner's intervention(s).
(d) The treatment plan, and all subsequent revisions of it, shall be reviewed and signed by the recipient and the adult as described in paragraph (B)(3) of this rule, and the IHBT practitioner.
(I) The following activities are not reimbursable as part of IHBT:
(1) Time spent doing, attending, or participating in recreational activities.
(2) Child care services or services provided as a substitute for the parent or other individuals responsible for providing care and supervision.
(3) Respite care.
(4) Transportation for the beneficiary or family.
(5) Any art, movement, dance, or drama therapies.
(6) Services provided to teach academic subjects or as a substitute for educational personnel including, but not limited to, a teacher, teacher's aide, or an academic tutor.
(J) Medicaid payment will not be made for any of the following services or treatments while the recipient is enrolled in IHBT services:
(1) Assessments, screenings, and diagnostic evaluations.
(2) Mental health day treatment.
(3) Individual, group, or family psychotherapy and counseling.
(4) Therapeutic behavioral services.
(5) Community psychiatric supportive treatment.
(6) Psychosocial rehabilitation.
(7) Substance use disorder residential treatment services.
(8) Assertive community treatment.
(9) Crisis intervention provided by the provider agency employing the IHBT practitioner.
(10) Health home services.
(K) Substance use disorder (SUD) targeted case management requires prior authorization from the ODM designated entity while a recipient is enrolled in IHBT.
(L) The medicaid payment rate for IHBT is stated in appendix DD to rule 5160-1-60 of the Administrative Code. Payment for services provided by authorized IHBT teams is only available for dates of services on or after January 1, 2018.