Behavioral Health Assessment Services  

  •  

    AGENCY FOR HEALTH CARE ADMINISTRATION

    Medicaid

    RULE NO.:RULE TITLE:

    59G-4.028Behavioral Health Assessment Services

    NOTICE OF CHANGE

    Notice is hereby given that the following changes have been made to the proposed rule in accordance with subparagraph 120.54(3)(d)1., F.S., published in Vol. 44 No. 218, November 7, 2018 issue of the Florida Administrative Register.

    The Florida Medicaid Behavioral Health Assessment Services Coverage Policy has been changed as follows:

    Section 1.0, Introduction,  now reads:

    Florida Medicaid provides behavioral health community support services to promote recovery from

    behavioral health disorders or cognitive symptoms by improving the ability of recipients to

    strengthen or regain skills necessary to function successfully.

    Section 2.0, Eligible Recipient,  No Change.

    Subsection 2.2, now reads:

    Who Can Receive:

    Florida Medicaid recipients requiring medically necessary behavioral health community

    support services that have a mental health diagnosis and exhibit one of the following

    symptoms:

    Psychiatric

    Behavioral or cognitive

    Addictive behavior

    Clinical conditions severe enough to cause significant impairment in day-to-day

    functioning

    Section 3.0, Eligible Provider

    Subsection 3.1, General Criteria, No Change.

    Subsection 3.2, Who Can Provide now reads:

    All providers that deliver behavioral health assessment services must be either employed or contracted with a community behavioral health agency. The following providers can deliver all services specified in section 4.0:

             Community behavioral health agencies that employ or contract with practitioners who perform services under the supervision of a treating practitioner

             Practitioners licensed in accordance with Chapters 458 or 459, F.S.

             Psychiatric advanced practice registered nurses licensed in accordance with Chapter 464, F.S.

    The following providers can deliver all services specified in section 4.0 except for psychiatric evaluations and psychiatric reviews of records

             Practitioners licensed in accordance with Chapters 490 or 491, F.S.

    The following providers can deliver brief behavioral health status examinations, in-depth assessments, and bio-psychosocial evaluations and participate on treatment teams

             Master’s level certified addiction professionals

    The following providers can deliver in-depth assessments and bio-psychosocial evaluations and participate on treatment teams:

             Certified addiction professionals

             Master’s level practitioners

    The following providers can deliver bio-psychosocial evaluations and participate on treatment teams:

             Bachelor’s level practitioners

    Providers delivering limited functional assessments using the Functional Assessment Rating Scale (FARS) or Children’s Functional Assessment Rating Scale (C-FARS) must hold certification from the Department of Children and Families.

    Section 4.0, Coverage Information

    Section 4.1, General Criteria, No Change.

    Section 4.2, Specific Criteria now reads:

    Florida Medicaid covers the following in accordance with the Healthcare Common Procedure Coding System and the applicable Florida Medicaid fee schedule, or as specified in this policy.  Recipients residing in a nursing facility, reimbursed on a per diem basis, can receive behavioral health assessment services reimbursed under this benefit.

    4.2.1 Bio-psychosocial Evaluation

    Bio-psychosocial evaluations describe biological, psychological, and social factors that contribute to a recipient’s need for services and include brief mental health status examinations and preliminary service recommendations.

    Bio-psychosocial evaluations must provide information on the following:

          Biological factors

          Diagnostic impressions

          Mental health status examinations

          Presenting problems

          Psychological factors

          Social factors

          Summary of findings

          Treatment recommendations or plans

    Master’s level, bachelor’s level certified addiction professionals, or treating practitioners must review bio-psychosocial evaluations completed by bachelor’s level practitioners and include a statement that concurs with the findings or provides alternative recommendations.

     

    4.2.2 Brief Behavioral Health Status Examination

    Brief behavioral health status examinations consist of brief clinical, psychiatric, diagnostic, or evaluative interviews to assess behavioral stability or treatment status. An examination is required prior to the development of a recipient’s treatment plan. Brief behavioral health status examinations must provide information on the following:

          Diagnostic formulation

          Mental health status

          Purpose of the exam

          Summary of findings

          Treatment recommendations or plans

    Brief behavioral health status examinations are not required prior to the development of a recipient’s treatment plan when a bio-psychosocial evaluation or in-depth assessment had been completed during the previous six months.

     

    4.2.3 In-depth Assessment

    In-depth assessments gather information to establish or support a diagnosis, provide the basis for developing or modifying a treatment plan, and developing discharge criteria.

     

    In-depth assessments for recipients ages seven and older must provide information on the following:

          Personal history that includes the following:

             Alcohol and other drug use

             Educational analysis

             Identifying information

             Legal involvement

             Medical information

             Resources and strengths

             Traumatic experiences

          Recipient’s perception of problems, needs, or symptoms

          History of treatment that includes the following:

             Acute care treatment

             Desired services and goals from the recipient’s viewpoint

             Inpatient behavioral health treatment

             Mental health status examinations

             Psychiatric treatment and psychotropic medication information

             Therapy and counseling

             Treatment recommendations or plans

    In-depth assessments for recipients under the age of seven must include the following:

          Clinical interview with the primary caretaker and observation of the caretaker and recipient

          Developmental and medical history that includes the following:

       Developmental milestones

       History of the mother’s pregnancy and delivery

       Past and current medical conditions

          Family functioning, cultural and communication patterns, and current environmental conditions and stressors

          Family psychosocial and medical history

          Observation and assessment of the recipient’s affective, language, cognitive, motor, sensory, self-care, and social functioning

          Presenting symptoms and behaviors

     

    In-depth assessments for new patients must be administered to recipients for one of the following reasons:

             Another type of assessment is insufficient for providing a comprehensive evaluation for treatment planning.

             Recipient is high risk

    In-depth assessments for established patients must be administered to recipients for one of the following reasons:

          Recipient has received outpatient treatment with unsuccessful results and may require more intensive services.

          Recipients identified as high utilizers of behavioral health services.

    In-depth assessments require completion of an integrated summary that evaluates history and assessment information collected and provides the following:

          Diagnosis

          Discharge criteria

          Evaluation of past intervention efficacy

          Service needs

    4.2.4 Limited Functional Assessment

    Limited functional assessments consist of the following:

          American Society for Addiction Medicine Patient Placement Criteria (ASAM PPC-2R)

          Children’s Functional Assessment Rating Scale (C-FARS)

          Functional Assessment Rating Scale (FARS)

          Other functional assessment required by the Department of Children and Families

    4.2.5 Psychiatric Evaluation

    Psychiatric evaluations consist of comprehensive evaluations that investigate a recipient’s clinical status and include the following:

          Establishment of a therapeutic doctor-patient relationship

          Gather accurate data to formulate a diagnosis

          Initiation of an effective treatment plan

    Psychiatric evaluations must include information on the following:

          Alcohol and other drug abuse history

          Diagnostic formulation

          History of presenting illnesses or problems

          Mental health status examination

          Personal strengths

          Presenting problems

          Psychiatric, physical, medication, and trauma history

          Relevant personal and family medical history

          Summary of findings

          Treatment recommendations or plans

    Psychiatric evaluations must occur at the onset of illness and can be utilized following an extended hiatus, marked change in mental status, or admission to an inpatient setting due to psychiatric illness.

    Psychiatric evaluations are not necessary for recipients diagnosed with an organic brain disorder unless a change in mental status requires an evaluation.

     

    4.2.6 Psychiatric Review of Records

    Psychiatric reviews of records consist of reviewing the following to evaluate and plan recipient care:

          Clinical and psychological evaluation data for diagnostic use

          Psychiatric reports

          Psychometric or projective tests

     

    Psychiatric reviews of records must include a written report or progress note to be included in the recipient’s clinical record.

     

    4.2.7 Psychological Testing

    Psychological testing consists of the assessment, evaluation, and diagnosis of the recipient’s mental status or   psychological condition through the use of standardized testing methodologies.

    Psychological testing must be administered to recipients for one of the following reasons:

          Extended hiatuses, marked changes in mental status, or assessing for admission or readmission to a psychiatric inpatient setting

          Onset of illness or suspected illness when a recipient first presents for treatment

          To obtain additional information needed to evaluate treatment or make a diagnosis

    4.2.8 Treatment Plan Development

    Treatment plans include individualized, structured, and goal-oriented schedules of services with measurable objectives that promote the maximum reduction of a recipient’s disability and restoration to the best possible functional level. Plans must address a recipient’s primary and secondary diagnoses and be consistent with assessments.

     

    Treatment teams that are recipient-centered must develop treatment plans that consistent with a recipient’s identified strengths, abilities, needs, and preferences.

    Treatment plans must include the following:

          Amount, frequency, and duration of each service for the six-month duration of the treatment plan

       Providers may not specify that services will be provided “as needed” or within a given range.

          Dated signature of the recipient or recipient’s guardian if the recipient is under the age of 18

          Diagnoses consistent with assessment

          Discharge criteria

          Individualized and strength-based goals that are appropriate to each recipient

          List of services to be provided

          Measurable objectives with target completion dates listed for each goal

          Treating practitioner statement that services are medically necessary

          Treatment team member signatures

    Treatment plans become effective on the date of the treating practitioner’s signature. Florida Medicaid reimburses for services provided within 45 days of the signature.

     

    Providers may use addendums to modify treatment plans when significant changes have not occurred. Addendums can add or modify services and must be signed by the treating practitioner and recipient.

     

    4.2.9 Treatment Plan Review

    Treatment plan reviews occur once per six months or when significant changes occur and consist of the treatment team and recipient reviewing the goals, objectives, and services to determine whether they continue to be appropriate for the recipient’s needs and progress.

    Treatment plan reviews must consist of the following:

          Dated signature of the recipient or recipient’s guardian if the recipient is under the age of 18

          Diagnosis and justification for changes in diagnosis

          Findings

          Recipient’s progress toward meeting individualized goals, objectives, and discharge criteria

          Recommendations

          Treating practitioner statement that services are medically necessary

          Treatment team member signatures

          Updates to aftercare plan

    Treatment teams must document activities, notations of discussions, findings, conclusions, and modifications. If a recipient does not meet treatment goals, the treatment team must provide justification if it makes no changes.

    4.3, Early and Periodic Screening, Diagnosis, and Treatment, No Change.

    5.0, Exclusion

    5.1, General Non-Covered Criteria, No Change.

    5.2, Specific Non-Covered Criteria

    Florida Medicaid does not cover the following as part of this service benefit:

          Activities performed to maintain and review records for facility utilization, continuous quality improvement, recipient eligibility status processing, and staff training purposes

          Behavior analysis assessments or reassessments on the same day as behavioral health assessments

          Bio-psychosocial evaluation for the same recipient after an in-depth assessment has been completed, unless there is a documented change in the recipient’s status and additional information must be gathered to modify the recipient’s treatment plan

          Brief behavioral assessment on the same day that a psychiatric evaluation, biopsychosocial assessment, or in-depth assessment has been completed

          Case management services

          Services provided to a recipient on the day of admission into the Statewide Inpatient Psychiatric Program (SIPP); however, community behavioral health services are reimbursable on the day of discharge

          Services rendered to individuals residing in an institution for mental diseases

          Services rendered to institutionalized individuals, as defined in 42 CFR 435.1009

          Travel time

    6.0, Documentation

    6.1, General Criteria, No Change

    6.2, Specific Criteria, now reads:

    Providers must maintain the following in the recipient’s file:

    Record of a mental health diagnosis from a licensed practitioner

    Daily progress notes that list each service and activity provided

          7.0, Authorization through 8.0, Reimbursement, No Change.

Document Information

Related Rules: (1)
59G-4.028.