65E-11.002. Definitions

Definitions as used in Chapter 65E-11, F.A.C.

(1) “Alternative Services” means services other than those specified in Rule 65E-11.003, F.A.C., that a Lead Agency or a Provider of Behavioral Health Services and district deems necessary to meet the objectives outlined in a child’s treatment plan.

(2) “Assessment” means the systematic collection and integrated review of individual-specific data and completion of evaluations for determining clinical eligibility and treatment planning.

(3) “Behavioral Health Interventions” means the prevention, diagnosis, and treatment of disabling mental and substance dependence disorders covered under the Title XXI part of the Florida KidCare Program, as described in Sections 409.810-.820, F.S.

(4) “Behavioral Health Liaison” means the primary person designated and employed by the Lead Agency to coordinate care between and among the various departments, agencies, providers, and families and to determine eligibility.

(5) “Behavioral Health Network” means the statewide network of Providers of Behavioral Health Services who serve non-Medicaid eligible children with mental or substance-related disorders who are determined eligible for the Title XXI part of the KidCare Program. This network includes providers who are managed behavioral health organizations, private and state funded mental health and substance-related disorders providers, and Lead Agencies. The Behavioral Health Network is administered by the Department of Children and Family Services, Children’s Mental Health State Program Office to provide a comprehensive behavioral health benefits package for children with serious mental or substance-related disorders.

(6) “Behavioral Health Services” means those services, contingent on the child’s presenting condition, that are provided to enrolled children in the Behavioral Health Network for the treatment of mental or substance-related disorders.

(7) “Behavioral Health Network Coordinator” means the department’s designated representative for overseeing the enrollment and provision of care by a single entity or local alliance of Providers of Behavioral Health services who comprise a behavioral health care network.

(8) “Benefits Package” means the required benefits and Alternative Services described in Rule 65E-11.003, F.A.C., that are made available to each child upon enrollment into the Behavioral Health Network.

(9) “Child” means any individual five (5) years of age and not yet (19) years of age who is enrolled in the Behavioral Health Network.

(10) “Children’s Medical Services Network” means a state wide managed care service system that includes health care providers as defined in Section 391.021, F.S.

(11) “Eligible” means a child that has been screened by the behavioral health liaison as meeting the Behavioral Health Network clinical and treatability criteria and by the Department for Title XXI financial eligibility criteria but is not yet enrolled in the program to receive Behavioral Health Network.

(12) “Emergency Behavioral Health Care” means those services necessary to stabilize a child who is experiencing an acute crisis attributable to his or her mental or substance-related disorder, and without care or treatment, there exists a substantial likelihood the child will cause serious bodily harm to himself or herself or others in the near future, as evidenced by recent behavior.

(13) “Enrollment” means a child is eligible for and receiving services in the Behavioral Health Network after an official acceptance into the Behavioral Health Network based on separate determinations of financial eligibility by the Department that the child is eligible for the Title XXI component of KidCare and that the child is clinically eligible for enrollment.

(14) “Enrollment Pool” means the total number of all children enrolled in a Behavioral Health Care Network and who are receiving Title XXI capitated behavioral health services during a specified contract period, where enrollment capacity is calculated as a separate calendar month per child.

(15) “Family” means the individual(s) consisting of parents(s), or adult caretaker(s) that reside with and have legal responsibility for the child.

(16) “Integrated Care System” means a comprehensive contracted program of services for children with special health care needs. This is the core service delivery structure of the Children’s Medical Services Network.

(17) “Lead Agency” means a Provider of Behavioral Health Services who is the legal entity within a Behavioral Health Care Network and is responsible for the provision and coordination of medically necessary behavioral health services to children and enrolled in its Behavioral Health Care Network.

(18) “Medically Necessary Behavioral Health Services” means any behavioral health treatment and service necessary to prevent, diagnose, correct, or alleviate, or preclude deterioration of a condition that interferes with a child’s ability to function in the home, school and community. Medically necessary behavioral health services shall be individualized and consistent with the symptoms, diagnosis, and treatment of the child’s presenting condition; and shall be (1) provided in accordance with generally accepted professional practice standards; (2) shall not be primarily intended for the convenience of the child, the child’s family, and the Provider of Behavioral Health Services; (3) shall be the most appropriate level of service for the diagnosis and treatment of the child’s condition; and (4) shall be approved by the medical body or health care specialty involved in the child’s treatment as effective, appropriate, and essential for the care and treatment of the child’s condition.

(19) “Providers of Behavioral Health Services” means those managed behavioral health care organizations, or substance-related and treatment programs, or independent behavioral health providers, or subcontracted providers that directly provide behavioral health services to enrolled children and who also meet the minimal licensure and credentialing standards set forth in statutes and rules of the department or the Department of Health, Division of Medical Quality Assurance, pertinent to the treatment and prevention of mental and substance-related disorders.

(20) “Reverification” means the redetermination of a child’s eligibility based on the criteria described in Rule 65E-11.004, F.A.C.

(21) “Risk” means the potential financial liability assumed by the Lead Agency for all behavioral health services included in the behavioral health benefit package, and non-direct client services specified in Rule 65E-11.003, F.A.C.

(22) “Routine Care” means Behavioral health services intended to maintain and improve the child’s optimal level of functioning in the home, school, and community.

(23) “Rural” means an area which consist of a population density of 100 or fewer individuals per mile.

(24) “Screening” means the preliminary determination of a child’s potential eligibility for behavioral health services from a Behavioral Health Care Provider based on the eligibility criteria described in Rule 65E-11.004, F.A.C.

(25) “Targeted Outreach” means the planned and coordinated efforts to communicate information about the Behavioral Health Network with an overall intent to increase awareness, participation, and enrollment in the program.

(26) “Treatment Plan” means that identifiable section of the medical record that depicts goals and objectives for the provision of services with specific treatment environments. The treatment plan shall be developed by a team consisting of individuals with experiences and competencies in the provision of behavioral health services to children as described in subsection 65E-11.002(10), F.A.C.; including if deemed appropriate by the family, the child and family or family representatives; and other agencies, providers or other persons.

(27) “Urgent Care” means those behavioral health services provided to children with mental or substance dependence disorders, whose presenting condition, although not life-threatening, could result in serious injury or disability unless behavioral health services is received.

Rulemaking Authority 409.8135(6) FS. Law Implemented 409.8135 FS. History–New 1-17-01, Amended 8-31-03.