Current through Register Vol. 50, No. 9, March 1, 2024
RELATES TO:
KRS
205.520,
369.101
- 369.120,
20 U.S.C.
1400 et seq.,
29 U.S.C.
701 et seq.,
42
U.S.C. 290 ee-3, 1320d-2 - 1320d-8,
1396a(a)(10)(B), 1396a(a)(23),
42 C.F.R. Part 2,
431.17, 45 C.F.R. Parts 160, 164
NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and
Family Services, Department for Medicaid Services, has a responsibility to
administer the Medicaid Program.
KRS
205.520(3) authorizes the
cabinet, by administrative regulation, to comply with any requirement that may
be imposed or opportunity presented by federal law to qualify for federal
Medicaid funds. This administrative regulation establishes the coverage
provisions and requirements regarding Medicaid Program behavioral health
services provided by tier I behavioral health services organizations.
Section 1. General Coverage Requirements.
(1) For the department to reimburse for a
service covered under this administrative regulation, the service shall be:
(a) Medically necessary; and
(b) Provided:
1. To a recipient; and
2. By a behavioral health services
organization that meets the provider participation requirements established in
Section 2 of this administrative regulation.
(2)
(a)
Direct contact between a practitioner and a recipient shall be required for
each service except for:
1. Collateral
outpatient therapy for a child under the age of twenty-one (21) years if the
collateral outpatient therapy is in the child's plan of care;
2. A family outpatient service in which the
corresponding current procedural terminology code establishes that the
recipient is not present; or
3. A
psychological testing service comprised of interpreting or explaining results
of an examination or data to family members or other kin if the corresponding
current procedural terminology code establishes that the recipient is not
present.
(b) A service
that does not meet the requirement in paragraph (a) of this subsection shall
not be covered.
(3) A
billable unit of service shall be actual time spent delivering a service in an
encounter.
(4) A service shall be:
(a) Stated in the recipient's plan of care;
and
(b) Provided in accordance with
the recipient's plan of care.
(5)
(a) A
behavioral health services organization shall establish a plan of care for each
recipient receiving services from the behavioral health services
organization.
(b) A plan of care
shall meet the plan of care requirements established in
902
KAR 20:430.
Section 2. Provider Participation.
(1) To be eligible to provide services under
this administrative regulation, a behavioral health services organization
shall:
(a) Be currently enrolled in the
Kentucky Medicaid Program in accordance with
907
KAR 1:672;
(b) Be currently participating in the
Kentucky Medicaid Program in accordance with
907
KAR 1:671; and
(c) Have:
1.
For each service it provides, the capacity to provide the full range of the
service as established in this administrative regulation;
2. Documented experience in serving
individuals with behavioral health disorders;
3. The administrative capacity to ensure
quality of services;
4. A financial
management system that provides documentation of services and costs;
and
5. The capacity to document and
maintain individual case records in accordance with Section 6 of this
administrative regulation.
(2) A behavioral health services organization
shall:
(a) Agree to provide services in
compliance with federal and state laws regardless of age, sex, race, creed,
religion, national origin, handicap, or disability;
(b) Comply with the Americans with
Disabilities Act (42 U.S.C.
12101 et seq.) and any amendments to the Act;
and
(c) Provide, directly or
through written agreement with another behavioral health services provider,
access to face-to-face or telehealth, as appropriate pursuant to
907
KAR 3:170, emergency services twenty-four (24) hours
per day, seven (7) days per week.
(3) A BHSO I shall:
(a) Not receive reimbursement for services
provided for outpatient or residential substance use disorder treatment, except
as permitted pursuant to Section 3 of this administrative regulation if the
primary diagnosis is mental health;
(b) Provide services in accordance with its
licensure,
902
KAR 20:430, and Section 3 of this administrative
regulation for mental health treatment; and
(c) Except as provided by subsection (4) of
this section, possess accreditation within one (1) year of initial enrollment
by one (1) of the following:
1. The Joint
Commission;
2. The Commission on
Accreditation of Rehabilitation Facilities;
3. The Council on Accreditation; or
4. A nationally recognized accreditation
organization.
(4) The department shall grant a one (1) time
extension to a BHSO I that requests a one (1) time extension to complete the
accreditation process, if the request is submitted at least ninety (90) days
prior to expiration of provider enrollment.
Section 3. Covered Services.
(1) The following providers shall not be
eligible to provide services under this administrative regulation for a BHSO I:
(a) A licensed clinical alcohol and drug
counselor (LCADC);
(b) A licensed
clinical alcohol and drug counselor associate (LCADCA);
(c) A certified alcohol and drug counselor
(CADC); or
(d) A substance use
disorder peer support specialist.
(2) Except as specified in the requirements
stated for a given service, the services covered may be provided for a:
(a) Mental health disorder; or
(b) Co-occurring disorders, if the:
1. Substance use disorder diagnosis is
secondary to a primary mental health diagnosis; and
2. Services are provided by an independently
licensed practitioner who could independently practice and provide treatment
for a co-occurring disorder. The following qualifying practitioners may provide
co-occurring disorder treatment within a BHSO I:
a. A physician;
b. A psychiatrist;
c. An advanced practice registered
nurse;
d. A physician
assistant;
e. A licensed
psychologist;
f. A licensed
psychological practitioner;
g. A
certified psychologist with autonomous functioning;
h. A licensed clinical social
worker;
i. A licensed professional
clinical counselor; or
j. A
licensed marriage and family therapist.
(3) The services established in
this subsection shall be covered under this administrative regulation in
accordance with the requirements established in this section.
(a) A screening shall:
1. Determine the likelihood that an
individual has a mental health disorder, substance use disorder, or
co-occurring disorders;
2. Not
establish the presence or specific type of disorder;
3. Establish the need for an in-depth
assessment;
4. Be face-to-face or
via telehealth, as appropriate pursuant to
907
KAR 3:170; and
5. Be provided by:
a. An approved behavioral health
practitioner; or
b. An approved
behavioral health practitioner under supervision.
(b) An assessment shall:
1. Include gathering information and engaging
in a process with the individual that enables the practitioner to:
a. Establish the presence or absence of a
mental health disorder, substance use disorder, or co-occurring
disorders;
b. Determine the
individual's readiness for change;
c. Identify the individual's strengths or
problem areas that may affect the treatment and recovery processes;
and
d. Engage the individual in
developing an appropriate treatment relationship;
2. Establish or rule out the existence of a
clinical disorder or service need;
3. Include working with the individual to
develop a plan of care;
4. Not
include psychological or psychiatric evaluations or assessments;
5. Be face-to-face or via telehealth as
appropriate pursuant to
907
KAR 3:170; and
6. Be provided by:
a. An approved behavioral health
practitioner; or
b. An approved
behavioral health practitioner under supervision.
(c)
1. Psychological testing shall include:
a. A psychodiagnostic assessment of
personality, psychopathology, emotionality, or intellectual disabilities;
and
b. Interpretation and a written
report of testing results.
2. Psychological testing shall be provided
face-to-face or via telehealth as appropriate pursuant to
907
KAR 3:170.
3. Psychological testing shall be provided
by:
a. A licensed psychologist;
b. A certified psychologist with autonomous
functioning;
c. A licensed
psychological practitioner;
d. A
certified psychologist under supervision; or
e. A licensed psychological associate under
supervision.
(d) Crisis intervention:
1. Shall be a therapeutic intervention for
the purpose of immediately reducing or eliminating the risk of physical or
emotional harm to:
a. The recipient; or
b. Another individual;
2. Shall consist of
clinical intervention and support services necessary to provide integrated
crisis response, crisis stabilization interventions, or crisis prevention
activities for individuals;
3.
Shall be provided:
a. As an immediate relief
to the presenting problem or threat; and
b. In a one (1) on one (1) encounter between
the provider and the recipient, which is delivered either face-to-face or as a
comparable service provided via telehealth as appropriate pursuant to
907
KAR 3:170;
4. Shall be followed by a referral to
non-crisis services if applicable;
5. May include:
a. Further service prevention planning
including lethal means reduction for suicide risk; or
b. Verbal de-escalation, risk assessment, or
cognitive therapy; and
6.
Shall be provided by:
a. An approved
behavioral health practitioner; or
b. An approved behavioral health practitioner
under supervision.
(e) Mobile crisis services shall:
1. Be available twenty-four (24) hours a day,
seven (7) days a week, every day of the year;
2. Be provided for a duration of less than
twenty-four (24) hours;
3. Not be
an overnight service;
4. Be
provided via face-to-face contact by a multi-disciplinary team based
intervention in a home or community setting that ensures access to mental
health services and supports to:
a. Reduce
symptoms or harm; or
b. Safely
transition an individual in an acute crisis to the appropriate least
restrictive level of care;
5. Involve all services and supports
necessary to provide:
a. Integrated crisis
prevention;
b. Assessment and
disposition;
c.
Intervention;
d. Continuity of care
recommendations; and
e. Follow-up
services;
6. Be provided
face-to-face in a home or community setting;
7. Include access to a board-certified or
board-eligible psychiatrist twenty-four (24) hours a day, seven (7) days a
week, every day of the year; and
8.
Be provided by:
a. An approved behavioral
health practitioner;
b. An approved
behavioral health practitioner under supervision; or
c. A peer support specialist who:
(i) Is under the supervision of an approved
behavioral health practitioner; and
(ii) Provides support services under this
paragraph.
(f)
1. Day
treatment shall be a non-residential, intensive treatment program for a child
under the age of twenty-one (21) years who has:
a. A mental health disorder; and
b. A high risk of out-of-home placement due
to a behavioral health issue.
2. Day treatment shall:
a. Consist of an organized, behavioral health
program of treatment and rehabilitative services;
b. Include:
(i) Individual outpatient therapy, family
outpatient therapy, or group outpatient therapy;
(ii) Behavior management and social skills
training;
(iii) Independent living
skills that correlate to the age and developmental stage of the recipient;
or
(iv) Services designed to
explore and link with community resources before discharge and to assist the
recipient and family with transition to community services after discharge;
and
c. Be provided:
(i) In collaboration with the education
services of the local education authority including those provided through
20 U.S.C.
1400 et seq. (Individuals with Disabilities
Education Act) or
29 U.S.C.
701 et seq. (Section 504 of the
Rehabilitation Act);
(ii) On school
days and during scheduled school breaks;
(iii) In coordination with the recipient's
individualized education program or Section 504 plan if the recipient has an
individualized education program or Section 504 plan;
(iv) Under the supervision of an approved
behavioral health practitioner or an approved behavioral health practitioner
under supervision;
(v) With a
linkage agreement with the local education authority that specifies the
responsibilities of the local education authority and the day treatment
provider; and
(vi)
Face-to-face.
3. To provide day treatment services, a
behavioral health services organization shall have:
a. The capacity to employ staff authorized to
provide day treatment services in accordance with this section and to
coordinate the provision of services among team members; and
b. Knowledge of mental health
disorders.
4. Day
treatment shall not include a therapeutic clinical service that is included in
a child's individualized education program or Section 504 plan.
5.
a. Day
treatment shall be provided by:
(i) An
approved behavioral health practitioner; or
(ii) An approved behavioral health
practitioner under supervision.
b. A peer support specialist working under
the supervision of an approved behavioral health practitioner may provide
support services under this paragraph.
(g)
1. Peer
support services shall:
a. Be emotional
support that is provided by:
(i) An individual
who has been trained and certified in accordance with
908 KAR
2:220 and who is experiencing or has experienced a
mental health disorder to a recipient by sharing a similar mental health
disorder in order to bring about a desired social or personal change;
(ii) A parent or other family member, who has
been trained and certified in accordance with
908 KAR
2:230, of a child having or who has had a mental
health disorder to a parent or family member of a child sharing a similar
mental health disorder in order to bring about a desired social or personal
change; or
(iii) An individual, who
has been trained and certified in accordance with
908 KAR
2:240 and identified as experiencing as a child or
youth an emotional, social, or behavioral disorder that is defined in the
current version of the Diagnostic and Statistical Manual for Mental
Disorders;
b. Be an
evidence-based practice;
c. Be
structured and scheduled non-clinical therapeutic activities with an individual
recipient or a group of recipients;
d. Promote socialization, recovery,
self-advocacy, preservation, and enhancement of community living skills for the
recipient;
e. Be coordinated within
the context of a comprehensive, individualized plan of care developed through a
person-centered planning process;
f. Be identified in each recipient's plan of
care;
g. Be designed to directly
contribute to the recipient's individualized goals as specified in the
recipient's plan of care; and
h. Be
provided face-to-face.
2.
To provide peer support services, a behavioral health services organization
shall:
a. Have demonstrated:
(i) The capacity to provide peer support
services for the behavioral health population being served including the age
range of the population being served; and
(ii) Experience in serving individuals with
behavioral health disorders;
b. Employ peer support specialists who are
qualified to provide peer support services in accordance with
908 KAR
2:220,
908 KAR
2:230, or
908 KAR
2:240;
c.
Use an approved behavioral health practitioner to supervise peer support
specialists;
d. Have the capacity
to coordinate the provision of services among team members;
e. Have the capacity to provide on-going
continuing education and technical assistance to peer support
specialists;
f. Require individuals
providing peer support services to recipients to provide no more than thirty
(30) hours per week of direct recipient contact; and
g. Require peer support services provided to
recipients in a group setting not exceed eight (8) individuals within any group
at a time.
(h)
1. Intensive outpatient program services
shall:
a. Be an alternative to or transition
from a higher level of care for a mental health disorder;
b. Offer a multi-modal, multi-disciplinary
structured outpatient treatment program that is significantly more intensive
than individual outpatient therapy, group outpatient therapy, or family
outpatient therapy;
c. Be provided
at least three (3) hours per day at least three (3) days per week for
adults;
d. Be provided at least six
(6) hours per week for adolescents;
e. Include:
(i) Individual outpatient therapy, group
outpatient therapy, or family outpatient therapy unless
contraindicated;
(ii) Crisis
intervention; or
(iii)
Psycho-education related to identified goals in the recipient's treatment plan;
and
f. Be provided
face-to-face.
2. During
psycho-education, the recipient or recipient's family member shall be:
a. Provided with knowledge regarding the
recipient's diagnosis, the causes of the condition, and the reasons why a
particular treatment might be effective for reducing symptoms; and
b. Taught how to cope with the recipient's
diagnosis or condition in a successful manner.
3. An intensive outpatient program services
treatment plan shall:
a. Be individualized;
and
b. Focus on stabilization and
transition to a lesser level of care.
4. To provide intensive outpatient program
services, a behavioral health services organization shall have:
a. Access to a board-certified or
board-eligible psychiatrist for consultation;
b. Access to a psychiatrist, physician, or
advanced practiced registered nurse for medication prescribing and
monitoring;
c. Adequate staffing to
ensure a minimum recipient-to-staff ratio of ten (10) recipients to one (1)
staff person;
d. The capacity to
provide services utilizing a recognized intervention protocol based on
nationally accepted treatment principles; and
e. The capacity to employ staff authorized to
provide intensive outpatient program services in accordance with this section
and to coordinate the provision of services among team members.
5. Intensive outpatient program
services shall be provided by:
a. An approved
behavioral health practitioner, except for a licensed behavior analyst; or
b. An approved behavioral health
practitioner under supervision, except for a licensed assistant behavior
analyst.
(i)
Individual outpatient therapy shall:
1. Be
provided to promote the:
a. Health and
wellbeing of the individual; and
b.
Restoration of a recipient to the recipient's best possible functional level
from a mental health disorder;
2. Consist of:
a. A one (1) on one (1) encounter between the
provider and recipient, which is delivered either face-to-face or provided via
telehealth as appropriate pursuant to
907
KAR 3:170; and
b. A behavioral health therapeutic
intervention provided in accordance with the recipient's identified plan of
care;
3. Be aimed at:
a. Reducing adverse symptoms;
b. Reducing or eliminating the presenting
problem of the recipient; and
c.
Improving functioning;
4. Not exceed three (3) hours per day, alone
or in combination with any other outpatient therapy per recipient, unless
additional time is medically necessary; and
5. Be provided by:
a. An approved behavioral health
practitioner; or
b. An approved
behavioral health practitioner under supervision.
(j)
1. Group outpatient therapy shall:
a. Be a behavioral health therapeutic
intervention provided in accordance with a recipient's identified plan of
care;
b. Be provided to promote
the:
(i) Health and wellbeing of the
individual; and
(ii) Restoration of
a recipient to the recipient's best possible functional level from a mental
health disorder;
c.
Consist of a face-to-face behavioral health therapeutic intervention provided
in accordance with the recipient's identified plan of care;
d. Be provided to a recipient in a group
setting:
(i) Of nonrelated individuals except
for multi-family group therapy; and
(ii) Not to exceed twelve (12) individuals in
size;
e. Focus on the
psychological needs of the recipients as evidenced in each recipient's plan of
care;
f. Center on goals including
building and maintaining healthy relationships, personal goals setting, and the
exercise of personal judgment;
g.
Not include physical exercise, a recreational activity, an educational
activity, or a social activity; and
h. Not exceed three (3) hours per day, alone
or in combination with any other outpatient therapy, per recipient unless
additional time is medically necessary.
2. The group shall have a:
a. Deliberate focus; and
b. Defined course of treatment.
3. The subject of group outpatient
therapy shall relate to each recipient participating in the group.
4. The provider shall keep individual notes
regarding each recipient within the group and within each recipient's health
record.
5. Group outpatient therapy
shall be provided by:
a. An approved
behavioral health practitioner; or
b. An approved behavioral health practitioner
under supervision.
(k)
1.
Family outpatient therapy shall consist of a face-to-face behavioral health
therapeutic intervention or occur via telehealth as appropriate pursuant to
907
KAR 3:170, and shall be provided:
a. Through scheduled therapeutic visits
between the therapist and the recipient and at least one (1) member of the
recipient's family; and
b. To
address issues interfering with the relational functioning of the family and to
improve interpersonal relationships within the recipient's home environment.
2. A family outpatient
therapy session shall be billed as one (1) service regardless of the number of
individuals (including multiple members from one (1) family) who participate in
the session.
3. Family outpatient
therapy shall:
a. Be provided to promote the:
(i) Health and wellbeing of the individual;
or
(ii) Restoration of a recipient
to the recipient's best possible functional level from a mental health
disorder; and
b. Not
exceed three (3) hours per day alone or in combination with any other
outpatient therapy per recipient unless additional time is medically
necessary.
4. Family
outpatient therapy shall be provided by:
a. An
approved behavioral health practitioner; or
b. An approved behavioral health practitioner
under supervision.
(l)
1.
Collateral outpatient therapy shall:
a.
Consist of a face-to-face behavioral health consultation or occur via
telehealth as appropriate pursuant to
907
KAR 3:170:
(i) With
a parent or caregiver of a recipient, household member of a recipient, legal
representative of a recipient, school personnel, treating professional, or
other person with custodial control or supervision of the recipient;
and
(ii) That is provided in
accordance with the recipient's plan of care; and
b. Not be reimbursable if the therapy is for
a recipient who is at least twenty-one (21) years of age.
2. Written consent by a parent or custodial
guardian to discuss a recipient's treatment with any person other than a parent
or legal guardian shall be signed and filed in the recipient's health
record.
3. Collateral outpatient
therapy shall be provided by:
a. An approved
behavioral health practitioner; or
b. An approved behavioral health practitioner
under supervision.
(m)
1.
Service planning shall:
a. Involve assisting a
recipient in creating an individualized plan for services and developing
measurable goals and objectives needed for maximum reduction of the effects of
a mental health disorder;
b.
Involve restoring a recipient's functional level to the recipient's best
possible functional level;
c. Be
performed using a person-centered planning process; and
d. Be provided
face-to-face.
2. A service
plan:
a. Shall be directed and signed by the
recipient;
b. Shall include
practitioners of the recipient's choosing; and
c. May include:
(i) A mental health advance directive being
filed with a local hospital;
(ii) A
crisis plan; or
(iii) A relapse
prevention strategy or plan.
3. Service planning shall be provided by:
a. An approved behavioral health
practitioner; or
b. An approved
behavioral health practitioner under supervision.
(n) Screening, brief intervention, and
referral to treatment for a substance use disorder shall:
1. Be an evidence-based early intervention
approach for an individual with non-dependent substance use to provide an
effective strategy for intervention prior to the need for more extensive or
specialized treatment;
2. Consist
of:
a. Using a standardized screening tool to
assess an individual for risky substance use behavior;
b. Engaging a recipient, who demonstrates
risky substance use behavior, in a short conversation and providing feedback
and advice; and
c. Referring a
recipient to additional mental health disorder, substance use disorder, or
co-occurring disorders services if the recipient is determined to need
additional services to address substance use; and
3. Be provided by:
a. An approved behavioral health
practitioner; or
b. An approved
behavioral health practitioner under supervision.
(o)
1.
Assertive community treatment shall:
a. Be an
evidence-based psychiatric rehabilitation practice that provides a
comprehensive approach to service delivery for individuals with a serious
mental illness;
b. Include:
(i) Assessment;
(ii) Treatment planning;
(iii) Case management;
(iv) Psychiatric services;
(v) Individual outpatient therapy;
(vi) Family outpatient therapy;
(vii) Group outpatient therapy;
(viii) Mobile crisis services;
(ix) Crisis intervention;
(x) Mental health consultation; or
(xi) Family support and basic living skills;
and
c. Be provided
face-to-face.
2.
a. Mental health consultation shall involve
brief, collateral interactions with other treating professionals who may have
information for the purpose of treatment planning and service
delivery.
b. Family support shall
involve the assertive community treatment team's working with the recipient's
natural support systems to improve family relations in order to:
(i) Reduce conflict; and
(ii) Increase the recipient's autonomy and
independent functioning.
c. Basic living skills shall be
rehabilitative services focused on teaching activities of daily living
necessary to maintain independent functioning and community
living.
3. To provide
assertive community treatment services, a behavioral health services
organization shall:
a. Employ at least one
(1) team of multidisciplinary professionals:
(i) Led by an approved behavioral health
services practitioner; and
(ii)
Comprised of at least four (4) full-time equivalents including a prescriber, a
nurse, an approved behavioral health services practitioner, or a case
manager;
b. Have
adequate staffing to ensure that a team's caseload size shall not exceed ten
(10) participants per team member (for example, if the team includes five (5)
individuals, the caseload for the team shall not exceed fifty (50)
recipients);
c. Have the capacity
to:
(i) Employ staff authorized to provide
assertive community treatment services in accordance with this
paragraph;
(ii) Coordinate the
provision of services among team members;
(iii) Provide the full range of assertive
community treatment services as stated in this paragraph; and
(iv) Document and maintain individual case
records; and
d.
Demonstrate experience in serving individuals with persistent and serious
mental illness who have difficulty living independently in the
community.
4. Assertive
community treatment shall be provided by:
a.
An approved behavioral health practitioner; or
b. An approved behavioral health practitioner
under supervision.
5.
a. A peer support specialist under the
supervision of an approved behavioral health practitioner may provide support
services under this paragraph.
b. A
community support associate under supervision of an approved behavioral health
practitioner may provide support services under this paragraph.
(p)
1. Comprehensive community support services
shall:
a. Be activities necessary to allow an
individual to live with maximum independence in the community;
b. Be intended to ensure successful community
living through the utilization of skills training as identified in the
recipient's plan of care;
c.
Consist of using a variety of psychiatric rehabilitation techniques to:
(i) Improve daily living skills;
(ii) Improve self-monitoring of symptoms and
side effects;
(iii) Improve
emotional regulation skills;
(iv)
Improve crisis coping skills; and
(v) Develop and enhance interpersonal skills;
and
d. Be provided
face-to-face.
2. To
provide comprehensive community support services, a behavioral health services
organization shall:
a. Have the capacity to
employ staff authorized pursuant to
908
KAR 2:250 to provide comprehensive community support
services and to coordinate the provision of services among team members; and
b. Meet the requirements for
comprehensive community support services established in
908
KAR 2:250.
3. Comprehensive community support services
shall be provided by:
a. An approved
behavioral health practitioner; or
b. An approved behavioral health practitioner
under supervision.
4. A
community support associate under supervision of an approved behavioral health
practitioner may provide support services under this paragraph.
(q)
1. Therapeutic rehabilitation program
services shall be:
a. A rehabilitative
service for an:
(i) Adult with a serious
mental illness; or
(ii) Individual
under the age of twenty-one (21) years who has a serious emotional
disability;
b. Designed
to maximize the reduction of the effects of a mental health disorder and the
restoration of the individual's functional level to the individual's best
possible functional level; and
c.
Provided face-to-face.
2.
A recipient in a therapeutic rehabilitation program shall establish the
recipient's own rehabilitation goals within the person-centered service
plan.
3. A therapeutic
rehabilitation program shall:
a. Provide
face-to-face, on-site psychiatric rehabilitation and supports;
b. Be delivered using a variety of
psychiatric rehabilitation techniques;
c. Focus on:
(i) Improving daily living skills;
(ii) Self-monitoring of symptoms and side
effects;
(iii) Emotional regulation
skills;
(iv) Crisis coping skill;
and
(v) Interpersonal
skills;
d. Be delivered
individually or in a group; and
e.
Include:
(i) An individualized plan of care
identifying measurable goals and objectives including discharge and relapse
prevention planning;
(ii)
Coordination of services the individual may be receiving; and
(iii) Referral to other necessary service
supports as needed.
4. Therapeutic rehabilitation staffing shall
include:
a. Licensed clinical supervision,
consultation, and support to direct care staff; and
b. Direct care staff to provide scheduled
therapeutic activities, training, and support for Med-icaid
recipients.
5.
Therapeutic rehabilitation program services shall be provided by:
a. An approved behavioral health
practitioner, except for a licensed behavior analyst; or
b. An approved behavioral health practitioner
under supervision, except for a licensed assistant behavior analyst.
6. A peer support specialist
working under the supervision of an approved behavioral health practitioner may
provide support services under this paragraph.
(r)
1.
Partial hospitalization services shall be:
a.
Short-term with an average of four (4) to six (6) weeks;
b. Less than twenty-four (24)-hours each day;
and
c. An intensive treatment
program for an individual who is experiencing significant impairment to daily
functioning due to a mental health disorder.
2. Partial hospitalization may be provided to
an adult or a minor.
3. Admission
criteria for partial hospitalization shall be based on an inability of
community-based therapies or intensive outpatient services to adequately treat
the recipient.
4. A partial
hospitalization program shall consist of:
a.
Individual outpatient therapy;
b.
Group outpatient therapy;
c. Family
outpatient therapy; or
d. Medication
management.
5. The
department shall not reimburse for educational, vocational, or job training
services provided as part of partial hospitalization.
6. An outpatient behavioral health services
organization's partial hospitalization program shall have an agreement with the
local educational authority to come into the program to provide all educational
components and instruction that are not Medicaid billable or
reimbursable.
7. Partial
hospitalization shall be:
a. Provided for at
least four (4) hours per day;
b.
Focused on one (1) primary presenting problem; and
c. Provided face-to-face.
8. A partial hospitalization program operated
by a behavioral health services organization shall:
a. Include the following personnel for the
purpose of providing medical care:
(i) An
advanced practice registered nurse, a physician assistant, or a physician
available on site; and
(ii) A
board-certified or board-eligible psychiatrist available for consultation; and
b. Have the capacity
to:
(i) Provide services utilizing a
recognized intervention protocol based on nationally accepted treatment
principles;
(ii) Employ required
practitioners and coordinate service provision among rendering practitioners;
and
(iii) Provide the full range of
services included in the scope of partial hospitalization established in this
paragraph.
9.
Partial hospitalization services shall be provided by:
a. An approved behavioral health
practitioner; or
b. An approved
behavioral health practitioner under supervision.
(s)
1. Applied behavior analysis services shall
produce socially significant improvement in human behavior via the:
a. Design, implementation, and evaluation of
environmental modifications;
b. Use
of behavioral stimuli and consequences; or
c. Use of direct observation, measurement,
and functional analysis of the relationship between environment and
behavior.
2. Applied
behavior analysis shall be based on scientific research and the direct
observation and measurement of behavior and environment, which utilize
contextual factors, establishing operations, antecedent stimuli, positive
reinforcement, and other consequences to assist recipients in:
a. Developing new behaviors;
b. Increasing or decreasing existing
behaviors; and
c. Eliciting
behaviors under specific environmental conditions.
3. Applied behavior analysis services may
include principles, methods, and procedures of the experimental analysis of
behavior and applied behavior analysis, including applications of those
principles, methods, and procedures to:
a.
Design, implement, evaluate, and modify treatment programs to change the
behavior of individuals;
b. Design,
implement, evaluate, and modify treatment programs to change the behavior of
individuals that interact with a recipient;
c. Design, implement, evaluate, and modify
treatment programs to change the behavior of a group or groups that interact
with a recipient; or
d. Consult
with individuals and organizations.
4.
a.
Applied behavior analysis services shall be provided by:
(i) A licensed behavior analyst;
(ii) A licensed assistant behavior analyst;
(iii) An approved behavioral health
practitioner with documented training in applied behavior analysis;
or
(iv) An approved behavioral
health practitioner under supervision with documented training in applied
behavior analysis.
b. A
registered behavior technician under the supervision of an appropriate
practitioner pursuant to clause a. of this subparagraph may provide support
services under this paragraph.
(4)
(a)
Laboratory services shall be reimbursable in accordance with
907
KAR 1:028 if provided by a BHSO I if:
1. The BHSO I has the appropriate CLIA
certificate to perform laboratory testing pursuant to
907
KAR 1:028; and
2. The services are prescribed by a
physician, advanced practice registered nurse, or physician assistant who has a
contractual relationship with the BHSO I.
(b) Laboratory services may be administered,
as appropriate, by:
1. An approved behavioral
health practitioner; or
2. An
approved behavioral health practitioner under supervision.
Section 4. Additional
Limits and Non-covered Services or Activities.
(1)
(a)
Except as established in paragraph (b) of this subsection, unless a diagnosis
is made and documented in the recipient's medical record within three (3)
visits, the service shall not be covered.
(b) The requirement established in paragraph
(a) of this subsection shall not apply to:
1.
Mobile crisis services;
2. Crisis
intervention;
3. A screening;
or
4. An assessment.
(2) For a recipient who
is receiving assertive community treatment, the following shall not be billed
or reimbursed for the same date of service for the recipient:
(a) An assessment;
(b) Case management;
(c) Individual outpatient therapy;
(d) Group outpatient therapy;
(e) Peer support services; or
(f) Mobile crisis services.
(3) The department shall not
reimburse for both a screening provided pursuant to this administrative
regulation and a screening, brief intervention and referral to treatment
(SBIRT) provided to a recipient on the same date of service.
(4) The following services or activities
shall not be covered under this administrative regulation:
(a) A service provided to:
1. A resident of:
a. A nursing facility; or
b. An intermediate care facility for
individuals with an intellectual disability;
2. An inmate of a federal, local, or state:
a. Jail;
b. Detention center; or
c. Prison; or
3. An individual with an intellectual
disability without documentation of an additional psychiatric
diagnosis;
(b)
Psychiatric or psychological testing for another agency, including a court or
school, that does not result in the individual receiving psychiatric
intervention or behavioral health therapy from the behavioral health services
organization;
(c) A consultation or
educational service provided to a recipient or to others;
(d) A telephone call, an email, a text
message, or other electronic contact that does not meet the requirements stated
in the definition of "face-to-face" established in
907
KAR 15:005, Section 1(21). Contact prohibited under
subparagraph 1. of this paragraph may be permissible if it is conducted in the
course of a telehealth service permitted pursuant to
907
KAR 3:170 or this administrative regulation, as
applicable;
(e) Travel
time;
(f) A field trip;
(g) A recreational activity;
(h) A social activity; or
(i) A physical exercise activity
group.
(5)
(a) A consultation by one (1) provider or
professional with another shall not be covered under this administrative
regulation except as established in Section 3(3)(l)1. of this administrative
regulation.
(b) A third party
contract shall not be covered under this administrative regulation.
(6) A billing supervisor
arrangement between a billing supervisor and an approved behavioral health
practitioner under supervision shall not violate the supervision rules or
policies of the respective professional licensure boards governing the billing
supervisor and the approved behavioral health practitioner under
supervision.
Section 5.
No Duplication of Service.
(1) The department
shall not reimburse for a service provided to a recipient by more than one (1)
provider, of any program in which the service is covered, during the same time
period.
(2) For example, if a
recipient is receiving a behavioral health service from an independent
behavioral health provider, the department shall not reimburse for the same
service provided to the same recipient during the same time period by a
behavioral health services organization.
Section 6. Records Maintenance,
Documentation, Protection, and Security.
(1) A
behavioral health services organization shall maintain a current health record
for each recipient.
(2) A health
record shall document each service provided to the recipient including the date
of the service and the signature of the individual who provided the
service.
(3) A health record shall:
(a) Include:
1. An identification and intake record
including:
a. Name;
b. Social Security number;
c. Date of intake;
d. Home (legal) address;
e. Health insurance or Medicaid
information;
f. Referral source and
address of referral source;
g.
Primary care physician and address;
h. The reason the individual is seeking help
including the presenting problem and diagnosis;
i. Any physical health diagnosis, if a
physical health diagnosis exists for the individual, and information regarding:
(i) Where the individual is receiving
treatment for the physical health diagnosis; and
(ii) The physical health provider; and
j. The name of the
informant and any other information deemed necessary by the behavioral health
services organization to comply with the requirements of:
(i) This administrative regulation;
(ii) The behavioral health services
organization's licensure board;
(iii) State law; or
(iv) Federal
law;
2.
Documentation of the:
a. Screening;
b. Assessment if an assessment was performed;
and
c. Disposition if a disposition
was performed;
3. A
complete history including mental status and previous treatment;
4. An identification sheet;
5. A consent for treatment sheet that is
accurately signed and dated; and
6.
The individual's stated purpose for seeking services; and
(b) Be:
1.
Maintained in an organized central file;
2. Furnished to the:
a. Cabinet for Health and Family Services
upon request; or
b. Managed care
organization in which the recipient is enrolled upon request if the recipient
is enrolled with a managed care organization;
3. Made available for inspection and copying
by:
a. Cabinet for Health and Family Services'
personnel; or
b. Personnel of the
managed care organization in which the recipient is enrolled if the recipient
is enrolled with a managed care organization;
4. Readily accessible; and
5. Adequate for the purpose of establishing
the current treatment modality and progress of the recipient if the recipient
received services beyond a screening.
(4) Documentation of a screening shall
include:
(a) Information relative to the
individual's stated request for services; and
(b) Other stated personal or health concerns
if other concerns are stated.
(5)
(a) A
behavioral health services organization's service note regarding a recipient
shall:
1. Be made within forty-eight (48)
hours of each service visit;
2.
Indicate if the service was provided face-to-face or via telehealth;
and
3. Describe the:
a. Recipient's symptoms or behavior, reaction
to treatment, and attitude;
b.
Therapist's intervention;
c.
Changes in the plan of care if changes are made; and
d. Need for continued treatment if continued
treatment is needed.
(b)
1. Any
edit to notes shall:
a. Clearly display the
changes; and
b. Be initialed and
dated by the person who edited the notes.
2. Notes shall not be erased or illegibly
marked out.
(c)
1. Notes recorded by an approved behavioral
health practitioner under supervision shall be co-signed and dated by the
supervising professional within thirty (30) days.
2. If services are provided by an approved
behavioral health practitioner under supervision, there shall be a monthly
supervisory note recorded by the supervising professional reflecting
consultations with the approved behavioral health practitioner under
supervision concerning the:
a. Case; and
b. Supervising professional's
evaluation of the services being provided to the recipient.
(6)
Immediately following a screening of a recipient, the practitioner shall
perform a disposition related to:
(a) A
provisional diagnosis;
(b) A
referral for further consultation and disposition, if applicable; or
(c)
1. If
applicable, termination of services and referral to an outside source for
further services; or
2. If
applicable, termination of services without a referral to further
services.
(7)
Any change to a recipient's plan of care shall be documented, signed, and dated
by the rendering practitioner and by the recipient or recipient's
representative.
(8)
(a) Notes regarding services to a recipient
shall:
1. Be organized in chronological
order;
2. Be dated;
3. Be titled to indicate the service
rendered;
4. State a starting and
ending time for the service; and
5.
Be recorded and signed by the rendering practitioner and include the
professional title (for example, licensed clinical social worker) of the
provider.
(b) Initials,
typed signatures, or stamped signatures shall not be accepted.
(c) Telephone contacts, family collateral
contacts not covered under this administrative regulation, or other
non-reimbursable contacts shall:
1. Be
recorded in the notes; and
2. Not
be reimbursable.
(9)
(a) A
termination summary shall:
1. Be required,
upon termination of services, for each recipient who received at least three
(3) service visits; and
2. Contain
a summary of the significant findings and events during the course of treatment
including the:
a. Final assessment regarding
the progress of the individual toward reaching goals and objectives established
in the individual's plan of care;
b. Final diagnosis of clinical impression;
and
c. Individual's condition upon
termination and disposition.
(b) A health record relating to an individual
who terminated from receiving services shall be fully completed within ten (10)
days following termination.
(10) If an individual's case is reopened
within ninety (90) days of terminating services for the same or related issue,
a reference to the prior case history with a note regarding the interval period
shall be acceptable.
(11)
(a) Except as established in paragraph (b) of
this subsection, if a recipient is transferred or referred to a health care
facility or other provider for care or treatment, the transferring behavioral
health services organization shall, within ten (10) business days of the
transfer or referral, transfer the recipient's records in a manner that
complies with the records' use and disclosure requirements as established in or
required by:
1.
a. The Health Insurance Portability and
Accountability Act;
b.
42
U.S.C. 1320d-2
to 1320d-8;
and
c.45 C.F.R. Parts 160 and 164;
or
2.
a.
42
U.S.C. 290 ee-3; and
b. 42 C.F.R. Part 2 .
(b) If a recipient is transferred
or referred to a residential crisis stabilization unit, a psychiatric hospital,
a psychiatric distinct part unit in an acute care hospital, or an acute care
hospital for care or treatment, the transferring behavioral health services
organization shall, within forty-eight (48) hours of the transfer or referral,
transfer the recipient's records in a manner that complies with the records'
use and disclosure requirements as established in or required by:
1.
a. The
Health Insurance Portability and Accountability Act;
b.
42
U.S.C. 1320d-2
to 1320d-8;
and
c.45 C.F.R. Parts 160 and 164;
or
2.
a.
42
U.S.C. 290 ee-3; and
b. 42 C.F.R Part 2 .
(12)
(a) If a behavioral health services
organization's Medicaid Program participation status changes as a result of
voluntarily terminating from the Medicaid Program, involuntarily terminating
from the Medicaid Program, a licensure suspension, or death of an owner or
deaths of owners, the health records of the behavioral health services
organization shall:
1. Remain the property of
the behavioral health services organization; and
2. Be subject to the retention requirements
established in subsection (13) of this section.
(b) A behavioral health services organization
shall have a written plan addressing how to maintain health records in the
event of death of an owner or deaths of owners.
(13)
(a)
Except as established in paragraph (b) or (c) of this subsection, a behavioral
health services organization shall maintain a case record regarding a recipient
for at least six (6) years from the date of the service or until any audit
dispute or issue is resolved beyond six (6) years.
(b) After a recipient's death or discharge
from services, a provider shall maintain the recipient's record for the longest
of the following periods:
1. Six (6) years
unless the recipient is a minor; or
2. If the recipient is a minor, three (3)
years after the recipient reaches the age of majority under state
law.
(c) If the
Secretary of the United States Department of Health and Human Services requires
a longer document retention period than the period referenced in paragraph (a)
of this subsection, pursuant to
42 C.F.R.
431.17, the period established by the
secretary shall be the required period.
(14)
(a) A
behavioral health services organization shall comply with 45 C.F.R. Part
164.
(b) All information contained
in a health record shall:
1. Be treated as
confidential;
2. Not be disclosed
to an unauthorized individual; and
3. Be disclosed to an authorized
representative of:
a. The department; or
b. Federal
government.
(c)
1. Upon request, a behavioral health services
organization shall provide to an authorized representative of the department or
federal government information requested to substantiate:
a. Staff notes detailing a service that was
rendered;
b. The professional who
rendered a service; and
c. The type
of service rendered and any other requested information necessary to determine,
on an individual basis, whether the service is reimbursable by the
department.
2. Failure to
provide information required by subparagraph 1. of this paragraph shall result
in denial of payment for any service associated with the requested
information.
Section 7. Medicaid Program Participation
Compliance.
(1) A behavioral health services
organization shall comply with:
(a)
907
KAR 1:671;
(b)
907
KAR 1:672; and
(c) All applicable state and federal
laws.
(2)
(a) If a behavioral health services
organization receives any duplicate payment or overpayment from the department,
regardless of reason, the behavioral health services organization shall return
the payment to the department.
(b)
Failure to return a payment to the department in accordance with paragraph (a)
of this subsection may be:
1. Interpreted to
be fraud or abuse; and
2.
Prosecuted in accordance with applicable federal or state law.
(3)
(a) When the department makes payment for a
covered service and the behavioral health services organization accepts the
payment:
1. The payment shall be considered
payment in full;
2. A bill for the
same service shall not be given to the recipient; and
3. Payment from the recipient for the same
service shall not be accepted by the behavioral health services
organization.
(b)
1. A behavioral health services organization
may bill a recipient for a service that is not covered by the Kentucky Medicaid
Program if the:
a. Recipient requests the
service; and
b. Behavioral health
services organization makes the recipient aware in advance of providing the
service that the:
(i) Recipient is liable for
the payment; and
(ii) Department is
not covering the service.
2. If a recipient makes payment for a service
in accordance with subparagraph 1. of this paragraph, the:
a. Behavioral health services organization
shall not bill the department for the service; and
b. Department shall not:
(i) Be liable for any part of the payment
associated with the service; and
(ii) Make any payment to the behavioral
health services organization regarding the service.
(4)
(a) A behavioral health services organization
shall attest by the behavioral health services organization's staff's or
representative's signature that any claim associated with a service is valid
and submitted in good faith.
(b)
Any claim and substantiating record associated with a service shall be subject
to audit by the:
1. Department or its
designee;
2. Cabinet for Health and
Family Services, Office of Inspector General, or its designee;
3. Kentucky Office of Attorney General or its
designee;
4. Kentucky Office of the
Auditor for Public Accounts or its designee; or
5. United States General Accounting Office or
its designee.
(c) If a
behavioral health services organization receives a request from the department
to provide a claim, related information, related documentation, or record for
auditing purposes, the behavioral health services organization shall provide
the requested information to the department within the timeframe requested by
the department.
(d)
1. All services provided shall be subject to
review for recipient or provider abuse.
2. Willful abuse by a behavioral health
services organization shall result in the suspension or termination of the
behavioral health services organization from Medicaid Program
participation.
Section 8. Third Party Liability. A
behavioral health services organization shall comply with
KRS
205.622.
Section 9. Use of Electronic Signatures.
(1) The creation, transmission, storage, and
other use of electronic signatures and documents shall comply with the
requirements established in
KRS
369.101 to
369.120.
(2) A behavioral health services organization
that chooses to use electronic signatures shall:
(a) Develop and implement a written security
policy that shall:
1. Be adhered to by each of
the behavioral health services organization's employees, officers, agents, or
contractors;
2. Identify each
electronic signature for which an individual has access; and
3. Ensure that each electronic signature is
created, transmitted, and stored in a secure fashion;
(b) Develop a consent form that shall:
1. Be completed and executed by each
individual using an electronic signature;
2. Attest to the signature's authenticity;
and
3. Include a statement
indicating that the individual has been notified of his or her responsibility
in allowing the use of the electronic signature; and
(c) Provide the department, immediately upon
request, with:
1. A copy of the behavioral
health services organization's electronic signature policy;
2. The signed consent form; and
3. The original filed signature.
Section 10.
Auditing Authority. The department shall have the authority to audit any:
(1) Claim;
(2) Medical record; or
(3) Documentation associated with any claim
or medical record.
Section
11. Federal Approval and Federal Financial Participation. The
department's coverage of services pursuant to this administrative regulation
shall be contingent upon:
(1) Receipt of
federal financial participation for the coverage; and
(2) Centers for Medicare and Medicaid
Services' approval for the coverage.
Section 12. Appeals.
(1) An appeal of an adverse action by the
department regarding a service and a recipient who is not enrolled with a
managed care organization shall be in accordance with
907
KAR 1:563.
(2) An appeal of an adverse action by a
managed care organization regarding a service and an enrollee shall be in
accordance with
907
KAR 17:010.
STATUTORY AUTHORITY:
KRS
194A.030(2),
194A.050(1),
205.520(3)