Missouri Code of State Regulations
Title 13 - DEPARTMENT OF SOCIAL SERVICES
Division 70 - MO HealthNet Division
Chapter 25 - Physician Program
Section 13 CSR 70-25.140 - Biopsychosocial Treatment of Obesity for Youth and Adults
Universal Citation: 13 MO Code of State Regs 70-25.140
Current through Register Vol. 49, No. 18, September 16, 2024
PURPOSE: This rule establishes the MO HealthNet payment policy for the biopsychosocial treatment of obesity for youth and adult participants. The goal of this policy is to improve health outcomes for both the youth and adult population by managing obesity and associated co-morbidities.
PUBLISHER'S NOTE: The secretary of state has determined that the publication of the entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here.
(1) Administration. The MO HealthNet Division, Department of Social Services, shall administer Biopsychosocial Treatment of Obesity for Youth and Adult participants. Biopsychosocial treatment of obesity services covered and not covered, the limitations under which services are covered, and the maximum allowable fees for all covered services shall be determined by the MO HealthNet Division and shall be included in the MO HealthNet Physician Provider Manual and Behavioral Health Services Manual, which are incorporated by reference and made part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its website at, http://manuals.momed.com/manuals, December 27, 2019. This rule does not incorporate any subsequent amendments or additions. Biopsychosocial treatment of obesity services covered by the MO HealthNet program shall include only those which are shown to be medically necessary.
(A) In the administration of the
rule, the following definitions are used:
1.
"Biopsychosocial Treatment of Obesity" means using a combination of obesity
screenings, Medical Nutrition Therapy (MNT), and Intensive Behavioral Therapy
(IBT) to promote life style changes leading to weight loss in adult and youth
participants.
A. "Adult Intensive Behavioral
Therapy (IBT)" means obesity management by utilizing intensive multicomponent,
behavior-based weight loss interventions that promote and sustain weight loss
in adult participants.
B. "Youth
Intensive Behavioral Therapy (IBT)" means obesity management by utilizing
comprehensive, intensive behavior-based weight loss interventions that can
include multi-component family-based behavioral treatment (FBT) interventions
tailored to participant needs targeting both the parent/guardian and the
youth;
2. "Body Mass
Index (BMI)" means a measure that relates body weight to height and is
calculated by dividing weight in kilograms (kg) by the square of height in
meters (expressed in kg/m2).
A. "Body Mass
Index (BMI) Percentile" means the range of BMI values as expressed in
percentiles for age and gender as plotted on the pediatric BMI chart.
B. "Pediatric Body Mass Index (BMI) Chart"
means a graphic display of normal progressive changes in body mass index for
the pediatric population ages two (2) to twenty (20) years of age;
3. "Consultation" for the purpose
of this rule means the experienced behavioral health clinician who meets
provider requirements for Intensive Behavioral Therapy (IBT) outlined in this
regulation support and evaluate the newly certified provider's competency in
delivery of behaviorally based intervention for patients diagnosed with
obesity;
4. "Medical Nutrition
Therapy (MNT)" means nutritional diagnostic, therapy, and counseling services
furnished by a licensed registered dietitian or registered dietitian
nutritionist, and includes a review of nutritional health, eating habits, and
development of an individualized nutrition plan; and
5. "Qualified University" means a United
States regionally accredited college, university, or foreign equivalent, or an
academic university-based medical center affiliated with such a
university.
(2) Provider Participation. To be eligible to provide services for the MO HealthNet Biopsychosocial Treatment of Obesity Program-
(A) All Biopsychosocial Treatment of Obesity
service providers must be enrolled as MO HealthNet providers;
(B) Provider Requirements for MNT. In order
to provide medical nutrition therapy for obesity a provider is required to meet
the following criteria:
1. Have a current
license to practice as a Licensed Registered Dietitian or Registered Dietitian
Nutritionist in the state in which they practice;
2. The Provider will need to obtain one (1)
of the following specialist certificates in order to provide MNT for treatment
of obesity:
A. Certificate of Training in
Adult Weight Management Program;
B.
Certificate of Training in Obesity Interventions for Adults;
C. Certificate of Training in Child and
Adolescent Weight Management; or
D.
Completion of a qualified training program that provides professional medical
nutrition therapy training addressing obesity and weight management treatment
for participant population(s) served;
3. A licensed provider may provide MNT
without a certificate as listed above if the provider meets the following
criteria:
A. The provider has maintained a
dietitian license credential for a minimum of two (2) years;
B. The provider has a minimum of two thousand
(2,000) hours of specialty practice experience delivering weight management
behavioral treatment for individuals and/or families or youth with obesity
diagnoses within the past five (5) years; and
C. The provider will have documentation of a
minimum of six (6) hours of obesity or weight management CEUs or professional
equivalent post receipt of license credential;
(C) Provider Requirements for IBT. In order
to provide individual and/or group intensive behavioral therapy (IBT) and/or
family-based behavioral treatment (FBT) for youth and adults a provider is
required to meet the following criteria:
1.
Have a current license to practice as one (1) of the following provider types:
psychiatrist, clinical social worker, psychologist, or professional counselor,
martial and family therapist, or psychiatric advanced practice registered
nurses. Registered dietitians are eligible to provide group IBT and/or FBT; 2.
A specialist certification for the participant population(s) served that was
attained through completion of a qualified training program that addresses
delivery of behaviorally based intervention for adult and/or youth participants
diagnosed with obesity; 3. A licensed provider may provide IBT without a
certificate with the following criteria:
A.
The licensed provider has maintained one (1) of the aforementioned license
credentials for a minimum of two (2) years; B. The provider has a minimum of
two thousand (2,000) hours of specialty practice experience delivering weight
management behavioral treatment for individuals and/or families and youth with
obesity diagnosis within the past five (5) years; and C. The provider will have
documentation with a minimum of six (6) hours of obesity or weight management
CEUs or professional equivalent post receipt of license credential;
(D) Continuing Education
Unit (CEU) requirement. The provider must maintain six (6) hours of obesity or
weight management CEUs or professional equivalent every two (2) years for the
patient population served, either youth or adult or both.
1. The required evaluation and documentation
on compliance with certification standards post completion of a qualified
training program from an experienced provider does not count toward the six (6)
hours of CEUs.
(E) The
provider must meet the provider qualifications outlined in this regulation in
order to bill MO HealthNet for the service.
(3) Qualified Training Program Requirements.
(A) A qualified training program has stated
learning objectives for the course content and includes the following:
1. Content-expert instruction and interactive
discussion (which may occur face-to-face or by electronic delivery);
2. Course materials developed by
professionals with demonstrated expertise in the content area;
3. Content areas cover evidence-based
approaches to effectively deliver weight management and obesity treatment for
adult and/or youth participants using a family-centered, comprehensive
approach; and 4. Sponsored by or conducted in affiliation with a qualified
university.
(B) The
training program for youth and adults participants shall contain a mix of
didactics with simulation work conducted by members of the training center
staff.
(C) The qualified training
program shall provide a certificate upon completion of the program.
(D) Qualified training programs on IBT and
FBT shall provide a means for newly certified behavioral providers to receive
evaluation and documentation on compliance with post-program certification
standards from an experienced provider using established procedures.
1. After completion of the qualified training
program for IBT, the provider is certified for one (1) year.
2. To receive the specialty certificate
after one (1) year to continue delivering IBT/FBT, the provider is required to
complete clinical consultations with an experienced IBT/FBT provider in
accordance with established procedures.
3. The qualified training program will provide those completing
the program details on how to obtain a renewal specialist certification and a
list of experienced eligible providers to provide consultation and review
IBT/FBT competency.
4. Renewal of
specialist certification for IBT/FBT will not be issued until the new provider
receives documentation on compliance with certification standards from an
experienced provider.
(4) Participant Criteria. Any person who is eligible for Title XIX benefits from the Family Support Division and who also meets the following criteria shall be deemed eligible to receive these services:
(A) Be five (5) through twenty (20)
years of age for youth services or twenty-one (21) years of age or older for
adult services;
(B) Not currently
pregnant;
(C) Be obese by meeting
the following criteria:
1. For youth
participants a body mass index (BMI) percentile equal to or greater than the
ninety-fifth (95th) percentile for age and gender on the pediatric body mass
index (BMI) chart.
2. For adult
participants a body mass index (BMI) equal to or greater than thirty (30);
and
(D) Not concurrently
receiving authorization for other MO HealthNet reimbursed weight reduction
services.
(5) Biopsychosocial Treatment of Obesity Services.
(A) Biopsychosocial Treatment of Obesity
Services provide integrated medical nutrition therapy and behavioral health
services, coordinated by the primary care or referring physician, or other
licensed practitioner of healing, to facilitate behavior changes to manage
obesity and associated co-morbidities. Biopsychosocial treatment of obesity for
youth and adult participants requires a referral and a prescribed service in
the participant's plan of care from a prescribing provider as part of an office
visit for evaluation and management. The prescribing provider must obtain prior
authorization from MO HealthNet before the participant starts receiving
services. A prescribing provider is defined as a physician or other licensed
practitioner of healing arts within the scope of authorized practice under
State law.
1. Service structure for youth
participants.
A. Biopsychosocial Treatment of
Obesity Youth Services include a six (6) month period of intervention that
allows a maximum of four (4) hours of individual IBT and twenty-two (22) hours
of group IBT for a total of twenty-six (26) hours of IBT and one (1) hour and
forty-five (45) minutes of MNT.
B.
Upon completion of the six (6) month period of services, the dietitian and
behavioral health provider shall make recommendations to the prescribing
provider regarding continuation of services based on the continuation criteria
set forth by MO HealthNet. The prescribing provider shall make the final
determination for the participant to continue with the services based on the
participant meeting the continuation criteria and shall request prior
authorization for the additional six (6) months of services.
C. Continuation Criteria for the youth
participant months seven (7) through twelve (12) include the following:
(I) The youth participant must meet whichever
is lesser of the three (3) youth benchmarks listed below, at the end of month
six (6) of services-
(a) A decrease in their
BMI chart percentile to less than the ninety-fifth (95th) percentile or five
percent (5%) of body weight;
(b)
The youth participants that had a BMI percentile at the beginning of treatment
>99th percentile, shows a decrease of nine (9) units in percentage above the
ninety-fifth (95th) percentile (as calculated by age and gender norms of the
CDC BMI percentile curve); or
(c)
Weight stabilization (defined as ±0.5 BMI units); and
(II) If the youth participant does
not meet the weight loss threshold, the prescribing provider shall perform the
necessary lab work to rule out the presence of other conditions (e.g.,
endocrine disorders) that may complicate efforts to reduce weight, and if
present, should request to continue with biopsychosocial treatment with medical
treatment for the identified condition(s).
D. Continuation of Biopsychosocial Treatment
of Obesity Youth services for months seven (7) through twelve (12) include an
additional one (1) hour of individual IBT and two (2) hours of group IBT for a
maximum of three (3) hours of IBT; and an additional thirty (30) minutes of
MNT.
E. Providers are able to
structure the services in order to meet the individual needs of the participant
within the maximum allowable service structure. The total annual limit for
services for the youth participant is twenty-nine (29) hours for IBT and two
(2) hours and fifteen (15) minutes for MNT.
F. If the parent or caregiver does not notify
the MNT or IBT providers of absences of the patient and have missed four (4) or
more sessions, the MNT or IBT provider may reevaluate the need for further
services.
2. Service
structure for adult participants-
A.
Biopsychosocial Treatment of Obesity Adult Services include a six (6) month
period of intervention that allows a maximum of three (3) hours of individual
behavior therapy and nine (9) hours of group behavior therapy for a total of
twelve (12) hours of behavior therapy and one (1) hour forty-five (45) minutes
of MNT;
B. Upon completion of the
six (6) month period of services, the dietitian and behavioral health provider
shall make recommendations to the prescribing provider regarding continuation
of services based on the continuation criteria set forth by MO HealthNet. The
prescribing provider shall make the final determination for the participant to
continue with the services based on the participant meeting the continuation
criteria and shall request prior authorization for the additional six (6)
months of services;
C. Continuation
Criteria for the adult participant months seven (7) through twelve (12) include
the following:
(I) The adult participant must
meet the adult benchmark of a reduction in body weight of five percent (5%) at
the end of month six (6) of services; and
(II) If the adult participant does not meet
the weight loss threshold, the prescribing provider shall perform the necessary
lab work to rule out the presence of other conditions (e.g. endocrine
disorders) that may complicate efforts to reduce weight, and if present, should
request to continue with biopsychosocial treatment with medical treatment for
the identified condition(s);
D. Continuation of Biopsychosocial Treatment
of Obesity Adult services for months seven (7) through twelve (12) include an
additional one (1) hour of individual IBT and two (2) hours of group IBT for a
maximum of three (3) hours of IBT; and an additional thirty (30) minutes of
MNT;
E. Providers are able to
structure the services in order to meet the individual needs of the participant
within the maximum allowable service structure. The total annual limit for
services for the adult participants is fifteen (15) hours for behavior therapy
and two (2) hours fifteen (15) minutes for medical nutritional therapy;
and
F. If the participant does not
notify the provider of absences and has missed two (2) or more sessions, th
provider may reevaluate the need for further services.
G. If the participant does not notify the
provider of absences and has missed two (2) or more sessions, the provider may
reevaluate the need for further services.
(B) A participant that is unable to meet the
continuation criteria for the additional six (6) months of Biopsychosocial
Treatment of Obesity services has the option, after twelve (12) months, to
re-enroll for services if the participant meets the established criteria and
has an approved prior authorization.
(6) Documentation Requirements for Biopsychosocial Treatment of Obesity.
(A) The
participant's treatment record shall contain the following documentation, at a
minimum:
1. The referring provider's referral
with approval from MO HealthNet for months one (1) through six (6) of
services;
2. The medical
nutritional assessment completed by the dietitian;
3. The initial behavioral assessment
completed by the behavioral health provider;
4. Progress notes that include the following
information from each visit:
A. A measured
weight and calculated BMI for adult participants or BMI percentile for youth
participants.
B. Progress the
youth/parent/participant is making towards weight loss goals;
C. Challenges (social determinants) the
participant is facing and proposed solutions;
D. Recommendations for treatment/care plans;
and
E. Collaborative efforts
between the providers delivering primary care, MNT, and IBT;
5. The documented evaluation by
the dietitian, behavioral health provider, and referring provider at the end of
six (6) months to determine the appropriateness for continuation of services.
This should include documented progress towards weight loss goals, a desire to
continue receiving services, and confirmation of met continuation
criteria;
6. If applicable the
referring provider's referral with approval from MO HealthNet for months seven
(7) through twelve (12) of services;
7. Final evaluation at the end of the twelve
(12) month period including documented metabolic, social, and behavior change
end-points and identified barriers to maintaining weight loss if the
participant qualified for continuation of services; and
8. Once services are completed, the
prescribing provider shall maintain a treatment record, incorporating
recommendations provided by the dietitian and behavioral health provider as
appropriate, which outlines how the participant will maintain the weight
loss.
(B) The behavioral
health provider and dietitian must complete a six (6) month evaluation and the
final evaluation report detailing the amount of weight lost over the treatment
period, progress with metabolic, social, and behavior change endpoints,
challenges to maintaining weight loss, and any future recommendations for
maintaining the weight loss in the context of identified challenges. Both
evaluations shall be shared with the referring provider and will become part of
the treatment record. The referring provider may incorporate these
recommendations and considerations into ongoing care planning and patient
management.
(7) Reimbursement Methodology.
(A) MO HealthNet
provides reimbursement to enrolled providers providing biopsychosocial
treatment of obesity for youth and adults and who are currently licensed,
certified, and in good standing with the state.
(B) Reimbursement for services is made on a
fee-for-services basis. The maximum allowable fee for a unit of service has
been determined by MO HealthNet to be a reasonable fee, consistent with
efficiency, economy, and quality of care. Payment for covered services is the
lower of the provider's actual billed charge (should be the provider's usual
and customary charge to the general public for the service), or the maximum
allowable per unit of service. Reimbursement shall only be made for services
authorized by MO HealthNet or its designee.
Disclaimer: These regulations may not be the most recent version. Missouri may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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