Current through September 17, 2024
Day treatment services are available to clients age 20 or
younger when the client has participated in a HEALTH CHECK (EPSDT) screen, the
treatment is clinically necessary, and the need for this level of care is
identified as part of a Substance Use Disorder Assessment. These services are
part of a continuum of care designed to prevent hospitalization or to
facilitate the movement of the client in an acute psychiatric setting to a
status in which the client is capable of functioning within the community with
less frequent contact with the mental health or substance abuse
provider.
Day treatment services must be community based, family
centered, culturally competent, and developmentally appropriate.
Day treatment services must meet all requirements in 471 NAC
32-001.
Providers must encourage family members to be involved in the
assessment of the client, the development of the treatment plan, and all
aspects of the client's treatment unless prohibited by the client, through
legal action, or because of federal confidentiality laws.
Providers must be available to schedule meetings and sessions
in a flexible manner to accommodate and work with a family's schedule. This
includes the ability to schedule sessions at a variety of times including
weekends or evenings.
The provider must document their attempts to involve the
family in treatment plan development and treatment plan reviews. A variety of
communication means should be considered. These may include, but should not be
limited to, including the family via conference telephone calls, using
registered letters to notify the family of meetings, and scheduling meetings in
the evening and on weekends.
004.01
Covered Day Treatment Services
Day treatment programs shall provide the following mandatory
services and at least two of the following optional services. Payment for both
mandatory services and optional services is included in the rate for day
treatment. Individual services to the client by a supervising practitioner that
are not administrative in nature and are clinically necessary will be
considered for payment when billed by the supervising practitioner. Providers
shall not make any additional charges to the Department or to the
client.
32-004.01A
Mandatory Services: The following services must be
included in a program for day treatment to be approved for participation in the
Nebraska Medical Assistance Program. See 471 NAC
32-001 for definitions.
1.
Medically Necessary
Psychotherapy and Substance Abuse Counseling Services: These
services must demonstrate active treatment of a patient with a serious
emotional disturbance. These services are subject to program limitations.
a. Individual Psychotherapy or Substance
Abuse Counseling;
b. Group
Psychotherapy or Substance Abuse Counseling;
c. Family Psychotherapy or Substance Abuse
Counseling; and
d. Family
Assessment;
2.
Medically Necessary Nursing Services: Medical services
provided by a Qualified Registered Nurse who evaluates the particular medical
nursing needs of each client and provides for the medical care and treatment
that is indicated on the Department approved treatment planning document and
approved by the supervising practitioner.
3.
Medically Necessary
Psychological Diagnostic Services: Testing and evaluation services
must reasonably be expected to contribute to the diagnosis and plan of care
established for the individual client. Testing and evaluation services may be
performed by a Licensed Psychologist, Specially Licensed Psychologist or a
psychology resident acting within his/her scope of practice. Clinical necessity
must be documented by the program supervising practitioner. Reimbursement for
psychological diagnostic services is included in the per diem.
4.
Medically Necessary
Pharmaceutical Services: If medications are dispensed by the
program, pharmacy services must be provided under the supervision of a
registered pharmacy consultant; or the program may contract for these services
through an outside facility or provider. All medications must be stored in a
special locked storage space and administered only by a physician, registered
nurse, or licensed practical nurse.
5.
Medically Necessary Dietary
Services: If meals are provided by a day treatment program,
services must be supervised by a registered dietitian, based on the client's
individualized diet needs. Day treatment programs may contract for these
services through an outside facility or provider.
6. Transition and discharge planning that
meets the requirements of 471 NAC 32-001.07A.
32-004.01B
Optional
Services: The program must provide two of the following optional
services. The client must have a need for the services, the supervising
practitioner must order the services, and the services must be a part of the
client's treatment plan. The therapies must be restorative in nature, not
prescribed for conditions that have plateaued or cannot be significantly
improved by the therapy, or which would be considered maintenance therapy. In
appropriate circumstances, occupational therapy may be covered if prescribed as
an activities therapy in a day treatment program:
1. Services provided or supervised by a
licensed or certified therapist may be provided under the supervision of a
qualified consultant or the program may contract for these services from a
licensed/certified professional as listed below:
a. Recreational Therapy;
b. Speech Therapy;
c. Occupational Therapy;
d. Vocational Skills Therapy;
e. Self-Care Services: Services supervised by
a registered nurse or occupational therapist who is oriented toward activities
of daily living and personal hygiene. This includes toileting, bathing,
grooming, etc.
2.
Psychoeducational Services: Therapeutic psychoeducational services may be
provided as part of a total program. Therapeutic psychoeducational services
must be provided by teachers specially trained to work with child and
adolescents experiencing mental health or substance abuse problems. These
services may meet some strictly educational requirements, but must also include
the therapeutic component. Professionals providing these services must be
appropriately licensed and certified for the scope of practice.
3. Social Work Services by a Bachelor's Level
Social Worker: Social services to assist with personal, family, and adjustment
problems which may interfere with effective use of treatment, i.e., case
management type services.
4. Crisis
Intervention (may be provided in home);
5. Social Skills Building;
6. Life Survival Skills; and
7. Substance abuse prevention, intervention,
or treatment by an appropriately certified alcohol/drug abuse counselor.
32-004.01C
Educational Program Services: Services, when required
by law, must be available, though not necessarily provided by the day treatment
program. Educational services must be only one aspect of the treatment plan,
not the primary reason for admission or treatment. Educational services are not
eligible for payment by the Nebraska Medical Assistance Program (Medicaid), and
do not apply towards the three hours or six hours of therapeutic
services.
32-004.01D
Special Treatment Procedures in Day Treatment: If a
child/adolescent needs behavior management and containment beyond unlocked time
outs or redirection, special treatment procedures may be utilized. Special
treatment procedures in day treatment are limited to physical restraint, and
locked time out (LTO). Mechanical restraints and pressure point tactics are not
allowed. Parents or legal guardian or the Department case manager must approve
use of these procedures through informed consent and must be informed within 24
hours each time they are used.
Facilities must meet the following standards regarding
special treatment procedures:
1.
De-escalation techniques must be taught to staff and used appropriately before
the initiation of special treatment procedures;
2. Special treatment procedures may be used
only when a child/adolescent's behavior presents a danger to self or others, or
to prevent serious disruption to the therapeutic environment; and
3. The child/adolescent's treatment plan must
address the use of special treatment procedures and have a clear plan to
decrease the behavior requiring LTO, or physical restraints.
These standards must be reflected in all aspects of the
treatment program. Attempts to de-escalate, the special treatment procedure and
subsequent processing must be documented in the clinical record and reviewed by
the supervising practitioner.
004.02 Standards for Participation
32-004.02A
Provider
Standards: Providers of day treatment services shall meet the
following standards:
1.
A
community mental health or substance abuse program providing day treatment must
meet the following standards -a.
A community-based treatment facility appropriately licensed as determined by
the Department of Health and Human Services, Division of Public
Health;
b. Accreditation by the
Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the
Commission on the Accreditation of Rehabilitation Facilities (CARF), the
Council on Accreditation (COA) or the American Osteopathic Association (AOA).
Agencies that have applied for accreditation may be enrolled on a provisional
status; and
2.
A psychiatric or substance abuse hospital providing day treatment
must -
a. Be maintained for the
care and treatment of patients with primary psychiatric or substance abuse
disorders;
b. Be licensed or
formally approved as a hospital by the Nebraska Department of Health and Human
Services, Division of Public Health;
c. Be accredited by the Joint Commission on
Accreditation of Healthcare Organizations (JCAHO) or the American Osteopathic
Association (AOA);
d. Have licensed
and certified psychiatric or substance abuse beds;
e. Meet the requirements for participation in
Medicare; and
f. Have in effect a
utilization review plan applicable to all Medicaid clients.
3.
A licensed and
certified hospital which provides acute care services and which -
a. Is maintained for the care and treatment
of patients with acute medical disorders;
b. Is licensed or formally approved as a
hospital by the Nebraska Department of Health and Human Services, Division of
Public Health;
c. Is accredited by
the Joint Commission on Accreditation of Healthcare Organizations(JCAHO) or the
American Osteopathic Association (AOA);
d. Meets the requirements for participation
in Medicare for acute medical hospitals;
e. Has in effect a utilization review plan
applicable to all Medicaid clients; and
f. Has adequate staff to meet the
requirements of the mental health or substance abuse day treatment
standards.
4. If day
treatment services will be provided in a school, the school must have a written
contract with a mental health or substance abuse program that meets these
standards community mental health program or licensed hospital. This contract
shall demonstrate the working relationship between the school and the community
mental health or substance abuse program to provide the day treatment service.
32-004.02B
Service Standards:
1. The program must provide a minimum of
three hours of services five days a week, which is considered a half day for
billing purposes. Six hours a day of services is considered a full day of
services. Services may not be prorated for under three (or six) hours of
services, but may be for up to 12 hours of service.
2. A designated supervising practitioner must
be responsible for the care provided in a day treatment program. The
supervising practitioner must be present on a regularly-scheduled basis and
must assume responsibility for all clients. If the supervising practitioner is
present on a part-time basis, one of the clinical staff professionals acting
within the scope of practice standards of the Nebraska Department of Health and
Human Services, Division of Public Health (see 471 NAC 32-001.04) shall assume
delegated professional responsibility for the program and must be present at
all times when the program is providing services.
Psychotherapy and substance abuse counseling services must be
provided by clinical staff (see 471 NAC 32-001.04) who are operating within
their scope of practice and under the direction of the supervising
practitioner. The supervising practitioner's personal involvement must be
documented in the client's clinical record.
3. A licensed psychologist, physician, or
doctor of osteopathy may refer a client to a day treatment program, but all
treatment must be prescribed and directed by the program supervising
practitioner.
4. All treatment must
be conducted under the direction of the supervising practitioner in charge of
the program;
5. Admission Criteria:
The following criteria must be met for a client's admission to a day treatment
program:
a. The client must have sufficient
need for active treatment at the time of admission to justify the expenditure
of the client's and program's time, energy, and resources;
b. Of all reasonable options for active
treatment available to the client, treatment in this program must be the best
choice for expecting a reasonable improvement in the client's
condition;
6.
Pre-Admission Assessment: Before the client is admitted to the program, a
supervising practitioner and other staff shall complete a comprehensive
preadmission assessment to validate the appropriateness of care. This
assessment is described in 471 NAC 32-001.01.
7. Treatment Plan: The program supervising
practitioner shall determine the diagnosis and prescribe the treatment,
including the modalities and the professional staff to be used. He/she must be
responsible and accountable for all evaluations and treatment provided to the
client.
The goals and objectives documented on the treatment plan
must reflect the recommendations included in the Pre-treatment Assessment and
the integration of input from the supervising practitioner and the therapist.
The treatment interventions provided must reflect these recommendations, goals,
and objectives. Evaluation of the treatment plan by the therapist and the
supervising practitioner should reflect the client's response to the treatment
interventions based on the recommendations, goals and objectives.
The multi-disciplinary team shall complete the treatment plan
within the first 14 days after the client's admission to the program. The plan
must be reviewed and revised by the multi-disciplinary team, including the
supervising practitioner, at least every 30 days or more often if
necessary.
Changes in the treatment plan must be noted on the treatment
planning document. An updated treatment plan must be completed every 30 days,
or more frequently if necessary, to reflect changes in treatment needs.
The treatment plan must be signed by the supervising
practitioner for day treatment services.
The treatment plan review must be documented on the treatment
plan, if required, and in the medical records.
8. The supervising practitioner must meet
personally with the client for evaluation every 30 days, or more often, as
clinically necessary. Reimbursement for the 30-day update visit is not included
in the day treatment per diem and can be reimbursed separately.
9. Every 30 days a utilization review must be
conducted per 471 NAC 32-004.07. This review must be documented on the
treatment plan, and the facility's treatment plan review form. Utilization
review is not required for the calendar month in which the client was
admitted.
10. The program must have
a description of each of the services and treatment modalities available. This
includes psychotherapy services, substance abuse counseling, nursing services,
psychological diagnostic services, pharmaceutical services, dietary services,
and other day treatment services.
a. The
program must have a description of how the family-centered requirement in 471
NAC
32-001 will be met, including a
complete description of any family assessment and family services.
b. The program must have a description of how
the community-based requirement in 471 NAC
32-001 will be met.
c. The program shall state the
qualifications, education, and experience of each staff member and the therapy
services each provides.
d. The
program must have a daily schedule covering the total number of hours the
program operates per day. The schedule must be submitted to the Department for
approval. The program must be fully staffed and supervised during the time the
program is available for services, and must provide at least three hours of
approved treatment for each day services are provided. This schedule must be
updated annually, or more frequently if appropriate.
11. Outpatient Observation: When appropriate
for brief crisis stabilization, outpatient observation up to 23 hours 59
minutes in an emergency room or acute hospital may be used as follows:
An outpatient is defined as a person
who has not been admitted as an inpatient but is registered on the hospital
records as an outpatient and receives services (rather than supplies alone). If
a patient receives 24 or more hours of continuous outpatient care, that patient
is defined as an inpatient regardless of the hour of admission, whether s/he
used a bed and whether s/he remained in the hospital past midnight or the
census-taking hour, and all inpatient prior-authorization requirements
apply.
12. The program must
have a written plan for immediate admission or readmission for appropriate
inpatient services, if necessary. The written plan must include a cooperative
agreement with a psychiatric or substance abuse hospital or distinct part of a
hospital, as outlined in 471 NAC
32-008. A copy of this agreement must
accompany the provider application and agreement.
004.03 Provider Agreement
A provider of day treatment services shall complete a
provider agreement and submit the form to the Department for approval. The
provider shall attach to the provider agreement a written overview of the
program including philosophy, objectives, policies and procedures, and
documentation of the requirements in 471 NAC 32001 are met. Staff must meet the
standards outlined in 471 NAC 32-001.04, and:
1. Community mental health or substance abuse
programs and licensed health clinics shall complete Form MC-19, "Medical
Assistance Provider Agreement," and submit the completed form to the Department
for approval. A Department approved cost reporting document must also be
submitted. Satellites of community programs shall bill the Department through
their main community program, unless the satellite has a separate provider
number under Medicare. A satellite of a community program that has a separate
provider number under Medicare shall complete a separate provider agreement.
All claims submitted to the Department by these satellites must be filed under
the satellite's Medicaid provider number. The facility must have in effect a
utilization review plan applicable to all Medicaid clients.
2. Hospitals shall complete Form MC-20,
"Medical Assistance Hospital Provider Agreement," and submit the completed form
to the Department for approval. A Department approved cost reporting document
must also be submitted.
32-004.03A
Annual Renewal/Update: The program shall renew the
provider agreement, program overview, and cost report annually and whenever
requested by the Medicaid Division.
004.04 Coverage Criteria for Mental Health or
Substance Abuse Day Treatment Services
The Nebraska Medical Assistance Program covers day treatment
services for clients 20 and younger when the services meet the requirements in
471 NAC
32-001 and the client has
participated in a HEALTH CHECK (EPSDT) screen.
Day treatment services must be prior authorized by the
Division of Medicaid and Long-Term Care or its designee.
The client must be observed and interviewed by the
supervising practitioner at least once every 30 days, or more frequently if
medically necessary, and the interaction must be documented in the client's
clinical record.
32-004.04A
Services Not Covered Under NMAP: Payment is not
available for day treatment services for clients -
1. Receiving services in an out-of-state
facility, except as outlined in 471 NAC 1-002.01F, Services Provided Outside
Nebraska;
2. In long term care
facilities;
3. Whose needs are
social or educational and may be met through a less structured
program;
4. Whose primary diagnosis
and functional impairment is acutely psychiatric in nature and whose condition
is not stable enough to allow them to participate in and benefit from the
program; or
5. Whose behavior may
be very disruptive and/or harmful to other program participants or staff
members.
004.05 Documentation in the Client's Clinical
Record
All documents submitted to NMAP must contain sufficient
information for identification (i.e., client's name, dates of service,
provider's name). In addition to the requirements of 471 NAC 32-001.05, each
client's medical record must contain the following documentation:
1. The supervising practitioner's
orders;
2. The treatment
plan;
3. The team progress notes,
recorded chronologically. The frequency is determined by the client's
condition, but the team's progress notes must be recorded at least daily. The
progress notes must contain a concise assessment of the client's progress and
recommendations for revising the treatment plan, as indicated by the client's
condition, and discharge planning.
4. Documentation indicating compliance with
all requirements in 471 NAC
32-001;
5. Records of the treatment plan review by
the multi-disciplinary team including attendees and decisions;
6. The program's utilization review
committee's abstract or summary; and
7. The discharge summary.
004.06 Transition and Discharge
Planning
Each provider must meet the 471 NAC 32-001.07A requirements
for transition and discharge planning.
004.07 Utilization Review (UR)
Each program is responsible for establishing a utilization
review plan and procedure which meets the following guidelines. A site visit by
Medicaid staff for purposes of utilization review may be required for further
clarification.
32-004.07A
Components of UR: Utilization review must provide -
1. Timely review (at least every 30 days) of
the medical necessity of admissions and continued treatment;
2. Utilization of professional services
provided;
3. High quality patient
care; and
4. Effective and
efficient utilization of available health facilities and services.
32-004.07B
UR
Overview: An overview of the program's utilization review process
must be submitted with the provider application and agreement before the
program is enrolled as a Medicaid provider. The overview must include -
1. The organization and composition of the
utilization review committee which is responsible for the utilization review
function;
2. The frequency of
meetings (not less than once a month);
3. The type of records to be kept;
and
4. The arrangement for
committee reports and their dissemination, including how the program and
supervising practitioner is informed of the findings.
32-004.07C
UR
Committee: The utilization review committee must contain a
licensed practitioner of the healing arts who is able to diagnose and treat
major mental illness within their scope of practice and at least two clinical
staff professionals (as defined in 471 NAC
32-001). The committee's reviews may
not be conducted by any person whose primary interest in or responsibility to
the program is financial or who is professionally involved in the care of the
client whose case is being reviewed. At the Department's discretion, an
alternative plan for facilities that do not have these resources readily
available may be approved.
32-004.07D
Basis of
Review: The review must be based on -
1. The identification of the individual
client by appropriate means to ensure confidentiality;
2. The identification of the supervising
practitioner;
3. The date of
admission;
4. The diagnosis and
symptoms;
5. The supervising
practitioner's plan of treatment; and
6. Other supporting materials (progress
notes, test findings, consultations) the group may deem appropriate.
32-004.07E
Contents of
Report: The written report must contain -
1. An evaluation of treatment, progress, and
prognosis based on -
a. Appropriateness of
the current level of care and treatment;
b. Alternate levels of care and treatment
available; and
c. The effective and
efficient utilization of services provided;
2. Verification that -
a. Treatment provided is documented in the
client's record;
b. All entries in
the client's record are signed by the person responsible for entry and dated.
The supervising practitioner shall sign and date all of his/her orders;
and
c. All entries in the client's
record are dated;
3.
Recommendations for -
a. Continued
treatment;
b. Alternate
treatment/level of care; and
c.
Disapproval of continued treatment.
4. The date of the review;
5. The names of the program utilization
review committee members; and
6.
The date of the next review if continued treatment is recommended.
A copy of the admission review and the extended stay review
must be attached to all claims for mental health services submitted to the
Department for payment.
004.08 Limitations on Reimbursement of
Allowable Costs
The following limitations apply to reimbursement of
allowable costs:
1. Payment for a full
day of day treatment is allowable when services are provided to a client for at
least six hours per day.
2. Payment
for a half day of day treatment is allowable when services are provided to a
client for at least three hours per day but less than six hours per day. The
rate for a half day of day treatment is limited to one half of the "full day"
rate.
3. For programs that provide
services for more than six hours, and up to twelve hours, payment can be
prorated by the hour. For each additional hour of service beyond six, NMAP will
pay an additional amount based on the cost-report.
32-004.08A
Documentation for
Claims: The following documentation is required for all claims for
day treatment/claims and must be kept in the client's record:
1. A psychiatric assessment with mental
status exam and diagnosis;
2. The
treatment plan, if required (required at admission and every 30 days
thereafter);
3. Orders by the
supervising practitioner;
4. A
complete family assessment;
5.
Nurses' notes; and
6. Progress
notes for all disciplines.
All claims are subject to utilization review by the
Department prior to payment.
32-004.08B
Exception: Additional documentation from the client's
medical record may be requested by the Department prior to considering
authorization of payment.
32-004.08C
Costs Not Included in
the Day Treatment Fee: The mandatory and optional services are
considered to be part of the fee for day treatment services. The following
charges can be reimbursed separately from the day treatment fee when the
services are necessary, part of the client's overall treatment plan, and in
compliance with NMAP policy:
1. Direct client
services performed by the supervising practitioner;
2. Prescription medications (including
injectable medications);
3. Direct
client services performed by a physician other than the supervising
practitioner; and
4. Treatment
services for a physical injury or illness provided by other professionals.
If the client is enrolled with another managed care vendor
for medical-surgical services, it may be necessary to pursue prior
authorization or referral with that entity.
004.09 Procedure Codes
and Descriptions for Mental Health or Substance Abuse Day Treatment
HCPCS/CPT procedure codes used by NMAP are listed in the
Nebraska Medicaid Practitioner Fee Schedule at 471-000-532.
