The Nebraska Medical Assistance Program (NMAP) covers
rehabilitative psychiatric services to rehabilitate clients experiencing severe
and persistent mental illnesses in the community and thereby avoid more
restrictive levels of care such as inpatient psychiatric hospital or nursing
facility. Rehabilitative psychiatric services for children age 20 and younger
are covered under EPSDT treatment plans, as described in Chapter 32-000 of this
Title. Rehabilitative psychiatric services for adults age 21 and older are
covered under the rules and regulations of this chapter. The services must be
medically necessary and the most appropriate level of treatment for the
individual client. This does not include treatment for a primary substance
abuse diagnosis.
001.01 Definition of
Severe and Persistent Mental Illness
Clients with severe and persistent mental illness must meet
the following criteria:
1. The client
is age 21 and over;
2. The client
has a primary diagnosis of schizophrenia, major affective disorder, or other
major mental illness under the current edition of the Diagnostic and
Statistical Manual of Mental Disorders published by the American Psychiatric
Association. Developmental disorders, or psychoactive substance use disorders
may be included if they co-occur with the primary mental illnesses listed
above;
3. The client has a
persistent mental illness as demonstrated by the presence of the disorder for
the last 12 months or which is expected to last 12 months or longer and will
result in a degree of limitation that seriously interferes with the client's
ability to function independently in an appropriate and effective manner in two
of three functional areas: Vocational/Education, Social Skills, Activities of
Daily Living.
a. Functional limitations in
the area of
Vocational/Education abilities are defined
as:
(1) An inability to be consistently
employed or an ability to be employed only with extensive supports, except that
a person who can work but is recurrently unemployed because of acute episodes
of mental illness is considered vocationally impaired;
(2) Deterioration or decompensation resulting
in an inability to establish or pursue educational goals within a normal time
frame or without extensive supports;
(3) An inability to consistently and
independently carry out home management tasks, including household meal
preparation, washing clothes, budgeting, and child care tasks and
responsibilities;
b.
Functional limitations in the area of
Social Skills
and abilities are defined as:
(1) Repeated
inappropriate or inadequate social behavior or an ability to behave
appropriately or adequately only with extensive or consistent support or
coaching or only in special contexts or situations, such as social groups
organized by treatment staff; or
(2) Consistent participation in adult
activities only with extensive support or coaching and when involvement is
mostly limited to special activities established for persons with mental
illness or other persons with interpersonal impairments; or
(3) A history of dangerousness to self or
others.
c. Functional
limitations in the area of
Activities of Daily Living
are defined as an inability to consistently perform the range of practical
daily living tasks required for basic adult functioning in the community, in
three of five areas listed below:
(1)
Grooming, hygiene, washing of clothes, and meeting nutritional needs;
(2) Care of personal business
affairs;
(3) Transportation and
care of residence;
(4) Procurement
of medical, legal, and housing services; or
(5) Recognition and avoidance of common
dangers or hazards to self and possessions.
4. The client is at significant risk of
continuing in a pattern of either institutionalization or living in a severely
dysfunctional way if needed mental health services are not provided, and this
pattern has existed for one year or longer and is likely to endure for one year
or longer; and
5. The client does
not have a primary diagnosis of substance abuse/substance dependency or
developmental disabilities.
001.02 Definition of Medical Necessity
The NMAP uses the following definition of medical
necessity:
"Health care services and supplies which are medically
appropriate and -
1. Necessary to meet
the basic health needs of the client;
2. Rendered in the most cost-efficient manner
and type of setting appropriate for the delivery of the covered
service;
3. Consistent in type,
frequency, duration of treatment with scientifically based guidelines of
national medical, research, or health care coverage organizations or
governmental agencies;
4.
Consistent with the diagnosis of the condition;
5. Required for means other than convenience
of the client or his or her physician;
6. No more intrusive or restrictive than
necessary to provide a proper balance of safety, effectiveness, and
efficiency;
7. Of demonstrated
value; and
8. No more intense level
of service than can be safely provided.
The fact that the physician has performed or prescribed a
procedure or treatment or the fact that it may be the only treatment for a
particular injury, sickness, or mental illness does not mean that it is covered
by Medicaid. Services and supplies which do not meet the definition of medical
necessity set out above are not covered."
For purposes of covering rehabilitative psychiatric services
under this Chapter, the following interpretative notes apply. Medical necessity
for rehabilitative psychiatric services includes:
Health care services which are medically appropriate and
-
1. Necessary to meet the psychiatric
rehabilitation needs of the client;
2. Rendered in the most cost-efficient manner
and type of setting appropriate for the delivery of the covered
service;
3. Consistent in type,
frequency, duration of service with accepted principles of psychiatric
rehabilitation;
4. Consistent with
the diagnosis of the condition;
5.
Required for means other than convenience of the client or his or her service
provider(s);
6. No more intrusive
or restrictive than necessary to provide a proper balance of safety,
effectiveness, and efficiency;
7.
Of demonstrated value; and
8. A no
more intense level of service than can be safely provided.
For the purpose of this Chapter, rehabilitative psychiatric
services are medically necessary when those services can reasonably be expected
to increase or maintain the level of functioning in the community of clients
with severe and persistent mental illness.
