Nebraska Administrative Code
Topic - HEALTH AND HUMAN SERVICES SYSTEM
Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES
Chapter 35 - REHABILITATIVE PSYCHIATRIC SERVICES
Section 471-35-004 - Covered Services

Universal Citation: 471 NE Admin Rules and Regs ch 35 ยง 004

Current through September 17, 2024

Medicaid covers the following rehabilitative psychiatric services under the rules and regulations of this chapter.

1. Community Support;

2. Day Rehabilitation;

3. Psychiatric Residential rehabilitation.

For the purposes of meeting the requirements of 471 NAC 35-002, programs certified by the Department of Health and Human Services under 204 NAC 5 (effective date December 19, 1994) as Residential Support and/or Service Coordination providers shall be considered to be certified as Community Support providers.

004.01 Community Support

The Community Support program is designed to:

1. Provide/develop the necessary services and supports to enable clients to reside in the community;

2. Maximize the client's community participation, community and daily living skills, and quality of life;

3. Facilitate communication and coordination between mental health rehabilitation providers that serve the same client; and

4. Decrease the frequency and duration of hospitalization.

Community support shall provide client advocacy, ensures- continuity of care, supports clients in time of crisis, provide/procure skill training, ensures- the acquisition of necessary resources, to assist clients with spend downs and other financial insurance coverage programs and assists- the client in achieving community/social integration. The community support program shall provide a clear focus of accountability for meeting the client's needs within the resources available in the community. The role(s) of the community support provider may vary based on client's needs. Community support is a service in which the client's contact occurs outside the program offices in community locations consistent with the individual client choice/need. Community support is frequently provided in the home and is not facility or office-based. Ninety-day treatment, rehabilitation and recovery team meetings are not considered to be a community support service. The frequency of contact between the community support provider and the client is individualized and adjusted in accordance with the needs of the client.

Prior to admission to a community support program, a client shall have a comprehensive Pretreatment Assessment. The Initial Diagnostic Interview (Part II of the PTA) shall be completed by an independently licensed practitioner (psychiatrist, psychologist, or LIMHP). The purpose of this assessment is to determine/verify the presence of a severe and persistent mental illness which requires psychiatric rehabilitation services. The document must include the need of the specific rehabilitation services necessary to meet the treatment and recovery goals of the client.

Community Support is a separate and distinct service, and may not be provided as a component of other Rehabilitative Psychiatric Services or Mental Health Outpatient Services. Agencies that provide more than one level of rehabilitative psychiatric or Mental Health Outpatient service shall have staff dedicated to the Community Support program. These Community Support staff shall not provide any other rehabilitative psychiatric or treatment service to the client.

35-004.01A Program Components: The Community Support program shall -
1. Facilitate communication and coordination among the mental health rehabilitation providers serving the client;

2. Ensure that if a Pretreatment Assessment was completed 12 months or more prior to admission, the licensed mental health practitioner shall review and update the Biopsychosocial Assessment (Part I of the Pretreatment Assessment) within 30 days of admission of the client into the program. The assessments shall identify needed services and resources for each client;

3. Ensure completion of a strength-based needs assessment which may include skills inventories, interviews and other tools to develop treatment and rehabilitation plans which must be completed within 30 days of admission by the rehabilitation team or team members.

4. Ensure the completion of an Individual Treatment, Rehabilitation, and Recovery Plan for each client served. The Individual Treatment, Rehabilitation, and Recovery Plan shall be completed within 30 days following the admission of the client and reviewed and updated every 90 days or as often as clinically necessary thereafter while receiving services. The Individual Treatment, Rehabilitation, and Recovery Plan shall be based on the results of comprehensive assessments and is developed with the client's involvement and through an interdisciplinary team process. The Individual Treatment, Rehabilitation, and Recovery Plan shall include methods and interventions to address: activities of daily living, community living skills, budgeting, education, independent living skills, social skills, interpersonal skills, psychiatric emergency/relapse, medication management including recognition of signs of relapse and control of symptoms, mental health services, physical health care, vocational/educational: services, resource acquisition, and other related areas as necessary for successful living in the community.

5. Ensure the Individual Treatment, Rehabilitation, and Recovery Plan that encompasses the supportive/rehabilitative interventions that will be directly provided by the Community Support Program;

6. Identify the provision of services/interventions identified in the Individual Treatment, Rehabilitation, and Recovery Plan as the responsibility of other rehabilitative service providers;

7. Develop and implement strategies to assist the client in becoming engaged and remaining engaged in medically necessary mental health treatment and psychiatric rehabilitation services;

8. Provide service coordination and case management activities, including coordination or assistance in accessing medical, social, education, housing, transportation or other appropriate support services as well as linkage to other community services identified in the Individual Treatment, Rehabilitation, and Recovery Plan.

9. Facilitate communication between the treatment and rehabilitation providers and with the primary care physician/psychiatrist serving the client.

10. Monitor client progress of the services being received and participate in the revision of the Individual Treatment, Rehabilitation, and Recovery Plan as needed or at the request of the client;

11. Provide contact as needed with other service provider(s), client family member(s), and/or other significant people in the client's life to facilitate communication necessary to support the individual in maintaining community living;

12. Assist the client in the developing, evaluating and updating a crisis and relapse prevention plan. This plan shall be coordinated with any other rehabilitative service and include the client's natural supports. Provide therapeutic support and intervention to the client in time of crisis. If hospitalization is necessary, facilitate, in cooperation with the inpatient treatment provider, the client's transition back into the community upon discharge.-;

13. Participate with and report to the treatment/rehabilitation team on the progress of the client in areas of medication compliance, relapse prevention, social skill acquisition, application, education, substance abuse, and ability to sustain community living.

14. Monitor medication compliance; and

15. Assist the client with all health insurance issues including Share of Cost eligibility issues. Ensures client understanding of financial benefits and procedures to use those benefits such as Medicaid spend downs, AABD, SSI and SSA, etc.

35-004.01B Admission and Discharge Criteria for Community Support Services

35-004.01C Admission Criteria: Community Support Services shall be prior authorized by the Division of Medicaid and Long-Term Care or its designee. To be eligible for Community Support Services, the client shall meet all of the criteria described in 471 NAC 35-001.01 and the Community Support specific criteria identified by this prior authorization process.

35-004.01D Staffing Requirements: Rehabilitative programs shall provide staff to deliver rehabilitative psychiatric services and staff may be either licensed practitioners operating within their scope of practice or skilled direct care staff that shall meet the following minimum standards:
1. Have demonstrated skills and competencies in working with people experiencing severe and persistent mental illness;

2. Have completed a staff training curriculum for initial orientation and completes a continuing education curriculum at intervals as defined and prepared by the providing agency. This curriculum and periodic updates shall be included in the program description submitted to the Division of Medicaid and Long-Term Care;

3. Licensed staff provide services as identified within their scope of practice; and

4. All staff are trained in the principles of recovery.

35-004.01E Clinical Staff: The Community Support program shall have available a:
1. Licensed Clinical Supervisor: The clinical supervisor shall qualify as a licensed practitioner and shall participate in the Individual Treatment, Rehabilitation, and Recovery Plan development and provide clinical supervision, consultation, and support. The Licensed Clinical Supervisor will review community support client's clinical needs and progress toward their goals with the community support worker every 30 days. The review should be completed preferably face-to-face. The review may be accomplished by the supervisor consulting with the community support worker on their assigned clients and providing clinical guidance or recommendations to better serve the client.

2. Other Consultants: Consultation by licensed professionals for general medical, psychopharmacology, and psychological issues, as well, as overall program design and shall be available and accessed as necessary.

35-004.01F Direct Care Staff: The Community Support program shall have Community Support staff who:
1. Direct Care staff having a bachelor's degree in psychology, sociology or related human services field or two years of course work in the human services field and two years of experience/training in the human services field or two years of lived recovery experience is acceptable. All community support workers shall be trained in rehabilitation and recovery principles and shall have demonstrated skills and competency. Each staff shall have demonstrated skills and competency in treatment with individuals with mental health diagnosis.

Direct care staff employed by an agency before the effective date of these regulations will be considered to meet staffing requirements when the provider submits documentation identifying the name, address and the provider number, service provided, names of direct care staff employed before the effective date of the these regulations, and their date of hire. Documentation shall be submitted to Medicaid within 30 days following the effective date of these regulations. Staff hired on or after the effective date of these regulations shall meet the specified requirements identified in the above paragraph;

2. Receive monthly supervision by the Community Support Clinical Supervisor.

004.02 Program Availability

The Community Support Program shall establish hours of service delivery that ensure program staff are accessible and responsive to the needs of the client. Scheduled services shall include evening and weekend hours. The Community Support Program shall directly provide or otherwise demonstrate that each client has on-call access to a licensed mental health practitioner on a 24 hour, 7 days per week basis. Access to a licensed mental health practitioner shall be documented in the client's Individual Treatment, Rehabilitation, and Recovery Plan.

004.03 Contacts

The frequency of contact between the client and the Community Support worker shall be individualized and adjusted in accordance with the needs of the client. Community Support providers shall ensure that the amount of direct contact is sufficient to meet the client's needs as identified in the Individual Treatment, Rehabilitation, and Recovery Plan. Contacts may either be direct client contact or collateral contact.

1. Direct Client Contact. Direct client contacts are face-to-face services between the community support worker and the client. Direct contacts with the client that focus on the development of skills or the management of other activities are identified on the Individual Treatment, Rehabilitation, and Recovery Plan. Contacts shall occur in community settings and be medically necessary for the client's recovery. Face to face contact shall be individualized to the client's recovery needs and shall be identified in the client's Individual Treatment, Rehabilitation, and Recovery Plan in anticipated occurrences. Face to face contacts shall be calculated in 15 minute increments up to a maximum of 144 units per 180 days. In situations of client absence or unavailability for a scheduled contact, providers shall document the circumstances in which the scheduled face-to-face contact did not occur and the program's response to the lack of clients availability to participate in the community support intervention.

2. Collateral Contact. Collateral contacts are defined as contacts which occur outside the provider organization without the client present and are related to the client's Individual Treatment, Rehabilitation, and Recovery Plan. Collateral contacts shall be documented in the client's clinical record and are considered an essential supportive component to the client's treatment, recovery and rehabilitation plan but may not be billed as a separate service to Medicaid.

004.04 Clinical Documentation

Rehabilitative psychiatric service providers shall maintain a clinical record that is confidential, complete, accurate, and contains up-to-date information relevant to the client's care and services. The record shall sufficiently document assessments, Individual Treatment, Rehabilitation, and Recovery Plans and plan reviews, and important provider discussion. The clinical record shall document client contacts describing the nature and extent of the services provided, such that a clinician unfamiliar with the service can identify the client's service needs and services received. The documentation shall reflect the rehabilitative services provided, and is consistent with the goals in the treatment and recovery plan, and based upon the comprehensive assessment. The absence of appropriate, legible, and complete records may result in the recoupment of previous payments for services. Providers shall provide the clinical record in the English language, however, providers shall accommodate clients of other cultures and language in order that the client can completely participate in and understand their treatment and recovery rehabilitation program. Each entry shall identify the date, beginning and end time of the service and the location of service. The individuals in attendance shall be identified by name and relationship to the identified client and the name and title of the staff person providing the intervention and entering the information.

Clinical records shall be maintained at the provider's headquarters. Records shall be kept in a locked file when not in use. For purposes of confidentiality, disclosure of treatment information is subject to all the provisions of applicable State and Federal laws. The client's clinical record shall be available for review by the client (and his/her guardian with appropriate consent) unless there is a specific medically indicated reason to preclude this availability. The specific reason shall be documented in the clinical record and reviewed periodically.

35-004.04A The clinical record shall include, at a minimum:
1. Client identifying data, including demographic information and the client's legal status;

2. Assessment and Evaluations;
a. Pretreatment Assessment completed prior to admission;

b. Strength-based needs assessment;

c. Other appropriate assessments.

3. Treatment and Recovery Plan and updates to plans;

4. Documentation of review of Client Rights with the client;

5. A chronological record of all services provided to the client. Each entry shall include the staff member who performed the service received. Each entry includes the date the service was performed, the duration of the service (beginning and end time), the place of the service, and the staff member's identity and legible signature, (name and title);

6. Documentation of the involvement of family and significant others;

7. Documentation of treatment and recovery services and discharge planning;

8. A chronological listing of the medications prescribed (including dosages and schedule) for the client and the client's response to the medication;

9. Documentation of coordination with other services and treatment providers;

10. Discharge summaries from previous levels of care;

11. Discharge summary (when appropriate); and

12. Any clinical documentation requirements identified in the specific service.

004.05 Provider Participation

To participate as a Medicaid provider of psychiatric community support, the provider shall be enrolled as a provider of services according to Medicaid regulations. Providers shall contact the Medicaid Managed Care entity to credential into its network. The provider shall provide updates to the program information and staffing as necessary. The provider shall sign an agreement at the time of enrollment that states the provider will submit initial and annual cost information to Medicaid as a part of the enrollment. The cost information shall be updated upon request.

Community support providers shall be appropriately licensed when licensure is required to provide the service and the program shall have acquired national accreditation in JCAHO, CARF or COA as a condition for enrollment as a participating provider. Accreditation shall be maintained throughout the Medicaid participation period.

004.06 Clients' Rights

Individual staff and the treatment and recovery team shall provide all services in a manner to support and maintain the client's rights with a continuous focus on client empowerment and movement toward recovery. Providers shall have written Client Rights and Responsibility policy and staff shall review client rights, responsibilities, and grievance procedures with each new client at admission, at treatment and recovery plan review and at the request of the client. This review shall be documented in the clinical record. Substance Abuse Treatment providers shall comply with all State and Federal Clients' Rights requirements.

Client rights shall be observed when receiving substance abuse services through Medicaid. The client has the right to:

1. Be treated with respect and dignity regardless of state of mind or condition;

2. Have privacy and confidentiality related to all aspects of care;

3. Be protected from neglect; physical, emotional or verbal abuse; and exploitation of any kind;

4. Be part of developing an individual treatment and recovery plan and decision-making regarding his/her treatment and rehabilitative services;

5. Refuse treatment or therapy (unless ordered by a mental health board or court);

6. Receive care which does not discriminate and is sensitive to gender, race, national origin, language, age, disability, and sexual orientation;

7. Be free of any sexual exploitation or harassment;

8. Voice complaints and file grievances without discrimination or reprisal and to have those complaints and grievances addressed; and

9. Receive such forms, instructions and assistance as needed to file a complaint or request a state fair hearing.

004.07 Billing for Community Support Services

Community Support Services shall be billed in 15-minute increments for a maximum of 144 units per 180 days.

004.08 Day Rehabilitation

The Day Rehabilitation program is designed to-

1. Enhance and maintain the client's ability to function in community settings; and

2. Decrease the frequency and duration of hospitalization. Clients served in this program receive rehabilitation and support services to develop and maintain the skills needed to successfully live in the community. Day Rehabilitation is a facility-based program.
35-004.08A Program Components: The program shall provide:
1. Prevocational services including services designed to rehabilitate and develop the general skills and behaviors needed to prepare the client to be employed and/or engage in other related substantial gainful activity. The program does not provide training for a specific job or assistance in obtaining permanent competitive employment positions for clients.

2. Community living skills and daily living skills development.

3. Client skills development for self-administration of medication, as well as recognition of signs of relapse and control of symptoms.

4. Planned socialization and skills training and recreation activities focused on identified rehabilitative needs.

5. Skill building in the usage of public transportation and/or assistance in accessing suitable local transportation to and from the Day Rehabilitation program.

6. A scheduled program of services to clients for a minimum of five hours per day, five days per week. Specific services for each client will be individualized, based on client needs.

7. Directly provide or otherwise demonstrate that each client has on-call access to a mental health provider on a (24) hour, (7) days per week basis.

35-004.08B Supportive Services: The program provides the following supportive services for all active clients: referrals, problem identification/solution, and coordination of the Day Rehabilitative program with other services.

004.09 Psychiatric Residential Rehabilitation

The Psychiatric Residential Rehabilitation Program is designed to:

1. Increase the client's functioning so that s/he can eventually live successfully in the residential setting of his/her choice, capabilities and resources;

2. Decrease the frequency and duration of hospitalization.

The Psychiatric Residential Rehabilitation program provides skill building in community living skills, daily living skills, medication management, and other related psychiatric rehabilitation services as needed to meet individual client needs. Psychiatric Residential Rehabilitation is a facility-based, non-hospital or non-nursing facility program for persons disabled by severe and persistent mental illness, who are unable to reside in a less restrictive residential setting. These facilities are integrated into the community, and every effort is made for these residences to approximate other homes in their neighborhoods.

35-004.09A Program Components: The program provides -
1. Community living skills and daily living skills development.

2. Client skills development for self-administration of medication, as well as recognition of signs of relapse and control of symptoms.

3. Skill building in the usage of public transportation and/or assistance in accessing suitable local transportation to and from the Psychiatric Residential Rehabilitation program.

35-004.09B Licensure Requirements: The program shall be licensed as a Residential Care Facility, Domiciliary, or Mental Health Center by the Department of Health and Human Services.

35-004.09C Staffing Requirements: The program must have the appropriate staff coverage to provide services for clients needing to remain in the residence during the day.

35-004.09D Bed Limitation: The maximum capacity for this facility shall not exceed 15 beds

35-004.09E Supportive Services: The program provides the following supportive services for all active clients: referrals, problem identification/solution, and coordination of the Residential Rehabilitation program with other services the client may be receiving.

Disclaimer: These regulations may not be the most recent version. Nebraska 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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