Current through all regulations passed and filed through September 16, 2024
(A) For the purposes of medicaid
reimbursement, assertive community treatment (ACT) refers to the evidence based
model of delivering comprehensive community based behavioral health services to
adults with certain serious and persistent mental illnesses who have not
benefited from traditional outpatient treatment. The ACT model utilizes a
multidisciplinary team of practitioners to deliver services to eligible
individuals.
(B) For the purposes
of this rule, collateral contact occurs when the practitioner contacts
individuals who play a significant role in a medicaid recipient's life. The
information gained from the collateral contact can provide insight into
treatment or the basic psychoeducation provided to that collateral contact can
assist with the treatment of the medicaid recipient.
(C) The ACT team is the sole provider to ACT
recipients of outpatient behavioral health services, including level one
outpatient services as defined by the American society of addiction
medicine.
(D) ACT services include
but are not limited to the following:
(1)
Psychiatry and primary care as related to the mental health or substance use
disorder diagnoses;
(2) Service
coordination;
(3) Crisis assessment
and intervention;
(4) Symptom
assessment and management;
(5)
Community based rehabilitative services;
(6) Education, support, and consultation to
families, legal custodians, and significant others who are part of the
recipient's support network.
(E) The desired outcomes of ACT intervention
for medicaid recipients include but are not limited to:
(1) Achieving and maintaining a stable life
in a community based setting;
(2)
Reducing the need for inpatient hospital admission and emergency department
visits;
(3) Improving mental and
physical health status, and improving life satisfaction.
(F) A medicaid recipient may receive ACT
services when determined by the ODM designated entity to have met all of the
following:
(1) The recipient has a diagnosis
of schizophrenia, bipolar, or major depressive disorder with psychosis, in
accordance with the ICD-10 diagnosis code group list found at
https://bh.medicaid.ohio.gov/manuals;
(2) The recipient has a supplemental security
income or social security disability insurance determination or has a score of
two or greater on at least one of the items in the "mental health needs" or
"risk behaviors" sections or a score of three on at least one of the items in
the "life domain function" section of the adult needs and strengths assessment
(ANSA) administered by an individual with a bachelor's degree or higher and
with training in the administration of the assessment; and
(3) The recipient has one or more of the
following:
(a) Two or more admissions to a
psychiatric inpatient hospital setting during the past twelve months;
or
(b) Two or more occasions of
utilizing psychiatric emergency services during the past twelve months;
or
(c) Significant difficulty
meeting basic survival needs within the last twenty-four months; or
(d) History within the past two years of
criminal justice involvement including but not limited to arrest,
incarceration, or probation; and
(4) The recipient experiences one or more of
the following:
(a) Persistent or recurrent
severe psychiatric symptoms; or
(b)
Coexisting substance use disorder of more than six month in duration;
or
(c) Residing in an inpatient or
supervised residence, but clinically assessed to be able to live in a more
independent living situation if intensive services are provided; or
(d) At risk of psychiatric hospitalization,
institutional or supervised residential placement if more intensive services
are not available; or
(e) Has been
unsuccessful in using traditional office-based outpatient services; and
(5) The recipient is
eighteen years of age or older at the time of ACT enrollment.
(G) Prior authorization of ACT
services.
(1) The provider must submit a
request for prior authorization and receive approval from the ODM designated
entity before ACT services can be rendered. The request for prior authorization
must be accompanied by the appropriate documentation which includes, but is not
limited to, the ANSA results or the documentation that supports the social
security determination. The maximum amount of ACT service which may be prior
authorized at any one time is twelve months.
(2) At the conclusion of the previous ACT
service period, the provider agency may request additional ACT service to be
prior authorized by the ODM designated entity.
(3) The provider may begin submitting claims
for medicaid reimbursement of ACT services for dates of service within the
subsequent calendar month following the date on which prior authorization is
approved by the ODM designated entity.
(H) Disenrollment of a recipient from ACT.
Upon planned or unplanned disenrollment of an ACT recipient, the ACT team shall
document the circumstances regarding disenrollment in the recipient's medical
record.
(1) A planned disenrollment from ACT
occurs when a recipient, or recipient's guardian and ACT team members mutually
agree to the termination of ACT services and transition of the recipient to a
different care setting, provider, or benefit package. A planned disenrollment
is appropriate when:
(a) The recipient has
successfully reached established goals for disenrollment and the recipient
and/or their guardian and ACT team members agree to the discharge from ACT;
or
(b) The recipient moves outside
the geographic area of the ACT team's responsibility. In such cases, the ACT
team shall arrange to transfer mental health and substance use disorder service
responsibility to another ACT program or other provider wherever the recipient
is moving. The ACT team shall maintain contact with the recipient until the
transfer is complete; or
(c) The
recipient or their guardian requests a disenrollment; or
(d) The recipient is determined by the ODM
designated entity to no longer meet the eligibility or medical necessity
criteria for ACT.
(2) As
part of a planned disenrollment, the ACT team shall document that the recipient
has actively participated in disenrollment activities by documenting in the
recipient's medical record the following information:
(a) The reason(s) for the recipient's
disenrollment as stated by both the recipient and the ACT team;
(b) The recipient's progress toward the goals
set forth in the treatment plan;
(c) Documentation that the recipient's
behavioral health care is being linked and transfered to a provider other than
the ACT team;
(d) The signature of
the recipient or their guardian, the ACT team leader, and the psychiatric
prescriber.
(3) A
recipient's disenrollment from ACT may be unplanned and due to circumstances
facilitated by:
(a) The inability of the ACT
team to locate the recipient for more than forty-five days; or
(b) The recipient's incarceration,
hospitalization or admission to a residential substance use disorder treatment
facility. In these circumstances, the primary responsibility for the
recipient's health care is transferred to the aforementioned setting.
(i) The ACT team is expected to maintain
contact with the recipient to assist with transition between settings if the
recipient is likely to be discharged and resume service from the ACT team
within two months.
(ii) If the
recipient's stay is predicted to be longer than two months, the recipient shall
be disenrolled from the ACT team.
(iii) The recipient may be re-enrolled with
the ACT team when discharged from the incarcerated, inpatient or residential
setting. Any re-enrollment shall follow the eligibility determination criteria
described in paragraph (F) of this rule.
(4) Except for services found in paragraph
(O) of this rule, a recipient may not obtain behavioral health services from a
provider other than the ACT team unless the recipient is disenrolled from ACT
services.
(5) The provider must
inform the ODM designated entity of disenrollment within three business days of
the discharge date. The ODM designated entity shall deactivate the
authorization for the ACT service. Failure to timely disenroll the recipient
from ACT may result in claim denial for other mental health or substance use
disorder services.
(I) A
provider furnishing ACT services must meet both of the following criteria:
(1) Meets the eligibility requirements found
in paragraph (A)(1) or (A)(2) of rule
5160-27-01 of the Administrative
Code; and
(2) Employs one or more
teams of mental health and substance use disorder practitioners who comprise
the ACT treatment team.
(J) Each team must meet the following
criteria:
(1) Completed
a
fidelity review within the previous twelve months by an independent validation
entity recognized by ODM. In year one of an ACT team's participation with Ohio
medicaid the team must participate in a fidelity review
based
on the dartmouth assertive community treatment scale (DACTS)
and
performed by an independent validation
entity recognized by ODM. The DACTS fidelity scale and protocol can be found at
www.medicaid.ohio.gov.
(a) Fidelity reviews of ACT teams must be
repeated every twelve months from the report date of the previous fidelity
review.
(b) An ACT team must have documented evidence of
compliance to the requirements stated in paragraph (J) of this
rule prior to submitting any prior authorization requests for recipients
of ACT services.
(2) Each
team shall have a designated full-time team leader who may serve in that
capacity with only one team.
(a) An ACT team
leader shall have a national provider identification number and be actively
enrolled as an Ohio medicaid provider.
(b) A team leader shall have psychiatric
training and shall hold one of the following valid licenses from the
appropriate Ohio professional licensure board or licensure equivalents for ACT
teams located in other states:
(i) Licensed
independent social worker.
(ii)
Licensed independent marriage and family therapist.
(iii) Licensed professional clinical
counselor.
(iv) Licensed
psychologist.
(v) Physician -
medical doctor, psychiatrist, doctor of osteopathy.
(vi) Clinical nurse specialist
(vii) Certified nurse practitioner.
(viii) Physician assistant.
(ix) Registered nurse.
(c) Team leaders who are licensed in
accordance with paragraph (A)(5) of rule
5160-27-01 of the Administrative
Code but do not have independent licensure status from one of the boards
referenced in paragraph (A)(5) of rule
5160-27-01 of the Administrative
Code must receive approval from ODM before the ACT team to which they are
assigned can begin billing Ohio medicaid.
(3) ACT teams that employ peer recovery
supporters must ensure that they meet the criteria and requirements for the
peer recovery support services set forth in rule
5160-43-09 of the Administrative
Code.
(4) ACT teams must have a
caseload no greater than one hundred and twenty and must maintain an average
caseload ratio of one practitioner for every ten ACT recipients. Upon request
from the ODM, the ACT team must provide to the ODM or its designated entity the
ACT team caseload size and composition of medicaid and non-medicaid
enrollees.
(K) ODM
reserves the right to suspend or terminate the payment of ACT services and to
require subsequent review of an ACT team's fidelity performance
if ODM has reason to believe that the ACT team's fidelity to the DACTS model
described in paragraph (J)(1) of this rule may be in question. ODM may, at its
discretion, suspend payment of ACT medicaid claims from the provider agency
employing the ACT team until such time as ODM receives documentation from its
independent validation entity that the team does meet the fidelity criteria
described in paragraph (J)(1) of this rule.
(L) A provider employing an ACT team may bill
up to four ACT units per month per recipient when all clinical and billing
requirements for each unit are met. The billing of ACT units are subject to the
following limits per provider category, per recipient, per month:
(1) Not more than one unit may be billed per
medicaid recipient per month for services rendered by the ACT team medical
prescriber including physician, clinical nurse specialist, certified nurse
practitioner, or physician assistant operating within their respective scopes
of practice.
(2) Not more than one
unit per medicaid recipient per month may be billed for services rendered by
any one of the following ACT team members: psychologist, licensed independent
social worker, licensed social worker, licensed clinical social worker,
licensed professional counselor, licensed professional clinical counselor,
licensed independent clinical counselor, licensed independent marriage and
family therapist, licensed marriage and family therapist, licensed practical
nurse, registered nurse, licensed independent chemical dependency counselor,
licensed chemical dependency counselor II or licensed chemical dependency
counselor III.
(3) Not more than
two units per medicaid recipient per month may be billed by an ACT team member
not listed in paragraph (L)(1) or (L)(2) of this rule. This unit category
includes: psychology assistant, psychology intern, psychology trainee, social
worker assistant, social worker trainee, marriage and family therapist trainee,
counselor trainee, chemical dependency counselor assistant, qualified mental
health specialist (QMHS), including QMHS with three or more years of
experience, and peer recovery supporter.
(M) The medicaid payment rates for ACT are
stated in the appendix to rule
5160-27-03 of the Administrative
Code. Payment for services provided by authorized ACT teams is only available
for dates of services on or after January 1, 2018.
(N) ACT teams shall maintain regular contact
and deliver all medically necessary outpatient mental health and substance use
disorder services and supports to ACT recipients enrolled with their team.
(O)
Services rendered by the ACT team medical prescriber, including physician,
clinical nurse specialist, certified nurse practitioner, or physician
assistant, are billable when rendered to an ACT recipient
or via a case specific
consultation with another member of the ACT team regarding the medical aspects
of the ACT recipient's treatment plan. The ACT team medical prescriber must
have at least one contact with
each ACT recipient every three months.
(P) When a recipient is enrolled on an ACT
team, no other medicaid community behavioral health services, as defined in
Chapter 5160-27 of the Administrative Code, are eligible for reimbursement
except:
(1) Supported employment as identified
on a recipient's specialized recovery services program treatment plan if
applicable, as described in rule
5160-43-01 of the Administrative
Code.
(2) Substance use disorder
services that are not considered part of the benefit package encompassed under
level one of the american society of addiction medicine (ASAM) as defined in
rule 5160-27-09 of the Administrative
Code. Prior authorization from the ODM designated entity is required.
(3) Crisis services furnished by a provider
other than the billing provider agency employing the ACT
team.
(Q) Documentation
requirements for ACT.
(1) Documentation in
the recipient's medical record of the services provided by the ACT team must
meet the requirements stated in this paragraph as well as those stated in rules
5160-1-27 and
5160-8-05 of the Administrative
Code.
(2) The ACT team must develop
a specific treatment plan for each enrolled recipient. The treatment plan must,
at a minimum, meet the requirements of rule
5160-8-05 of the Administrative
Code plus the following additional requirements:
(a) The treatment plan shall be
individualized based on the recipient's needs, strengths, and preferences and
shall set measurable long-term and short-term goals and specify approaches and
interventions necessary for the recipient to achieve the recipient goals. The
treatment plan shall also identify who will carry out the approaches and
interventions.
(b) The treatment
plan shall address, at a minimum, the following key areas:
(i) Psychiatric illness or symptom
reduction.
(ii) Stable, safe, and
affordable housing.
(iii)
Activities of daily living.
(iv)
Daily structure and activities, including employment if appropriate.
(v) Family and social
relationships.
(c) The
treatment plan shall be reviewed and revised by a member of the ACT team with
the recipient whenever a change is needed in the recipient's course of
treatment or at least every six months. In conjunction with a treatment plan
review, the ACT team member shall prepare a summary of the recipient's
progress, goal attainment, effectiveness of the intervention and recipient's
satisfaction with the ACT team interventions since enactment of the previous
treatment plan.
(d) The treatment
plan, and all subsequent revisions of it, shall be reviewed and signed by the
recipient and the ACT team practitioner.
(R) The following activities performed by
members of the ACT team are not eligible for reimbursement:
(1) Time spent attending or participating in
recreational activities.
(2)
Services provided to teach academic subjects or as a substitute for educational
personnel, including but not limited to a teacher, teacher's aide, or an
academic tutor.
(3) Habilitative
services for the recipient to acquire, retain, and improve the self-help,
socialization, and adaptive skills necessary to reside successfully in
community settings.
(4) Child care
services or services provided as a substitute for the parent or other
individuals responsible for providing care and supervision.
(5) Respite care.
(6) Transportation for the recipient or
family.
(7) Services provided to
children, spouse, parents, or siblings of the eligible recipient under
treatment or others in the eligible recipient's life to address problems not
directly related to the eligible recipient's issues and not listed in the
eligible recipient's ACT treatment plan.
(8) Art, movement, dance, or drama
therapies.
(9) Services provided to
collaterals of the recipient.
(10)
Contacts that are not medically necessary.
(11) Any service outside the responsibility
of the ACT team.
(12) Vocational
training and supported employment services, unless the recipient is enrolled in
the specialized recovery services program as described in rule
5160-43-01 of the Administrative
Code.
(13) Crisis intervention
provided by the provider agency employing the ACT team.
