Optum By United Behavioral Health Florida Medicaid Managed Medical Assistance (MMA) Level of Care Guidelines

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1 Optum By United Behavioral Health 2015 Florida Medicaid Managed Medical Assistance (MMA) Level of Care Guidelines Therapeutic group care services are community-based, psychiatric residential treatment services designed for recipients under the age of 21 years with moderate to severe emotional disturbances. They are provided in a licensed residential group home setting serving no more than 12 recipients under the age of 21 years. Therapeutic group care services are intended to support, promote, and enhance competency and participation in normal age-appropriate activities of recipients who present moderate to severe psychiatric, emotional, or behavior management problems related to a psychiatric diagnosis. Programming and interventions are highly individualized and tailored to the age and diagnosis of the recipient. Therapeutic group care is intended to provide a high degree of structure, support, supervision, and clinical intervention in a home-like setting. These services are appropriate for members who are ready to transition from a more restrictive treatment program or for those who require more intensive community-based treatment to avoid placement in a more restrictive treatment setting. Generally, these services include psychiatric and therapy services, therapeutic supervision, and the teaching of problem solving skills, behavior strategies, normalization activities, and other treatment modalities, as authorized in the treatment plan. INSTRUCTIONS FOR USE Optum s Level of Care Guidelines are used to standardize coverage determinations, promote evidence-based practices, and support member s recovery, resiliency, and wellbeing. Optum s Level of Care Guidelines are derived from generally accepted standards of behavioral health practice. These standards include guidelines and consensus statements produced by professional specialty societies, as well as guidance from governmental sources such as CMS National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs). While this Level of Care Guideline does reflect Optum s understanding of current best practices in care, it does not constitute medical advice. Optum reserves the right, in its sole discretion, to modify its Level of Care Guidelines as necessary. Optum is a brand used by United Behavioral Health and its affiliates.

2 1. Admission Criteria 1.1. The member is eligible for benefits i The member s current condition cannot be safely, efficiently and effectively assessed and/or treated in a less intensive setting due to changes in the member s signs and symptoms, level of functioning, and/or psychosocial and environmental factors (i.e., the why now factor leading the member to admission) Failure of treatment in a lower level of care is not a prerequisite for authorizing coverage The member is not in imminent risk of harm to self or others and/or property Co-occurring behavioral health or physical conditions can be safely managed Services are medically necessary ii. 2. Continued Service Criteria 2.1. The admission criteria are still met Services continue to be medically necessary The why now factor leading to admission have been identified and are integrated into the treatment plan Best practices are being provided timely with sufficient intensity to address the member s needs. 3. Discharge Criteria 3.1. The continued stay criteria are no longer met. Examples include: Services are no longer medically necessary The why now factors which led to admission have been addressed to the extent that the member can be safely transitioned to a less intensive level of care. 2

3 The why now factors which led to admission cannot be addressed and the member must be transitioned to a more intensive level of care The member is receiving care that is primarily social, recreational, or for purpose of respite The member requires treatment in a medical-surgical setting The member is no longer eligible for benefits. OR 3.2. The member moves outside the geographic area of the Therapeutic Group Care Service s responsibility. OR 3.3. The member declines or refuses services and requests discharge, despite the provider s best efforts to develop an acceptable rehabilitation plan with the member. 4. Clinical Best Practices 4.1. Evaluation and Treatment Planning The provider collects information from the member and other sources as part of a comprehensive psychiatric, psychological, substance abuse and bio-psychosocial assessment of the following: The member s chief complaint; The presenting problem/reason for referral (i.e., the why now factors); The member s current mental status; The member s psychiatric history including the histories of substance use; abuse, neglect and other forms of trauma; The member s medical history including the member s chronological age and developmental level; The history of treatment including use of services outside the scope of services provided in Therapeutic Group Care (e.g., the Emergency Room); The service agencies with which the member will be involved and other support systems that may contribute to the success of treatment; Psychosocial and environmental problems; The strengths and needs of involved family members and other natural supports; 3

4 The member s previous living situation; Risk factors including those related to harm to self or others, as well as risk stemming from co-occurring behavioral health or medical conditions; The member s strengths, coping strategies, and other resilience factors; The member s understanding of the need for change as context for planning services including interventions that will promote informed decisionmaking and participation in services; The member s rehabilitation goal as well as broader recovery and resiliency goals; The member s present level of skills and knowledge relative to the rehabilitation goal, and the skills and knowledge needed to achieve the member s rehabilitation goal; The member s present resources and the resources needed to achieve the member s rehabilitation goal In the event that not all information is available at the time of the evaluation, there must be enough information to guide development of the treatment plan, and support the need for Therapeutic Group Care Services The provider and member use the findings of the initial evaluation to develop a treatment plan as close to the date the member accessed, but no later than fourteen (14) days after admission The treatment plan is developed with input from the member, the member s parent(s) or guardian, child welfare or community based care case manager, foster parents and guardian ad litem, if applicable, and any other party involved in the development of the plan The treatment plan is signed by the provider and the member or the member s representative The treatment plan includes the following: Observable and measurable goals and objectives that are time-limited and written in behavioral and measurable terms, based on the child and family s strengths and needs; Written objectives of what the child and family, when applicable, will do or accomplish; 4

5 Written interventions of what the staff will do; The frequency of treatment services and treatment modalities, projected time frames for completion and the staff member prescribing the treatment and/or those responsible for ensuring its provision specified for each major problem or need; Goals that reflect improved functioning which when attained, constitutes the criteria for discharge for the particular problem or need; The expected degree of the parent or guardian s involvement and planned regular provider contact with the child s parent or guardian The provider shall deliver: Individualized face-to-face therapeutic contact twice weekly with more frequent contacts as indicated by the member s needs; Individual and group therapy; Family therapy or counseling at least weekly, based on the member s treatment needs and permanency plan with documentation in the member s record of the circumstances whenever this contact has not occurred; Substance abuse prevention, assessment and treatment services whenever indicated; Social and rehabilitative services when indicated and prescribed in the member s treatment plan; Supportive and psycho-educational services that promote increased capacity for independent living for older adolescents; Behavioral programming that is individually designed and implemented and includes structured interventions and contingencies to support the development of adaptive, pro-social interpersonal behavior; Psychiatric crisis management with demonstrated 24- hour response capability with access to acute care setting and behavioral health emergency management services; Coordination of care that includes linkages with the schools, primary medical care, and community services. 5

6 The provider shall review the treatment plan within thirty (30) days of admission and at least monthly thereafter with input from the child and parent or guardian, guardian ad litem, and other stakeholders to assess the appropriateness and suitability of the member s placement in the program, to evaluate the member s progress toward treatment goals, to review and modify, when necessary, the treatment plan and treatment approaches, to review and update the discharge plan and to determine if the child is ready to move to a less restrictive placement The provider shall prepare a written report of findings and pending discharge plans at a minimum of every thirty (30) days Factors such as a change in the member s condition, a change in participation in, or a change in utilization of services outside of the Therapeutic Group Care Services (e.g., the Emergency Room) prompt a reassessment of the treatment plan sooner than the regular schedule of reviews. When the member s condition has not improved or it has worsened, the reassessment should determine whether the treatment plan should be modified, or the member s condition should be treated in another level of care Discharge Planning At the time of admission, the provider shall develop an initial discharge plan in collaboration with the member, the member s parent or guardian, foster parents and guardian ad litem, if applicable, within ten (10) calendar days of admission. The initial discharge plan should include a projected discharge date Discharge planning may include a period of transition into the community, such as home visits and meetings with community mental health service providers The provider and the member update the initial discharge plan in response to completion of goals ensuring that: An appropriate discharge plan is in place prior to discharge; The discharge plan is designed to mitigate the risk that the why now factors which precipitated access to will reoccur; and The member or member s representative agrees with the discharge plan The final discharge plan shall include: The initial formulation and diagnosis; 6

7 A summary of treatment and services which have been provided, the outcomes of treatment in relation to the member s presenting problem on admission, and identification of needs for continuing treatment and services in the community following discharge; Recommendations for the child and parent or guardian following release from care, including referrals for community-based mental health services; The projected date of discharge and the name, address, telephone number and relationship of the person or organization to whom the child will be discharged; and A copy of the member s medical, dental, educational, medication and other records for the use of the person or organization who will assume care of the member following discharge For members age 17, the provider shall assess the need for continuing services in the adult mental health service system and provide assistance planning for and accessing those services The member may be discharged only to the parent, guardian or placing organization, unless the provider is otherwise ordered by the court A copy of the final discharge plan shall be provided to the parent or legal guardian, guardian ad litem at least thirty (30) calendar days before the proposed discharge date The provider shall have at least one contact with the member and the member s parent or guardian and guardian ad litem within the first thirty (30) days following discharge. References 1. Anthony, W.A., & Farkas, M.D. (2009). Primer on the Psychiatric Rehabilitation Process. Boston: Boston University Center for Psychiatric Rehabilitation. 2. State of Florida, Administrative Code. (2008). 65E-9.009, Mental Health Program, Licensure of Residential Treatment Centers, Treatment Planning. Retrieved from 3. State of Florida, Administrative Code. (2008). 65E-9.011, Mental Health Program, Licensure of Residential Treatment Centers, Discharge and Discharge Planning. Retrieved from 9. 7

8 4. State of Florida, Agency for Health Care Administration. (2014). Florida Medicaid: Community Behavioral Health Services Coverage and Limitations Handbook. Retrieved from 5. State of Florida, Agency for Health Care Administration. (2014). Florida Medicaid: Specialized Therapeutic Services Coverage and Limitations Handbook. Retrieved from 6. Winarski, J., Thomas, G., Dhont, K., & Ort, R. (2006). Recovery-Oriented Medicaid Services for Adults with Severe Mental Illness. Tampa FL: Louis de la Parte Florida Mental Health Institute. University of South Florida. i In addition to the eligibility requirements for Florida s Medicaid Managed Medical Assistance (MMA) Program, 1, 2, if applicable, and 3(a) or 3(b) of the following must be met: 1. A child or adolescent, under 18 years of age, is diagnosed by a psychiatrist or other licensed practitioner of the healing arts as having a moderate to serious psychiatric, emotional, or behavioral disorder and, due to the emotional or psychiatric symptoms, is exhibiting severe maladaptive behaviors or an inability to perform activities of daily living. To be considered eligible for this service a child s functional and behavioral problems may not be primarily related to cognitive or developmental disabilities. The child must require intensive, structured mental health interventions and the availability of highly trained therapeutic group care staff. The child or adolescent must have reached maximum benefit from a more restrictive setting or a less restrictive treatment option may have been tried or considered and found not sufficient to meet safely the child s treatment needs. 2. For dependent children, placement in a therapeutic group home must be determined appropriate by a qualified evaluator. 3. The child or adolescent must meet the diagnostic eligibility criteria described below in a) or b). a) Have a diagnosis of schizophrenia or other psychotic disorder, major depression, or bipolar disorder. b) Have an ICD-9-CM diagnosis in the following range: (Other Persistent Mental Disorders Due to Conditions Classified Elsewhere), (Unspecified Persistent Mental Disorders Due to Conditions Classified Elsewhere), 300 through (Anxiety, Dissociative and Somatoform Disorders; Personality Disorders), (Anorexia Nervosa), (Tourette s Disorder), through (Eating Disorder Unspecified, Bulimia Nervosa, Pica, Rumination Disorder, Psychogenic Vomiting, Other Disorders of Eating, Enuresis, Encopresis), through (Acute Reaction to Stress and subtypes, Adjustment Reaction and subtypes, Specific Nonpsychotic Mental Disorders Due to Brain Damage and subtypes, Depressive Disorder Not Elsewhere Classified, Undersocialized Conduct Disorder Aggressive Type, Undersocialized Conduct Disorder Unaggressive Type, Socialized Conduct Disorder, Disorders of Impulse Control Note Elsewhere Classified and subtypes, and Mixed Disturbance of Conduct and Emotions), through (Conduct Disorder Childhood Onset Type, Conduct Disorder Adolescent Onset Type, Other Conduct Disorder, Disturbance of Emotions Specific to Childhood and Adolescence and subtypes, Hyperkinetic Syndrome of Childhood and subtypes), and through (Alcohol Dependence Syndrome and subtypes, Drug Dependence and subtypes, and Nondependent Abuse of Drugs and subtypes). Have been enrolled in a special education program for the seriously emotionally disturbed or emotionally handicapped. OR Have scored 50 or below on the Axis V Global Assessment of functioning Scale or CGAS within the past six months. The justification for the score must be well documented and detailed on the certification form. ii Rule 59G (166), Florida Administrative Code defines medically necessary or medical necessity as follows: The medical or allied care, gods, or services furnished or ordered must meet the following conditions: 1) be necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain 2) be individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the patient s needs 3) be consistent with generally accepted professional medical standards as determined by the Medicaid program, and not experimental or investigational 4) reflect the level of services that can be safely furnished, and for which no equally effective and more conservative or less costly treatment is available statewide 5) be furnished in a manner, not primarily intended for the convenience of the recipient, the recipient s caretaker, or the provider. The fact that a provider 8

9 has prescribed, recommended, or approved medical or allied care, goods, or services, does not, in itself, make such care, goods or services medically necessary or a covered service. 9

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