Authority: IC 12-15
Affected: IC 12-13-7-3
Sec. 8.
Medicaid reimbursement is available for outpatient mental
health services provided by licensed physicians, psychiatric hospitals,
psychiatric wings of acute care hospitals, outpatient mental health facilities,
and psychologists endorsed as a health service provider in psychology (HSPP).
Outpatient mental health services rendered by a medical doctor, doctor of
osteopathy, or HSPP are subject to the following limitations:
(1) Outpatient mental health services
rendered by a medical doctor or doctor of osteopathy are subject to the
limitations set out in
405 IAC 5-25.
(2) Subject to prior authorization by the
office Medicaid will reimburse physician or HSPP directed outpatient mental
health services for group, family, and individual outpatient psychotherapy when
the services are provided by one (1) of the following practitioners:
(A) A licensed psychologist.
(B) A licensed independent practice school
psychologist.
(C) A licensed
clinical social worker.
(D) A
licensed marital and family therapist.
(E) A licensed mental health
counselor.
(F) A person holding a
master's degree in social work, marital and family therapy, or mental health
counseling, except that partial hospitalization services provided by such
person shall not be reimbursed by Medicaid.
(G) An advanced practice nurse who is a
licensed, registered nurse with a master's degree in nursing with a major in
psychiatric or mental health nursing from an accredited school of
nursing.
(3) The
physician, psychiatrist, or HSPP is responsible for certifying the diagnosis
and for supervising the plan of treatment described as follows:
(A) The physician, psychiatrist, or HSPP is
responsible for seeing the member during the intake process or reviewing the
medical information obtained by the practitioner listed in subdivision (2)
within seven (7) days of the intake process. This review by the physician,
psychiatrist, or HSPP must be documented in writing.
(B) The physician, psychiatrist, or HSPP must
again see the member or review the medical information and certify the service
is medically necessary on the basis of medical information provided by the
practitioner listed in subdivision (2) at intervals not to exceed ninety (90)
days. This review must be documented in writing.
(4) Medicaid will reimburse partial
hospitalization services under the following conditions and subject to prior
authorization:
(A) Partial hospitalization
programs must be highly intensive, time-limited medical services that either
provide a transition from inpatient psychiatric hospitalization to
community-based care, or serve as a substitute for an inpatient admission.
Partial hospitalization programs are highly individualized with treatment goals
that are measurable and medically necessary. Treatment goals must include
specific time frames for achievement of goals, and treatment goals must be
directly related to the reason for admission.
(B) Partial hospitalization programs must
have the ability to reliably contract for safety. Members with clear intent to
seriously harm the self or others are not candidates for partial
hospitalization services.
(C)
Services may be provided for consumers of all ages who are not at imminent risk
of harm to self or others. Members who currently reside in a group home or
other residential care setting are not eligible for partial hospitalization
services. Members must have a diagnosed or suspected behavioral health
condition and one (1) of the following:
(i) A
short-term deficit in daily functioning.
(ii) An assessment of the member indicating a
high probability of serious deterioration of the member's general medical or
behavioral health.
(D)
Program standards shall be as follows:
(i)
Services must be ordered and authorized by a psychiatrist.
(iii) A face-to-face evaluation and an
assignment of a behavioral health diagnosis must take place within twenty-four
(24) hours following admission to the program.
(iv) A psychiatrist must actively participate
in the case review and monitoring of care.
(v) Documentation of active oversight and
monitoring of progress by a physician, a psychiatrist, or an HSPP must appear
in the member's clinical record.
(vi) At least one (1) individual
psychotherapy service or group psychotherapy service must be delivered daily.
(vii) For members under eighteen (18) years of age, documentation of active
psychotherapy must appear in the member's clinical record.
(viii) For members under eighteen (18) years
of age, a minimum of one (1) family encounter per five (5) business days of
episode of care is required.
(ix)
Programs must include four (4) to six (6) hours of active treatment per day and
be provided at least four (4) days per week.
(x) Programs must not mix members receiving
partial hospitalization services with members receiving outpatient behavioral
health services.
(E)
Exclusions shall be as follows:
(i) Members
at imminent risk of harm to self or others are not eligible for
services.
(ii) Members who
concurrently reside in a group home or other residential care setting are not
eligible for services.
(iii)
Members who cannot actively engage in psychotherapy are not eligible for
services.
(iv) Members with
withdrawal risk or symptoms of a substance-related disorder whose needs cannot
be managed at this level of care or who need detoxification services.
(v) Members who by virtue of age or medical
condition cannot actively participate in group therapies are not eligible for
services.
(5)
Medicaid will reimburse for evaluation and group, family, and individual
psychotherapy when provided by a psychologist endorsed as an HSPP.
(6) Subject to prior authorization by the
office, Medicaid will reimburse for neuropsychological and psychological
testing when the services are provided by one (1) of the following
practitioners:
(A) A physician.
(B) An HSPP.
(C) A practitioner listed in subdivision
(7).
(7) The following
practitioners may only administer neuropsychological and psychological testing
under the direct supervision of a physician or HSPP:
(A) A licensed psychologist.
(B) A licensed independent practice school
psychologist.
(C) A person holding
a master's degree in a mental health field and one (1) of the following:
(i) A certified specialist in psychometry
(CSP).
(ii) Two thousand (2,000)
hours of experience, under direct supervision of a physician or HSPP, in
administering the type of test being performed.
(8) The physician and HSPP are responsible
for the interpretation and reporting of the testing performed.
(9) The physician and HSPP must provide
direct supervision and maintain documentation to support the education,
training, and hours of experience for any practitioner providing services under
their supervision. A cosignature by the physician or HSPP is required for
services rendered by one (1) of the practitioners listed in subdivision
(7).
(10) Prior authorization is
required for mental health services provided in an outpatient or office setting
that exceed twenty (20) units per member, per provider, per rolling twelve (12)
month period of time, except neuropsychological and psychological testing,
which is subject to prior authorization as stated in subdivision
(4)(D)(ii).
(11) The following are
services that are not reimbursable by Medicaid:
(A) Daycare.
(B) Hypnosis.
(C) Biofeedback.
(D) Missed appointments.
(12) All outpatient services rendered must be
identified and itemized on the Medicaid claim form. Additionally, the length of
time of each therapy session must be indicated on the claim form. The medical
record documentation must identify the services and the length of time of each
therapy session. This information must be available for audit
purposes.
(13) A current plan of
treatment and progress notes, as to the necessity and effectiveness of therapy,
must be attached to the prior authorization form and available for audit
purposes.
(14) For psychiatric
diagnostic interview examinations, Medicaid reimbursement is available for one
(1) unit per member, per provider, per rolling twelve (12) month period of
time, except as follows:
(A) A maximum of two
(2) units per rolling twelve (12) month period of time per member, per
provider, may be reimbursed without prior authorization, when a member is
separately evaluated by both a physician or HSPP and a midlevel
practitioner.
(B) Of the two (2)
units allowed without prior authorization, as stated in clause (A), one (1)
unit must be provided by the physician or HSPP and one (1) unit must be
provided by the midlevel practitioner.
(C) All additional units require prior
authorization.