RELATES TO:
KRS
205.520,
205.622,
309.0831,
369.101
- 369.120,
20 U.S.C.
1400 et seq.,
21 U.S.C.
823(g)(2),
29 U.S.C.
701 et seq.,
42
U.S.C. 290ee-3,
1320d-2 -
1320d-8,
1396a(a)(10)(B),
1396a(a)(23),
12101,
42 C.F.R. Part 2,
431.17,
435.1010,
45 C.F.R. Parts 160, 164
NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and
Family Services, Department for Medicaid Services, has a responsibility to
administer the Medicaid Program.
KRS
205.520(3) authorizes the
cabinet, by administrative regulation, to comply with any requirement that may
be imposed or opportunity presented by federal law to qualify for federal
Medicaid funds. This administrative regulation establishes the coverage
provisions and requirements regarding Medicaid Program behavioral health
services provided by tier II and III behavioral health services
organizations.
Section 1. General
Coverage Requirements.
(1) For the department
to reimburse for a service covered under this administrative regulation, the
service shall be:
(a) Medically necessary;
and
(b) Provided:
1. To a recipient; and
2. By a behavioral health services
organization that meets the provider participation requirements established in
Section 2 of this administrative regulation.
(2)
(a)
Direct contact between a practitioner and a recipient shall be required for
each service except for:
1. Collateral
outpatient therapy for a child under the age of twenty-one (21) years if the
collateral outpatient therapy is in the child's plan of care;
2. A family outpatient service in which the
corresponding current procedural terminology code establishes that the
recipient is not present; or
3. A
psychological testing service comprised of interpreting or explaining results
of an examination or data to family members or other kin if the corresponding
current procedural terminology code establishes that the recipient is not
present.
(b) A service
that does not meet the requirement in paragraph (a) of this subsection shall
not be covered.
(3) A
billable unit of service shall be actual time spent delivering a service in an
encounter.
(4) A service shall be:
(a) Stated in the recipient's plan of care;
and
(b) Provided in accordance with
the recipient's plan of care.
(5)
(a) A
behavioral health services organization shall establish a plan of care for each
recipient receiving services from the behavioral health services
organization.
(b) A plan of care
shall meet the plan of care requirements established in
908
KAR 1:370, Section 19.
Section 2. Provider Participation.
(1) To be eligible to provide services under
this administrative regulation, a behavioral health services organization
shall:
(a) Be currently enrolled in the
Kentucky Medicaid Program in accordance with
907
KAR 1:672;
(b) Be currently participating in the
Kentucky Medicaid Program in accordance with
907
KAR 1:671; and
(c) Have:
1. For each service it provides, the capacity
to provide the full range of the service as established in this administrative
regulation;
2. Documented
experience in serving individuals with substance use disorders;
3. The administrative capacity to ensure
quality of services;
4. A financial
management system that provides documentation of services and costs;
and
5. The capacity to document and
maintain individual case records.
(2) A behavioral health services organization
shall:
(a) Agree to provide services in
compliance with federal and state laws regardless of age, sex, race, creed,
religion, national origin, handicap, or disability;
(b) Comply with the Americans with
Disabilities Act (42 U.S.C.
12101 et seq.) and any amendments to the Act;
and
(c) Provide, directly or
through written agreement with another behavioral health services provider,
access to face-to-face or telehealth, as appropriate pursuant to
907
KAR 3:170, emergency services twenty-four (24) hours
per day, seven (7) days per week.
(3)
(a)
Each behavioral health services organization II (BHSO II) shall provide
services in accordance with
908
KAR 1:374 and this administrative regulation for
outpatient substance use disorder services and co-occurring
disorders.
(b) Each behavioral
health services organization III (BHSO III) shall provide services in
accordance with
908
KAR 1:372 and this administrative regulation for
residential substance use disorder services and co-occurring
disorders.
(4) A BHSO II
shall:
(a) Possess an outpatient alcohol and
other drug treatment entity (AODE) license issued pursuant to
908
KAR 1:370 and
908
KAR 1:374;
(b) Except as provided by subsection (6) of
this section, possess accreditation within one (1) year of initial enrollment
by one (1) of the following:
1. The Joint
Commission;
2. The Commission on
Accreditation of Rehabilitation Facilities;
3. The Council on Accreditation; or
4. A nationally recognized accreditation
organization; and
(c) Be
authorized to provide outpatient substance use disorder treatment services
authorized by Section 3 of this administrative regulation to treat substance
use disorders and co-occurring disorders by the appropriate provider.
(5) A BHSO III shall:
(a) Possess a residential alcohol and other
drug treatment entity (AODE) license issued pursuant to
908
KAR 1:370 and
908
KAR 1:372;
(b) Except as provided by subsection (6) of
this section, possess accreditation within one (1) year of initial enrollment
by one (1) of the following:
1. The Joint
Commission;
2. The Commission on
Accreditation of Rehabilitation Facilities;
3. The Council on Accreditation; or
4. A nationally recognized accreditation
organization; and
(c) Be
authorized to provide residential substance use disorder treatment services
authorized by Section 3 of this administrative regulation to treat substance
use disorders and co-occurring disorders by the appropriate provider.
(6) The department shall grant a
one (1) time extension to a BHSO II or III that requests a one (1) time
extension to complete the accreditation process, if the request is submitted at
least ninety (90) days prior to expiration of provider enrollment.
Section 3. Covered Services.
(1) Reimbursement shall not be available for
services performed within a BHSO II by a:
(a)
Licensed behavior analyst;
(b)
Licensed assistant behavior analyst;
(c) Registered behavior technician;
or
(d) Community support
associate.
(2) A BHSO
III shall provide services on a residential basis to treat a beneficiary's
substance use disorder.
(3)
Reimbursement shall not be available for services performed within a BHSO III
by a:
(a) Licensed behavior analyst;
(b) Licensed assistant behavior
analyst;
(c) Registered behavior
technician; or
(d) Community
support associate.
(4)
Except as specified in the requirements stated for a given service, the
services covered may be provided for:
(a) A
substance use disorder; or
(b)
Co-occurring disorders if provided in accordance with Section 2 of this
administrative regulation.
(5) The services established in this
subsection shall be covered under this administrative regulation in accordance
with the requirements established in this subsection.
(a) A screening shall:
1. Determine the likelihood that an
individual has a mental health disorder, substance use disorder, or
co-occurring disorders;
2. Not
establish the presence or specific type of disorder;
3. Establish the need for an in-depth
assessment;
4. Be provided
face-to-face or via telehealth as appropriate pursuant to
907
KAR 3:170; and
5. Be provided by:
a. An approved behavioral health
practitioner, as limited by subsections (1) and (3) of this section; or
b. An approved behavioral health
practitioner under supervision, as limited by subsections (1) and (3) of this
section.
(b)
An assessment shall:
1. Include gathering
information and engaging in a process with the individual that enables the
practitioner to:
a. Establish the presence or
absence of a substance use disorder, mental health disorder, or co-occurring
disorders;
b. Determine the
individual's readiness for change;
c. Identify the individual's strengths or
problem areas that may affect the treatment and recovery processes;
and
d. Engage the individual in
developing an appropriate treatment relationship;
2. Establish or rule out the existence of a
clinical disorder or service need;
3. Include working with the individual to
develop a plan of care;
4. Not
include a psychological or psychiatric evaluation or assessment;
5. If being made for the treatment of a
substance use disorder, utilize a multidimensional assessment that complies
with the most current edition of The ASAM Criteria to determine the most
appropriate level of care;
6. Be
provided face-to-face or via telehealth as appropriate pursuant to
907
KAR 3:170; and
7. Be provided by:
a. An approved behavioral health
practitioner, as limited by subsections (1) and (3) of this section; or
b. An approved behavioral health
practitioner under supervision, as limited by subsections (1) and (3) of this
section.
(c)
Psychological testing shall:
1. Include a
psychodiagnostic assessment of personality, psychopathology, emotionality, or
intellectual disabilities;
2.
Include an interpretation and a written report of testing results;
3. Be face-to-face or via telehealth as
appropriate pursuant to
907
KAR 3:170; and
4. Be provided by:
a. A licensed psychologist;
b. A certified psychologist with autonomous
functioning;
c. A licensed
psychological practitioner;
d. A
certified psychologist under supervision; or
e. A licensed psychological associate under
supervision.
(d) Crisis intervention:
1. Shall be a therapeutic intervention for
the purpose of immediately reducing or eliminating the risk of physical or
emotional harm to:
a. The recipient; or
b. Another individual;
2. Shall consist of clinical
intervention and support services necessary to provide integrated crisis
response, crisis stabilization interventions, or crisis prevention activities
for individuals;
3. Shall be
provided:
a. As an immediate relief to the
presenting problem or threat; and
b. In a one (1) on one (1) encounter between
the provider and the recipient, which is delivered either face-to-face or via
telehealth if appropriate pursuant to
907
KAR 3:170;
4. Shall be followed by a referral to
non-crisis services if applicable;
5. May include:
a. Further service prevention planning
including:
(i) Lethal means reduction for
suicide risk; or
(ii) Substance use
disorder relapse prevention; or
b. Verbal de-escalation, risk assessment, or
cognitive therapy; and
6.
Shall be provided by:
a. An approved
behavioral health practitioner, as limited by subsections (1) and (3) of this
section; or
b. An approved
behavioral health practitioner under supervision, as limited by subsections (1)
and (3) of this section.
(e) Mobile crisis services shall:
1. Be available twenty-four (24) hours a day,
seven (7) days a week, every day of the year;
2. Be provided for a duration of less than
twenty-four (24) hours;
3. Not be
an overnight service;
4. Be a
face-to-face multi-disciplinary team based intervention in a home or community
setting that ensures access to substance use disorder and co-occurring disorder
services and supports to:
a. Reduce symptoms
or harm; or
b. Safely transition
an individual in an acute crisis to the appropriate least restrictive level of
care;
5. Involve all
services and supports necessary to provide:
a. Integrated crisis prevention;
b. Assessment and disposition;
c. Intervention;
d. Continuity of care recommendations;
and
e. Follow-up services;
6. Include access to a
board-certified or board-eligible psychiatrist twenty-four (24) hours a day,
seven (7) days a week, every day of the year; and
7. Be provided by:
a. An approved behavioral health
practitioner, as limited by subsections (1) and (3) of this section;
b. An approved behavioral health practitioner
under supervision, as limited by subsections (1) and (3) of this section; or
c. A peer support specialist who:
(i) Is under the supervision of an approved
behavioral health practitioner; and
(ii) Provides support services for a mobile
crisis service.
(f)
1. Day
treatment shall be a non-residential, intensive treatment program for a child
under the age of twenty-one (21) years who has:
a. A substance use disorder or co-occurring
disorders; and
b. A high risk of
out-of-home placement due to a behavioral health issue.
2. Day treatment shall:
a. Be face-to-face;
b. Consist of an organized, behavioral health
program of treatment and rehabilitative services;
c. Include:
(i) Individual outpatient therapy, family
outpatient therapy, or group outpatient therapy;
(ii) Behavior management and social skills
training;
(iii) Independent living
skills that correlate to the age and developmental stage of the recipient;
or
(iv) Services designed to
explore and link with community resources before discharge and to assist the
recipient and family with transition to community services after discharge;
and
d. Be provided:
(i) In collaboration with the education
services of the local education authority including those provided through
20 U.S.C.
1400 et seq. (Individuals with Disabilities
Education Act) or
29 U.S.C.
701 et seq. (Section 504 of the
Rehabilitation Act);
(ii) On school
days and during scheduled school breaks;
(iii) In coordination with the recipient's
individualized education program or Section 504 plan if the recipient has an
individualized education program or Section 504 plan; and
(iv) With a linkage agreement with the local
education authority that specifies the responsibilities of the local education
authority and the day treatment provider.
3. To provide day treatment services, a
behavioral health services organization shall have:
a. The capacity to employ staff authorized to
provide day treatment services in accordance with this section and to
coordinate the provision of services among team members; and
b. Knowledge of substance use disorders and
co-occurring disorders.
4. Day treatment shall not include a
therapeutic clinical service that is included in a child's individualized
education program or Section 504 plan.
5. Day treatment shall be provided by:
a. An approved behavioral health
practitioner, as limited by subsections (1) and (3) of this section; or
b. An approved behavioral health
practitioner under supervision, as limited by subsections (1) and (3) of this
section.
6. Day
treatment support services conducted by a provider working under the
supervision of an approved behavioral health practitioner may be provided by:
a. A registered alcohol and drug peer support
specialist;
b. An adult peer
support specialist;
c. A family
peer support specialist; or
d. A
youth peer support specialist.
(g)
1. Peer
support services shall:
a. Be emotional
support that is provided by:
(i) An
individual who has been trained and certified in accordance with
908 KAR
2:220 and who is experiencing or has experienced a
substance use disorder or co-occurring disorders to a recipient by sharing a
similar substance use disorder or co-occurring disorders in order to bring
about a desired social or personal change;
(ii) A parent or other family member, who has
been trained and certified in accordance with
908 KAR
2:230, of a child having or who has had a substance
use or co-occurring disorders to a parent or family member of a child sharing a
similar substance use or co-occurring disorders in order to bring about a
desired social or personal change;
(iii) An individual who has been trained and
certified in accordance with
908 KAR
2:240 and identified as experiencing a substance use
disorder or co-occurring disorders; or
(iv) A registered alcohol and drug peer
support specialist who has been trained and certified in accordance with
KRS
309.0831 and is a self-identified consumer of
substance use disorder services who provides emotional support to others with
substance use disorders to achieve a desired social or personal
change;
b. Be an
evidence-based practice;
c. Be
structured and scheduled non-clinical therapeutic activities with an individual
recipient or a group of recipients;
d. Be provided face-to-face;
e. Promote socialization, recovery,
self-advocacy, preservation, and enhancement of community living skills for the
recipient;
f. Except for the
engagement into substance use disorder treatment through an emergency
department bridge clinic, be coordinated within the context of a comprehensive,
individualized plan of care developed through a person-centered planning
process;
g. Be identified in each
recipient's plan of care; and
h. Be
designed to directly contribute to the recipient's individualized goals as
specified in the recipient's plan of care.
2. To provide peer support services, a
behavioral health services organization shall:
a. Have demonstrated:
(i) The capacity to provide peer support
services for the behavioral health population being served including the age
range of the population being served; and
(ii) Experience in serving individuals with
behavioral health disorders;
c. Use an approved behavioral health
practitioner to supervise peer support specialists;
d. Have the capacity to coordinate the
provision of services among team members;
e. Have the capacity to provide on-going
continuing education and technical assistance to peer support
specialists;
f. Require individuals
providing peer support services to recipients to provide no more than thirty
(30) hours per week of direct recipient contact; and
g. Require peer support services provided to
recipients in a group setting not exceed eight (8) individuals within any group
at one (1) time.
(h)
1.
Intensive outpatient program services shall:
a. Be an alternative to or transition from a
higher level of care for a substance use disorder or co-occurring
disorders;
b. Offer a multi-modal,
multi-disciplinary structured outpatient treatment program that is
significantly more intensive than individual outpatient therapy, group
outpatient therapy, or family outpatient therapy;
c. Meet the service criteria, including the
components for support systems, staffing, and therapies outlined in the most
current edition of The ASAM Criteria for intensive outpatient level of care
services;
d. Be provided
face-to-face;
e. Be provided at
least three (3) hours per day at least three (3) days per week for
adults;
f. Be provided at least six
(6) hours per week for adolescents; and
g. Include:
(i) Individual outpatient therapy, group
outpatient therapy, or family outpatient therapy unless
contraindicated;
(ii) Crisis
intervention; or
(iii)
Psycho-education related to identified goals in the recipient's treatment
plan.
2.
During psycho-education, the recipient or recipient's family member shall be:
a. Provided with knowledge regarding the
recipient's diagnosis, the causes of the condition, and the reasons why a
particular treatment might be effective for reducing symptoms; and
b. Taught how to cope with the recipient's
diagnosis or condition in a successful manner.
3. An intensive outpatient program services
treatment plan shall:
a. Be individualized;
and
b. Focus on stabilization and
transition to a lesser level of care.
4. To provide intensive outpatient program
services, a behavioral health services organization shall have:
a. Access to a board-certified or
board-eligible psychiatrist for consultation;
b. Access to a psychiatrist, physician, or
advanced practiced registered nurse for medication prescribing and
monitoring;
c. Adequate staffing to
ensure a minimum recipient-to-staff ratio of ten (10) recipients to one (1)
staff person;
d. The capacity to
provide services utilizing a recognized intervention protocol based on
nationally accepted treatment principles; and e. The capacity to employ staff
authorized to provide intensive outpatient program services in accordance with
this section and to coordinate the provision of services among team
members.
5. Intensive
outpatient program services shall be provided by:
a. An approved behavioral health
practitioner, as limited by subsections (1) and (3) of this section; or
b. An approved behavioral health
practitioner under supervision, as limited by subsections (1) and (3) of this
section.
(i)
Individual outpatient therapy shall:
1. Be
provided to promote the:
a. Health and
wellbeing of the individual; and
b.
Restoration of a recipient to their best possible functional level from a
substance use disorder or co-occurring disorders;
2. Consist of:
a. A face-to-face encounter or via telehealth
as appropriate pursuant to
907
KAR 3:170 that is a one (1) on one (1) encounter
between the provider and recipient; and
b. A behavioral health therapeutic
intervention provided in accordance with the recipient's identified plan of
care;
3. Be aimed at:
a. Reducing adverse symptoms;
b. Reducing or eliminating the presenting
problem of the recipient; and
c.
Improving functioning;
4. Not exceed three (3) hours per day alone
or in combination with any other outpatient therapy per recipient unless
additional time is medically necessary; and
5. Be provided by:
a. An approved behavioral health
practitioner, as limited by subsections (1) and (3) of this section; or
b. An approved behavioral health
practitioner under supervision, as limited by subsections (1) and (3) of this
section.
(j)
1. Group outpatient therapy shall:
a. Be a behavioral health therapeutic
intervention provided in accordance with a recipient's identified plan of
care;
b. Be provided to promote
the:
(i) Health and wellbeing of the
individual; and
(ii) Restoration of
a recipient to their best possible functional level from a substance use
disorder or co-occurring disorders;
c. Consist of a face-to-face behavioral
health therapeutic intervention provided in accordance with the recipient's
identified plan of care;
d. Be
provided to a recipient in a group setting:
(i) Of nonrelated individuals except for
multi-family group therapy; and
(ii) Not to exceed twelve (12) individuals in
size;
e. Focus on the
psychological needs of the recipients as evidenced in each recipient's plan of
care;
f. Center on goals including
building and maintaining healthy relationships, personal goals setting, and the
exercise of personal judgment;
g.
Not include physical exercise, a recreational activity, an educational
activity, or a social activity; and
h. Not exceed three (3) hours per day alone
or in combination with any other outpatient therapy per recipient unless
additional time is medically necessary.
2. The group shall have a:
a. Deliberate focus; and
b. Defined course of treatment.
3. The subject of group outpatient
therapy shall relate to each recipient participating in the group.
4. The provider shall keep individual notes
regarding each recipient within the group and within each recipient's health
record.
5. Group outpatient therapy
shall be provided by:
a. An approved
behavioral health practitioner, as limited by subsections (1) and (3) of this
section; or
b. An approved
behavioral health practitioner under supervision, as limited by subsections (1)
and (3) of this section.
(k)
1.
Family outpatient therapy shall consist of a face-to-face or appropriate
telehealth, pursuant to
907
KAR 3:170, behavioral health therapeutic intervention
provided:
a. Through scheduled therapeutic
visits between the therapist and the recipient and at least one (1) member of
the recipient's family; and
b. To
address issues interfering with the relational functioning of the family and to
improve interpersonal relationships within the recipient's home
environment.
2. A family
outpatient therapy session shall be billed as one (1) service regardless of the
number of individuals (including multiple members from one (1) family) who
participate in the session.
3.
Family outpatient therapy shall:
a. Be
provided to promote the:
(i) Health and
wellbeing of the individual; or
(ii) Restoration of a recipient to their best
possible functional level from a substance use disorder or co-occurring
disorders; and
b. Not
exceed three (3) hours per day alone or in combination with any other
outpatient therapy per recipient unless additional time is medically
necessary.
4. Family
outpatient therapy shall be provided by:
a.
An approved behavioral health practitioner; or
b. An approved behavioral health practitioner
under supervision.
(l)
1. Collateral outpatient
therapy shall:
a. Consist of a face-to-face
or appropriate telehealth, provided pursuant to
907
KAR 3:170, behavioral health consultation:
(i) With a parent or caregiver of a
recipient, household member of a recipient, legal representative of a
recipient, school personnel, treating professional, or other person with
custodial control or supervision of the recipient; and
(ii) That is provided in accordance with the
recipient's plan of care; and b. Not be reimbursable if the therapy is for a
recipient who is at least twenty-one (21) years of age.
2. Written consent by a
parent or custodial guardian to discuss a recipient's treatment with any person
other than a parent or legal guardian shall be signed and filed in the
recipient's health record.
3.
Collateral outpatient therapy shall be provided by:
a. An approved behavioral health
practitioner, as limited by subsections (1) and (3) of this section; or
b. An approved behavioral health
practitioner under supervision, as limited by subsections (1) and (3) of this
section.
(m)
1. Service planning shall:
a. Be provided face-to-face;
b. Involve assisting a recipient in creating
an individualized plan for services and developing measurable goals and
objectives needed for maximum reduction of the effects of a substance use
disorder or co-occurring disorders;
c. Involve restoring a recipient's functional
level to the recipient's best possible functional level; and
d. Be performed using a person-centered
planning process.
2. A
service plan:
a. Shall be directed and signed
by the recipient;
b. Shall include
practitioners of the recipient's choosing; and
c. May include:
(i) A mental health advance directive being
filed with a local hospital;
(ii) A
crisis plan; or
(iii) A relapse
prevention strategy or plan.
3. Service planning shall be provided by:
a. An approved behavioral health
practitioner, as limited by subsections (1) and (3) of this section; or
b. An approved behavioral health
practitioner under supervision, as limited by subsections (1) and (3) of this
section.
(n)
1. Residential services for substance use
disorders shall:
a. Be provided in a
twenty-four (24) hour per day unit that is a live-in facility that offers a
planned and structured regimen of care aimed to treat individuals with
addiction or co-occurring disorders;
b. Provide intensive treatment and skills
building in a structured and supportive environment;
c. Assist an individual in abstaining from
alcohol or substance use and in entering alcohol or drug addiction
recovery;
d. Assist a recipient in
making necessary changes in the recipient's life to enable the recipi-ent to
live drug- or alcohol-free;
e. Be
provided under the medical direction of a physician;
f. Provide continuous nursing services in
which a registered nurse shall be:
(i)
On-site during traditional first shift hours, Monday through Friday;
(ii) Continuously available by phone after
hours; and
(iii) On-site as needed
in follow-up to telephone consultation after hours;
g. Be provided following an assessment of an
individual and a determination that the individual meets the dimensional
admission criteria for approval of residential level of care placement in
accordance with the most current edition of The ASAM Criteria; and
h. Be based on individual need and shall
include clinical activities to help the recipient develop and apply recovery
skills.
2. Residential
services may include:
a. A
screening;
b. An
assessment;
c. Service
planning;
d. Individual outpatient
therapy;
e. Group outpatient
therapy;
f. Family outpatient
therapy;
g. Peer support;
h. Withdrawal management; or
i. Medication assisted treatment.
3. For recipients in residential
substance use treatment, care coordination shall include at minimum:
a. If the recipient chooses medication
assisted treatment, facilitation of medication assisted treatment off-site of
the BHSO III, if not offered on-site;
b. Referral to appropriate community
services;
c. Facilitation of
medical and behavioral health follow ups; and
d. Linking the recipient to the appropriate
level of substance use treatment within the continuum to provide ongoing
supports.
5. Length-of-stay for residential services
for substance use disorders shall be person-centered and according to an
individually designed plan of care that is consistent with this administrative
regulation and the licensure of the facility and practitioner.
6.
a.
Except as established in clause b. or c. of this subparagraph, the physical
structure in which residential services for substance use disorders is provided
shall:
(i) Have between nine (9) and sixteen
(16) beds; and
(ii) Not be part of
multiple units comprising one (1) facility with more than sixteen (16) beds in
aggregate.
b. If every
recipient receiving services in the physical structure is under the age of
twenty-one (21) years or over the age of sixty-five (65) years, the limit of
sixteen (16) beds established in clause a. of this subparagraph shall not
apply.
c. The limit of sixteen (16)
beds established in clause a. of this subparagraph shall not apply if the
facility possesses a departmental provisional certification to provide
residential substance use disorder services that are equivalent to the
appropriate level of The ASAM Criteria.
7. Residential services for substance use
disorders shall not include:
a. Room and
board;
b. Educational
services;
c. Vocational
services;
d. Job training
services;
e. Habilitation
services;
f. Services to an inmate
in a public institution pursuant to
42 C.F.R.
435.1010;
g. Services to an individual residing in an
institution for mental diseases pursuant to
42 C.F.R.
435.1010;
h. Recreational activities;
i. Social activities; or
j. Services required to be covered elsewhere
in the Medicaid state plan.
8. To provide residential services for
substance use disorders, a behavioral health services organization shall:
a. Have the capacity to employ staff
authorized to provide services in accordance with this section and to
coordinate the provision of services among team members;
b. Be licensed as a non-medical and
non-hospital based alcohol and other drug abuse treatment entity in accordance
with
908
KAR 1:370 and
908
KAR 1:372; and
c. After July 1, 2021, possess an appropriate
ASAM Level of Care Certification in accordance with The ASAM
Criteria.
9. A BHSO III
may provide residential services for substance use disorders, if provided by:
a. An approved behavioral health
practitioner, as limited by subsections (1) and (3) of this section; or
b. An approved behavioral health
practitioner under supervision, as limited by subsections (1) and (3) of this
section.
10. Support
services for residential services for substance use disorders may be provided
by a peer support specialist under the supervision of an approved behavioral
health practitioner.
(o)
1. Screening, brief intervention, and
referral to treatment for a substance use disorder shall:
a. Be provided face-to-face or via telehealth
as appropriate according to
907
KAR 3:170;
b. Be an evidence-based early intervention
approach for an individual with non-dependent substance use to provide an
effective strategy for intervention prior to the need for more extensive or
specialized treatment; and
c.
Consist of:
(i) Using a standardized screening
tool to assess an individual for risky substance use behavior;
(ii) Engaging a recipient, who demonstrates
risky substance use behavior, in a short conversation and providing feedback
and advice; and
(iii) Referring a
recipient to additional substance use disorder or co-occurring disorder
services if the recipient is determined to need additional services to address
substance use.
2. A screening and brief intervention that
does not meet criteria for referral to treatment may be subject to coverage by
the department.
3. A screening,
brief intervention, and referral to treatment for a substance use disorder
shall be provided by:
a. An approved
behavioral health practitioner, as limited by subsections (1) and (3) this
section; or
b. An approved
behavioral health practitioner under supervision, as limited by subsections (1)
and (3) of this section.
(p)
1.
Withdrawal management services shall:
a. Be
provided face-to-face for recipients with a substance use disorder or
co-occurring disorders;
b. Be
incorporated into a recipient's care as appropriate according to the continuum
of care described in the most current version of The ASAM Criteria;
c. Be in accordance with the most current
version of The ASAM Criteria for withdrawal management levels in an outpatient
setting;
d. If provided in an
outpatient setting, comply with
908
KAR 1:374, Section 2; and
e. If provided in a substance use disorder
residential program, comply with
908
KAR 1:372, Section 2.
2. A recipient who is receiving withdrawal
management services shall:
a. Meet the most
current edition of diagnostic criteria for substance withdrawal management
found in the Diagnostic and Statistical Manual of Mental Disorders; and
b. Meet the current dimensional
admissions criteria for withdrawal management level of care as found in The
ASAM Criteria.
3.
Withdrawal management services shall be provided by:
a. A physician;
b. A psychiatrist;
c. A physician assistant;
d. An advanced practice registered nurse;
or
e. Any other approved behavioral
health practitioner with oversight by a physician, advanced practice registered
nurse, or a physician assistant, as limited by subsections (1) and (3) of this
section.
(q)
1. Medication assisted treatment services
shall be provided by an authorized prescribing provider who:
a.
(i) Is a
physician licensed to practice medicine under KRS Chapter 311; or
(ii) Is an advanced practice registered nurse
(APRN);
c. Maintains a current waiver under
21 U.S.C.
823(g)(2) to prescribe
buprenorphine products; and
d. Has
experience and knowledge in addiction medicine.
2. Medication assisted treatment with
behavioral health therapies shall:
a. Be
co-located within the same practicing site or via telehealth as appropriate
according to
907
KAR 3:170 as the practitioner with a waiver pursuant
to subparagraph 1.c. of this paragraph; or
b. Be conducted with agreements in place for
linkage to appropriate behavioral health treatment providers who specialize in
substance use disorders and are knowledgeable in bi-opsychosocial dimensions of
alcohol or other substance use disorder, such as:
(i) An approved behavioral health
practitioner, as limited by subsections (1) and (3) of this section;
or
(ii) A multi-specialty group or
behavioral health provider group pursuant to
907
KAR 15:010.
3. Medication assisted treatment may be
provided in:
a. An outpatient behavioral
health setting, including in a narcotic treatment program for substance use
disorder treatment with methadone operating in accordance with
908
KAR 1:374, Section 7; or
b. A residential treatment program for
substance use disorders. If a residential treatment program for substance use
disorders does not offer medication assisted treatment on-site, care
coordination shall be provided to facilitate medication assisted treatment
off-site if necessary by recipient choice. If the choice of medication in
medication assisted treatment is metha-done, the residential treatment provider
shall establish a contractual relationship with a narcotic treatment program
that dispenses methadone.
4. A medication assisted treatment program
shall:
a. Assess the need for treatment
including:
(i) A full patient history to
determine the severity of the patient's substance use disorder; and
(ii) Identifying and addressing any
underlying or co-occurring diseases or conditions, as necessary;
b. Educate the patient about how
the medication works, including:
(i) The
associated risks and benefits; and
(ii) Overdose prevention;
c. Evaluate the need for medically
managed withdrawal from substances;
d. Refer patients for higher levels of care
if necessary; and
e. Obtain informed
consent prior to integrating pharmacologic or nonpharmacologic
therapies.
5. Medication
assisted treatment shall be provided by:
a. A
physician;
b. A psychiatrist; or
c. An advanced practice registered
nurse.
6.
a. Notwithstanding any other provision of
907 KAR Chapter 15 to the contrary, temporary licensure shall be permissible
for a certified alcohol and drug counselor practicing within a narcotic
treatment program.
b. A
temporarily certified alcohol and drug counselor practicing within a narcotic
treatment program shall be under the direct supervision of a licensed clinical
alcohol and drug counselor.
c.
(i) The provisions of this subparagraph shall
no longer be operational three (3) years after this administrative regulation
becomes effective.
(ii) After the
three (3) year period has lapsed, an individual performing temporarily licensed
certified alcohol and drug counselor duties shall possess an appropriate
license to perform those duties.
(r)
1.
Partial hospitalization services shall be:
a.
Short-term with an average of four (4) to six (6) weeks,
b. Less than twenty-four (24) hours each
day;
c. An intensive treatment
program for an individual who is experiencing significant impairment to daily
functioning due to a substance use disorder or co-occurring disorders;
and
d. Provided
face-to-face.
2. Partial
hospitalization may be provided to an adult or a minor.
3. Admission criteria for partial
hospitalization shall be based on an inability of community-based therapies or
intensive outpatient services to adequately treat the recipient.
4. A partial hospitalization program shall
meet the service criteria, including the components for support systems,
staffing, and therapies outlined in the most current edition of The ASAM
Criteria for partial hospitalization level of care services.
5. A partial hospitalization program shall
consist of:
a. Individual outpatient
therapy;
b. Group outpatient
therapy;
c. Family outpatient
therapy; or
d. Medication
management.
6. The
department shall not reimburse for educational, vocational, or job training
services provided as part of partial hospitalization.
7.
a. A
behavioral health services organization's partial hospitalization program shall
have an agreement with the local educational authority to come into the program
to provide all educational components and instruction that are not Medicaid
billable or reimbursable.
b.
Services in a Medicaid eligible child's individualized education program shall
be covera-ble under Medicaid.
8. Partial hospitalization shall be:
a. Provided for at least four (4) hours per
day; and
b. Focused on one (1)
primary presenting problem.
9. A partial hospitalization program operated
by a behavioral health services organization shall:
a. Include the following personnel for the
purpose of providing medical care:
(i) An
advanced practice registered nurse, a physician assistant, or a physician
available on site; and
(ii) A
board-certified or board-eligible psychiatrist available for consultation;
and
b. Have the
capacity to:
(i) Provide services utilizing a
recognized intervention protocol based on nationally accepted treatment
principles;
(ii) Employ required
practitioners and coordinate service provision among rendering practitioners;
and
(iii) Provide the full range of
services included in the scope of partial hospitalization established in this
paragraph.
(6)
(a)
Laboratory services shall be reimbursable in accordance with
907
KAR 1:028 if provided by a BHSO II or a BHSO III if:
1. The BHSO II or BHSO III has the
appropriate CLIA certificate to perform laboratory testing pursuant to
907
KAR 1:028; and
2. The services are prescribed by a
physician, advanced practice registered nurse, or physician assistant who has a
contractual relationship with the BHSO II or BHSO III.
(b) Laboratory services shall be
administered, as appropriate, by:
1. An
approved behavioral health practitioner, as limited by subsections (1) and (3)
of this section; or
2. An approved
behavioral health practitioner under supervision, as limited by subsections (1)
and (3) of this section.
Section 4. Additional Limits and Non-covered
Services or Activities.
(1)
(a) Except as established in paragraph (b) of
this subsection, unless a diagnosis is made and documented in the recipient's
medical record within three (3) visits, the service shall not be
covered.
(b) The requirement
established in paragraph (a) of this subsection shall not apply to:
1. Mobile crisis services;
2. Crisis intervention;
3. A screening;
4. An assessment; or
5. Peer support services for the engagement
into substance use disorder treatment within an emergency department bridge
clinic.
(2)
For a recipient who is receiving residential services for a substance use
disorder, the following shall not be billed or reimbursed for the same date of
service for the recipient:
(a) A
screening;
(b) An
assessment;
(c) Service
planning;
(d) A psychiatric
service;
(e) Individual outpatient
therapy;
(f) Group outpatient
therapy;
(g) Family outpatient
therapy; or
(h) Peer support
services.
(3) For a
recipient who is receiving assertive community treatment for non-substance use
disorder treatment pursuant to
907
KAR 15:020, the following shall not be billed or
reimbursed for the same date of service for the recipient:
(a) An assessment;
(b) Case management;
(c) Individual outpatient therapy;
(d) Group outpatient therapy;
(e) Peer support services; or
(f) Mobile crisis services.
(4) The department shall not
reimburse for both a screening and a screening, brief intervention, and
referral to treatment provided to a recipient on the same date of
service.
(5) The following services
or activities shall not be covered under this administrative regulation:
(a) A service provided to:
1. A resident of:
a. A nursing facility; or
b. An intermediate care facility for
individuals with an intellectual disability;
2. An inmate of a federal, local, or state:
a. Jail;
b. Detention center; or
c. Prison; or
3. An individual with an intellectual
disability without documentation of an additional psychiatric
diagnosis;
(b)
Psychiatric or psychological testing for another agency, including a court or
school, that does not result in the individual receiving psychiatric
intervention or behavioral health therapy from the behavioral health services
organization;
(c) A consultation or
educational service provided to a recipient or to others;
(d) A telephone call, an email, a text
message, or other electronic contact that is not face-to-face, unless permitted
as a telehealth service pursuant to
907
KAR 3:170 and this administrative
regulation;
(e) Travel
time;
(f) A field trip;
(g) A recreational activity;
(h) A social activity; or
(i) A physical exercise activity
group.
(6)
(a) A consultation by one (1) provider or
professional with another shall not be covered under this administrative
regulation except as established in Section 3(5)(m)1. of this administrative
regulation.
(b) A third party
contract shall not be covered under this administrative regulation.
(7) A billing supervisor
arrangement between a billing supervisor and an approved behavioral health
practitioner under supervision shall not violate the supervision rules or
policies of the respective professional licensure boards governing the billing
supervisor and the approved behavioral health practitioner under
supervision.
Section 5.
No Duplication of Service.
(1) The department
shall not reimburse for a service provided to a recipient by more than one (1)
provider, of any program in which the service is covered, during the same time
period.
(2) For example, if a
recipient is receiving a behavioral health service from an independent
behavioral health provider, the department shall not reimburse for the same
service provided to the same recipient during the same time period by a
behavioral health services organization.
Section 6. Records Maintenance,
Documentation, Protection, and Security.
(1)
A behavioral health services organization shall maintain a current health
record for each recipient.
(2) A
health record shall document each service provided to the recipient including
the date of the service and the signature of the individual who provided the
service.
(3) A health record shall:
(a) Include:
1. An identification and intake record
including:
a. Name;
b. Social Security number;
c. Date of intake;
d. Home (legal) address;
e. Health insurance or Medicaid
information;
f. Referral source and
address of referral source;
g.
Primary care physician and address;
h. The reason the individual is seeking help
including the presenting problem and diagnosis;
i. Any physical health diagnosis, if a
physical health diagnosis exists for the individual, and information regarding:
(i) Where the individual is receiving
treatment for the physical health diagnosis; and
(ii) The physical health provider;
and
j. The name of the
informant and any other information deemed necessary by the behavioral health
services organization to comply with the requirements of:
(i) This administrative regulation;
(ii) The behavioral health services
organization's licensure board;
(iii) State law; or
(iv) Federal
law;
2.
Documentation of the:
a. Screening;
b. Assessment if an assessment was performed;
and
c. Disposition if a disposition
was performed;
3. A
complete history including mental status and previous treatment;
4. An identification sheet;
5. A consent for treatment sheet that is
accurately signed and dated; and
6.
The individual's stated purpose for seeking services; and
(b) Be:
1.
Maintained in an organized central file;
2. Furnished to the:
a. Cabinet for Health and Family Services
upon request; or
b. Managed care
organization in which the recipient is enrolled upon request if the recipient
is enrolled with a managed care organization;
3. Made available for inspection and copying
by:
a. Cabinet for Health and Family Services'
personnel; or
b. Personnel of the
managed care organization in which the recipient is enrolled if the recipient
is enrolled with a managed care organization;
4. Readily accessible; and
5. Adequate for the purpose of establishing
the current treatment modality and progress of the recipient if the recipient
received services beyond a screening.
(4) Documentation of a screening shall
include:
(a) Information relative to the
individual's stated request for services; and
(b) Other stated personal or health concerns
if other concerns are stated.
(5)
(a) A
behavioral health services organization's service notes regarding a recipient
shall:
1. Be made within forty-eight (48)
hours of each service visit;
2.
Indicate if the service was provided face-to-face or via telehealth;
and
3. Describe the:
a. Recipient's symptoms or behavior, reaction
to treatment, and attitude;
b.
Therapist's intervention;
c.
Changes in the plan of care if changes are made; and
d. Need for continued treatment if continued treatment
is needed.
(b)
1. Any edit to notes shall:
a. Clearly display the changes; and
b. Be initialed and dated by the
person who edited the notes.
2. Notes shall not be erased or illegibly
marked out.
(c)
1. Notes recorded by an approved behavioral
health practitioner under supervision shall be co-signed and dated by the
supervising professional within thirty (30) days.
2. If services are provided by an approved
behavioral health practitioner under supervision, there shall be a monthly
supervisory note recorded by the supervising professional reflecting
consultations with the approved behavioral health practitioner under
supervision concerning the:
a. Case; and
b. Supervising professional's
evaluation of the services being provided to the recipient.
(6)
Immediately following a screening of a recipient, the practitioner shall
perform a disposition related to:
(a) A
provisional diagnosis;
(b) A
referral for further consultation and disposition, if applicable; or
(c)
1. If
applicable, termination of services and referral to an outside source for
further services; or
2. If
applicable, termination of services without a referral to further
services.
(7)
Any change to a recipient's plan of care shall be documented, signed, and dated
by the rendering practitioner and by the recipient or recipient's
representative.
(8)
(a) Notes regarding services to a recipient
shall:
1. Be organized in chronological
order;
2. Be dated;
3. Be titled to indicate the service
rendered;
4. State a starting and
ending time for the service; and
5.
Be recorded and signed by the rendering practitioner and include the
professional title (for example, licensed clinical social worker) of the
provider.
(b) Initials,
typed signatures, or stamped signatures shall not be accepted.
(c) Telephone contacts, family collateral
contacts not covered under this administrative regulation, or other
non-reimbursable contacts shall:
1. Be
recorded in the notes; and
2. Not
be reimbursable.
(9)
(a) A
termination summary shall:
1. Be required,
upon termination of services, for each recipient who received at least three
(3) service visits; and
2. Contain
a summary of the significant findings and events during the course of treatment
including the:
a. Final assessment regarding
the progress of the individual toward reaching goals and objectives established
in the individual's plan of care;
b. Final diagnosis of clinical impression;
and
c. Individual's condition upon
termination and disposition.
(b) A health record relating to an individual
who terminated from receiving services shall be fully completed within ten (10)
days following termination.
(10) If an individual's case is reopened
within ninety (90) days of terminating services for the same or related issue,
a reference to the prior case history with a note regarding the interval period
shall be acceptable.
(11)
(a) Except as established in paragraph (b) of
this subsection, if a recipient is transferred or referred to a health care
facility or other provider for care or treatment, the transferring behavioral
health services organization shall, within ten (10) business days of the
transfer or referral, transfer the recipient's records in a manner that
complies with the records' use and disclosure requirements as established in or
required by:
1.
a. The Health Insurance Portability and
Accountability Act;
2.
a.
42
U.S.C.
290 ee-3; and
(b) If a
recipient is transferred or referred to a residential crisis stabilization
unit, a psychiatric hospital, a psychiatric distinct part unit in an acute care
hospital, or an acute care hospital for care or treatment, the transferring
behavioral health services organization shall, within forty-eight (48) hours of
the transfer or referral, transfer the recipient's records in a manner that
complies with the records' use and disclosure requirements as established in or
required by:
1.
a. The Health Insurance Portability and
Accountability Act;
2.
a.
42
U.S.C.
290 ee-3; and
(12)
(a) If a behavioral health services
organization's Medicaid Program participation status changes as a result of
voluntarily terminating from the Medicaid Program, involuntarily terminating
from the Medicaid Program, a licensure suspension, or death of an owner or
deaths of owners, the health records of the behavioral health services
organization shall:
1. Remain the property of
the behavioral health services organization; and
2. Be subject to the retention requirements
established in subsection (13) of this section.
(b) A behavioral health services organization
shall have a written plan addressing how to maintain health records in the
event of death of an owner or deaths of owners.
(13)
(a)
Except as established in paragraph (b) or (c) of this subsection, a behavioral
health services organization shall maintain a case record regarding a recipient
for at least six (6) years from the date of the service or until any audit
dispute or issue is resolved beyond six (6) years.
(b) After a recipient's death or discharge
from services, a provider shall maintain the recipient's record for the longest
of the following periods:
1. Six (6) years
unless the recipient is a minor; or
2. If the recipient is a minor, three (3)
years after the recipient reaches the age of majority under state
law.
(c) If the
Secretary of the United States Department of Health and Human Services requires
a longer document retention period than the period referenced in paragraph (a)
of this subsection, pursuant to
42 C.F.R.
431.17, the period established by the
secretary shall be the required period.
(14)
(a) A
behavioral health services organization shall comply with 45 C.F.R. Part
164.
(b) All information contained
in a health record shall:
1. Be treated as
confidential;
2. Not be disclosed
to an unauthorized individual; and
3. Be disclosed to an authorized
representative of:
a. The department; or
b. Federal government.
(c)
1. Upon request, a behavioral health services
organization shall provide to an authorized representative of the department or
federal government information requested to substantiate:
a. Staff notes detailing a service that was
rendered;
b. The professional who
rendered a service; and
c. The type
of service rendered and any other requested information necessary to determine,
on an individual basis, whether the service is reimbursable by the
department.
2. Failure
to provide information required by subparagraph 1. of this paragraph shall
result in denial of payment for any service associated with the requested
information.
Section 7. Medicaid Program Participation
Compliance.
(1) A behavioral health services
organization shall comply with:
(c) All applicable state and federal
laws.
(2)
(a) If a behavioral health services
organization receives any duplicate payment or overpayment from the department,
regardless of reason, the behavioral health services organization shall return
the payment to the department.
(b)
Failure to return a payment to the department in accordance with paragraph (a)
of this subsection may be:
1. Interpreted to
be fraud or abuse; and
2.
Prosecuted in accordance with applicable federal or state law.
(3)
(a) When the department makes payment for a
covered service and the behavioral health services organization accepts the
payment:
1. The payment shall be considered
payment in full;
2. A bill for the
same service shall not be given to the recipient; and
3. Payment from the recipient for the same
service shall not be accepted by the behavioral health services
organization.
(b)
1. A behavioral health services organization
may bill a recipient for a service that is not covered by the Kentucky Medicaid
Program if the:
a. Recipient requests the
service; and
b. Behavioral health
services organization makes the recipient aware in advance of providing the
service that the:
(i) Recipient is liable for
the payment; and
(ii) Department is
not covering the service.
2. If a recipient makes payment for a service
in accordance with subparagraph 1. of this paragraph, the:
a. Behavioral health services organization
shall not bill the department for the service; and
b. Department shall not:
(i) Be liable for any part of the payment
associated with the service; and
(ii) Make any payment to the behavioral
health services organization regarding the service.
(4)
(a) A behavioral health services organization
shall attest by the behavioral health services organization's staff's or
representative's signature that any claim associated with a service is valid
and submitted in good faith.
(b)
Any claim and substantiating record associated with a service shall be subject
to audit by the:
1. Department or its
designee;
2. Cabinet for Health and
Family Services, Office of Inspector General, or its designee;
3. Kentucky Office of Attorney General or its
designee;
4. Kentucky Office of the
Auditor for Public Accounts or its designee; or
5. United States General Accounting Office or
its designee.
(c) If a
behavioral health services organization receives a request from the department
to provide a claim, related information, related documentation, or record for
auditing purposes, the behavioral health services organization shall provide
the requested information to the department within the timeframe requested by
the department.
(d)
1. All services provided shall be subject to
review for recipient or provider abuse.
2. Willful abuse by a behavioral health
services organization shall result in the suspension or termination of the
behavioral health services organization from Medicaid Program
participation.
Section 8. Third Party Liability. A
behavioral health services organization shall comply with
KRS
205.622.
Section 9. Use of Electronic Signatures.
(1) The creation, transmission, storage, and
other use of electronic signatures and documents shall comply with the
requirements established in
KRS
369.101 to
369.120.
(2) A behavioral health services organization
that chooses to use electronic signatures shall:
(a) Develop and implement a written security
policy that shall:
1. Be adhered to by each
of the behavioral health services organization's employees, officers, agents,
or contractors;
2. Identify each
electronic signature for which an individual has access; and
3. Ensure that each electronic signature is
created, transmitted, and stored in a secure fashion;
(b) Develop a consent form that shall:
1. Be completed and executed by each
individual using an electronic signature;
2. Attest to the signature's authenticity;
and
3. Include a statement
indicating that the individual has been notified of his or her responsibility
in allowing the use of the electronic signature; and
(c) Provide the department, immediately upon
request, with:
1. A copy of the behavioral
health services organization's electronic signature policy;
2. The signed consent form; and
3. The original filed signature.
Section 10.
Auditing Authority. The department shall have the authority to audit any:
(1) Claim;
(2) Medical record; or
(3) Documentation associated with any claim
or medical record.
Section
11. Federal Approval and Federal Financial Participation. The
department's coverage of services pursuant to this administrative regulation
shall be contingent upon:
(1) Receipt of
federal financial participation for the coverage; and
(2) Centers for Medicare and Medicaid
Services' approval for the coverage.
Section 12. Appeals.
(1) An appeal of an adverse action by the
department regarding a service and a recipient who is not enrolled with a
managed care organization shall be in accordance with
907
KAR 1:563.
(2) An appeal of an adverse action by a
managed care organization regarding a service and an enrollee shall be in
accordance with
907
KAR 17:010.