Section 441.78.12. Behavioral health intervention.

Payment will be made for behavioral health intervention services not otherwise covered under this chapter that are designed to minimize or, if possible, eliminate the symptoms or causes of a mental disorder, subject to the limitations in this rule.

         78.12(1) Definitions.

“Behavioral health intervention” means skill-building services that focus on:

            1.      Addressing the mental and functional disabilities that negatively affect a member’s integration and stability in the community and quality of life;

            2.      Improving a member’s health and well-being related to the member’s mental disorder by reducing or managing the symptoms or behaviors that prevent the member from functioning at the member’s best possible functional level; and

            3.      Promoting a member’s mental health recovery and resilience through increasing the member’s ability to manage symptoms.

“Licensed practitioner of the healing arts”  or “LPHA,”  as used in this rule, means a practitioner such as a physician (M.D. or D.O.), a physician assistant (PA), an advanced registered nurse practitioner (ARNP), a psychologist, a social worker (LMSW or LISW), a marital and family therapist (LMFT), or a mental health counselor (LMHC) who is licensed by the applicable state authority for that profession.

“Managed care organization” means an entity that (1) is under contract with the department to provide services to Medicaid recipients and (2) meets the definition of “health maintenance organization” as defined in Iowa Code section 514B.1.

“Mental disorder” means a disorder, dysfunction, or dysphoria diagnosed pursuant to the current version of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association, excluding intellectual disabilities, personality disorders, medication-induced movement disorders and other adverse effects of medication, and other conditions that may be a focus of clinical attention.

         78.12(2) Covered services.

            a.                Service setting.

             (1)             Community-based behavioral health intervention is available to a member living in a community-based environment. Services have a primary goal of assisting the member and the member’s family to learn age-appropriate skills to manage behavior and regain or retain self-control. Depending on the member’s age and diagnosis, specific services offered may include:

            1.      Behavior intervention,

            2.      Crisis intervention,

            3.      Skill training and development, and

            4.      Family training.

             (2)             Residential behavioral health intervention is available to members eligible for foster group care payment pursuant to 441—subrule 156.20(1). Services have the primary goal of assisting the member to prepare to transition to the community through learning age-appropriate skills to manage behavior and regain or retain self-control. Specific services offered include:

            1.      Behavior intervention,

            2.      Crisis intervention, and

            3.      Family training.

             (3)             Behavioral health intervention is not covered for members who are in an acute care or psychiatric hospital, a long-term care facility, or a psychiatric medical institution for children.

            b.                Crisis intervention. Crisis intervention services shall provide a focused intervention and rapid stabilization of acute symptoms of mental illness or emotional distress. The intervention shall be designed to de-escalate situations in which a risk to self, others, or property exists.

             (1)             Services shall assist a member to regain self-control and reestablish effective management of behavioral symptoms associated with a psychological disorder in an age-appropriate manner.

             (2)             Crisis intervention is covered only for Medicaid members who are aged 20 or under and shall be provided as outlined in a written treatment plan.

             (3)             Crisis intervention services do not include control room or other restraint activities.

            c.                Behavior intervention. Behavior intervention includes services designed to modify the psychological, behavioral, emotional, cognitive, and social factors affecting a member’s functioning.

             (1)             Interventions may address the following skills for effective functioning with family, peers, and community in an age-appropriate manner:

            1.      Cognitive flexibility skills,

            2.      Communication skills,

            3.      Conflict resolution skills,

            4.      Emotional regulation skills,

            5.      Executive skills,

            6.      Interpersonal relationship skills,

            7.      Problem-solving skills, and

            8.      Social skills.

             (2)             Behavior intervention shall be provided in a location appropriate for skill identification, teaching and development. Intervention may be provided in an individual, family, or group format as appropriate to meet the member’s needs.

             (3)             Behavior intervention is covered only for Medicaid members aged 20 or under.

             (4)             Covered services include only direct teaching or development of skills and not general recreation, non-skill-based activities, mentoring, or interruption of school.

            d.                Family training. Family training is covered only for Medicaid members aged 20 or under.

             (1)             Family training services shall:

            1.      Enhance the family’s ability to effectively interact with the child and support the child’s functioning in the home and community, and

            2.      Teach parents to identify and implement strategies to reduce target behaviors and reinforce the appropriate skills.

             (2)             Training provided must:

            1.      Be for the direct benefit of the member, and

            2.      Be based on a curriculum with a training manual.

            e.                Skill training and development. Skill training and development services are covered for Medicaid members aged 18 or over.

             (1)             Skill training and development shall consist of interventions to:

            1.      Enhance a member’s independent living, social, and communication skills;

            2.      Minimize or eliminate psychological barriers to a member’s ability to effectively manage symptoms associated with a psychological disorder; and

            3.      Maximize a member’s ability to live and participate in the community.

             (2)             Interventions may include training in the following skills for effective functioning with family, peers, and community:

            1.      Communication skills,

            2.      Conflict resolution skills,

            3.      Daily living skills,

            4.      Employment-related skills,

            5.      Interpersonal relationship skills,

            6.      Problem-solving skills, and

            7.      Social skills.

         78.12(3) Excluded services.

            a.               Services that are habilitative in nature are not covered under behavioral health intervention. For purposes of this subrule, “habilitative services” means services that are designed to assist individuals in acquiring skills that they never had, as well as associated training to acquire self-help, socialization, and adaptive skills necessary to reside successfully in a home or community setting.

            b.               Respite, day care, education, and recreation services are not covered under behavioral health intervention.

         78.12(4) Coverage requirements. Medicaid covers behavioral health intervention only when the following conditions are met:

            a.               A licensed practitioner of the healing arts acting within the practitioner’s scope of practice under state law has diagnosed the member with a psychological disorder.

            b.               The licensed practitioner of the healing arts has recommended the behavioral health intervention as part of a plan of treatment designed to treat the member’s psychological disorder. The plan of treatment shall be comprehensive in nature and shall detail all behavioral health services that the member may require, not only services included under behavioral health intervention.

             (1)             The member’s need for services must meet specific individual goals that are focused to address:

            1.      Risk of harm to self or others,

            2.      Behavioral support in the community,

            3.      Specific skills impaired due to the member’s mental illness, and

            4.      Needs of children at risk of out-of-home placement due to mental health needs or the transition back to the community or home following an out-of-home placement.

             (2)             Diagnosis and treatment plan development are covered services.

            c.               For a member under the age of 21, the licensed practitioner of the healing arts:

             (1)             Has, in cooperation with the managed care contractor, selected a standardized assessment instrument appropriate for baseline measurement of the member’s current skill level in managing mental health needs;

             (2)             Has completed an initial formal assessment of the member using the instrument selected; and

             (3)             Completes a formal assessment every six months thereafter if continued services are ordered.

            d.               The behavioral health intervention provider has prepared a written services implementation plan that meets the requirements of subrule 78.12(5).

         78.12(5) Approval of plan. The behavioral health intervention provider shall contact the Iowa Plan provider for authorization of the services.

            a.                Initial plan. The initial services implementation plan must meet all of the following criteria:

             (1)             The plan conforms to the medical necessity requirements in subrule 78.12(6);

             (2)             The plan is consistent with the written diagnosis and treatment recommendations made by the licensed practitioner of the healing arts;

             (3)             The plan is sufficient in amount, duration, and scope to reasonably achieve its purpose;

             (4)             The provider meets the requirements of rule 441—77.12(249A); and

             (5)             The plan does not exceed six months’ duration.

            b.                Subsequent plans. The Iowa Plan contractor may approve a subsequent services implementation plan according to the conditions in paragraph 78.12(5)“a” if the services are recommended by a licensed practitioner of the healing arts who has:

             (1)             Reexamined the member;

             (2)             Reviewed the original diagnosis and treatment plan; and

             (3)             Evaluated the member’s progress, including a formal assessment as required by 78.12(4)“c”(3).

         78.12(6) Medical necessity. Nothing in this rule shall be deemed to exempt coverage of behavioral health intervention from the requirement that services be medically necessary. For purposes of behavioral health intervention, “medically necessary” means that the service is:

            a.               Consistent with the diagnosis and treatment of the member’s condition and specific to a daily impairment caused by a mental disorder;

            b.               Required to meet the medical needs of the member and is needed for reasons other than the convenience of the member or the member’s caregiver;

            c.               The least costly type of service that can reasonably meet the medical needs of the member; and

            d.               In accordance with the standards of evidence-based medical practice. The standards of practice for each field of medical and remedial care covered by the Iowa Medicaid program are those standards of practice identified by:

             (1)             Knowledgeable Iowa clinicians practicing or teaching in the field; and

             (2)             The professional literature regarding evidence-based practices in the field.

This rule is intended to implement Iowa Code section 249A.4 and 2010 Iowa Acts, chapter 1192, section 31.

[ARC 8504B, IAB 2/10/10, effective 3/22/10; ARC 9487B, IAB 5/4/11, effective 7/1/11; ARC 1850C, IAB 2/4/15, effective 4/1/15; ARC 2164C, IAB 9/30/15, effective 10/1/15; ARC 2361C, IAB 1/6/16, effective 1/1/16]