907 KAR 15:070. Coverage provisions
and requirements regarding services provided by residential crisis
stabilization units.
RELATES TO: KRS 205.520, 42 U.S.C.
1396a(a)(10)(B), 42 U.S.C. 1396a(a)(23)
STATUTORY AUTHORITY: KRS 194A.030(2),
194A.050(1), 205.520(3)
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 residential crisis stabilization units.
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 residential crisis stabilization
unit 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.
(b) A service that does not meet the requirement
in paragraph (a) of this subsection shall not be covered.
(3) 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.
Section 2. Provider Participation. (1) To
be eligible to provide services under this administrative regulation, a residential
crisis stabilization unit shall:
(a) Be currently enrolled in the Kentucky
Medicaid Program in accordance with 907 KAR 1:672;
(b) Except as established in subsection (3)
of this section, be currently participating in the Kentucky Medicaid Program in
accordance with 907 KAR 1:671;
(c) Be licensed as a residential crisis
stabilization unit in accordance with 902 KAR 20:440;
(d) Comply with the requirements
established in 902 KAR 20:440;
(e) Have:
1. For each service it provides, the
capacity to provide the full range of the service as established in this
administrative regulation;
2. Demonstrated experience in serving
individuals with behavioral health 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;
(f) Be a community-based,
residential program that offers an array of services including:
1. Screening;
2. Assessment;
3. Treatment
planning;
4. Individual
outpatient therapy;
5. Group outpatient
therapy;
6. Psychiatric
services;
7. Family
outpatient therapy at the option of the residential crisis stabilization unit;
or
8. Peer support at
the option of the residential crisis stabilization unit;
(g) Provide
services in order to:
1. Stabilize a
crisis and divert an individual from a higher level of care;
2. Stabilize an
individual and provide treatment for acute withdrawal, if applicable; and
3. Re-integrate an
individual into the individual’s community or other appropriate setting in a
timely fashion;
(h) Not be part of
a hospital;
(i) Be used when an
individual:
1. Is experiencing
a behavioral health crisis that cannot be safely accommodated within the
individual’s community; and
2. Needs overnight
care that is not hospitalization;
(j) Except as
established in subsection (2)(a) of this section, not contain more than sixteen
(16) beds;
(k) Except as
established in subsection (2)(b) of this section, not be part of multiple units
comprising one (1) facility with more than sixteen (16) beds in aggregate;
(l) Agree to provide services in
compliance with federal and state laws regardless of age, sex, race, creed,
religion, national origin, handicap, or disability;
(m) Comply with the Americans with
Disabilities Act (42 U.S.C. 12101 et seq.) and any amendments to the Act;
(n) Have the
capacity to employ staff authorized to provide treatment services in accordance
with this section and to coordinate the provision of services among team
members;
(o) Have the
capacity to provide the full range of residential crisis stabilization services
as stated in Section 3(2) of this administrative regulation and on a
twenty-four (24) hour a day, seven (7) day a week, every day of the year basis;
(p) Have 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
(q) Have knowledgeable
staff regarding substance use disorders.
(2) If every recipient
receiving services in the:
(a) Single unit 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 subsection (1)(j) of this
section shall not apply; or
(b) Multiple units
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 subsection (1)(k) of this
section shall not apply.
(3) In accordance with 907 KAR 17:015,
Section 3(3), a residential crisis stabilization unit which provides a service
to an enrollee shall not be required to be currently participating in the fee-for-service
Medicaid Program.
Section 3. Covered Services. (1)(a)
Except as specified in the requirements stated for a given service, the services
covered may be provided for:
1. A mental health disorder;
2. A substance use disorder; or
3. Co-occurring mental health and substance
use disorders.
(b) Residential crisis stabilization
services shall be provided in a residential crisis stabilization unit.
(2) Residential crisis stabilization
services shall include:
(a) A screening provided by:
1. A licensed psychologist;
2. A licensed psychological practitioner;
3. A licensed clinical social worker;
4. A licensed professional clinical counselor;
5. A licensed professional art therapist;
6. A licensed marriage and family therapist;
7. A physician;
8. A psychiatrist;
9. An advanced practice registered nurse;
or
10. A behavioral health practitioner
under supervision except for a licensed assistant behavior analyst;
(b) An assessment provided by:
1. A licensed psychologist;
2. A licensed psychological practitioner;
3. A licensed clinical social worker;
4. A licensed professional clinical counselor;
5. A licensed professional art therapist;
6. A licensed marriage and family therapist;
7. A physician;
8. A psychiatrist;
9. An advanced practice registered nurse;
10. A licensed behavior analyst; or
11. A behavioral health practitioner
under supervision;
(c) Individual outpatient therapy or group
outpatient therapy provided by:
1. A licensed psychologist;
2. A licensed psychological practitioner;
3. A licensed clinical social worker;
4. A licensed professional clinical counselor;
5. A licensed professional art therapist;
6. A licensed marriage and family therapist;
7. A physician;
8. A psychiatrist;
9. An advanced practice registered nurse;
10. A licensed behavior analyst; or
11. A behavioral health practitioner
under supervision;
(d) Treatment planning provided by:
1. A licensed psychologist;
2. A licensed psychological practitioner;
3. A licensed clinical social worker;
4. A licensed professional clinical counselor;
5. A licensed professional art therapist;
6. A licensed marriage and family therapist;
7. A physician;
8. A psychiatrist;
9. An advanced practice registered nurse;
10. A licensed behavior analyst; or
11. A behavioral health practitioner
under supervision except for a certified alcohol and drug counselor;
(e) Psychiatric services provided by:
1. A psychiatrist; or
2. An APRN; or
(f) At the option of the residential
crisis stabilization unit:
1. Family outpatient therapy provided by:
a. A licensed psychologist;
b. A licensed psychological practitioner;
c. A licensed clinical social worker;
d. A licensed professional clinical counselor;
e. A licensed professional art therapist;
f. A licensed marriage and family
therapist;
g. A physician;
h. A psychiatrist;
i. An advanced practice registered nurse;
or
j. A behavioral health practitioner under
supervision except for a licensed assistant behavior analyst; or
2. Peer support provided by a peer
support specialist working under the supervision of:
a. An approved behavioral health service
provider; or
b. A certified alcohol and drug counselor.
(3)(a) A screening shall:
1. Establish the need for a level of care
evaluation to determine the most appropriate and least restrictive service to
maintain the safety of the individual who may have a mental health disorder, substance
use disorder, or co-occurring disorders;
2. Not establish the presence or specific
type of disorder; and
3. Establish the need for an in-depth
assessment of the number and duration of risk factors including:
a. Imminent danger and availability of lethal
weapons;
b. Verbalization of suicidal or homicidal
risk;
c. Need of immediate medical attention;
d. Positive and negative coping strategies;
e. Lack of family or social supports;
f. Active psychiatric diagnosis; or
g. Current drug and alcohol use.
(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
mental health disorder, a substance use 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 treatment and service plan; and
4. Not include psychological or
psychiatric evaluations or assessments.
(c) Individual outpatient therapy shall:
1. Be provided to promote the:
a. Health and wellbeing of the
individual; or
b. Recovery from a substance use disorder,
a mental health disorder, or co-occurring disorders;
2. Consist of:
a. A face-to-face, 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 crisis treatment
plan;
3. Be aimed at:
a. Reducing adverse symptoms;
b. Reducing or eliminating the presenting
problem of the recipient; and
c. Improving functioning; and
4. Not exceed three (3) hours per day unless
additional time is medically necessary.
(d)1. Group outpatient therapy shall:
a. Be a behavioral health therapeutic
intervention provided in accordance with a recipient’s identified crisis treatment
plan;
b. Be provided to promote the:
(i) Health and wellbeing of the individual;
or
(ii) Recovery from a substance use
disorder, a mental health disorder, or co-occurring disorders;
c. Consist of a face-to-face behavioral
health therapeutic intervention provided in accordance with the recipient’s
identified crisis treatment plan;
d. Be provided to a recipient in a group
setting:
(i) Of nonrelated individuals; 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 crisis treatment plan;
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 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.
(e)1. Treatment planning shall:
a. Involve assisting a recipient in
creating an individualized plan for services needed;
b. Involve restoring a recipient's
functional level to the recipient's best possible functional level; and
c. Be performed using a person-centered
planning process.
2. A service plan:
a. Shall be directed 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.
(f)1. Family outpatient therapy shall
consist of a face-to-face 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. Family outpatient therapy shall:
a. Be provided to promote:
(i) The health and wellbeing of the
individual; or
(ii) Recovery from a substance use
disorder, a mental health disorder, or co-occurring disorders; and
b. Not exceed three (3) hours per day per
individual unless additional time is medically necessary.
(g)1. Peer support services shall:
a. Be social and
emotional support that is provided by an individual who is experiencing a
mental health disorder, a substance use disorder, or co-occurring mental health
and substance use disorders to a recipient by sharing a similar mental health
disorder, substance use disorder, or co-occurring mental health and substance
use disorders in order to bring about 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 by a
self-identified consumer, parent, or family member:
(i) Of a child
consumer of mental health disorder services, substance use disorder services,
or co-occurring mental health disorder services and substance use disorder services;
and
(ii) Who has been
trained and certified in accordance with 908 KAR 2:220, 908 KAR 2:230, or 908
KAR 2:240;
e. Promote
socialization, recovery, self-advocacy, preservation, and enhancement of community
living skills for the recipient;
f. Be coordinated
within the context of a comprehensive, individualized treatment plan developed
through a person-centered planning process;
g. Be identified in
each recipient’s treatment plan; and
h. Be designed to
directly contribute to the recipient’s individualized goals as specified in the
recipient’s treatment plan.
2. To provide peer
support services, a residential crisis stabilization unit shall:
a. Employ peer
support specialists who are qualified to provide peer support services in accordance
with 908 KAR 2:220, 908 2:230, or 908 2:240;
b. Use an approved
behavioral health services provider or certified alcohol and drug counselor to
supervise peer support specialists;
c. Have the
capacity to coordinate the provision of services among team members; and
d. Have the
capacity to provide on-going continuing education and technical assistance to
peer support specialists.
(4) The extent and type of a screening
shall depend upon the problem of the individual seeking or being referred for
services.
(5) A diagnosis or clinical impression
shall be made using terminology established in the most current edition of the
American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders.
(6) The department shall not reimburse
for a service billed by or on behalf of an entity or individual who is not a
billing provider.
Section 4. Additional Limits and Non-covered
Services or Activities. (1) 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 residential crisis stabilization unit;
(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 does not meet the requirements stated
in the definition of "face-to-face";
(e) Travel time;
(f) A field trip;
(g) A recreational activity;
(h) A social activity; or
(i) A physical exercise activity group.
(2) Residential
crisis stabilization services 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 state plan.
(3)(a) A consultation by one (1) provider
or professional with another shall not be covered under this administrative
regulation.
(b) A third party contract shall not be
covered under this administrative regulation.
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 residential crisis stabilization service from a community mental
health center, the department shall not reimburse for the same service provided
to the same recipient during the same time period by a residential crisis
stabilization unit.
Section 6. Records Maintenance, Documentation,
Protection, and Security. A residential crisis stabilization unit shall
maintain a current health record for each recipient in accordance with 902 KAR
20:440.
Section 7. Medicaid Program Participation
Compliance. (1) A residential crisis stabilization unit shall comply with:
(a) 907 KAR 1:671;
(b) 907 KAR 1:672; and
(c) All applicable state and federal
laws.
(2)(a) If a residential crisis
stabilization unit receives any duplicate payment or overpayment from the
department, regardless of reason, the residential crisis stabilization unit
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 residential crisis stabilization unit 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 residential crisis stabilization unit.
(b)1. A residential crisis stabilization
unit 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. Residential crisis stabilization unit
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. Residential crisis stabilization unit
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 residential
crisis stabilization unit regarding the service.
(4)(a) The signature of the residential
crisis stabilization unit’s staff or representative shall indicate that the
residential crisis stabilization unit attests 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 residential crisis stabilization
unit receives a request from the department to provide a claim, related
information, related documentation, or record for auditing purposes, the residential
crisis stabilization unit 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 residential crisis
stabilization unit shall result in the suspension or termination of the residential
crisis stabilization unit from Medicaid Program participation.
Section 8. Third Party Liability. A residential
crisis stabilization unit 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 residential crisis stabilization
unit 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 residential
crisis stabilization unit'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 residential crisis
stabilization unit'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. (41 Ky.R. 970; Am. 1807; eff. 3-6-2015.)
