907 KAR 15:070. Coverage provisions and requirements regarding services provided by residential crisis stabilization units

Link to law: http://www.lrc.ky.gov/kar/907/015/070.htm
Published: 2015

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      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.)