No. 27322 (New Rule): R414-36. Services by Community Mental Health Centers

DAR File No.: 27322
Filed: 08/02/2004, 11:45
Received by: NL

 

RULE ANALYSIS

Purpose of the rule or reason for the change:

This rulemaking is necessary to comply with Subsection 26-18-3(2)(a), which requires that programs previously allowed to be implemented by policy now be implemented by rule. Rule R414-25, Mental Health Clinic Services, will be repealed as a result of this rulemaking because the rule is outdated and does not reflect current policy.

 

Summary of the rule or change:

This is a proposed new rule for community mental health center services that puts into rule the program that Section 26-18-3 previously allowed to be in policy. This new rule replaces Rule R414-25 which will be repealed. The rule outlines community mental health center services that are currently covered and delineates the ways community mental health center services are provided. In 27 counties of the State, Medicaid recipients are automatically enrolled in the capitated Prepaid Mental Health Plan. Community mental health centers participating in this program receive premiums to serve all Medicaid recipients in their catchment areas. Exceptions to enrollment in the Prepaid Mental Health Plan are also delineated. In two counties, community mental health centers continue to be reimbursed on a fee-for-service basis rather than a prepaid capitation basis.

 

State statutory or constitutional authorization for this rule:

Subsection 26-18-3(2)(a); and 42 CFR 440.130, 1902(a)(1), 1915(b)(3), and 1915(b)(4) of the Social Security Act

 

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget associated with this rulemaking because the program was previously implemented by policy and now needs to be implemented in rule pursuant to Subsection 26-18-3(2)(a).

 

local governments:

There is no budget impact to local governments as a result of this rulemaking because the program was previously implemented by policy and now needs to be implemented in rule pursuant to Subsection 26-18-3(2)(a).

 

other persons:

There is no budget impact to other persons as a result of this rulemaking because the program was previously implemented by policy and now needs to be implemented in rule pursuant to Subsection 26-18-3(2)(a).

 

Compliance costs for affected persons:

There are no compliance costs for affected persons because the program was previously implemented by policy and now needs to be implemented in rule pursuant to Subsection 26-18-3(2)(a).

 

Comments by the department head on the fiscal impact the rule may have on businesses:

There will be no compliance costs on businesses because of this rule. The rule implements existing policy that is now required to be in rule. Scott Williams, MD, Executive Director

 

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Health
Health Care Financing, Coverage and Reimbursement Policy
CANNON HEALTH BLDG
288 N 1460 W
SALT LAKE CITY UT 84116-3231

 

Direct questions regarding this rule to:

Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at [e-mail]

 

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

09/14/2004

 

This rule may become effective on:

09/15/2004

 

Authorized by:

Scott D. Williams, Executive Director

 

 

RULE TEXT

R414. Health, Health Care Financing, Coverage and Reimbusement Policy.

R414-36. Services by Community Mental Health Centers.

R414-36-1. Introduction and Authority.

(1) This rule outlines the diagnostic and rehabilitative mental health services provided to Medicaid clients by community mental health centers.

(2) This rule is authorized under UCA 26-18-3 and governs the services allowed under 42 CFR 440.130, Oct. 2003 ed., and implements waivers authorized under federal waiver authority in subsections 1902(a)(1), 1915(b)(3) and 1915(b)(4) of the Social Security Act.

 

R414-36-2. Definitions.

In this rule:

"Diagnostic services '' means any medical procedure recommended by a physician or other licensed mental health therapist to enable him to identify the existence, nature, or extent of a mental health disorder in a client.

"Prepaid Mental Health Plan" means the prepaid, capitated program through which the Department pays contracted community mental health centers to provide all needed inpatient and outpatient mental health services to residents of the community mental health center's catchment area who are enrolled in the plan.

"Rehabilitative services '' means any medical or remedial services recommended by a physician or other licensed mental health therapist for maximum reduction of a client's mental health disorder and restoration of the client to his best possible functional level.

 

R414-36-3. Client Eligibility Requirements.

Diagnostic and rehabilitative mental health services are available to any Categorically or Medically Needy Medicaid client, except that

(1) Medicaid clients who reside at the Utah State Hospital and the Utah Developmental Center are not covered under the Prepaid Mental Health Plan;

(2) children in State custody are enrolled in the Prepaid Mental Health Plan only for inpatient mental health services;

(3) Medicaid clients who enroll in the UNI HOME Program are disenrolled from the Prepaid Mental Health Plan;

(4) state subsidized adoptive children who have been exempted from the Prepaid Mental Health Plan by parent request are enrolled in the Prepaid Mental Health Plan only for inpatient mental health services.

 

R414-36-4. Program Access Requirements.

(1) Diagnostic and rehabilitative mental health services must be provided by or through a community mental health center that is under contract with or directly operated by a local county mental health authority.

(2) The community mental health center must evaluate the client to determine if the client has a mental health disorder that requires mental health services.

 

R414-36-5. Service Coverage.

(1) Services must be recommended by a licensed mental health therapist.

(2) The scope of diagnostic and rehabilitative mental health services includes:

(a) psychiatric diagnostic interview examination;

(b) mental health assessment by non-physician;

(c) psychological testing;

(d) individual psychotherapy;

(e) group psychotherapy;

(f) individual psychotherapy with medical evaluation and management services;

(g) family psychotherapy with patient present;

(h) family psychotherapy without patient present;

(i) therapeutic behavioral services;

(j) pharmacologic management;

(k) individual skills training and development;

(l) psychosocial rehabilitative services; and

(m) intensive psychosocial rehabilitative services for children ages 0 through the month of their 13th birthday.

(3) Medicaid clients who reside in counties covered by a Prepaid Mental Health Plan contractor are automatically enrolled in the Prepaid Mental Health Plan for that county. A Medicaid client covered by a Prepaid Mental Health Plan may receive additional services approved by CMS under the Social Security Act section 1915(b)(3) waiver authority.

(4) Medicaid adult recipients ages 19 and over in the TANF and Medically Needy eligibility categories who are enrolled in the Non-Traditional Medicaid Plan have the following service limitations:

(a) inpatient mental health care is limited to a maximum of 30 days per year;

(b) outpatient mental health services are limited to a maximum of 30 outpatient mental health treatment services or visits per year

(c) targeted case management services under R414-33A for the chronically mentally ill also count toward the maximum of 30 outpatient mental health services.

(4) Medicaid clients enrolled in the Non-Traditional Medicaid Plan also have the following service exclusions:

(a) services for conditions without manifest psychiatric diagnoses;

(b) hypnosis, occupational, or recreational therapy; and

(c) office calls in conjunction with medication management for repetitive therapeutic injections.

(4) Psychiatric diagnosis interview examinations for legal purposes only, such as for custodial or visitation rights are excluded from coverage for all Medicaid clients.

 

R414-36-6. Qualified Providers.

(1) Diagnostic and rehabilitative services must be provided by an individual, as limited by the scope of his license, who is:

(a) a licensed physician, a licensed psychologist, a licensed clinical social worker, a licensed certified social worker, a licensed social service worker, a licensed advanced practice registered nurse specializing in mental health nursing, a licensed registered nurse, a licensed professional counselor, or a licensed marriage and family counselor; or

(b) an individual working toward licensure in one of the professions identified in subsection (a); or

(c) a licensed practical nurse or other trained staff working under the supervision of one of the individuals identified in subsection (1)(a) or (b).

 

R414-36-7. Reimbursement Methodology.

(1) Two community mental health centers are not under contract with the Department as Prepaid Mental Health Plan contractors. The Department reimburses these two community mental health centers on a fee-for-service basis. The Department pays the lower of the amount billed or the Medicaid fee schedule. The fee schedule was initially established after consultation with provider representatives. A provider shall not charge the Department a fee that exceeds the provider's usual and customary charges for the provider's private pay clients.

(2) The Department pays Prepaid Mental Health Plan contractors a capitated monthly premium to cover all inpatient and outpatient mental health services needed by Medicaid clients.

The premiums are developed and certified as actuarially sound by independent actuaries who meet the qualification standards established by the American Academy of Actuaries.

 

KEY: Medicaid

2004

26-18-3