Section 429.421 - Scope of Services(A)Required Services. Each center must have services available to treat a wide range of behavioral health disorders, including co-occurring substance use disorders. All services must be clinically determined to be medically necessary and appropriate and must be delivered by qualified staff in accordance with 130 CMR 429.424, and as part of the treatment plan in accordance with 130 CMR 429.421(A)(2). A center must have the capacity to provide at least the services set forth in 130 CMR 429.421(A). In certain rare circumstances, the MassHealth agency may waive the requirement that the center directly provide one or more of these services if the center has a written referral agreement with another source of care to provide such services, and makes such referrals according to the provisions of 130 CMR 429.421(A)(6). (1)Diagnostic Evaluation Services.(a) Diagnostic Evaluation Services that must occur on a member's initial date of service shall include:1. Identification of the member's presenting complaint or problem at the time of assessment; and(b) Diagnostic Evaluation Services that may occur on a member's initial date of service or over subsequent visits to complete the diagnostic evaluation, develop a treatment plan, and substantiate treatment rendered, shall include:1. An assessment of the current status and history of the member's physical and psychological health, including any current or former substance use;2. Current and former behavioral health disorder treatment, or any other related treatment, including pharmacotherapy or substance use disorder treatment; and3. Current and former social, economic, developmental, and educational functioning, describing both strengths and needs.(c) As treatment progresses, further diagnostic information shall be gathered and documented to inform longitudinal treatment planning.(d) For members younger than 21 years old, a CANS assessment must be completed during the initial behavioral-health assessment before the initiation of therapy and be updated at least every 90 days thereafter by a CANS-certified provider.(2)Treatment Planning Services.(a) Each center must complete a treatment plan for every member by the later of the member's fourth visit or 30 days after the initiation of treatment. Where an existing written treatment plan has been completed by a different provider prior to the member's initiation of treatment with the center, the center may rely on such treatment plan, provided that the treatment plan satisfies the requirements of 130 CMR 429.421(A)(2) and that the center reviews the treatment plan and updates the treatment plan, as clinically appropriate, upon initiation of treatment.(b) The member's written treatment plan shall be appropriate to the member's presenting complaint or problem and based on information gathered during the intake and diagnostic evaluation process, including any substance use disorder screening results.(c) The treatment plan must be in writing, and must include at least the following information, as appropriate to the member's presenting complaint or problem:1. identified problems and needs relevant to treatment and discharge expressed in behavioral, descriptive terms;2. the member's strengths and needs;3. measurable treatment goals addressing identified problems, with time guidelines for accomplishing goals and working towards discharge;4. identified clinical interventions, including pharmacotherapy, to obtain treatment goals;5. evidence of member's input in formulation of the treatment plan, for example, the member's stated goals, and direct quotes from the member;6. clearly defined staff responsibilities and assignments for implementing the plan;7. the date the plan was last reviewed or revised; and8. the signatures and licenses or degrees of staff involved in the review or revision.(d) Treatment plans must be updated at least every six months or sooner in the event of a significant change in clinical presentation or treatment needs, which may include, but is not limited to, admission to inpatient level of care or initiation of psychopharmacology or therapy services.(e) Upon the member meeting the goals and objectives within the treatment plan, a written discharge summary must be completed by the clinician that describes the member's response to the course of treatment and referrals to aftercare and other resources.(3)Case and Family Consultation and Therapy Services. These services must include case and family consultation, individual, group, couple, and family therapies provided by or supervised by the mental health professionals identified in 130 CMR 429.422.(4)Pharmacotherapy Services.(a) Pharmacotherapy services must include, but are not limited to, an assessment of the patient's: 1. psychiatric symptoms and disorders;2. health status including medical conditions and medications;3. use or misuse of alcohol or other substances; and4. prior experience with psychiatric medications.(b) Pharmacotherapy services must include medication prescribing, reviewing, and monitoring.(c) Pharmacotherapy services must be provided by an appropriately licensed individual with the authority to prescribe medications.(d) Pharmacotherapy services may be provided by a provider that is not employed by the center, who is operating under a documented agreement with the center.(e) These requirements do not preclude the one-time administration of a medication in an emergency in accordance with a prescribing practitioner's order.(5)Crisis Intervention Services. Each center must provide clinic coverage to respond to members experiencing a crisis 24 hours per day, seven days per week. (a) During business hours, clinic coverage must include, at minimum, crisis evaluation by a qualified professional and triage to appropriate services for the member's presenting crisis. (b) After hours crisis intervention services must include live telephonic access to qualified professionals and, if indicated, triage in real-time to an appropriate provider to determine whether a higher level of care and/or additional diversionary services are necessary. A prerecorded message will not fulfill the requirement for access to a qualified professional.(6)Referral Services. (a) Each center must have written policies and procedures for addressing a member's behavioral health disorder needs that exceed the scope of services provided by the center including but not limited to substance use disorder needs. Policies and procedures must minimally include personnel, referral, coordination, and other procedural commitments to address the referral of members to the appropriate health care providers, including but not limited to substance use disorder providers.(b) When referring a member to another provider for services, each center must ensure continuity of care, exchange of relevant health information, such as test results and records, and avoidance of service duplication between the center and the provider to whom a member is referred. Each center must also ensure that the referral process is completed successfully and documented in the member's medical record.(c) In the case of a member who is referred to services outside of the center, the rendering provider must bill the MassHealth agency directly for any services rendered to a member. The rendering provider may not bill through the referring mental health center.(B)Optional Services. The below services are reimbursed by the MassHealth agency and are intended to complement the required services set forth in 130 CMR 429.414(A). The following services set forth in 130 CMR 429.421(B) are billable services and are allowed but not required to be provided by a center. All optional services provided by the center must be set forth in a member's Treatment Plan developed pursuant to 130 CMR 429.421(A)(2). (1)Certified Peer Specialist (CPS) Services. The MassHealth agency will pay for CPS services that promote empowerment, self-determination, self-advocacy, understanding, coping skills, and resiliency through a specialized set of activities and interactions when provided by a qualified Certified Peer Specialist to an individual with a mental health disorder.(2)Structured Outpatient Addiction Program (SOAP). The MassHealth agency will pay for SOAP services delivered by centers in conformance with all applicable sections of 130 CMR 418.000: Substances Use Disorder Treatment Services.(3)Enhanced Structured Outpatient Addiction Program (E-SOAP). The MassHealth agency will pay for E-SOAP services delivered by centers in conformance with all applicable sections of 130 CMR 418.000: Substance Use Disorder Treatment Services.(4)Peer Recovery Coach Services. The MassHealth agency will pay for peer recovery coach services delivered by centers in conformance with all applicable sections of 130 CMR 418.000: Substance Use Disorder Treatment Services.(5)Recovery Support Navigator Services. The MassHealth agency will pay for recovery support navigator services delivered by centers in conformance with all applicable sections of 130 CMR 418.000: Substance Use Disorder Treatment Services(6)Intensive Outpatient Program (IOP). The MassHealth agency will pay for the following clinical interventions, when delivered as part of an Intensive Outpatient Program.(a) IOPs must provide a member with 3.5 hours of services each day for a minimum of five days per week. Specific IOP clinical interventions must include: 1. bio-psychosocial evaluation;2. individualized treatment planning based on results of bio-psychosocial evaluation;3. case and family consultation;4. crisis prevention planning, and safety planning for youth, as applicable;5. discharge planning and case management;6. individual, group, and family therapy;7. multi-disciplinary treatment team review;8. peer support and recovery-oriented services;9. provision of access to medication evaluation and medication; management, as indicated, directly or by referral;11. substance use disorder assessment and treatment services; and12. access to Medication evaluation and Medication management. If medication evaluation and medication management services are not provided within the IOP service, the center may provide these services through the MHC.
(b)Preventive Behavioral Health Services. Preventive behavioral health services are provided to members younger than 21 years old who have a positive behavioral health screen, or in the case of an infant, a caregiver who has had a positive post partum depression screen. Preventive behavioral health services are delivered by a qualified behavioral health clinician. During the delivery of preventive behavioral health services, if the provider determines that a member has further clinical needs, members and families should be referred for evaluation, diagnostic, and treatment services. After six sessions, if the provider determines that further preventive behavioral health services are needed, providers should document the clinical appropriateness of ongoing preventive services.Amended by Mass Register Issue 1296, eff. 9/25/2015.Amended by Mass Register Issue 1485, eff. 1/1/2023.