405 Ind. Admin. Code 5-21.8-2

Current through December 4, 2024

Section 405 IAC 5-21.8-2 - Definitions

Authority: IC 12-8-6.5-5; IC 12-15

Affected: IC 12-7-2-40.6; IC 12-13-7-3; IC 12-15-2-3.5; IC 12-29-2; IC 25-23-1-1; IC 25-23.6-10.5; IC 25-27.5-5

Sec. 2.

(a) The definitions in this section apply throughout this rule.

(b) "Applicant" refers to an individual who is seeking enrollment in BPHC services.

(c) "Behavioral and primary health care coordination services" or "BPHC services" refers to coordination of health care services to manage the health care needs of the member including direct assistance in gaining access to health services, coordination of care within and across systems, oversight of the entire case, and linkage to appropriate services.

(d) "Certified community health worker" or "CHW" refers to an individual who meets all of the following:

(1) Has completed the CHW office and Indiana state department of health state-approved training program.

(2) Receives a passing score on the certification exam.

(3) Is supervised by a licensed professional or QBHP.

(4) Delivers services as defined at section 8(a) of this rule.

(e) "Certified recovery specialist" or "CRS" refers to an individual who meets all of the following:

(1) Is maintaining healthy recovery from mental illness.

(2) Has completed the CRS office state-approved training program.

(3) Receives a passing score on the certification exam.

(4) Is supervised by a licensed professional or QBHP.

(5) Delivers services as defined at section 8(a) of this rule.

(f) "DMHA" means the division of mental health and addiction.

(g) "Health" means physical and behavioral health.

(h) "Individualized integrated care plan" or "IICP" means a treatment plan that meets all of the following:

(1) Integrates all components and aspects of care that are:

(A) deemed medically necessary;

(B) needs-based;

(C) clinically indicated; and

(D) provided in the most appropriate setting to achieve the member's goals.

(2) Includes all indicated medical and support services needed by the member in order to:

(A) remain in the community;

(B) function at the highest level of independence possible; and

(C) achieve goals identified in the IICP.

(3) Reflects the member's desires and choices.

(i) "Level of need" means a recommended intensity of services based on a pattern of a member's needs, as determined using the office-approved behavioral health assessment tool.

(j) "Licensed professional" means any of the following persons:

(1) A licensed psychiatrist.

(2) A licensed physician.

(3) A licensed psychologist or a psychologist endorsed as a health service provider in psychology (HSPP).

(4) A licensed clinical social worker (LCSW).

(5) A licensed mental health counselor (LMHC).

(6) A licensed marriage and family therapist (LMFT).

(7) A licensed clinical addiction counselor (LCAC), as defined under IC 25-23.6-10.5.

(k) "Medicaid rehabilitation services" means any medical or remedial service recommended by a physician or other licensed practitioner of the healing arts, within the scope of that individual's practice under state law, for:

(1) maximum reduction of physical or mental health disability; and

(2) restoration to a member's best possible level of functioning.

(l) "Member" means a person receiving BPHC services.

(m) "Needs-based eligibility criteria" means factors used to determine an applicant's need for BPHC services. The applicant meets the BPHC needs-based eligibility criteria when the following are demonstrated:

(1) Needs related to management of the applicant's health.

(2) Impairment in self-management of the applicant's health services.

(3) A health need that requires assistance and support in coordinating health treatment.

(4) A recommendation for intensive community based care based on the uniform office-approved behavioral health assessment tool as indicated by a rating of three (3) or higher.

(n) "Office-approved behavioral health assessment tool" means the state designated assessment tool administered by a qualified individual who is trained and office-certified to administer the tool in order to assist in determining the level of need and functional impairment of an applicant or a member.

(o) "Other behavioral health professional" or "OBHP" means any of the following:

(1) An individual with an associate's or bachelor's degree, or equivalent behavioral health experience who:

(A) meets minimum competency standards set forth by a behavioral health service provider; and

(B) is supervised by either a licensed professional or a QBHP.

(2) A licensed addiction counselor, as defined under IC 25-23.6-10.5, who is supervised by either a licensed professional or a QBHP.

(p) "Provider agency" means any office-approved agency that meets the qualifications and criteria to become a BPHC provider agency, as required by this rule.

(q) "Provider staff" means any individual working for an office-approved BPHC provider agency who meets the qualifications and requirements mandated by the BPHC service being provided, as defined in this rule.

(r) "Qualified behavioral health professional" or "QBHP" means any of the following:

(1) An individual who has had at least two (2) years of clinical experience treating persons with mental illness under the supervision of a licensed professional, with such experience occurring after the completion of a master's degree or a doctoral degree, or both, in any of the following disciplines from an accredited university:

(A) Psychiatric or mental health nursing, including a license as a registered nurse in Indiana.

(B) Pastoral counseling.

(C) Rehabilitation counseling.

(2) An individual who:

(A) is supervised by a licensed professional;

(B) is eligible for and working toward professional licensure; and

(C) has completed a master's degree or a doctoral degree, or both, in any of the following disciplines from an accredited university:

(i) Social work from a university accredited by the Council on Social Work Education.

(ii) Psychology.

(iii) Mental health counseling.

(iv) Marital and family therapy.

(3) A licensed, independent practice school psychologist under the supervision of a licensed professional.

(4) An authorized health care professional (AHCP) who is either of the following:

(A) A physician assistant with the authority to prescribe, dispense, and administer drugs and medical devices or services under an agreement with a supervising physician and subject to the requirements of IC 25-27.5-5.

(B) A nurse practitioner or clinical nurse specialist, with prescriptive authority, performing duties within the scope of that person's license and under the supervision of, or under a supervisory agreement with, a licensed physician under IC 25-23-1.

(s) "State evaluation team" means the office independent evaluation team that will review and assess all evaluation information and supporting clinical documentation collected for BPHC applicants and members and will be responsible for making final determinations regarding the following:

(1) Needs-based and target group eligibility of applicants for BPHC services.

(2) Authorization for BPHC services for eligible members.

(3) Continued eligibility determination for BPHC members.

(4) Appropriate service delivery to BPHC members as a result of conducting quality improvement reviews of BPHC service provider agencies.

(t) "Target group eligibility criteria" means factors used to determine an applicant's eligibility for BPHC services. To meet the BPHC target group criteria, an applicant must:

(1) be nineteen (19) years of age or older; and

(2) have been diagnosed with an eligible primary mental health diagnosis as defined at section 4(3) of this rule.

405 IAC 5-21.8-2

Office of the Secretary of Family and Social Services; 405 IAC 5-21.8-2; filed Apr 8, 2014, 12:41 p.m.: 20140507-IR-405130530FRA

Filed 8/1/2016, 3:44 p.m.: 20160831-IR-405150418FRA

Readopted filed 7/28/2022, 2:21 p.m.: 20220824-IR-405220205RFA

Readopted filed 5/30/2023, 11:54 a.m.: 20230628-IR-405230292RFA