Section 405 IAC 5-21.8-8 - BPHC activitiesAuthority: 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. 8.
(a) BPHC reimbursable activities consist of coordination of health care services to manage the health care needs of the member. The BPHC services include the following reimbursable activities:(2) Advocacy and education to assist individuals in navigating the health care system.(3) Activities that help members: (A) gain access to needed health services; and(B) manage their health conditions, including, but not limited to: (i) adhering to health regimens;(ii) scheduling and keeping medical appointments;(iii) obtaining and maintaining a primary medical provider; and(iv) facilitating communication across medical providers.(6) Referral and linkage.(7) Coordination of health services across systems.(8) Monitoring and follow-up.(b) This subsection defines the activities identified at subsection (a)(4) through (a)(9) as follows:(1) Needs assessment consists of identifying the member's needs for coordination of health services. Specific assessment activities necessary to form a complete needs assessment of the member may include the following:(A) Taking the member's history.(B) Identifying the member's needs.(C) Completing related documentation.(D) Gathering information from other sources, such as:(2) IICP development activities include the development of a written IICP based upon the information collected during the needs assessment phase. An IICP shall include member-driven goals for health care or lifestyle changes and identify the health activities and assistance needed to accomplish the member's objectives. An IICP may include activities and goals such as: (A) referrals to medical services;(B) education on health conditions;(C) activities to ensure compliance with health regimens and health care provider recommendations; or(D) activities or contacts necessary to ensure that the IICP is effectively implemented and adequately address the health needs of the individual.(3) Referral and linkage include activities that help link the member with medical providers and other programs and services that are capable of providing needed health services.(4) Coordination of health services includes, but is not limited to, the following: (A) Physician consults, defined as facilitating linkage and communication between medical providers.(B) The BPHC provider serving as a communication conduit between the member and specialty medical and behavioral health providers.(C) Notification, with the member's consent, of changes in medication regimens and health status.(D) Coaching members to help them interact more effectively with providers.(5) Monitoring and follow-up include the following:(A) Face-to-face contact with the member at least every ninety (90) days.(B) Contacts and activities necessary to ensure that the IICP is effectively implemented and adequately addresses the needs of the member.(C) Contacts and activities with the following individuals: (ii) Family members or others who have a significant relationship with the member.(iii) Nonprofessional caregivers.(6) Evaluation includes periodic reevaluation of the member's progress in order to: (A) ensure the IICP is effectively implemented and adequately addresses the member's needs;(B) determine whether the services are consistent with the IICP and any changes to the IICP;(C) make changes or adjustments to the IICP in order to meet the member's ongoing needs; and(D) evaluate the member's progress toward achieving the IICP's objectives.(c) The time devoted to formal supervision between the BPHC provider and the licensed supervisor to review the member's care and treatment shall be:(1) an included BPHC activity;(2) documented in the member's clinical record; and(3) billed under only one (1) provider staff member.(d) The BPHC activities under subsection (b)(1) through (b)(3) and b(4)(A) must be delivered by provider staff who are one (1) of the following: (1) A licensed professional.(e) With the exception of those activities described in subsection (d), provider staff delivering services under this section must be one (1) of the following:(1) A licensed professional.(5) An office-certified community health worker.(f) The following are not reimbursable under this section: (1) Activities billed under behavioral health level of need redetermination.(2) Activities billed under Medicaid rehabilitation option case management.(3) Activities billed under adult mental health habilitation care coordination.(4) Direct provision of medical services or treatment, including, but not limited to, the following: (A) Medical screening such as blood pressure screenings or weight checks.(B) Medication training and support.(C) Individual, group, or family therapy services.(D) Crisis intervention services.(5) Services provided to the member at the same time as another service that is the same in nature and scope, regardless of funding source.(6) Services provided while the member is in an institutional or noncommunity-based setting.(7) Services provided in a manner that is not within the scope or limitations of a BPHC service.(8) Services not documented as covered or approved on the member's office-approved IICP.(9) Services not supported by documentation in the member's clinical record.(10) Services provided that exceed the defined limits of the service, including service quantity, limits, duration, or frequency.(11) Activities excluded from the service scope or definition.(g) BPHC services are limited to a maximum of twelve (12) hours, or forty-eight (48) units, per six (6) months.Office of the Secretary of Family and Social Services; 405 IAC 5-21.8-8; filed Apr 8, 2014, 12:41 p.m.: 20140507-IR-405130530FRAFiled 8/1/2016, 3:44 p.m.: 20160831-IR-405150418FRAReadopted filed 7/28/2022, 2:21 p.m.: 20220824-IR-405220205RFAReadopted filed 5/30/2023, 11:54 a.m.: 20230628-IR-405230292RFA