23 Miss. Code. R. 206-1.3

Current through October 31, 2024

Rule 23-206-1.3 - Covered Services

A. The Division of Medicaid covers four (4) medically necessary mental health assessments by a non-physician per fiscal year when:

1. Completed during the intake process and/or when there is a need for reassessment.

2. Provided by a staff member who holds a master's degree and professional license or is one (1) of the following as appropriate:

a) A Department of Mental Health (DMH) Certified Mental Health Therapist (CMHT),

b) DMH Certified Intellectual and Developmental Disabilities Therapist (CIDDT), or

c) A DMH Certified Addiction Therapist (CAT).

B. The Division of Medicaid covers up to twelve (12) brief emotional/behavioral health assessments per state fiscal year when administered via a standardized behavioral or emotional assessment tool when medically necessary to identify emotional and/or behavioral conditions, including, but not limited to:

1. Depression,

2. Alcohol, substance use or substance abuse,

3. Attention Deficit Hyperactivity Disorder (ADHD), or

4. Other behavioral disorders that may require treatment and/or other forms of intervention.

C. The Division of Medicaid covers four (4) medically necessary treatment plan development and reviews per state fiscal year when:

1. Part of a treatment plan approved by one (1) of the providers listed in Miss. Admin. Code Title 23, Part 206, Rule 1.1.B.1 through B.8., and

2. Provided by one of the providers listed in Miss. Admin. Code Title 23, Part 206, Rule 1.1 B.1 through B.8 or B.9.c.

D. The Division of Medicaid covers medically necessary Targeted Case Management which must include:

1. Completion of a comprehensive assessment and periodic reassessments of beneficiary needs to determine the need for services, including:

a) Beneficiary history,

b) Identifying the needs of the beneficiary and completing related documentation, and

c) Gathering information from other sources to form a complete assessment/reassessment of the beneficiary.

2. Development and periodic revisions of a specific treatment plan that is based on the information collected through the assessment/reassessments that:

a) Specifies the goals and actions to address the medical, social, educational, and other services needed by the beneficiary,

b) Includes activities such as ensuring the active participation of the eligible beneficiary, and working with the beneficiary or the beneficiary's authorized health care decision maker and others to develop those goals,

c) Identifies a course of action to respond to the assessed needs of the eligible beneficiary,

d) Provides referral and related activities, such as scheduling appointments for the beneficiary, to address any identified needs including medical, social, educational providers, or other programs and services to address identified needs and achieve goals specified in the treatment plan.

3. Monitoring and follow-up activities including:

a) Activities and contacts necessary to ensure the treatment plan is implemented and adequately addresses the beneficiary's needs, which may include with the family members, service providers, or other entities or individuals conducted as frequently as necessary including at least one (1) annual monitoring, to determine whether the following conditions are met:

b) Services are being furnished in accordance with the beneficiary's treatment plan;

c) Services in the treatment plan are adequate; and

d) Changes in the needs or status of the beneficiaries are reflected in the treatment plan. Monitoring and follow-up activities at least annually include making necessary adjustments in the treatment plan and service arrangements with providers.

E. The Division of Medicaid covers medically necessary crisis response services.

1. Crisis response services include:

a) Assessment,

b) De-escalation, and

c) Service coordination and facilitation.

2. Crisis response teams must include:

a) A Certified Peer Support Professional with specific roles and responsibilities,

b) A licensed and/or Credentialed Master's Level Therapist with experience and training in crisis response,

c) A Community Support Specialist with experience and training in crisis response,

d) A Crisis Response Coordinator for the provider's catchment area who is a licensed and/or credentialed master's level therapist with a minimum of two (2) years' experience and training in crisis response, and

e) At least one (1) employee with experience and training in crisis response to each population served by the provider.

F. The Division of Medicaid covers up to sixty (60) days of medically necessary crisis residential services per state fiscal year when ordered by a psychiatrist, physician, psychologist, psychiatric mental health nurse practitioner (PMHNP) or physician assistant (PA) and prior authorized by the Division of Medicaid, Utilization Management/Quality Improvement Organization (UM/QIO) or designee.

1. Crisis residential services must provide the following within twenty-four (24) hours of admission:

a) Initial assessment,

b) Medical screening,

c) Drug toxicology screening, and

d) Psychiatric consultation.

2. Crisis residential services include:

a) Treatment plan development and review,

b) Medication management,

c) Nursing assessment,

d) Individual therapy,

e) Family therapy,

f) Group therapy,

g) Crisis response, and

h) Skill building groups such as social skills training, self-esteem building, anger control, conflict resolution and daily living skills.

3. Crisis residential room and board is not covered by the Division of Medicaid.

4. Crisis residential providers must maintain staffing ratios according to DMH standards.

G. The Division of Medicaid covers up to four hundred (400) fifteen (15) minute units per state fiscal year of medically necessary community support services.

1. Community support services must include:

a) Resource coordination that directly increases the acquisition of skills needed to accomplish the goals set forth in the treatment plan.

b) Monitoring and evaluating the effectiveness of interventions, as documented by symptom reduction and progress toward goals.

c) Psychoeducation:

(1) On the identification and self-management of prescribed medication regimen and communication with the prescribing provider.

(2) And training of family, unpaid caregivers, and/or others who have a legitimate role in addressing the needs of the beneficiary.

d) Direct interventions in de-escalating situations to prevent crisis.

e) Home and community visits for the purpose of monitoring the beneficiary's condition and orientation.

f) Assisting the beneficiary and natural supports in implementation of therapeutic interventions outlined in the treatment plan.

2. Community support services must be provided by a Certified Community Support Specialist professional.

H. The Division of Medicaid covers up to four (4) units of medically necessary psychiatric diagnostic evaluations per state fiscal year when prior authorized by the Division of Medicaid, UM/QIO or designee.

I. The Division of Medicaid covers up to four (4) hours of medically necessary psychological diagnostic evaluations per state fiscal year when prior authorized by the Division of Medicaid, UM/QIO or designee and entirely completed by a psychologist.

J. The Division of Medicaid covers medically necessary medication evaluation and management services.

1. Medication evaluation and management services provided by community/private mental health centers are not limited.

2. Medication evaluation and management services provided by independent practitioners within their scope of practice are subject to the physician visit limits in Miss. Admin. Code Title 23, Part 203, Rule 9.5.C.1.

3. Medication evaluation and management must be provided by one (1) of the following:

a) Psychiatrist,

b) Physician,

c) PMHNP, or

d) PA.

K. The Division of Medicaid covers medically necessary medication administration per state fiscal year when provide by one (1) of the following:

1. Psychiatrist,

2. Physician,

3. PMHNP,

4. PA,

5. RN, or

6. LPN.

L. The Division of Medicaid covers up to one hundred forty-four (144), fifteen (15) minute units of nursing assessments performed by an RN per state fiscal year.

M. The Division of Medicaid covers the following medically necessary psychotherapeutic services when part of a treatment plan approved by one (1) of the providers listed in Miss. Admin. Code Part 206, Rule 1.1.B.1 through B.8. and provided by one of the providers listed in Miss. Admin. Code Part 206, Rule 1.1.B.1 through B.8. or B.9.c) as appropriate:

1. Up to thirty-six (36) individual therapy sessions per state fiscal year,

2. Up to twenty-four (24) family therapy sessions per state fiscal year,

3. A combined total of up to forty (40) group therapy or multi-family group therapy sessions per state fiscal year, and

4. Interactive complexity for individual and group therapy as appropriate within yearly limits.

N. The Division of Medicaid covers up to one hundred (100) days of medically necessary acute partial hospitalization services when prior authorized by the Division of Medicaid, UM/QIO or designee.

1. Acute partial hospitalization includes, but is not limited to:

a) Treatment plan development and review,

b) Medication management,

c) Nursing assessment,

d) Individual therapy,

e) Group therapy, and

f) Family therapy.

2. Acute partial hospitalization programs must be provided by licensed/certified providers including, but not limited to:

a) CMHC/PMHC,

b) The outpatient department of a hospital or free-standing psychiatric unit,

c) A private psychiatric clinic, or

d) Other provider approved by the Mississippi Department of Mental Health.

O. The Division of Medicaid covers up to five (5) hours per day, five (5) days per week of medically necessary psychosocial rehabilitation when prior authorized by the Division of Medicaid, UM/QIO or designee.

1. Psychosocial rehabilitation services are not covered when provided on the same day as group therapy, crisis residential services or acute partial hospitalization.

2. Psychosocial rehabilitation services must be included in a treatment plan approved by one (1) of the providers listed in Miss. Admin. Code Title 23, Rule 1.1.B.1 through B.8.

3. Psychosocial rehabilitation service must be provided according to DMH standards for that population.

P. The Division of Medicaid covers one thousand six hundred (1600) fifteen minute units per state fiscal year of medically necessary assertive community treatment services provided through Programs of Assertive Community Treatment (PACT).

1. PACT is an all-inclusive service that includes, but is not limited to:

a) Treatment plan review and development,

b) Medication management,

c) Individual therapy,

d) Family therapy,

e) Group therapy,

f) Community support, and

g) Peer support.

2. The composition of the PACT team members must include, but is not limited to:

a) A team leader,

b) A Psychiatrist or PMHNP,

c) RN,

d) Master's level mental health professional,

e) Substance use disorder specialist,

f) Employment specialist,

g) Certified peer support specialist professional, and

h) Other clinical personnel as determined by DMH.

Q. The Division of Medicaid covers up to two hundred and seventy (270) days per year of medically necessary intensive community outreach and recovery team (ICORT) services when prior authorized by the Division of Medicaid, UM/QIO or designee.

1. ICORT services include:

a) Treatment plan development and review,

b) Medication management,

c) Individual therapy and family therapy in the home,

d) Group therapy,

e) Peer support services,

f) Community support services,

g) Skill building groups, including but not limited to:

1) Social skills training,

2) Self-esteem building,

3) Anger control,

4) Conflict resolution, and

5) Daily living skills.

2. ICORT providers must have the following staff:

a) Team Leader which must be a full-time Master's Level Mental Health Therapist,

b) A full-time registered nurse,

c) A full-time equivalent Certified Peer Support Specialist Professional,

d) A part-time clerical personnel, and

e) If deemed necessary by the DMH, a part-time Community Support Specialist must be added to ICORT.

3. ICORT services must be included in a treatment plan approved by one (1) of the providers listed in Miss. Admin. Code. Title 23, Part 106, Rule 1.1.B.1. through B.8.

4. Development and revision of a specific treatment plan based on the information collected through the assessment which must include:

a) Goals and actions to address the medical, social, educational, and other services needed by the beneficiary,

b) Activities such as ensuring the active participation of the beneficiary and working with the beneficiary or beneficiary's representative and others to develop goals, and

c) A course of action to respond to the assessed needs of the beneficiary.

5. Referral and related activities to help the beneficiary obtain needed services, including but not limited to:

a) Scheduling appointments, and

b) Linking the beneficiary with medical, social and educational providers or other programs and services that provide needed services as identified in the treatment plan.

6. Monitoring and follow-up activities to ensure the treatment plan is effectively implemented and adequately addresses the needs of the beneficiary conducted annually and as necessary to ensure:

a) Services are being furnished in accordance with the beneficiary's treatment plan,

b) Services in the treatment plan are adequate, and

c) Any necessary changes to the treatment plan are made based on any changes in the needs or status of the beneficiary.

R. The Division of Medicaid covers up to two hundred (200) fifteen (15) minute units per state fiscal year of medically necessary peer support services.

1. Peer support services must include:

a) Development of a recovery support plan, and

b) Skill building for coping with and managing symptoms while utilizing natural resources, and the preservation and enhancement of community living skills.

2. Services must be provided by a certified Peer Support Specialist Professional.

S. The Division of Medicaid covers medically necessary opioid treatment services that comply with all state and federal requirements.

1. Opioid Treatment services include, but are not limited to:

a) Assessments,

b) Laboratory services,

c) Physician services including Medication Evaluation and Management,

d) Medication Administration,

e) Therapy Services,

f) Medical Services, and

g) Pharmacy Services.

2. Opioid treatment services are provided by professionals operating within their scope of practice as part of a DMH certified opioid treatment program.

3. Physician visits provided as part of an opioid treatment program do not count toward the beneficiary's physician visit annual limit.

23 Miss. Code. R. 206-1.3

42 C.F.R. §§ 440.130, 440.169; Miss. Code Ann. §§ 43-13-117, 43-13-121.

Amended 9/1/2020

Amended 11/1/2020

Amended 7/1/2021

Amended 2/1/2022