Mo. Code Regs. tit. 13 § 70-25.140

Current through Register Vol. 49, No.12, June 17, 2024

Section 13 CSR 70-25.140 - Biopsychosocial Treatment of Obesity for Youth and Adults

PURPOSE: This rule establishes the MO HealthNet payment policy for the biopsychosocial treatment of obesity for youth and adult participants. The goal of this policy is to improve health outcomes for both the youth and adult population by managing obesity and associated co-morbidities.

PUBLISHER'S NOTE: The secretary of state has determined that the publication of the entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here.

(1) Administration. The MO HealthNet Division, Department of Social Services, shall administer Biopsychosocial Treatment of Obesity for Youth and Adult participants. Biopsychosocial treatment of obesity services covered and not covered, the limitations under which services are covered, and the maximum allowable fees for all covered services shall be determined by the MO HealthNet Division and shall be included in the MO HealthNet Physician Provider Manual and Behavioral Health Services Manual, which are incorporated by reference and made part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its website at, http://manuals.momed.com/manuals, December 27, 2019. This rule does not incorporate any subsequent amendments or additions. Biopsychosocial treatment of obesity services covered by the MO HealthNet program shall include only those which are shown to be medically necessary.

(A) In the administration of the rule, the following definitions are used:

1. "Biopsychosocial Treatment of Obesity" means using a combination of obesity screenings, Medical Nutrition Therapy (MNT), and Intensive Behavioral Therapy (IBT) to promote life style changes leading to weight loss in adult and youth participants.

A. "Adult Intensive Behavioral Therapy (IBT)" means obesity management by utilizing intensive multicomponent, behavior-based weight loss interventions that promote and sustain weight loss in adult participants.

B. "Youth Intensive Behavioral Therapy (IBT)" means obesity management by utilizing comprehensive, intensive behavior-based weight loss interventions that can include multi-component family-based behavioral treatment (FBT) interventions tailored to participant needs targeting both the parent/guardian and the youth;

2. "Body Mass Index (BMI)" means a measure that relates body weight to height and is calculated by dividing weight in kilograms (kg) by the square of height in meters (expressed in kg/m2).

A. "Body Mass Index (BMI) Percentile" means the range of BMI values as expressed in percentiles for age and gender as plotted on the pediatric BMI chart.

B. "Pediatric Body Mass Index (BMI) Chart" means a graphic display of normal progressive changes in body mass index for the pediatric population ages two (2) to twenty (20) years of age;

3. "Consultation" for the purpose of this rule means the experienced behavioral health clinician who meets provider requirements for Intensive Behavioral Therapy (IBT) outlined in this regulation support and evaluate the newly certified provider's competency in delivery of behaviorally based intervention for patients diagnosed with obesity;

4. "Medical Nutrition Therapy (MNT)" means nutritional diagnostic, therapy, and counseling services furnished by a licensed registered dietitian or registered dietitian nutritionist, and includes a review of nutritional health, eating habits, and development of an individualized nutrition plan; and

5. "Qualified University" means a United States regionally accredited college, university, or foreign equivalent, or an academic university-based medical center affiliated with such a university.

(2) Provider Participation. To be eligible to provide services for the MO HealthNet Biopsychosocial Treatment of Obesity Program-

(A) All Biopsychosocial Treatment of Obesity service providers must be enrolled as MO HealthNet providers;

(B) Provider Requirements for MNT. In order to provide medical nutrition therapy for obesity a provider is required to meet the following criteria:

1. Have a current license to practice as a Licensed Registered Dietitian or Registered Dietitian Nutritionist in the state in which they practice;

2. The Provider will need to obtain one (1) of the following specialist certificates in order to provide MNT for treatment of obesity:

A. Certificate of Training in Adult Weight Management Program;

B. Certificate of Training in Obesity Interventions for Adults;

C. Certificate of Training in Child and Adolescent Weight Management; or

D. Completion of a qualified training program that provides professional medical nutrition therapy training addressing obesity and weight management treatment for participant population(s) served;

3. A licensed provider may provide MNT without a certificate as listed above if the provider meets the following criteria:

A. The provider has maintained a dietitian license credential for a minimum of two (2) years;

B. The provider has a minimum of two thousand (2,000) hours of specialty practice experience delivering weight management behavioral treatment for individuals and/or families or youth with obesity diagnoses within the past five (5) years; and

C. The provider will have documentation of a minimum of six (6) hours of obesity or weight management CEUs or professional equivalent post receipt of license credential;

(C) Provider Requirements for IBT. In order to provide individual and/or group intensive behavioral therapy (IBT) and/or family-based behavioral treatment (FBT) for youth and adults a provider is required to meet the following criteria:

1. Have a current license to practice as one (1) of the following provider types: psychiatrist, clinical social worker, psychologist, or professional counselor, martial and family therapist, or psychiatric advanced practice registered nurses. Registered dietitians are eligible to provide group IBT and/or FBT; 2. A specialist certification for the participant population(s) served that was attained through completion of a qualified training program that addresses delivery of behaviorally based intervention for adult and/or youth participants diagnosed with obesity; 3. A licensed provider may provide IBT without a certificate with the following criteria:

A. The licensed provider has maintained one (1) of the aforementioned license credentials for a minimum of two (2) years; B. The provider has a minimum of two thousand (2,000) hours of specialty practice experience delivering weight management behavioral treatment for individuals and/or families and youth with obesity diagnosis within the past five (5) years; and C. The provider will have documentation with a minimum of six (6) hours of obesity or weight management CEUs or professional equivalent post receipt of license credential;

(D) Continuing Education Unit (CEU) requirement. The provider must maintain six (6) hours of obesity or weight management CEUs or professional equivalent every two (2) years for the patient population served, either youth or adult or both.

1. The required evaluation and documentation on compliance with certification standards post completion of a qualified training program from an experienced provider does not count toward the six (6) hours of CEUs.

(E) The provider must meet the provider qualifications outlined in this regulation in order to bill MO HealthNet for the service.

(3) Qualified Training Program Requirements.

(A) A qualified training program has stated learning objectives for the course content and includes the following:

1. Content-expert instruction and interactive discussion (which may occur face-to-face or by electronic delivery);

2. Course materials developed by professionals with demonstrated expertise in the content area;

3. Content areas cover evidence-based approaches to effectively deliver weight management and obesity treatment for adult and/or youth participants using a family-centered, comprehensive approach; and 4. Sponsored by or conducted in affiliation with a qualified university.

(B) The training program for youth and adults participants shall contain a mix of didactics with simulation work conducted by members of the training center staff.

(C) The qualified training program shall provide a certificate upon completion of the program.

(D) Qualified training programs on IBT and FBT shall provide a means for newly certified behavioral providers to receive evaluation and documentation on compliance with post-program certification standards from an experienced provider using established procedures.

1. After completion of the qualified training program for IBT, the provider is certified for one (1) year.

2. To receive the specialty certificate after one (1) year to continue delivering IBT/FBT, the provider is required to complete clinical consultations with an experienced IBT/FBT provider in accordance with established procedures.

3. The qualified training program will provide those completing the program details on how to obtain a renewal specialist certification and a list of experienced eligible providers to provide consultation and review IBT/FBT competency.

4. Renewal of specialist certification for IBT/FBT will not be issued until the new provider receives documentation on compliance with certification standards from an experienced provider.

(4) Participant Criteria. Any person who is eligible for Title XIX benefits from the Family Support Division and who also meets the following criteria shall be deemed eligible to receive these services:

(A) Be five (5) through twenty (20) years of age for youth services or twenty-one (21) years of age or older for adult services;

(B) Not currently pregnant;

(C) Be obese by meeting the following criteria:

1. For youth participants a body mass index (BMI) percentile equal to or greater than the ninety-fifth (95th) percentile for age and gender on the pediatric body mass index (BMI) chart.

2. For adult participants a body mass index (BMI) equal to or greater than thirty (30); and

(D) Not concurrently receiving authorization for other MO HealthNet reimbursed weight reduction services.

(5) Biopsychosocial Treatment of Obesity Services.

(A) Biopsychosocial Treatment of Obesity Services provide integrated medical nutrition therapy and behavioral health services, coordinated by the primary care or referring physician, or other licensed practitioner of healing, to facilitate behavior changes to manage obesity and associated co-morbidities. Biopsychosocial treatment of obesity for youth and adult participants requires a referral and a prescribed service in the participant's plan of care from a prescribing provider as part of an office visit for evaluation and management. The prescribing provider must obtain prior authorization from MO HealthNet before the participant starts receiving services. A prescribing provider is defined as a physician or other licensed practitioner of healing arts within the scope of authorized practice under State law.

1. Service structure for youth participants.

A. Biopsychosocial Treatment of Obesity Youth Services include a six (6) month period of intervention that allows a maximum of four (4) hours of individual IBT and twenty-two (22) hours of group IBT for a total of twenty-six (26) hours of IBT and one (1) hour and forty-five (45) minutes of MNT.

B. Upon completion of the six (6) month period of services, the dietitian and behavioral health provider shall make recommendations to the prescribing provider regarding continuation of services based on the continuation criteria set forth by MO HealthNet. The prescribing provider shall make the final determination for the participant to continue with the services based on the participant meeting the continuation criteria and shall request prior authorization for the additional six (6) months of services.

C. Continuation Criteria for the youth participant months seven (7) through twelve (12) include the following:

(I) The youth participant must meet whichever is lesser of the three (3) youth benchmarks listed below, at the end of month six (6) of services-

(a) A decrease in their BMI chart percentile to less than the ninety-fifth (95th) percentile or five percent (5%) of body weight;

(b) The youth participants that had a BMI percentile at the beginning of treatment >99th percentile, shows a decrease of nine (9) units in percentage above the ninety-fifth (95th) percentile (as calculated by age and gender norms of the CDC BMI percentile curve); or

(c) Weight stabilization (defined as ±0.5 BMI units); and

(II) If the youth participant does not meet the weight loss threshold, the prescribing provider shall perform the necessary lab work to rule out the presence of other conditions (e.g., endocrine disorders) that may complicate efforts to reduce weight, and if present, should request to continue with biopsychosocial treatment with medical treatment for the identified condition(s).

D. Continuation of Biopsychosocial Treatment of Obesity Youth services for months seven (7) through twelve (12) include an additional one (1) hour of individual IBT and two (2) hours of group IBT for a maximum of three (3) hours of IBT; and an additional thirty (30) minutes of MNT.

E. Providers are able to structure the services in order to meet the individual needs of the participant within the maximum allowable service structure. The total annual limit for services for the youth participant is twenty-nine (29) hours for IBT and two (2) hours and fifteen (15) minutes for MNT.

F. If the parent or caregiver does not notify the MNT or IBT providers of absences of the patient and have missed four (4) or more sessions, the MNT or IBT provider may reevaluate the need for further services.

2. Service structure for adult participants-

A. Biopsychosocial Treatment of Obesity Adult Services include a six (6) month period of intervention that allows a maximum of three (3) hours of individual behavior therapy and nine (9) hours of group behavior therapy for a total of twelve (12) hours of behavior therapy and one (1) hour forty-five (45) minutes of MNT;

B. Upon completion of the six (6) month period of services, the dietitian and behavioral health provider shall make recommendations to the prescribing provider regarding continuation of services based on the continuation criteria set forth by MO HealthNet. The prescribing provider shall make the final determination for the participant to continue with the services based on the participant meeting the continuation criteria and shall request prior authorization for the additional six (6) months of services;

C. Continuation Criteria for the adult participant months seven (7) through twelve (12) include the following:

(I) The adult participant must meet the adult benchmark of a reduction in body weight of five percent (5%) at the end of month six (6) of services; and

(II) If the adult participant does not meet the weight loss threshold, the prescribing provider shall perform the necessary lab work to rule out the presence of other conditions (e.g. endocrine disorders) that may complicate efforts to reduce weight, and if present, should request to continue with biopsychosocial treatment with medical treatment for the identified condition(s);

D. Continuation of Biopsychosocial Treatment of Obesity Adult services for months seven (7) through twelve (12) include an additional one (1) hour of individual IBT and two (2) hours of group IBT for a maximum of three (3) hours of IBT; and an additional thirty (30) minutes of MNT;

E. Providers are able to structure the services in order to meet the individual needs of the participant within the maximum allowable service structure. The total annual limit for services for the adult participants is fifteen (15) hours for behavior therapy and two (2) hours fifteen (15) minutes for medical nutritional therapy; and

F. If the participant does not notify the provider of absences and has missed two (2) or more sessions, th provider may reevaluate the need for further services.

G. If the participant does not notify the provider of absences and has missed two (2) or more sessions, the provider may reevaluate the need for further services.

(B) A participant that is unable to meet the continuation criteria for the additional six (6) months of Biopsychosocial Treatment of Obesity services has the option, after twelve (12) months, to re-enroll for services if the participant meets the established criteria and has an approved prior authorization.

(6) Documentation Requirements for Biopsychosocial Treatment of Obesity.

(A) The participant's treatment record shall contain the following documentation, at a minimum:

1. The referring provider's referral with approval from MO HealthNet for months one (1) through six (6) of services;

2. The medical nutritional assessment completed by the dietitian;

3. The initial behavioral assessment completed by the behavioral health provider;

4. Progress notes that include the following information from each visit:

A. A measured weight and calculated BMI for adult participants or BMI percentile for youth participants.

B. Progress the youth/parent/participant is making towards weight loss goals;

C. Challenges (social determinants) the participant is facing and proposed solutions;

D. Recommendations for treatment/care plans; and

E. Collaborative efforts between the providers delivering primary care, MNT, and IBT;

5. The documented evaluation by the dietitian, behavioral health provider, and referring provider at the end of six (6) months to determine the appropriateness for continuation of services. This should include documented progress towards weight loss goals, a desire to continue receiving services, and confirmation of met continuation criteria;

6. If applicable the referring provider's referral with approval from MO HealthNet for months seven (7) through twelve (12) of services;

7. Final evaluation at the end of the twelve (12) month period including documented metabolic, social, and behavior change end-points and identified barriers to maintaining weight loss if the participant qualified for continuation of services; and

8. Once services are completed, the prescribing provider shall maintain a treatment record, incorporating recommendations provided by the dietitian and behavioral health provider as appropriate, which outlines how the participant will maintain the weight loss.

(B) The behavioral health provider and dietitian must complete a six (6) month evaluation and the final evaluation report detailing the amount of weight lost over the treatment period, progress with metabolic, social, and behavior change endpoints, challenges to maintaining weight loss, and any future recommendations for maintaining the weight loss in the context of identified challenges. Both evaluations shall be shared with the referring provider and will become part of the treatment record. The referring provider may incorporate these recommendations and considerations into ongoing care planning and patient management.

(7) Reimbursement Methodology.

(A) MO HealthNet provides reimbursement to enrolled providers providing biopsychosocial treatment of obesity for youth and adults and who are currently licensed, certified, and in good standing with the state.

(B) Reimbursement for services is made on a fee-for-services basis. The maximum allowable fee for a unit of service has been determined by MO HealthNet to be a reasonable fee, consistent with efficiency, economy, and quality of care. Payment for covered services is the lower of the provider's actual billed charge (should be the provider's usual and customary charge to the general public for the service), or the maximum allowable per unit of service. Reimbursement shall only be made for services authorized by MO HealthNet or its designee.

13 CSR 70-25.140

Adopted by Missouri Register February 16, 2020/Volume 46, Number 04, effective 3/31/2021