Section 471-35-001 - Introduction The Nebraska Medical Assistance Program (NMAP) covers rehabilitative psychiatric services to rehabilitate clients experiencing severe and persistent mental illnesses in the community and thereby avoid more restrictive levels of care such as inpatient psychiatric hospital or nursing facility. Rehabilitative psychiatric services for children age 20 and younger are covered under EPSDT treatment plans, as described in Chapter 32-000 of this Title. Rehabilitative psychiatric services for adults age 21 and older are covered under the rules and regulations of this chapter. The services must be medically necessary and the most appropriate level of treatment for the individual client. This does not include treatment for a primary substance abuse diagnosis.
001.01 Definition of Severe and Persistent Mental Illness Clients with severe and persistent mental illness must meet the following criteria:
1. The client is age 21 and over;2. The client has a primary diagnosis of schizophrenia, major affective disorder, or other major mental illness under the current edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association. Developmental disorders, or psychoactive substance use disorders may be included if they co-occur with the primary mental illnesses listed above;3. The client has a persistent mental illness as demonstrated by the presence of the disorder for the last 12 months or which is expected to last 12 months or longer and will result in a degree of limitation that seriously interferes with the client's ability to function independently in an appropriate and effective manner in two of three functional areas: Vocational/Education, Social Skills, Activities of Daily Living. a. Functional limitations in the area of Vocational/Education abilities are defined as: (1) An inability to be consistently employed or an ability to be employed only with extensive supports, except that a person who can work but is recurrently unemployed because of acute episodes of mental illness is considered vocationally impaired;(2) Deterioration or decompensation resulting in an inability to establish or pursue educational goals within a normal time frame or without extensive supports;(3) An inability to consistently and independently carry out home management tasks, including household meal preparation, washing clothes, budgeting, and child care tasks and responsibilities;b. Functional limitations in the area of Social Skills and abilities are defined as:(1) Repeated inappropriate or inadequate social behavior or an ability to behave appropriately or adequately only with extensive or consistent support or coaching or only in special contexts or situations, such as social groups organized by treatment staff; or(2) Consistent participation in adult activities only with extensive support or coaching and when involvement is mostly limited to special activities established for persons with mental illness or other persons with interpersonal impairments; or(3) A history of dangerousness to self or others.c. Functional limitations in the area of Activities of Daily Living are defined as an inability to consistently perform the range of practical daily living tasks required for basic adult functioning in the community, in three of five areas listed below: (1) Grooming, hygiene, washing of clothes, and meeting nutritional needs;(2) Care of personal business affairs;(3) Transportation and care of residence;(4) Procurement of medical, legal, and housing services; or(5) Recognition and avoidance of common dangers or hazards to self and possessions.4. The client is at significant risk of continuing in a pattern of either institutionalization or living in a severely dysfunctional way if needed mental health services are not provided, and this pattern has existed for one year or longer and is likely to endure for one year or longer; and5. The client does not have a primary diagnosis of substance abuse/substance dependency or developmental disabilities.001.02 Definition of Medical Necessity The NMAP uses the following definition of medical necessity:
"Health care services and supplies which are medically appropriate and -
1. Necessary to meet the basic health needs of the client;2. Rendered in the most cost-efficient manner and type of setting appropriate for the delivery of the covered service;3. Consistent in type, frequency, duration of treatment with scientifically based guidelines of national medical, research, or health care coverage organizations or governmental agencies;4. Consistent with the diagnosis of the condition;5. Required for means other than convenience of the client or his or her physician;6. No more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness, and efficiency;7. Of demonstrated value; and8. No more intense level of service than can be safely provided. The fact that the physician has performed or prescribed a procedure or treatment or the fact that it may be the only treatment for a particular injury, sickness, or mental illness does not mean that it is covered by Medicaid. Services and supplies which do not meet the definition of medical necessity set out above are not covered."
For purposes of covering rehabilitative psychiatric services under this Chapter, the following interpretative notes apply. Medical necessity for rehabilitative psychiatric services includes:
Health care services which are medically appropriate and -
1. Necessary to meet the psychiatric rehabilitation needs of the client;2. Rendered in the most cost-efficient manner and type of setting appropriate for the delivery of the covered service;3. Consistent in type, frequency, duration of service with accepted principles of psychiatric rehabilitation;4. Consistent with the diagnosis of the condition;5. Required for means other than convenience of the client or his or her service provider(s);6. No more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness, and efficiency;7. Of demonstrated value; and8. A no more intense level of service than can be safely provided. For the purpose of this Chapter, rehabilitative psychiatric services are medically necessary when those services can reasonably be expected to increase or maintain the level of functioning in the community of clients with severe and persistent mental illness.
471 Neb. Admin. Code, ch. 35, § 001