CHAPTER 1155. INTENSIVE BEHAVIORAL HEALTH SERVICES
GENERAL PROVISIONS Sec.
1155.1. Policy.
1155.2. Definitions.
SCOPE OF BENEFITS
1155.11. Scope of benefits.
PROVIDER PARTICIPATION
1155.21. Participation requirements.
1155.22. Ongoing responsibilities of providers.
PAYMENT FOR INTENSIVE BEHAVIORAL
HEALTH SERVICES
1155.31. General payment policy.
1155.32. Payment conditions for individual services.
1155.33. Payment conditions for ABA services.
1155.34. Payment conditions for group services.
1155.35. Payment conditions for EBT delivered through individual services, ABA services or group services.
1155.36. Covered services.
1155.37. Limitations.
UTILIZATION REVIEW
1155.41. Scope of claims review procedures.
ADMINISTRATIVE SANCTIONS
1155.51. Provider misutilization.Authority The provisions of this Chapter 1155 issued under section 201(2) of the Human Services Code (62 P.S. § 201(2)); and section 201(2) of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. § 4201(2)), unless otherwise noted.
Source The provisions of the Chapter 1155 adopted October 18, 2019, effective October 19, 2019, 49 Pa.B. 6088, unless otherwise noted.
GENERAL PROVISIONS
§ 1155.1. Policy.
(a) The Medical Assistance (MA) Program provides payment for intensive behavioral health services (IBHS) when the services are medically necessary and provided to eligible children, youth or young adults with a behavioral health diagnosis by licensed IBHS agencies enrolled in the MA Program as providers under this chapter.
(b) Payment for IBHS is subject to the provisions in this chapter, Chapter 1101 (relating to general provisions), the limitations in Chapter 1150 (relating to MA Program payment policies) and the MA Program fee schedule.
(c) This chapter does not apply to individual licensed practitioners or group arrangements of licensed practitioners that bill only for services provided directly by the licensed practitioners.
§ 1155.2. Definitions.
The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:
ABA—Applied behavior analysis—The design, implementation and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior or to prevent loss of attained skill or function including the use of direct observation, measurement and functional analysis of the relations between environment and behavior.
Caregiver—An individual with responsibility for the care and supervision of a child, youth or young adult.
Child—A person under 14 years of age.
DSM—Diagnostic and Statistical Manual of Mental Disorders.
Department—The Department of Human Services of the Commonwealth.
EBT—Evidence-based therapy—Behavioral health therapy that uses scientifically established behavioral health interventions and meets one of the following:(i) Categorized as effective by the Substance Abuse and Mental Health Services Administration in the Evidence-Based Practice Resource Center.
(ii) Categorized as Model or Model Plus in the Blueprints for Healthy Youth Development registry.
(iii) Categorized as well-established by the American Psychological Association’s Society of Clinical Child and Adolescent Psychology.
(iv) Rated as having positive effects by the Institute of Education Sciences’ What Works Clearinghouse.
Group services—Therapeutic interventions provided primarily in a group format through psychotherapy; structured activities, including ABA services; and community integration activities that address a child’s, youth’s or young adult’s identified treatment needs.
IBHS—Intensive behavioral health services—An array of therapeutic interventions and supports provided to a child, youth or young adult in the home, school or other community setting.
IBHS agency—An entity that provides one or more IBHS.
ICD—International Classification of Diseases.
ITP—Individual treatment plan—A detailed written plan of treatment services specifically tailored to address a child’s, youth’s or young adult’s therapeutic needs that contains the type, amount, frequency, setting and duration of services to be provided and the specific goals, objectives and interventions for the service.
Individual services—Intensive therapeutic interventions and supports that are used to reduce and manage identified therapeutic needs, increase coping strategies and support skill development to promote positive behaviors with the goal of stabilizing, maintaining or maximizing functioning of a child, youth or young adult in the home, school or other community setting.
Initiation of service—The first day an individual service, ABA service or group service is provided. This includes the first day an assessment is conducted.
MA—Medical Assistance.
Staff—Any individual, including an independent contractor or consultant, who works for an IBHS agency.
Young adult—A person 18 years of age or older but under 21 years of age.
Youth—A person 14 years of age or older but under 18 years of age.
SCOPE OF BENEFITS
§ 1155.11. Scope of benefits.
Children, youth or young adults with a behavioral health diagnosis are eligible to receive covered IBHS.
PROVIDER PARTICIPATION
§ 1155.21. Participation requirements.
In addition to the participation requirements in Chapter 1101 (relating to general provisions), an IBHS agency shall meet the following requirements to participate in the MA Program:
(1) Be licensed as an IBHS agency in accordance with Chapters 20 and 5240 (relating to licensure or approval of facilities and agencies; and intensive behavioral health services).
(2) Enter into a written provider agreement with the Department.
(3) Be enrolled in the MA Program by the Department.
§ 1155.22. Ongoing responsibilities of providers.
(a) Ongoing responsibilities of IBHS agencies are in Chapters 1101 and 5240 (relating to general provisions; and intensive behavioral health services).
(b) Recordkeeping requirements for IBHS agencies are in § § 1101.51(e), 5240.41 and 5240.42 (relating to ongoing responsibilities of providers; individual records; and agency records).
(c) An IBHS agency shall notify the Department of a change in name or address.
PAYMENT FOR INTENSIVE BEHAVIORAL
HEALTH SERVICES
§ 1155.31. General payment policy.
(a) Except as provided in subsections (b)—(d), payment is made to a licensed IBHS agency for medically necessary IBHS provided by qualified individuals under the supervision and direction of a clinical director that meets the qualifications in § 5240.12(b) or § 5240.81(b) (relating to staff qualifications; and staff qualifications for ABA services), subject to the conditions and limitations in this chapter, Chapters 1101 and 1150 (relating to general provisions; and MA Program payment policies) and the MA Program fee schedule.
(b) Payment will be made to an IBHS agency that complies with Chapter 5240 (relating to intensive behavioral health services) and holds an outpatient psychiatric clinic, a psychiatric partial hospitalization program or a family-based mental health license issued by the Department as of October 19, 2019, until the agency’s license expires.
(c) Payment will be made to an unlicensed IBHS agency that complies with Chapter 5240 and is approved to provide behavioral health rehabilitation services as of October 19, 2019, for 1 year after promulgation of this chapter.
(d) Payment will be made to an unlicensed IBHS agency that complies with Chapter 5240 and is approved to provide ABA services as of October 19, 2019, for 180 days after promulgation of this chapter.
(e) Payment will not be made for a compensable IBHS if payment is available through a third party. Providers shall comply with § 1101.64 (relating to third-party medical resources (TPR)).
§ 1155.32. Payment conditions for individual services.
(a) Payment will be made to a licensed IBHS agency for individual services if the following conditions are met:
(1) There is a written order for services based on a face-to-face interaction with the child, youth or young adult that meets the following:
(i) Written within 12 months prior to the initiation of IBHS.
(ii) Written by a licensed physician, licensed psychologist, certified registered nurse practitioner or other licensed professional whose scope of practice includes the diagnosis and treatment of behavioral health disorders and the prescribing of behavioral health services, including IBHS.
(iii) Includes a behavioral health disorder diagnosis listed in the most recent edition of the DSM or ICD.
(iv) Orders one or more IBHS for the child, youth or young adult and includes the following:
(A) The clinical information to support the medical necessity of the service ordered.
(B) The maximum number of hours of each service per month.
(C) The settings where services may be provided.
(D) The measurable improvements in the identified therapeutic needs that indicate when services may be reduced, changed or terminated.
(2) A face-to-face assessment has been completed by an individual qualified to provide behavior consultation services or mobile therapy services within 15 days of the initiation of individual services and prior to completing the ITP in accordance with § 5240.21 (relating to assessment) or a face-to-face assessment has been reviewed and updated within 12 months of the previous face-to-face assessment.
(3) The assessment and all updates have been signed by the staff person who completed the assessment.
(4) An ITP based upon the assessment and the written order for services has been completed within 30 days after the initiation of services in accordance with § 5240.22 (relating to individual treatment plan) or an ITP has been reviewed and updated within 6 months of the previous ITP.
(5) The ITP and all updates have been reviewed and signed by the youth, young adult, or parent or legal guardian of the child or youth, the staff person who completed the ITP and an individual who meets the qualifications of a clinical director in § 5240.12 (relating to staff qualifications).
(6) For continued individual services, a child, youth or young adult shall have an order written within 12 months of the initiation of the continued services that complies with subsection (a)(1)(ii)—(iv).
(b) Payment will be made to a licensed IBHS agency for individual services for up to 45 days after initiation of services, if an ITP has not yet been completed but there is a written order for services that complies with subsection (a)(1) and there is a treatment plan for the individual services provided.
Cross References This section cited in 55 Pa. Code § 1155.34 (relating to payment conditions for group services); 55 Pa. Code § 1155.35 (relating to payment conditions for EBT delivered through individual services, ABA services or group services); 55 Pa. Code § 1155.37 (relating to limitations); 55 Pa. Code § 5240.22 (relating to individual treatment plan); 55 Pa. Code § 5240.41 (relating to individual records); 55 Pa. Code § 5240.74 (relating to individual services initiation requirements); and 55 Pa. Code § 5240.96 (relating to individual treatment plan).
§ 1155.33. Payment conditions for ABA services.
(a) Payment will be made to a licensed IBHS agency for ABA services if the following conditions are met:
(1) There is a written order for ABA services based on a face-to-face interaction with the child, youth or young adult that meets the following:
(i) Written within 12 months prior to the initiation of ABA services.
(ii) Written by a licensed physician, licensed psychologist, certified registered nurse practitioner or other licensed professional whose scope of practice includes the diagnosis and treatment of behavioral health disorders and the prescribing of behavioral health services, including IBHS.
(iii) Includes a behavioral health disorder diagnosis listed in the most recent edition of the DSM or ICD.
(iv) Orders ABA services for the child, youth or young adult and includes the following:
(A) The clinical information to support the medical necessity of each ABA service ordered.
(B) The maximum number of hours of each ABA service per month.
(C) The settings where ABA services may be provided.
(D) The measurable improvements in targeted behaviors or skill deficits that indicate when services may be reduced, changed or terminated.
(2) A face-to-face assessment has been completed by an individual qualified to provide behavior analytic services or behavior consultation-ABA services within 30 days of the initiation of ABA services and prior to completing the ITP in accordance with § 5240.85 (relating to assessment) or a face-to-face assessment has been reviewed and updated within 12 months of the previous face-to-face assessment.
(3) The assessment and all updates have been signed by the staff person who completed the assessment.
(4) An ITP based upon the assessment and the written order for ABA services has been completed within 45 days after the initiation of ABA services in accordance with § 5240.86 (relating to individual treatment plan) or an ITP has been reviewed and updated within 6 months of the previous ITP.
(5) The ITP and all updates have been reviewed and signed by the youth, young adult, or parent or legal guardian of the child or youth, the staff person who completed the ITP and an individual who meets the qualifications of a clinical director in § 5240.81 (relating to staff qualifications for ABA services).
(6) For continued ABA services, a child, youth or young adult shall have an order written within 12 months of the initiation of the continued services that complies with subsection (a)(1)(ii)—(iv).
(b) Payment will be made to a licensed IBHS agency for ABA services for up to 75 days after initiation of services, if an ITP has not yet been completed but there is a written order for services that complies with subsection (a)(1) and there is a treatment plan for the ABA services provided.
Cross References This section cited in 55 Pa. Code § 1155.35 (relating to payment conditions for EBT delivered through individual services, ABA services or group services); 55 Pa. Code § 1155.37 (relating to limitations); 55 Pa. Code § 5240.41 (relating to individual records); 55 Pa. Code § 5240.84 (relating to ABA services initiation requirements); and 55 Pa. Code § 5240.86 (relating to individual treatment plan).
§ 1155.34. Payment conditions for group services.
(a) Payment will be made to a licensed IBHS agency for group services if the following conditions are met:
(1) There is a written order for group services that meets the requirements of § 1155.32(a)(1) (relating to payment conditions for individual services).
(2) A face-to-face assessment has been completed by a graduate-level professional within 15 days of the initiation of group services and prior to completing the ITP in accordance with § 5240.95 (relating to assessment) or a face-to-face assessment has been reviewed and updated within 12 months of the previous face-to-face assessment.
(3) The assessment and all updates have been signed by the staff person who completed the assessment.
(4) An ITP based upon the assessment and written order for group services has been completed within 30 days after the initiation of services in accordance with § 5240.96 (relating to individual treatment plan) or an ITP has been reviewed and updated within 6 months of the previous ITP.
(5) The ITP and all updates have been reviewed and signed by the youth, young adult, or parent or legal guardian of the child or youth, the staff person who completed the ITP and an individual who meets the qualifications of a clinical director in § 5240.12 (relating to staff qualifications).
(6) For continued group services, a child, youth or young adult shall have an order written within 12 months of the initiation of the continued services that complies with § 1155.32(a)(1)(ii)—(iv).
(b) Payment will be made to a licensed IBHS agency for individual interventions provided as part of group services when included in the child’s, youth’s or young adult’s ITP.
(c) Payment will be made to a licensed IBHS agency for group services for up to 45 days after initiation of services, if an ITP has not yet been completed but there is a written order for services that complies with subsection (a)(1) and there is a treatment plan for the group services provided.
Cross References This section cited in 55 Pa. Code § 1155.35 (relating to payment conditions for EBT delivered through individual services, ABA services or group services); 55 Pa. Code § 1155.37 (relating to limitations); 55 Pa. Code § 5240.41 (relating to individual records); 55 Pa. Code § 5240.94 (relating to group services initiation requirements); and 55 Pa. Code § 5240.96 (relating to individual treatment plan).
§ 1155.35. Payment conditions for EBT delivered through individual services, ABA services or group services.
(a) Payment will be made to a licensed IBHS agency for EBT delivered through individual services, ABA services or group services if the following conditions are met:
(1) There is a written order for EBT that meets the requirements of § § 1155.32(a)(1), 1155.33(a)(1) or 1155.34(a)(1) (relating to payment conditions for individual services; payment conditions for ABA services; and payment conditions for group services).
(2) A face-to-face assessment has been completed by an individual with the qualifications required by the EBT within 15 days of the initiation of the services and prior to completing the ITP in accordance with § 5240.102 (relating to assessment and individual treatment plan) or a face-to-face assessment has been reviewed and updated within 12 months of the previous face-to-face assessment.
(3) The assessment and all updates have been signed by the staff person who completed the assessment.
(4) An ITP based upon the assessment and the written order for services has been completed within 30 days of the initiation of services in accordance with § 5240.102 or an ITP has been reviewed and updated within 6 months of the previous ITP.
(5) The ITP and all updates have been reviewed and signed by the youth, young adult, or parent or legal guardian of the child or youth, the staff person who completed the ITP and an individual who meets the qualifications of a clinical director in § 5240.12 (relating to staff qualifications).
(6) For continued EBT, a child, youth or young adult shall have an order written within 12 months of the initiation of the continued services that complies with § § 1155.32(a)(1)(ii)—(iv), 1155.33(a)(1)(ii)—(iv) or 1155.34(a)(1)(ii)—(iv).
(7) The IBHS agency or the individual providing the EBT has certification or licensure from the National certification organization or entity that developed or owns the EBT.
(8) Services are delivered in accordance with the specific EBT.
(b) Payment will be made to a licensed IBHS agency for EBT delivered through individual services, ABA services or group services for up to 45 days after initiation of services, if an ITP has not yet been completed but there is a written order for services that complies with subsection (a)(1) and there is a treatment plan for the EBT provided.
Cross References This section cited in 55 Pa. Code § 5240.101 (relating to EBT initiation requirements).
§ 1155.36. Covered services.
The Department will pay for the following IBHS when the services are medically necessary:
(1) Individual services, which include:
(i) Behavior consultation services.
(ii) Mobile therapy services.
(iii) Behavioral health technician services.
(2) ABA services, which include:
(i) Behavior analytic services.
(ii) Behavior consultation—ABA services.
(iii) Assistant behavior consultation—ABA services.
(iv) Behavioral health technician—ABA services.
(3) Group services.
(4) EBT delivered through individual services, ABA services or group services.
(5) Services approved through the program exception process under § 1150.63 (relating to waivers).
§ 1155.37. Limitations.
Payment is subject to the following limitations:
(1) Services provided to a child, youth or young adult must be included in the agency’s approved service description.
(2) Services provided to a child, youth or young adult residing in a 24-hour residential facility will not be paid for unless the IBHS is ordered in accordance with § § 1155.32(a)(1), 1155.33(a)(1) or 1155.34(a)(1) (relating to payment conditions for individual services; payment conditions for ABA services; and payment conditions for group services), the order explains why services are needed in addition to services provided by the facility and the service does not duplicate services included in the facility’s rate.
UTILIZATION REVIEW
§ 1155.41. Scope of claims review procedures.
Claims submitted for payment under the MA Program are subject to the utilization review procedures in Chapter 1101 (relating to general provisions).
ADMINISTRATIVE SANCTIONS
§ 1155.51. Provider misutilization.
If an IBHS agency is determined to have billed for services inconsistent with MA Program regulations, to have provided services outside the scope of customary standards of clinical practice or to have otherwise violated the standards in the provider agreement, the IBHS agency is subject to the sanctions in Chapter 1101 (relating to general provisions).
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