PROPOSED RULEMAKING
DEPARTMENT OF
HUMAN SERVICES
[ 55 PA. CODE CHS. 1155 AND 5240 ]
Intensive Behavioral Health Services
[48 Pa.B. 4762]
[Saturday, August 4, 2018]The Department of Human Services (Department), under the authority of sections 201(2) and 1021 of the Human Services Code (62 P.S. §§ 201(2) and 1021) and section 201(2) of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. § 4201(2)), proposes to add Chapters 1155 and 5240 (relating to intensive behavioral health services) to read as set forth in Annex A.
Purpose
The purpose of this proposed rulemaking is to codify the minimum licensing standards and program requirements for participation in the Medical Assistance (MA) Program and MA payment conditions for agencies that deliver intensive behavioral health services (IBHS) to children, youth and young adults under 21 years of age with mental, emotional and behavioral health needs. IBHS includes individual services, applied behavioral analysis (ABA) services, evidence-based therapy (EBT) services and group services.
This proposed rulemaking will support children, youth and young adults with mental, emotional and behavioral health needs by improving their functioning, promoting their resiliency and enhancing their quality of life, which will allow the children, youth and young adults to live and participate in the community with their families. This proposed rulemaking will replace the requirements for behavioral health rehabilitation services (BHRS) previously set forth in bulletins issued by the Department. It also adds a requirement for a separate and distinct license for agencies that deliver these services and additional oversight of services. This proposed rulemaking eliminates redundancies in bulletins, streamlines the admission process for IBHS, provides a process for the reinitiation of services within 60 days of discharge if the condition of the child, youth or young adult regresses, establishes training requirements and qualifications for staff delivering each IBHS, and includes provisions to protect the health and safety of a child, youth or young adult receiving services.
Background
BHRS were developed in response to the Omnibus Budget Reconciliation Act of 1989 (Pub.L. No. 101-239), which amended section 1905(r)(5) of the Social Security Act (42 U.S.C.A. § 1396d(r)) to require states to provide ''necessary health care, diagnostic services, treatment, and other measures described in [the Social Security Act] . . . whether or not such services are covered under the State plan.'' BHRS are individualized services provided in the home, school or community to meet the needs of children, youth and young adults under 21 years of age with mental, emotional and behavioral health needs. The Department has issued bulletins to inform providers of the policies and procedures governing BHRS, many of which were issued when these services were new in the continuum of care. The service delivery system has become more complex and sophisticated. Individuals and family members of individuals who receive BHRS, advocates, providers and county administrators have also expressed the need for revised standards for the delivery of BHRS. In response, the Department engaged a diverse group of stakeholders to provide input into the development of regulations that would address the delivery of IBHS.
Requirements
Proposed Chapter 1155 contains the MA payment conditions for IBHS. Proposed Chapter 5240 identifies the minimum program and operational standards for an agency to obtain a license to provide one or more IBHS.
Following is a summary of the major provisions of each chapter included in this proposed rulemaking.
Chapter 1155. Intensive behavioral health services
General provisions and scope of benefits—§§ 1155.1, 1155.2 and 1155.11
This proposed rulemaking establishes the requirements for MA payment for covered IBHS when the services are medically necessary and provided to children, youth and young adults under 21 years of age with mental, emotional and behavioral health needs.
Provider participation in the MA Program—§ 1155.21
This proposed rulemaking requires that for participation in the MA Program the IBHS agency is licensed under Chapter 5240 as an IBHS agency, has a written provider agreement with the Department and is enrolled in the MA Program.
Payment for IBHS—§§ 1155.31—1155.37
This proposed rulemaking establishes the conditions for MA payment for IBHS, which include that services be medically necessary and that there be a written order for the service based on a face-to-face interaction with the child, youth or young adult from a licensed professional whose scope of practice includes the diagnosis and treatment of behavioral health disorders; a comprehensive face-to-face assessment completed after the initiation of services; and an individual treatment plan (ITP) based upon the written order and the assessment. The requirements are consistent for each IBHS included in Chapter 1155 to avoid more stringent requirements creating barriers to access for one service or confusion for parents or caregivers of children, or a youth or young adult seeking the service. A written order can include more than one IBHS, which eliminates the need for duplicative evaluations for the child, youth or young adult. Previously, a psychological or psychiatric evaluation prescribing BHRS, an interagency service planning team (ISPT) meeting and documentation of the ISPT meeting, and a plan of care were required for MA payment for BHRS. Stakeholders have expressed concerns about the time it takes to convene an ISPT meeting and the impact this has had on the initiation of services. This proposed rulemaking makes changes to the MA payment requirements to ensure prompt delivery of the services based upon the written order. This proposed rulemaking also establishes the types of IBHS eligible for MA payment and limitations on MA payment for IBHS.
Chapter 5240. Intensive behavioral health services
General provisions—§§ 5240.1—5240.7
This proposed rulemaking requires that an IBHS agency obtain a license from the Department prior to beginning operations and describes the services that an agency may provide under an IBHS license. It also allows an IBHS agency that holds an outpatient psychiatric clinic, a psychiatric partial hospitalization program or a family based mental health license issued by the Department to continue to provide IBHS until that license expires and then obtain an IBHS license. To aid in the overall readability of this chapter, the provisions that apply to all licensed agencies, regardless of which IBHS they provide, are included in the first sections of Chapter 5240.
This proposed rulemaking requires IBHS agencies to have an administrative director, clinical director and staff. As part of their initial licensing application package, IBHS agencies will also be required to submit to the Department for review and approval a written description of the services the agency will provide. IBHS agencies can include all services in one service description that will be reviewed and approved as part of the licensing process. Previously, agencies were required to submit the service description for each service to the Department for review and approval.
This proposed rulemaking includes specific requirements related to the use of restrictive procedures. Manual restraints may only be used in an emergency situation by trained staff to prevent injury to the child, youth, young adult or others when other less intrusive interventions have been tried but have failed. This proposed rulemaking prohibits the use of any restrictive procedures other than manual restraints and prohibits manual restraints that use a prone position or that apply pressure or weight on a child's, youth's or young adult's respiratory system.
IBHS agencies will be required by this proposed rulemaking to have written agreements to coordinate services with other service providers, which shall be updated at least every 5 years. Coordination of care was a key issue discussed by stakeholders. Additionally, the agency shall have a list of community resources that provide behavioral health services that the agency can provide to parents or caregivers or individuals receiving services upon request.
Staffing and supervision—§§ 5240.11—5240.14, 5240.72, 5240.81, 5240.82 and 5240.102
This proposed rulemaking establishes the minimum staffing requirements for IBHS agencies and includes the minimum qualifications for an IBHS agency's administrative director and clinical director and the responsibilities of IBHS agencies' administrative directors and clinical directors. The staffing qualifications for the administrative director are intended to allow an agency to have an administrative director provide oversight for more than one IBHS agency.
This proposed rulemaking also establishes the minimum qualifications for an individual that supervises staff that provide individual services, ABA services and group services. Supervision requirements have been included in this proposed rulemaking to ensure that staff providing IBHS have the knowledge and skill to carry out the specific procedures and interventions that are identified in the ITP. The qualifications of a supervisor and the amount of supervision a staff person receives depends on the staff position and the qualifications of the individual providing services. Professionals with graduate degrees and clinical training are required to receive less supervision than individuals without these qualifications and are not required to receive supervision prior to the delivery of IBHS independently. Supervision can be provided individually or in group sessions as well as in person or through secure audio or visual technology to provide a variety of options to meet the supervision requirements. To ensure the health and safety of children, youth and young adults receiving IBHS, a supervisor shall be available to consult with all staff during all hours the IBHS agency provides services. If the IBHS agency employs nine or less full-time equivalent staff and provides individual services or ABA services, the clinical director may provide supervision. This will allow small agencies to employ one individual as both the clinical director and supervisor when one staff person could fill both roles without compromising the quality of service delivery.
Additionally, this proposed rulemaking requires the supervisor to document that supervision was provided. In addition to ensuring documentation of all required supervision, this provides a record that can be utilized to develop an individualized training plan that will assist the staff person with developing skills that are specific to the staff person's job. This proposed rulemaking also clarifies that staff do not have to repeat completed training when working for more than one IBHS agency or changing employment. This clarification will allow individuals who have received training and changed jobs to immediately begin providing IBHS. Stakeholders indicated that this not only was an unnecessary cost to agencies, but also that staff could not provide services until the additional training was completed.
This proposed rulemaking also requires IBHS agencies to have policies and procedures in place to ensure that staff having contact with children or youth comply with 23 Pa.C.S. §§ 6301—6386 (relating to Child Protective Services Law), including mandatory reporter and training requirements. This requirement will protect the health, safety and well-being of children and youth receiving IBHS.
Service planning and delivery—§§ 5240.21—5240.23, 5240.85, 5240.86, 5240.92, 5240.105 and 5240.106
This proposed rulemaking requires that IBHS be provided in accordance with each child's, youth's or young adult's ITP in a community-based, clinically appropriate setting as identified in the written order for each service and the ITP. The ITP is to be based upon a comprehensive individualized face-to-face assessment process. The assessment process is the same for individual services, EBT services and group services. There are some differences in the assessment process for ABA services to address the need for completion of standardized assessment tools and the compilation of observational data to identify developmental, cognitive, communicative, behavioral and adaptive functioning across home, school and community settings, which are needed to design appropriate interventions for the ITP. This proposed rulemaking includes time frames for completion of the initial assessment and for the review and update of the assessment to ensure that accurate information is utilized in the development and update of the ITP.
In addition to being based on the assessment, the ITP for all services will be required to include the recommendations from the licensed professional who completed the written order for services; be strength-based with individualized goals, objectives and interventions to address the identified therapeutic needs, skill deficits or targeted behaviors for the child, youth or young adult to function at home, school or in the community; and include the assistance, if any, parents or caregivers may require to address the therapeutic needs of the child, youth or young adult and be developed in collaboration with the child, youth or young adult, and parents or caregivers as appropriate. This proposed rulemaking also contains the time frame for review and update of the ITP and the staff qualified to develop the ITP. The components of the ITP are similar for each service, consistent with current practices and include the components that were discussed with stakeholders.
Service initiation—§§ 5240.74, 5240.84, 5240.91 and 5240.104
This proposed rulemaking requires an IBHS agency to provide IBHS in accordance with the written order for the services and requires the IBHS agency to obtain prior to the initiation of services written consent to receive the services identified in the written order from the youth, young adult, or parent or caregiver of a child or youth.
Discharge—§§ 5240.31 and 5240.32
This proposed rulemaking establishes the criteria for discharging a child, youth or young adult from IBHS including the assurance that other clinical services be in place prior to discharge if needed to ensure continuity of care. An IBHS agency is required to complete at least two telephone contacts within the first 30 days after discharge to monitor the child's, youth's or young adult's maintenance of treatment progress. Stakeholders advocated for follow up contact for a period of time after discharge.
This proposed rulemaking also allows an IBHS agency to continue to serve a child, youth or young adult after the child, youth or young adult is discharged for 90 days if the youth, young adult, parent or caregiver of the child or youth requests within 60 days after a child, youth or young adult is discharged that services be reinitiated for 90 days when the condition of the child, youth or young adult has regressed and impacts the child's, youth's or young adult's ability to function in the home, school or community and when there is a written order for services. This will allow services to be provided expeditiously to stabilize and maintain a child's, youth's or young adult's treatment progress. This provision addresses concerns identified by stakeholders.
Records—§§ 5240.41—5240.43
This proposed rulemaking addresses the elements that must be included in each individual record and the IBHS agency's records and how these records shall be maintained. In addition to other requirements, the individual record must include specific documentation of each IBHS provided to the child, youth or young adult as well as documentation of any use of a manual restraint procedure. Additionally, IBHS agency records must include, among other items, documentation of staffs' credentials and qualifications to provide IBHS to ensure that staff meet the minimum qualifications to provide IBHS; criminal history checks and child abuse certifications for all staff required to have a completed criminal history check or child abuse certifications to ensure the health and safety of each child, youth or young adult receiving services; and an approved service description for all IBHS provided by the agency. A review of IBHS agency records and individual records is included in the yearly licensure process for the Department to ensure the health and safety of children, youth and young adults receiving IBHS.
Nondiscrimination—§ 5240.51
This proposed rulemaking prohibits an IBHS agency from discriminating against staff, or children, youth or young adults receiving services on the basis of race, color, creed, disability, religious affiliation, ancestry, gender, gender identity or expression, sexual orientation, national origin or age and requires an IBHS agency to comply with all applicable Federal and State statutes and regulations.
Quality improvement—§ 5240.61
This proposed rulemaking includes requirements that promote quality services, including the requirement that an IBHS agency have a written quality improvement plan that provides for an annual review of the quality, timeliness and appropriateness of services, and identifies the type of review and the methodology for the review. The IBHS agency is required to prepare a report of the findings of the annual review and make this report available to the public upon request and shall notify the youth, young adult, or parent or caregiver of a child, youth or young adult that the report may be requested upon admission to services.
Individual services—§§ 5240.71, 5240.73 and 5240.75
Individual services are intensive one-to-one 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 and maintaining a child, youth or young adult in the home, school or community setting. Individual services are provided by behavior specialists, mobile therapists and behavioral health technicians (BHT).
This proposed rulemaking includes qualifications for behavior specialists, mobile therapists and BHTs, formerly known as therapeutic staff support (TSS) workers, that are generally consistent with the bulletins. Individuals with graduate-level certifications in behavior analysis from a Nationally-recognized certification board can be behavior specialists and individuals with graduate degrees in psychology, ABA, social work, education, counseling or related field that includes a clinical or mental health direct service practicum and a minimum of 1 year of full-time experience in providing mental health direct services to children, youth or young adults can be behavior specialists. In addition, licensed behavior specialists are qualified to be behavior specialists. If the behavior specialist provides individual services to a child diagnosed with autism spectrum disorder for the treatment of autism spectrum disorder, the behavior specialist shall have the same qualifications as a behavior specialist analyst that provides ABA services. Changes to the qualifications of behavior specialists were made to address stakeholders' concerns about the knowledge and skills of individuals providing services. Mobile therapists shall continue to meet the requirements provided for in the bulletins.
An individual can be a BHT if the individual has or obtains within 18 months of being hired by an IBHS agency as a BHT or within 2 years after the effective date of adoption of this proposed rulemaking, whichever is later, a behavior analysis certification from a Nationally-recognized certification board or the Pennsylvania Certification Board. If the individual does not have the required certification, the individual can be a BHT for 18 months after being hired by an IBHS agency as a BHT or for 2 years of the effective date of adoption of this proposed rulemaking, whichever is later, if the individual has a bachelor's degree in psychology, social work, counseling, sociology, education or related field, or is licensed as a registered nurse and has a minimum of 1 year of full-time experience in providing mental health direct services to children, youth or young adults. A BHT that does not have the required certification but has an associate's degree or at least 60 credits towards a bachelor's degree and 1 year of full-time experience in providing mental health direct services to children, youth or young adults can also provide individual services for 18 months after being hired by an IBHS agency as a BHT or for 2 years after the effective date of adoption of this proposed rulemaking, whichever is later. Previously an individual was required to have 3 years of full-time work experience in a job that involved direct contact with children, youth or young adults to provide services. The Department will be engaging the Pennsylvania Certification Board to develop State specific certifications as required by this proposed rulemaking.
This proposed rulemaking includes training requirements for behavior specialists and mobile therapists who are not required to complete continuing education units as part of their professional licensure. These staff will be required to complete at least 16 hours of Department-approved training annually related to their specific job functions. Training requirements for BHTs are similar to what was previously required for TSS workers. BHTs will be required to receive 30 hours of Department-approved training prior to working independently with a child, youth or young adult. Previously TSS workers had been required to receive 24 hours of training prior to working independently with a child, youth or young adult. Stakeholders recommended the 6-hour increase to allow sufficient time to receive training on the array of training topics that have been required in bulletins and included in this proposed rulemaking. In addition, BHTs shall complete at least 24 hours of Department-approved training within the first 6 months of employment and at least 20 hours of Department-approved training annually that is related to the BHT's specific job functions. BHTs who have a behavior analysis certification may count hours of training and completed coursework required for obtaining and maintaining certification towards the training requirements. In addition, equivalent college coursework may be counted.
The services behavior specialists, mobile therapists and BHTs can provide are also generally consistent with the bulletins. Behavior specialists can assess the behavioral needs of children, youth and young adults; design and direct the implementation of behavioral interventions in the ITP; identify behavioral goals and select appropriate interventions for inclusion in the ITP; and review, analyze and interpret data to determine any changes to goals and objectives included in the ITP; consult with mobile therapists or BHTs on behavioral management protocols and review clinical outcomes for the behavioral interventions being implemented in the treatment plan with the youth, young adult, or parent or caregiver of the child to determine effectiveness of the individual services on a monthly basis. Mobile therapists can provide individual and family therapy; assess the strengths and therapeutic needs of a child, youth or young adult and family or caregiver; and develop the ITP and provide assistance with crisis stabilization and addressing problems a child, youth or young adult has encountered. As part of implementing the ITP, BHTs support children's, youths' or young adults' problem solving skill development; instruct children, youth or young adults on how to understand, direct, interpret, manage and control feelings and emotional responses to situations; assist parents or caregivers with addressing the therapeutic needs of a child, youth or young adult; provide psychoeducational services related to mental health, including the development of improved decision making skills to manage a child's, youth's or young adult's behavior; assist with a child's, youth's or young adult's development of social skills and socially acceptable behaviors; and provide instruction on stress reduction techniques. BHTs are also responsible for collecting data; providing behavioral stabilizations and interventions to children, youth and young adults that support services provided by behavior specialists or mobile therapists; and for making referrals to other necessary services and supports.
ABA—§§ 5240.81—5240.83 and 5240.87
This proposed rulemaking separately identifies ABA as an IBHS that can be provided by qualified staff to children, youth or young adults with autism spectrum disorder and other behavioral health disorders. ABA is 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. ABA can be used for skill development and to target behaviors that impact the ability of the child, youth or young adult to function in the home, school or community setting.
This proposed rulemaking includes qualifications, training and supervision requirements for individuals who deliver ABA services to ensure that staff providing ABA have adequate knowledge, skills and experience. This proposed rulemaking includes additional requirements for the clinical director of an IBHS agency that provides ABA. All clinical directors of IBHS agencies shall be licensed or certified, but the clinical director of an IBHS agency that provides ABA shall either have a current certification as a board-certified behavior analyst (BCBA) from the Behavior Analyst Certification Board or other graduate-level certification in behavior analysis from a Nationally-recognized certification board, or a graduate degree in ABA and a minimum of 1 year of full-time experience in the provision of ABA and obtain BCBA certification or other graduate-level certification in behavior analysis from a Nationally-recognized certification board within 3 years from starting work as the clinical director for any IBHS agency. Based upon discussion and input from stakeholders, this proposed rulemaking allows individuals 3 years to obtain a BCBA or other graduate-level certification in behavior analysis from a Nationally-recognized certification board to ensure that there is adequate qualified staff to perform the functions of the clinical director in an IBHS agency providing ABA services when this proposed rulemaking becomes effective. The 3-year time frame accounts for the requirements for certification which include a graduate degree with specific coursework related to ABA, experience, supervision hours and testing.
ABA can be provided by a behavior specialist analyst, assistant behavior specialist analyst (ABSA) and a BHT-ABA. The qualifications for a behavior specialist analyst, formerly a behavior specialist consultant, have been changed from the requirements included in the bulletins. Behavior specialist analysts shall be licensed as a psychologist, professional counselor, marriage and family therapist, clinical social worker, social worker or behavior specialist, and have a graduate or undergraduate-level certification in behavior analysis from the Behavior Analyst Certification Board or other Nationally-recognized certification board, or a current certification as a behavior specialist analyst with a competency in ABA from the Pennsylvania Certification Board, or a minimum of 12 credits in ABA and 1 year of full-time experience in the provision of ABA, or a minimum of 1 year of full-time experience in the provision of ABA under the supervision of an individual with a graduate-level certification in behavior analysis.
The qualifications for a BHT-ABA, formerly a TSS worker, have also been changed to ensure that staff providing ABA have adequate training and skills to provide ABA services to children, youth and young adults with mental, emotional and behavioral health needs. A BHT-ABA shall have or obtain within 18 months of being hired by an IBHS agency as a BHT-ABA or within 2 years after the effective date of adoption of this proposed rulemaking, whichever is later, a behavior analysis certification from a Nationally-recognized certification board or the Pennsylvania Certification Board. If an individual does not have the required certification, the individual can be a BHT-ABA for 18 months after being hired by an IBHS agency as a BHT-ABA or for 2 years after the effective date of adoption of this proposed rulemaking, whichever is later, if the individual has a bachelor's degree in psychology, social work, nursing, counseling, education or related field or if the individual has an associate's degree or at least 60 credits towards a bachelor's degree with 12 credits in providing ABA and a minimum of 1 year of full-time experience in the provision of ABA. The Department will be engaging the Pennsylvania Certification Board to develop a State-specific certification in ABA for BHTs based upon the recommendations of stakeholders.
This proposed rulemaking also includes a staff position that allows a professional who meets all of the requirements for licensure as a behavior specialist under 49 Pa. Code § 18.524 (relating to criteria for licensure as behavior specialist) with the exception of the experience requirement to be employed as an ABSA. This will provide a path for an ABSA to gain the required hours of experience for licensure while providing ABA under the supervision of a qualified individual. This will increase the availability of ABA services while ensuring that ABA services are provided by qualified and appropriately supervised individuals. An individual who has a bachelor's degree in psychology, social work, counseling, education or related field and an undergraduate-level certification in behavior analysis or at least 12 credits in ABA and 6 months of experience in providing ABA can also be employed as an ABSA.
Supervision requirements have been included in this proposed rulemaking to ensure staff providing ABA services have the knowledge and skill to carry out the specific procedures and interventions that are identified in the ITP. Supervision includes direct observation of the provision of ABA to a child, youth or young adult during the implementation of the ITP goals. Supervision requirements are based upon staff qualifications, skills and job functions. Documentation of supervision is consistent with other IBHS supervision requirements and provides a mechanism to design the individual training plan for each staff.
This proposed rulemaking requires all staff providing ABA to have initial and ongoing training related to ABA with the number of hours of training varying based upon staff qualifications, credentials, experience and job function. Behavior specialist analysts who are licensed as behavior specialists will be required to complete at least 45 hours of training related to ABA that is approved by the Behavior Analyst Certification Board or the Department before independently providing ABA services to children, youth or young adults. ABA training completed prior to obtaining licensure as a behavior specialist may be counted towards the 45 hours of training related to ABA. In addition, behavior specialist analysts shall complete at least 16 hours of training annually that is approved by the Behavior Analyst Certification Board or the Department and related to the behavior specialist analyst's specific job functions. An ABSA who does not have a graduate or undergraduate certification in behavior analysis shall complete at least 20 hours of training related to ABA that is approved by the Behavior Analyst Certification Board or the Department before independently providing ABA services to a child, youth or young adult and at least 20 hours of training annually that is approved by the Behavior Analyst Certification Board or the Department and related to the ABSA's specific job functions. Finally, a BHT-ABA who does not have an undergraduate certification in behavior analysis shall complete the initial training requirements for a BHT that provides individual services and the training requirements a BHT shall complete during the BHT's first 6 months of employment. In addition, a BHT-ABA who does not have an undergraduate certification in behavior analysis shall complete at least 20 hours of training related to ABA that is approved by the Behavior Analyst Certification Board or the Department before independently providing ABA services to a child, youth or young adult and at least 20 hours of training annually that is approved by the Behavior Analyst Certification Board or the Department that is related to the BHT-ABA's specific job functions.
EBT—§ 5240.93
EBT is behavioral health therapy that uses scientifically established behavioral health interventions. This proposed rulemaking requires that an IBHS agency be licensed or certified from the entity that developed or owns the EBT that is being provided if required to provide the EBT. An IBHS agency can also use a model intervention that it has developed and that has been designated by the Department as a model intervention. This will provide IBHS agencies with the opportunity to expand the service array to meet the therapeutic needs of children, youth and young adults. Staff that provide EBT shall meet the qualifications and receive supervision as set forth in the EBT.
Group services—§§ 5240.101 and 5240.103—5240.108
This proposed rulemaking provides for group services for children, youth or young adults with mental, emotional and behavioral health needs that may benefit from a group intervention format that includes psychotherapy, structured therapeutic activities and community integration activities to address a child's, youth's or young adult's identified treatment needs. The services assist the child, youth or young adult to learn skills and strategies in a group format that will improve functioning in the home, school or community setting. Individual interventions may be provided to address therapeutic needs identified in the written order for group services. Group services are intended to replace summer therapeutic activities programs (STAP) and this proposed rulemaking incorporates the elements of STAP, although it expands the ability of IBHS agencies to provide group services. Group services can be provided for longer lengths of time than STAP and be provided in the school setting and at the IBHS agency site if approved in the service description. Stakeholders indicated that engaging in group activities may help the child, youth or young adult transfer and maintain skills in an array of different settings. This input was the impetus for including agency sites as places where group services may be delivered.
This proposed rulemaking requires that in addition to an administrative and clinical director, an IBHS agency that provides group services shall have a mental health professional. A mental health professional is required to have the same qualifications as a mobile therapist that provides individual services. Staff of an IBHS agency that provides group services may also include mental health workers and BHTs. A mental health worker that provides group services shall have either a bachelor's degree in a recognized clinical discipline including social work, psychology, nursing, rehabilitation or activity therapies, or have a graduate degree in a clinical discipline. A BHT shall have the qualifications of a BHT who provides individual services. If staff provides specialized therapies such as music, dance and movement, play or occupational therapies, the staff person shall be Nationally certified in the specific therapy, a mental health professional with at least 12 graduate-level credit hours in the specialized therapy and at least 1 year of supervised experience in the use of the specialized therapy technique or a mental health professional supervised by a Nationally-credentialed activities therapist.
Training requirements are established for each staff to ensure qualified staff provide group services. Mental health professionals who do not have a current professional license will be required to complete at least 16 hours of Department-approved training annually related to the mental health professional's specific job functions, mental health workers will be required to complete at least 20 hours of Department-approved training annually related to the mental health worker's specific job functions and BHTs who provide group services will be required to complete the same annual training as BHTs who provide individual services.
A mental health professional can provide individual, group and family psychotherapy. A mental health professional can also design psychoeducational group activities, assess the strengths and therapeutic needs of a child, youth or young adult, and develop a child's, youth's or young adult's ITP. A mental health worker can assist the mental health professional with conducting group psychotherapy; facilitate psychoeducational group activities; assist a child, youth or young adult to achieve a goal by implementing the child's, youth's or young adult's ITP; support a child, youth or young adult with the development of appropriate behaviors and interpersonal relationships in the community; and help a child, youth or young adult develop coping skills to aid in the development of age appropriate interpersonal relationships with peers. A BHT can assist with the facilitation of psychoeducational group activities; provide instruction on how to manage and control emotional responses in a group setting; provide behavioral stabilization and interventions to children, youth and young adults that support the child, youth or young adult in community settings; and model problem solving skills.
As with all other IBHS addressed in this chapter, this proposed rulemaking requires a written order prior to the initiation of group services, a comprehensive face-to-face assessment after the initiation of services with the same elements required for individual services, and the development of a strength-based ITP to address the therapeutic needs identified in the written order and the assessment. The time frames for the completion of the assessment and ITP are different for group services than for other services because group services may be provided for a specific period of time based upon the approved service description and the written order.
This proposed rulemaking includes additional requirements for group services that are provided in a school setting. These include that there be a written agreement with the authorized representative of the school that delineates the roles and responsibilities of the school staff and IBHS agency staff and assures a collaborative relationship between school staff and IBHS agency staff.
Waivers—§ 5240.111
This proposed rulemaking allows an IBHS agency to submit a written request to the Department for a waiver of a specific requirement of Chapter 5240. The Department may grant a waiver unconditionally or subject to conditions that shall be met and may revoke a waiver if conditions required by the waiver are not met. The Department will grant a waiver only in exceptional circumstances and if the waiver does not jeopardize the health and safety of the children, youths or young adults served by the IBHS agency; the waiver will not adversely affect the quality of services provided by the IBHS agency; the intent of the requirement to be waived will still be met; children, youth or young adults will benefit from the waiver of the requirement; and the waiver does not violate any Federal or State statute or other regulation.
Affected Individuals and Organizations
This proposed rulemaking affects children, youth and young adults with mental, emotional or behavioral health needs currently receiving BHRS and their families and caregivers and the agencies that provide these services. Approximately 228 agencies are enrolled in the MA Program and currently provide BHRS to approximately 60,000 children, youth and young adults. This proposed rulemaking will also affect providers that serve children, youth and young adults with a behavioral health diagnosis, including autism spectrum disorder, that are not currently enrolled in the MA Program.
The Department engaged in an active community participation process throughout the development of this proposed rulemaking to ensure that children, youth and young adults under 21 years of age that need IBHS and their families and the agencies that provide the services had the opportunity to provide input, express concerns and participate in the drafting process.
A total of 75 individuals were involved in a stakeholder workgroup that provided input on this proposed rulemaking, including providers of BHRS, advocates for individuals with autism spectrum disorder, physicians, family members of children receiving BHRS including ABA services, county administrators and representatives from provider associations, the Office of Mental Health and Substance Abuse Services Planning Council, the Pennsylvania Mental Health Consumers Association, the Pennsylvania Health Law Project, Disability Rights Pennsylvania and MA behavioral health managed care organizations. From May to September 2016, the Department participated in face-to-face meetings, telephone conference calls and webinars with stakeholders. The purpose of the workgroup meetings was for the Department to gather input and listen to concerns from interested parties regarding the development of a set of regulations for the licensure of agencies that will be providing IBHS.
Each of the major sections of the draft rulemaking were reviewed and discussed by members of the workgroup through a series of six telephone conference calls and webinars and two face-to-face meetings. One of the initial recommendations from the stakeholder workgroup was to change the name of the service from BHRS to IBHS. Key sections of this proposed rulemaking were the focus of the discussion during each of the telephone calls. Areas discussed with the stakeholder workgroup included the array of services to be included in the regulations, staff qualifications and training requirements for each service, service planning, the coordination of care and requirements for provider eligibility. Workgroup members were provided with notes and drafts of the regulations after each call or webinar. A dedicated e-mail account was established for workgroup members to submit written comments between meetings. Workgroup members were requested to gather input and feedback from other interested parties during the drafting of this proposed rulemaking. In addition, information on the draft rulemaking was provided at meetings with organizations and committees, including the Rehabilitation Community Providers Association, including its Mental Health Committee and Children's Committee; committees sponsored by the County Commissioner's Association of Pennsylvania, including the County Administrator's Advisory Committee, the Mental Health Committee and the HealthChoices Committee; county Mental Health Administrators and Child and Adolescent Service System Program Coordinators; the Managed Care Subcommittee of the Medical Assistance Advisory Committee; and the Mental Health Planning Council. Numerous edits were made to the draft rulemaking based upon the comments received from workgroup members and other interested parties.
The stakeholder workgroup again met from January to March 2017 to provide input on Chapter 1155, the companion payment regulations. There were again face-to-face meetings, telephone conference calls and webinars with stakeholders and workgroup members who provided comments and feedback on Chapter 1155, the payment regulations, and additional comments and feedback on Chapter 5240, the licensing regulations. The draft rulemaking was revised after each meeting to reflect the input of workgroup members. Workgroup members were able to provide written comments between meetings using the e-mail account.
The Department appreciates the workgroup members' expertise, time and commitment to the draft rulemaking and the helpful comments which guided the drafting of this proposed rulemaking.
The Department intends to reconvene the stakeholder workgroup to review the comments received and to consider any edits to this proposed rulemaking based upon the analysis of the formal public comments, comments from the Independent Regulatory Review Commission (IRRC), and comments from the House Human Services Committee, the House Health Committee and the Senate Committee on Health and Human Services.
Accomplishments and Benefits
This proposed rulemaking benefits children, youth and young adults under 21 years of age with mental, emotional and behavioral health needs by promoting quality services by establishing a minimum standard for licensure of IBHS agencies, minimum requirements for IBHS agencies to enroll in the MA Program and conditions for the MA Program to pay for IBHS. Additionally, the supervision and training requirements included in this proposed rulemaking will contribute to the development of a qualified IBHS workforce to deliver treatment services, which will also help to improve clinical outcomes for children, youth and young adults receiving IBHS.
This proposed rulemaking will also improve the accessibility of behavioral health care for children, youth and young adults under 21 years of age by eliminating requirements that have been identified as barriers to accessing services by workgroup members such as convening an ISPT meeting prior to the delivery of services and completing a comprehensive evaluation prior to a referral for services. In addition, this proposed rulemaking promotes the use of additional evidence-based practices and ABA services, which may reduce the need for higher levels of care or out-of-home placements for children, youth and young adults.
Fiscal Impact
It is anticipated that the implementation of this proposed rulemaking may result in an initial increase in costs for IBHS agencies as a result of changes to staff requirements and qualifications, which will vary based upon the services provided by the agency and the current organizational structure of the agency. The exact fiscal impact is unknown because staffing requirements are similar to the current staffing patterns for agencies that provide BHRS with the exception of the addition of the requirement that the clinical director of an IBHS agency that provides ABA services shall have a graduate-level certification in behavior analysis and BHTs shall be certified or obtain certification within 18 months of being hired by an IBHS agency or within 2 years of the effective date of adoption of this proposed rulemaking, whichever is later. It is anticipated that the ability of an IBHS agency to provide an array of IBHS may offset these costs.
It is also anticipated that IBHS agencies' training costs will decrease as this proposed rulemaking clarifies that staff do not need to repeat initial or annual training when changing employment to a different IBHS agency. Additionally, college coursework on topics that staff shall receive training on, training required for licensure and training related to certification requirements may be substituted for the required trainings, which may decrease the training costs for some staff.
Costs to the Department, local government and individuals receiving IBHS are not anticipated.
Paperwork Requirements
This proposed rulemaking will result in increased paperwork because it requires IBHS agencies to develop additional policies and procedures, and includes a new requirement that IBHS agencies develop quality improvement plans, staff training plans and written agreements to coordinate care with other agencies. The elimination of the requirement for an ISPT meeting will decrease the paperwork required to document the meeting.
Effective Date
This proposed rulemaking will be effective upon final-form publication in the Pennsylvania Bulletin. IBHS agencies that hold an outpatient psychiatric clinic, a psychiatric partial hospitalization program or family based mental health license and currently provide IBHS are required to comply with the final-form rulemaking as of its effective date and are required to obtain a license under Chapter 5240 upon expiration of their current license. IBHS agencies that are approved to provide ABA services as of the effective date of adoption of this proposed rulemaking are required to comply with the final-form rulemaking as of its effective date and are required to obtain a license under Chapter 5240 within 180 days of the effective date of Chapter 5240. IBHS agencies that do not currently hold an outpatient psychiatric clinic, a psychiatric partial hospitalization program or a family based mental health license or are not approved to provide ABA are required upon the effective date of the final-form rulemaking to obtain a license under Chapter 5240 if they are providing IBHS.
Public Comment
Interested persons are invited to submit written comments, suggestions or objections regarding this proposed rulemaking to Tara Pride, Bureau of Policy, Planning and Program Development, Commonwealth Towers, 11th Floor, P.O. Box 2675, 303 Walnut Street, Harrisburg, PA 17105, RA-PWIBHS@pa.gov within 30 calendar days after the date of publication of this proposed rulemaking in the Pennsylvania Bulletin. Reference Regulation No. 14-546 when submitting comments. Individuals with a disability who require an auxiliary aid or service may submit comments by using the Pennsylvania AT&T Relay Service at (800) 654-5984 (TDD users) or (800) 654-5988 (voice users).
Regulatory Review
Under section 5(a) of the Regulatory Review Act (71 P.S. § 745.5(a)), on July 18, 2018, the Department submitted a copy of this proposed rulemaking and a copy of a Regulatory Analysis Form to IRRC and to the Chairpersons of the House Human Services Committee, the House Health Committee and the Senate Health and Human Services Committee. A copy of this material is available to the public upon request.
Under section 5(g) of the Regulatory Review Act, IRRC may convey comments, recommendations or objections to the proposed rulemaking within 30 days of the close of the public comment period. The comments, recommendations or objections must specify the regulatory review criteria in section 5.2 of the Regulatory Review Act (71 P.S. § 745.5b) which have not been met. The Regulatory Review Act specifies detailed procedures for review prior to final publication of the rulemaking by the Department, the General Assembly and the Governor.
TERESA D. MILLER,
SecretaryFiscal Note: 14-546. No fiscal impact; (8) recommends adoption.
Annex A
TITLE 55. HUMAN SERVICES
PART III. MEDICAL ASSISTANCE MANUAL
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 SERVICES1155.31.
General payment policy. 1155.32. Payment conditions for individual services. 1155.33. Payment conditions for ABA. 1155.34. Payment conditions for EBT. 1155.35. Payment conditions for group services. 1155.36. Covered services. 1155.37. Limitations.
UTILIZATION REVIEW 1155.41.
Scope of claims review procedures.
ADMINISTRATIVE SANCTIONS 1155.51.
Provider misutilization.
GENERAL PROVISIONS § 1155.1. Policy.
(a) The MA Program provides payment for IBHS when the service is medically necessary and provided to eligible children, youth or young adults under 21 years of age with behavioral health diagnoses 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 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 behavioral 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, which includes all of the following:
(i) The use of direct observation, measurement and functional analysis of the relations between environment and behavior.
(ii) The attempt to address one or more behavior challenges or skill deficits using evidence-based principles and practices of learning and behavior.
(iii) The analysis of the relationship between a stimulus, consequence or other variable. The changes of stimuli, consequences or other variables may occur individually, as a combination or in relationship with each other. The change of stimuli, consequences or other variables may be external or internal to the person whose behavior is being analyzed.
Caregiver—An individual with responsibility for the care and supervision of a minor.
Child—A person under 14 years of age.
Consequence—A resulting directly measurable change of a child's, youth's or young adult's behavior produced by a change in a stimulus or stimuli.
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 in the Substance Abuse and Mental Health Services Administration's National Registry of Evidence-based Programs and Practices.
(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.
(v) Designated as a model intervention by the Department.
Group services—Therapeutic interventions provided primarily in a group format through psychotherapy, structured activities and community integration activities that address a child's, youth's or young adult's identified treatment needs. When included in a child's, youth's or young adult's ITP, group services may include individual interventions.
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 each 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 each service.
Individual services—Intensive one-to-one 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.
MA—Medical Assistance.
Stimulus—An event, circumstance or condition that can be changed or does change based upon the behavior specialist analyst's manipulation.
Variables—An observed or manipulable condition that can be changed or does change and a directly measurable change of a child's, youth's or young adult's behavior produced by the change.
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 under 21 years of age with behavioral health diagnoses are eligible for the full range of 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 all of the following requirements to participate in the MA Program:
(1) Have a current license as an IBHS agency issued by the Department.
(2) Enter into a written provider agreement with the Department.
(3) Be enrolled 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) A licensed IBHS agency shall have a current license for each branch location or satellite location.
(d) Each branch location or satellite location of a licensed IBHS agency shall be enrolled by the Department.
(e) An IBHS agency shall notify the Department, in writing, of a change in name, address or services provided prior to the effective date of the change.
PAYMENT FOR INTENSIVE BEHAVIORAL
HEALTH SERVICES§ 1155.31. General payment policy.
(a) Except as provided in subsection (b), payment is made to licensed IBHS agencies 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), subject to the conditions and limitations in this chapter and 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 holds an outpatient psychiatric clinic, a psychiatric partial hospitalization program or a family based mental health license issued by the Department as of ______ (Editor's Note: The blank refers to the effective date of adoption of this proposed rulemaking.), and the license has not expired.
(c) 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)).
(d) Payment will not be made for services rendered at an IBHS agency's branch or satellite location if the branch or satellite location is not licensed and enrolled.
§ 1155.32. Payment conditions for individual services.
Payment will be made to a licensed IBHS agency for individual services if all of 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 all of the following:
(i) Written within 6 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.
(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 all of the following:
(A) The clinical information to support the medical necessity of each service ordered.
(B) The maximum number of hours of each service each 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 comprehensive face-to-face assessment has been completed by a behavior specialist or mobile therapist within 15 days of the initiation of individual services and prior to developing the ITP in accordance with § 5240.21 (relating to assessment), or a comprehensive face-to-face assessment has been reviewed and updated within the last 6 months or a comprehensive face-to-face assessment has been reviewed and updated because one of the following has occurred:
(i) A parent or caregiver of a child or youth requests an update.
(ii) A young adult or youth requests an update.
(iii) A child or youth experiences a change in living situation that results in a change of the child's or youth's primary caregivers.
(iv) The child, youth or young adult completes an ITP goal.
(v) The child, youth or young adult is not progressing towards the goals identified in the ITP within 90 days from the initiation of services identified in the ITP.
(vi) The child, youth, young adult or the family experiences a crisis event.
(vii) An IBHS agency staff person, primary care physician, other treating clinician, case manager or other professional involved in the child's, youth's or young adult's services determines an update is needed.
(3) The assessment and all updates have been signed by the IBHS agency staff person that completed the assessment and the supervisor of the staff person that completed the assessment.
(4) An ITP based upon the assessment and the written order for services has been developed 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 the last 6 months or an ITP has been reviewed and updated because one of the following has occurred:
(i) An ITP goal is completed.
(ii) No significant progress is made within 90 days from the initiation of services identified in the ITP.
(iii) A youth or young adult requests a change.
(iv) A parent or caregiver of a child or youth requests a change.
(v) The child, youth or young adult experiences a crisis event.
(vi) The ITP is no longer clinically appropriate for the child, youth or young adult.
(vii) An IBHS agency staff person, primary care physician, other treating clinician, case manager or other professional involved in the child's, youth's or young adult's services recommends a change.
(5) The ITP and all updates have been reviewed and signed by the youth, young adult, or at least one parent or caregiver of the child or youth, the staff person who developed the ITP and the supervisor of the staff person who developed the ITP.
(6) For continued individual services, a child, youth or young adult shall have an order written in the last 6 months that complies with paragraph (1)(ii)—(iv).
(7) For individual services reinitiated after a child, youth or young adult is discharged, payment will be made for up to 90 days if reinitiation of services was requested within 60 days after discharge and there is a written order that complies with paragraph (1)(ii)—(iv).
§ 1155.33. Payment conditions for ABA.
Payment will be made to a licensed IBHS agency for ABA services if all of 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 all of the following:
(i) Written within 12 months prior to the initiation of ABA.
(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.
(iii) Includes a behavioral health disorder diagnosis that is listed in the most recent edition of the DSM or ICD.
(iv) Orders ABA services for the child, youth or young adult and includes all of 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 each 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 comprehensive face-to-face assessment has been completed by a behavior specialist analyst prior to the development of the ITP in accordance with § 5240.85 (relating to assessment), or a comprehensive face-to-face assessment has been reviewed and updated within the last year or a comprehensive face-to-face assessment has been reviewed and updated because one of the following has occurred:
(i) A parent or caregiver of a child or youth requests an update.
(ii) A youth or young adult requests an update.
(iii) A child or youth experiences a change in living situation that results in a change of the child's or youth's primary caregivers.
(iv) The child, youth or young adult completes an ITP goal.
(v) The child, youth or young adult is not progressing towards the goals identified in the ITP within 90 days from the initiation of the ABA services identified in the ITP.
(vi) The child, youth, young adult or the family experiences a crisis event.
(vii) The behavior specialist analyst, ABA clinical director, primary care physician, other treating clinician, case manager or other professional involved the child's, youth's or young adult's services determines an update is needed.
(3) The assessment and all updates have been signed by the behavior specialist analyst that completed the assessment and the ABA clinical director.
(4) An ITP based upon the assessment and the written order for ABA services has been developed within 30 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 the last 6 months or an ITP has been reviewed and updated because one of the following has occurred:
(i) An ITP goal is completed.
(ii) No significant progress has been made within 90 days from the initiation of ABA services identified in the ITP.
(iii) A youth or young adult requests a change.
(iv) A parent or caregiver of a child or youth requests a change.
(v) The child, youth or young adult experiences a crisis event.
(vi) The ITP is no longer clinically appropriate for the child, youth or young adult.
(vii) A behavior specialist analyst, ABA clinical director, primary care physician, other treating clinician, case manager or other professional involved in the child's, youth's or young adult's services recommends a change.
(5) The ITP and all updates have been reviewed and signed by the youth, young adult, or at least one parent or caregiver of the child or youth, the behavior specialist analyst who developed the ITP and the ABA clinical director.
(6) For continued ABA services, a child, youth or young adult shall have an order written in the last 12 months that complies with paragraph (1)(ii)—(iv).
(7) For ABA services reinitiated after a child, youth or young adult is discharged, payment will be made for up to 90 days if reinitiation of services was requested within 60 days after discharge and there is a written order that complies with paragraph (1)(ii)—(iv).
§ 1155.34. Payment conditions for EBT.
Payment will be made to a licensed IBHS agency for EBT services if all of the following conditions are met:
(1) There is a written order for EBT services that meets the requirements of § 1155.32(1) (relating to payment conditions for individual services).
(2) A comprehensive face-to-face assessment has been completed by a staff person with the qualifications required by the EBT within 15 days of the initiation of the service and prior to developing the ITP in accordance with § 5240.92 (relating to assessment and individual treatment plan), or a comprehensive face-to-face assessment has been reviewed and updated within the last 6 months or a comprehensive face-to-face assessment has been reviewed and updated because one of the following has occurred:
(i) A parent or caregiver of a child or youth requests an update.
(ii) A young adult or youth requests an update.
(iii) A child or youth experiences a change in living situation that results in a change of the child's or youth's primary caregivers.
(iv) The child, youth or young adult completes an ITP goal.
(v) The child, youth or young adult is not progressing towards the goals identified in the ITP within 90 days from the initiation of services identified in the ITP.
(vi) The child, youth, young adult or the family experiences a crisis event.
(viii) An IBHS agency staff person, primary care physician, other treating clinician, case manager or other professional involved in the child's, youth's or young adult's services determines an update is needed.
(3) The assessment and all updates have been signed by a staff person with the qualifications required by the EBT and the staff person's supervisor.
(4) An ITP based upon the assessment and the written order for services has been developed within 30 days of the initiation of services in accordance with § 5240.92, or an ITP has been reviewed and updated within the last 6 months or an ITP has been reviewed and updated because one of the following has occurred:
(i) An ITP goal is completed.
(ii) No significant progress is made within 90 days from the initiation of the EBT service identified in the ITP.
(iii) A youth or young adult requests a change.
(iv) A parent or caregiver of a child or youth requests a change.
(v) The child, youth or young adult experiences a crisis event.
(vii) The ITP is no longer clinically appropriate for the child, youth or young adult.
(viii) An IBHS agency staff person, primary care physician, other treating clinician, case manager or other professional involved in the child's, youth's or young adult's services recommends a change.
(5) The ITP and all updates have been reviewed and signed by the youth, young adult, or at least one parent or caregiver of the child or youth, the staff person who developed the ITP and the supervisor of the staff person who developed the ITP.
(6) For continued EBT services, a child, youth or young adult shall have an order written in the last 6 months that complies with § 1155.32(1)(ii)—(iv).
(7) The IBHS agency has a current certification or licensure from the National certification organization or entity that developed or owns the EBT provided or the EBT has been designated by the Department as a model intervention.
(8) The IBHS agency delivers the services in accordance with the specific EBT.
(9) For EBT services reinitiated after a child, youth or young adult is discharged, payment will be made for up to 90 days if reinitiation of services was requested within 60 days after discharge and there is a written order that complies with § 1155.32(1)(ii)—(iv).
§ 1155.35. Payment conditions for group services.
Payment will be made to a licensed IBHS agency for group services if all of the following conditions are met:
(1) There is a written order for group services that meets the requirements of § 1155.32(1) (relating to payment conditions for individual services).
(2) A comprehensive face-to-face assessment has been completed by a mental health professional within 5 days of the initiation of group services and prior to developing the ITP in accordance with § 5240.105 (relating to assessment), or a comprehensive face-to-face assessment has been reviewed and updated within the last 6 months or a comprehensive face-to-face assessment has been reviewed and updated because one of the following has occurred:
(i) A parent or caregiver of a child or youth requests an update.
(ii) A young adult or youth requests an update.
(iii) A child or youth experiences a change in living situation that results in a change of the child's or youth's primary caregivers.
(iv) The child, youth or young adult completes an ITP goal.
(v) The child, youth or young adult is not progressing towards the goals identified in the ITP within 90 days from the initiation of services identified in the ITP.
(vi) The child, youth, young adult or the family experiences a crisis event.
(vii) An IBHS agency staff person, primary care physician, other treating clinician, case manager or other professional involved in the child's, youth's or young adult's services determines an update is needed.
(3) The assessment and all updates have been signed by the mental health professional that completed the assessment and the mental health professional's supervisor.
(4) An ITP based upon the assessment and written order for group services has been developed within 10 days after the initiation of services in accordance with § 5240.106 (relating to individual treatment plan), an ITP has been reviewed and updated within the last 6 months or an ITP has been reviewed and updated because one of the following has occurred:
(i) An ITP goal is completed.
(ii) No significant progress is made within 45 days from the initiation of group services identified in the ITP.
(iii) A youth or young adult requests a change.
(iv) A parent or caregiver of a child or youth requests a change.
(v) The child, youth or young adult experiences a crisis event.
(vi) The ITP is no longer clinically appropriate for the child, youth or young adult.
(vii) An IBHS agency staff person, primary care physician, other treating clinician, case manager or other professional involved in the child's, youth's or young adult's services recommends a change.
(5) The ITP and all updates have been reviewed and signed by the youth, young adult, or at least one parent or caregiver of the child or youth, the mental health professional who developed the ITP and the IBHS clinical director.
(6) For continued group services, a child, youth or young adult shall have an order written in the last 6 months that complies with § 1155.32(1)(ii)—(iv).
(7) For group services reinitiated after a child, youth or young adult is discharged, payment will be made for up to 90 days if reinitiation of services was requested within 60 days after discharge and there is a written order that complies with § 1155.32(1)(ii)—(iv).
§ 1155.36. Covered services.
The Department will pay for all of the following IBHS when the services are medically necessary:
(1) Individual services, which include:
(i) Services provided by a behavior specialist.
(ii) Services provided by a mobile therapist.
(iii) Services provided by a behavioral health technician.
(2) ABA services, which include:
(i) Services provided by a behavior specialist analyst.
(ii) Services provided by an assistant behavior specialist analyst.
(iii) Services provided by a behavioral health technician-ABA.
(3) EBT.
(4) Group services.
(5) Services approved through the program exception process under § 1150.63 (relating to waivers).
§ 1155.37. Limitations.
Payment is subject to all of 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(1) or § 1155.33(1) (relating to payment conditions for individual services; and payment conditions for ABA) and are provided within 60 days of discharge from the facility to assist in a child's, youth's or young adult's transition to the home or community setting, 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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