PROPOSED RULEMAKING
DEPARTMENT OF
HUMAN SERVICES
[ 55 PA. CODE CHS. 1153 AND 5200 ]
Outpatient Psychiatric Services and Psychiatric Outpatient Clinics
[47 Pa.B. 4689]
[Saturday, August 12, 2017]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), sections 105 and 112 of the Mental Health Procedures Act (50 P.S. §§ 7105 and 7112) and section 201(2) of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. § 4201(2)), proposes to amend Chapters 1153 and 5200 (relating to outpatient behavioral health services; and psychiatric outpatient clinics) to read as set forth in Annex A.
Purpose of this Proposed Rulemaking
The purpose of this proposed rulemaking is to update Chapters 1153 and 5200 to be consistent with the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) (Pub.L. No. 110-343), to reflect changes in benefit packages resulting from the implementation of Medicaid expansion under the Patient Protection and Affordable Care Act (Pub.L. No. 111-148) and the consolidation of adult benefit packages, as well as codify the requirements for the delivery of Mobile Mental Health Treatment (MMHT) outlined in Medical Assistance Bulletin 08-06-18, Mobile Mental Health Treatment, issued November 30, 2006. This proposed rulemaking will allow licensed professionals to work within their scope of practice in psychiatric outpatient clinics, increase access to medically necessary treatment services for eligible individuals, including the provision of mobile treatment, and reduce the paperwork requirements for licensed providers. This proposed rulemaking supports the principles of recovery, resiliency and self-determination by updating language to reflect a person-first philosophy throughout the regulations, allowing consistent access to community-based services and focusing on appropriate evidence-based individual clinical interventions.
Background
The 2014 National Survey on Drug Use and Health (NSDUH) report was issued by the Substance Abuse and Mental Health Services Administration (SAMHSA), United States Department of Health and Human Services (DHHS), on September 4, 2014. The NSDUH report provided estimates of the prevalence of adult mental illness in the United States. The analysis was based upon the data collected from an annual survey of the civilian noninstitutionalized population of the United States 12 years of age or older. The NSDUH report presents estimates of mental health issues separately for adolescents 12 to 17 years of age based upon a variation in questions. The data collected is limited to major depressive episodes (MDE) for adolescents not an overall indication of mental health issues as is collected for adults. The results indicate that 1 in 10 adolescents reported an MDE, representing an estimated 2.6 million adolescents in the United States having an MDE during the reporting year. Nationally, an estimated 43.8 million adults 18 years of age or older experienced any mental illness in the past year, corresponding to a rate of 18.5% of the adult population. ''Any mental illness'' is defined in the NSDUH report as ''the presence of any mental, behavioral, or emotional disorder in the past year that met the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria.'' ''Serious mental illness'' (SMI) is defined in the NSDUH report as a mental disorder causing substantial functional impairment (such as substantial interference with or limitation in one or more major life activities) and individuals with SMI have the most urgent need for treatment. There were an estimated 10 million adults 18 years of age or older with SMI in the past year, which represents 4.2% of all adults in the United States. Nationally, 62.9% of adults with SMI received treatment in the past 12 months while only 41% of adults with any mental illness received mental health treatment in the past year.
Mental illness is a major public health concern in the United States. It is a primary cause of disability and carries a high financial cost. Depression accounts for 4.3% of the global burden of disease and is among the largest single cause of disability worldwide, particularly for women. World Health Organization (WHO), Mental Health Action Plan, 2013—2020. According to the Centers for Disease Control and Prevention (CDC) and WHO, mental illness accounts for more disability in developed countries than any other group of illnesses, including cancer and heart disease. Mood disorders, including major depression, dysthymic disorder and bipolar disorder, are the third most common cause of hospitalization in the United States for adults 18 to 44 years of age. Agency for Healthcare Research and Quality, DHHS, 2009. The economic burden of mental illness in the United States was approximately $300 billion in 2002. CDC (2011), Mental Illness Surveillance Among U.S. Adults. Additionally, SMI costs the United States approximately $193.2 billion in lost earnings per year. Insel, T.R. (2008), ''Assessing the Economic Costs of Serious Mental Illness,'' The American Journal of Psychiatry, 165(6), 663—665. Mental illness is also associated with increased occurrence of chronic diseases such as cardiovascular disease, diabetes, obesity, asthma, epilepsy and cancer. CDC (2011), Mental Illness Surveillance Among U.S. Adults. It is associated with lower use of medical care, reduced adherence to treatment for chronic diseases and higher risk of adverse health effects. Many mental illnesses can be managed successfully and increasing access to mental health services could substantially reduce the associated morbidity. Treatment of mental illness can improve both outcomes.
Access to community psychiatric services is not only a cost-effective alternative to institutionalization, it can also produce improved outcomes for individuals with mental illness, including the population identified with SMI. The most common types of treatment accessed are outpatient services and prescription medication according to the 2008 SAMHSA survey data. SAMHSA Administrator Pamela S. Hyde stated:
Although mental illness remains a serious public health issue, increasingly we know that people who experience it can be successfully treated and can live full and productive lives. Like other medical conditions, such as cardiovascular disease or diabetes, the key to recovery is identifying the problem and taking active measures to treat it as soon as possible.SAMHSA Data Survey, 2008.
Community-based psychiatric outpatient clinics are a key component of the public mental health system, and should be accessible to all individuals to provide an array of cost-effective clinical services and supports. In recognition of the importance of mental well-being, the overall goal of the WHO Mental Health Action Plan 2013—2020 is to promote mental health, prevent mental disorders, provide access to care and enhance recovery, and reduce mortality, morbidity and disability for persons with mental disorders by providing comprehensive, integrated and responsive mental health services in community-based settings. WHO recommends the development of comprehensive community-based mental health services. Community-based mental health service delivery should encompass a recovery-based approach that supports individuals with mental illness to achieve their own goals. The core services should include listening and responding to an individual's needs, working with the individual as an equal partner, offering choices of treatment and therapies, and the use of peer support staff to support recovery, all of which can be provided by licensed outpatient psychiatric clinics in the community. Another key element of the WHO plan is to be responsive to the needs of vulnerable and marginalized individuals to ensure community-based services are widely available.
Additionally, SAMHSA's strategic plan for 2015—2018 includes the goal of increasing access to effective treatment and support for recovery. To recover, individuals need access to affordable, accessible and high-quality behavioral health care. The expansion of access to MMHT for individuals with a broader array of diagnoses and for individuals under 21 years of age will broaden access to treatment services by allowing more individuals that would not be able to attend treatment at a traditional outpatient psychiatric clinic to receive services in alternative community settings. This will assist in engaging vulnerable individuals and reducing stigma.
The MHPAEA requires that health insurance coverage for mental health and substance use services have benefit limitations that are no more restrictive than the medical benefits offered by the plan. This proposed rulemaking will provide the same level of benefits to all eligible individuals by removing limits on the services or scope of covered services consistent with the approved State plan and the MHPAEA.
Requirements
The following is a summary of the specific provisions in this proposed rulemaking.
Chapter 1153. Outpatient behavioral health services
The Department proposes to amend the heading of this chapter to reflect broadening of its application with the inclusion of MMHT services provided by psychiatric outpatient clinics.
§ 1153.2. Definitions
The proposed definition of ''adult'' identifies individuals who are 21 years of age or older receiving services under this chapter.
The definitions of ''adult partial hospitalization program,'' ''children and youth partial hospitalization program,'' ''psychiatric outpatient clinic provider'' and ''psychiatric outpatient partial hospitalization program'' are proposed to be amended to recognize the current name of the Office of Mental Health and Substance Abuse Services. Additionally, the definition of ''psychiatric outpatient clinic provider'' is proposed to be amended to ''psychiatric outpatient clinic'' for consistency with use throughout this chapter.
In response to requests by stakeholders, the Department proposes to amend references to ''patient'' to ''individual'' in the definitions of ''collateral family psychotherapy,'' ''inpatient,'' ''intake,'' ''outpatient,'' ''psycho-therapy'' and ''treatment institution'' to distinguish the difference between an individual receiving services and an illness. For consistency in this chapter, references to ''patient'' or ''person'' are proposed to be replaced with ''individual.''
The definition of ''facility'' is proposed to be added to clarify the use of the term throughout this chapter as inclusive of establishments primarily focused on the diagnosis, treatment, care and rehabilitation of individuals with mental illness or emotional disturbance. The definition is congruent with the term used in Chapter 5200.
The definition of ''family psychotherapy'' is proposed to be amended by replacing ''mental disorder'' with ''mental illness or emotional disturbance'' to be congruent with the current Federal language. The Federal definition of ''mental illness or emotional disturbance'' is proposed to be added.
The definition of ''group psychotherapy'' is proposed to be amended by increasing the allowable maximum group size from 10 to 12 individuals. The most prominent published text on group psychotherapy is Theory and Practice of Group Psychotherapy by Irvin D. Yalom (1995), which states:
[t]he ideal size of an interactional therapy group is approximately 8 to as high as 12. Since it is likely that one or possibly two patients will drop out of the group in the course of treatment, it is advisable to have a slightly larger group than the preferred size.The proposed increase will conform to industry standards and clinical best practice. Further, this proposed amendment will allow more individuals to be served in psychiatric outpatient clinics and reduce wait times to access outpatient treatment.
The definition of ''home visit'' is proposed to be deleted due to the addition of MMHT services to this chapter. Services provided by psychiatric outpatient clinics outside the clinic setting are provided as MMHT rehabilitation services.
The definition of ''LPHA—licensed practitioner of the healing arts'' is proposed to be added to define who may order MMHT. MMHT is in the Commonwealth's Medical Assistance State Plan as a rehabilitation service and under 42 CFR 440.130(d) (relating to diagnostic, screening, preventive, and rehabilitative services) rehabilitation services shall be ''recommended by a physician or other licensed practitioner of the healing arts, within the scope of his practice under State law.'' This proposed definition allows a broad array of licensed professionals to order this service within their scope of practice under State law.
The definition of ''mental disorder'' is proposed to be deleted due to outdated terminology and replaced with ''mental illness or emotional disturbance.'' Mental illness or emotional disturbance is a mental or emotional disorder that meets the diagnostic criteria in the current version of the Diagnostic and Statistical Manual (DSM) or the International Classification of Diseases (ICD) with reference to an individual's level of functioning in various life domains. References to ''mental disorder'' through this chapter are proposed to be replaced with ''mental illness or emotional disturbance'' including in the definitions of ''family psychotherapy,'' ''group psychotherapy,'' ''individual psychotherapy,'' ''psychiatric outpatient clinic services'' and ''psychiatric outpatient partial hospitalization provider.''
The definitions of ''mental health professional'' and ''mental health worker'' are proposed to be amended to specify the required credentials.
The definition of ''MMHT—Mobile Mental Health Treatment'' is proposed to be added. MMHT services can be provided in the individual's residence or approved community site and include assessment, individual, group, family therapy and medication visits. They are intended to reduce the disabling effects of mental or physical illness for individuals who have encountered barriers to or have been unsuccessful in receiving services at a psychiatric outpatient clinic. The purpose of this service is to provide therapeutic treatment to reduce the need for more intensive levels of service, including crisis intervention or inpatient hospitalization by offering services in the community or home setting. These rehabilitation services may only be provided by a licensed outpatient clinic with an approved service description for MMHT.
The definitions of ''psychiatric clinic medication visit'' and ''psychiatric clinic clozapine monitoring and evaluation visit'' are proposed to be amended to replace the outdated term ''recipient'' with ''individual'' and include certified registered nurse practitioners (CRNP) and physician assistants (PA) in the list of professionals who may provide the visit.
The definition of ''psychiatric evaluation'' is proposed to be amended to include the provision of real-time, two-way interactive audio-video transmission in licensed psychiatric outpatient clinics. This proposed amendment will increase access to this service, especially in rural areas of this Commonwealth.
The definition of ''psychiatric outpatient clinic services'' is proposed to be amended to delete the outdated language of ''a mentally disordered outpatient'' and replace it with ''an individual with mental illness or emotional disturbance.'' This proposed amendment delineates the difference between an illness and the individual with the illness by using person first language.
The definition of ''psychiatric partial hospitalization'' is proposed to be amended to delete the limits on the service consistent with the MHPAEA.
The definition of ''psychiatric outpatient partial hospitalization provider'' is proposed to be amended to delete outdated language of ''mental disorders'' and replace it with ''mental illness or emotional disturbance'' and update program office names to reflect current titles.
§ 1153.11. Types of services covered
§ 1153.12. Outpatient services
This proposed rulemaking adds MMHT as a type of covered service that can be provided under this chapter. These services were added to the MA Program Fee Schedule in 2006. MMHT services can only be provided by a licensed outpatient clinic with an approved service description for MMHT.
§ 1153.14. Noncovered services
The time frame for the psychiatrist's review of assessments and treatment plans is proposed to be amended to up to 30 calendar days following intake. The proposed amendment from the current 15 calendar day limit allows the individual receiving services and the mental health professional to develop a treatment plan based upon a comprehensive intake and assessment process. Additionally, the proposed amendments include the codification of MMHT services, which allows licensed outpatient clinics to provide services in a home or community location to improve access.
§ 1153.21. Scope of benefits for children under 21 years of age
Proposed amendments to this section reflect the changes under Medicaid expansion and the consolidation of the current benefit packages to revise the scope of benefits section to provide the same level of benefits to all eligible children under 21 years of age.
§ 1153.22. Scope of benefits for adults 21 years of age or older
Proposed amendments to this section reflect the changes under Medicaid expansion and the consolidation of the current benefit packages to provide the same level of benefits to all eligible adults. Specifically, the amount, duration and scope variations between categories of eligibility are proposed to be amended to comply with Federal regulations and the MHPAEA.
§ 1153.23. Scope of benefits for State Blind Pension recipients
This section is proposed to be rescinded because with Medicaid expansion and the consolidation of the current benefit packages the State Blind Pension recipient category is no longer a benefit category.
§ 1153.24. Scope of benefits for General Assistance recipients
The scope of benefits sections are proposed to be amended to codify the benefits under the Medicaid expansion and provide the same level of benefits to all eligible adults. The General Assistance category is no longer included in this chapter.
§ 1153.41. Participation requirements
The proposed amendments to this section recognize the scope of practice of advanced practice professionals in this Commonwealth. The proposed amendments will allow CRNPs and PAs, within their scope of practice and applicable law, to prescribe medication in psychiatric outpatient clinics. A requirement for psychiatric outpatient clinics to have service description for MMHT approved by the Department to be an MMHT provider is proposed to be added and outdated language is proposed to be updated throughout this section.
§ 1153.42. Ongoing responsibilities of providers
The proposed amendments update outdated language, clarify licensure and MA enrollment requirements, and add MMHT services.
§ 1153.51. General payment policy
The Department proposes to add MMHT services under the payment policy for outpatient psychiatric services. MMHT services were added to the MA Program Fee Schedule in November 2006 for adults 21 years of age or older. These services were also recently amended in the MA State Plan and the MA Program Fee Schedule for children under 21 years of age.
§ 1153.52. Payment conditions for various services
This section is proposed to be amended to allow a psychiatric clinic medication visit to be provided by an advanced practice professional licensed by the Commonwealth, recognizing the scope of practice for CRNPs and PAs. Additionally, the Department proposes to allow a psychiatric evaluation to be performed by real-time, two-way interactive audio-video transmission.
The Department also proposes to require initial treatment plans to be developed within 30 days of intake, with updates of the treatment plans being required at least every 180 days, or more frequently based upon clinical need. Stakeholders representing the provider community and individuals receiving services stated this time frame is reasonable for the development of a comprehensive treatment plan based upon clinical assessment, history and input from the individual receiving services. Individuals are seen during various time frames on an outpatient basis which impacts when treatment plans should be updated. This proposed amendment is similar to outpatient clinic regulations regarding treatment planning in Maryland, South Carolina, Minnesota and Oregon.
The time frame for the psychiatrist to review, approve and sign the treatment plans is proposed to be amended. The psychiatrist will be responsible for reviewing and approving the initial treatment plan, in conjunction with the mental health professional and the individual receiving services, within 30 days of intake. The psychiatrist shall review and approve the updated treatment plans within 1 year of the previous psychiatric review and approval.
The psychiatric clinic clozapine monitoring and evaluation provisions are proposed to be amended for congruence with the program changes regarding prescribing and monitoring clozapine treatment. Clozapine is associated with severe neutropenia and is monitored by blood testing throughout the course of treatment. Absolute neutrophil count (ANC) testing is proposed to be added as part of the treatment protocols.
This proposed rulemaking establishes the conditions and limitations for the provision of MMHT services in the home or community. MMHT expands the ability of outpatient psychiatric clinics to provide services to individuals of any age in approved alternative settings based upon specific clinical criteria and a written order from a licensed practitioner of the healing arts. MMHT will provide access to psychiatric services, psychotherapy and medication visits for individuals who are unable to attend treatment in a traditional outpatient psychiatric clinic setting due to documented mental or physical illness. Subsection (e) is proposed to be deleted because it is no longer necessary with the addition of MMHT to this chapter. Outdated conditions and limitations are proposed to be amended.
§ 1153.53. Limitations on payment
Many of the limitations on services are proposed to be deleted.
§ 1153.53a. Requests for waiver of hourly limits
This section is proposed to be rescinded, as the proposed amendments to the limitations on services eliminate the need for this section.
Chapter 5200. Psychiatric outpatient clinics
§ 5200.1. Legal base
The short title of the ''Mental Health and Mental Retardation Act of 1966'' is proposed to be amended to reflect the legislative change to the ''Mental Health and Intellectual Disability Act of 1966.''
§ 5200.2. Scope
The outdated language of ''the mentally ill or the emotionally disturbed'' is proposed to be amended to ''individuals with mental illness or emotional disturbance.'' This proposed amendment delineates the difference between an illness and the individual who has a specific treatable illness by supporting person first language. The New Freedom Commission on Mental Health, Final Report, July 2003, recognized that the stigma surrounding mental illness can be reduced by reinforcing the hope of recovery for every individual with mental illness and providing person-centered treatment options that are readily accessible in every community. In SAMHSA's ''Leading Change: A Plan for SAMHSA's Roles and Action'' published in 2011, it was reported that one in five Americans believe that individuals with mental illness are dangerous. Based upon the ongoing public perception regarding mental illness, SAMHSA included a strategic initiative targeted at public awareness and support. The goal of the initiative is to increase public understanding about mental and substance use disorders, the reality that people recover and how to access treatment and recovery supports for behavioral health conditions.
''Public entities'' is proposed to be added to recognize facilities that are operated by a Federal, State or local governmental entity and licensed as psychiatric outpatient clinics. Facilities are identified as public or private facilities by the Department.
§ 5200.3. Definitions
The definition of ''advanced practice professional'' is proposed to be added in recognition of CRNPs with a mental health certification or PAs with either a mental health certification or at least 1 year of experience working in a behavioral health setting working under the supervision of a physician. This proposed definition will allow these licensed professionals to provide services within their scope of practice in psychiatric outpatient clinics, thereby expanding clinical resources.
In recognition of the codification of MMHT in this chapter, a variety of definitions are proposed to be added. The proposed definition of ''assessment'' provides a description of the face-to-face interview to evaluate clinical needs of the individual. The definition of ''LPHA—licensed practitioner of the healing arts'' is proposed to be added. MMHT is in the Commonwealth's Medical Assistance State Plan as a rehabilitation service and under 42 CFR 440.130(d), rehabilitation services shall be ''recommended by a physician or other licensed practitioner of the healing arts, within the scope of his practice under State law.'' The proposed definition of ''LPHA—licensed practitioner of the healing arts'' allows a broad array of licensed professionals to order this service within their scope of practice under State law. MMHT includes an array of treatment services to reduce the disabling effects of a mental or physical illness for individuals who have encountered barriers to or have been unsuccessful in receiving services in a traditional outpatient setting due to a physical or psychological condition. The ability to provide clinical treatment to individuals in an alternative setting such as a home or community-based environment increases access to outpatient treatment services potentially decreasing the utilization of higher levels of care.
The definition of ''facility'' is proposed to be amended to delete the outdated terminology ''mentally disabled persons,'' which does not distinguish the individual from the illness, and replace it with ''individuals with mental illness or emotional disturbance.'' This language is proposed to be amended in the definition of ''psychiatric outpatient clinic'' for congruence in the chapter. ''Psychiatric outpatient clinic'' is proposed to be amended throughout the chapter for consistency with the heading of the chapter.
The definition of ''FTE—full-time equivalent'' is proposed to be amended by deleting ''of staff time'' as recommended by the stakeholder workgroup. A person employed for 37 1/2 hours by a psychiatric outpatient clinic is considered a full-time employee.
The definition of ''mental illness or emotional disturbance'' is proposed to be added for consistency with Federal language and to support a person first approach for identifying an illness rather than the use of the outdated term ''mentally disturbed person.'' Mental illness or emotional disturbance is a mental or emotional disorder that meets the diagnostic criteria in the current version of the DSM or the ICD with reference to an individual's level of functioning in various life domains. References to ''mental disorder'' through this chapter are proposed to be amended as ''mental illness or emotional disturbance.''
The definition of ''psychiatrist'' is proposed to be amended to recognize that a residency in psychiatry is ''at least 3 years.''
The definition of ''quality assurance program'' is proposed to be amended to replace the outdated terminology ''patients'' with ''individuals receiving services'' for consistency with other proposed amendments.
The definition of ''telepsychiatry'' is proposed to be added to allow for the utilization of technology to provide clinical services. Telepsychiatry will improve access to mental health care in underserved, rural and remote areas of this Commonwealth, as well as offer specialized clinical services that may only be available in urban regions. According to research reviewed by the American Telemedicine Association, the majority of telemental health services are provided in the outpatient setting. It has been demonstrated that individuals receiving services can be reliably assessed, diagnosed and treated with pharmacology in outpatient clinics through telepsychiatry. Evidence-Based Practice for Telemental Health, July 2009.
This proposed rulemaking also distinguishes between ''mental health professional'' and ''mental health worker'' by clarifying qualifications and incorporating language that recognize the scope of practice of licensed behavioral health professionals. The definitions of ''psychiatric nurse'' and ''psychiatric social worker'' are no longer necessary as a result of this change and are proposed to be deleted.
All service durations are proposed to be deleted from the definitions since the required unit of service for each service is specified in the procedure code, technically known as the Current Procedural Terminology (CPT) code, for the service and therefore does not need to be included in the definition of the service, which could become outdated as CPT codes are revised.
§ 5200.4. Provider eligibility
Proposed amendments clarify that this chapter is not intended to regulate individual or group private practices that provide mental health services.
§ 5200.5. Application and review process
Proposed amendments delete outdated language regarding programs operating under a pre-existing approval to meet the requirements of the chapter and include the current annual inspection information.
§ 5200.6. Objective
Proposed amendments to this section support the ongoing transition to a recovery-oriented system of care by including language that recognizes individuals can, and do, recover from mental illness and emotional distress. The New Freedom Commission on Mental Health reports that ''too many individuals are unaware that mental illnesses can be treated and recovery is possible.'' ''Achieving the Promise: Transforming Mental Health Care in America,'' July 2003. SAMHSA included a strategic initiative in the 2015—2018 plan to promote home and community-based services that avoid unnecessary institutionalization and out-of-home placements. The strategic plan emphasizes that recovery provides the common and motivating goal for individuals and families—that people can and do overcome behavioral health problems to live full and productive lives in the community of their choice. Recovery often includes ongoing community-based treatment and support.
§ 5200.7. Program standards
Based upon stakeholder input, the requirement that for-profit facilities seeking licensure or approval shall have Joint Commission on Accreditation of Hospitals accreditation is proposed to be deleted. This requirement is cost-prohibitive for small psychiatric outpatient clinics, resulting in the Department issuing numerous waivers of this standard.
§ 5200.11. Organization and structure
Proposed amendments include the addition of a clinical supervisor and a director as part of the psychiatric clinic structure and staffing pattern. The director may provide clinical supervision based upon qualifications and structure of the clinic. The director is responsible for the overall daily management of the clinic while the clinical supervisor is responsible for the clinical oversight of service delivery.
§ 5200.12. Linkages with mental health service system
This proposed rulemaking clarifies the requirement for written documentation describing the accessibility and availability of services provided by other parts of the mental health service system. Emergency services, an integral resource, are specified in this proposed rulemaking to ensure access to services to support individuals in crisis in the community. Ready access to emergency assistance is important not only because it holds the promise of reducing the intensity and duration of the individual's distress, but also as the crisis escalates, options for effective interventions decrease. SAMHSA (2009), ''Practice Guidelines: Core Elements in Responding to Mental Health Crises.''
Additionally, ''Mental Health/Mental Retardation (MH/MR)'' is proposed to be updated to ''Mental Health/Intellectual Disability (MH/ID)'' to be congruent with previous statutory changes.
§ 5200.21. Qualifications and duties of the director/clinical supervisor
This section is proposed to be amended to require a clinical supervisor and a director, who may be the same person, to be employed by the psychiatric outpatient clinic to provide oversight and supervision for all clinical services provided at the clinic. This proposed amendment will ensure that clinical staff have access to daily supervision to support treatment services.
§ 5200.22. Staffing pattern
The current requirement is a clinic have four full-time equivalent mental health professionals. Proposed amendments require 50% of the psychiatric clinic treatment staff be mental health professionals. This proposed amendment will allow new clinics to provide clinical services while they build capacity and hire qualified staff. It will also ensure that larger clinics employ adequate professional staff to provide clinical services.
Additionally, the 16-hour psychiatric time requirement is proposed to be amended to 2 hours of psychiatric time per week for each full-time equivalent treatment staff. The psychiatrist shall provide 50% of this psychiatric time per week in-person, while the other 50% of the psychiatric time can be provided either by advanced practice professionals licensed to prescribe medication who specialize in behavioral health or using telepsychiatry with prior written approval of the Department, or a combination of both, to meet the time requirement. This proposed amendment allows for the use of current technology and other licensed professionals. The proposed amendments are also congruent with other states' regulations. In review of other states' outpatient clinic regulations, New York, New Jersey, Wisconsin, South Carolina and Oregon allow other licensed professionals within their scope of practice to provide services in the clinics. Maryland mandates the amount of time a psychiatrist shall be at the clinic, while the majority of regulations require adequate time to provide services based upon clinic size and other licensed professionals employed at the clinic. This proposed amendment will recognize the scope of practice of other licensed professionals in this Commonwealth and allow clinics to maximize the utilization of psychiatric time to provide clinical oversight and direct care to individuals with complex needs receiving services at the clinic.
Language regarding licensure for psychiatric residents is proposed to be amended. ''Unrestricted license'' is proposed to be added to reflect that a third year resident is granted an unrestricted license to practice medicine while first and second year residents receive a ''member in training'' license.
§ 5200.23. Psychiatric supervision
The outdated language of ''patient population'' is proposed to be amended to ''clinic population'' as suggested by the stakeholder community.
§ 5200.24. Criminal history and child abuse certification
This proposed section addresses requirements under 23 Pa.C.S. §§ 6301—6386 (relating to Child Protective Services Law) for background checks for any staff or volunteers having direct contact with an individual receiving outpatient psychiatric services in the clinic or community setting.
§ 5200.31. Treatment planning
Proposed amendments to this section increase the time frame for the development of the initial treatment plan from 15 days to 30 days. This proposed amendment will allow the individual receiving services and the mental health professional more time to identify key goals and objectives for the treatment plan based upon clinical need. The initial treatment plan shall be signed by the mental health professional, the psychiatrist and the individual receiving services.
The frequency of treatment plan updates is proposed to be amended from every 120 days or 15 visits to every 180 days to allow additional time to address the identified goals and objectives of the initial plan. The updated treatment plan shall be reviewed and signed by the mental health professional and the individual receiving treatment.
This proposed rulemaking requires the psychiatrist to review and approve the treatment plan within 1 year of the previous review and approval. This proposed amendment will reduce paperwork burden for the psychiatrist by changing review and sign off to yearly rather than every 120 days. This proposed amendment maintains compliance with definitions in section 1905(a)(9) of the Social Security Act (42 U.S.C.A. § 1396d(a)(9)) and 42 CFR 440.90 (relating to clinic services) that services furnished at the clinic be provided by or are under the direction of a physician. To meet this requirement, a physician shall see the individual, prescribe the type of care provided and periodically review the need for continued care.
Additionally, this proposed rulemaking specifies that the individual receiving services shall be actively involved in the creation of the treatment plan and updates which shall include both strengths and needs. In 2010, SAMHSA convened the leaders in the behavioral health field to develop a unified definition of recovery. Based upon this work, ''recovery'' is defined as ''a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.'' DHHS (2012), ''SAMHSA's Working Definition of Recovery.'' One of the major dimensions to support a life in recovery is overcoming or managing one's disease or symptoms by making informed choices to support emotional and physical well-being. Self-determination and self-direction are critical as individuals exercise choice of services and supports that will assist in their recovery. Person-driven services are one of the ten guiding principles of recovery developed by SAMHSA. DHHS (2012), ''SAMHSA's Working Definition of Recovery.'' Further, active involvement in treatment planning and goal setting is a key element in designing a unique pathway to recovery.
A requirement that treatment be provided according to the individual's treatment plan is proposed to be added to ensure that the services are being provided to help individuals meet their goals and according to their needs. This proposed addition is consistent with the Departments' requirements for other behavioral health services.
§ 5200.32. Treatment policies and procedures
''Patients'' is proposed to be amended to ''individuals'' for consistency with this proposed rulemaking.
§ 5200.41. Records
This section is proposed to be amended to update terminology and include the requirements for securing written and electronic records in accordance with all applicable Federal and State privacy and confidentiality laws and regulations.
§ 5200.42. Medications
Proposed amendments to this section recognize advanced practice professionals licensed to prescribe medication in this Commonwealth. Proposed amendments clarify ''written'' to include prescriptions that are handwritten or recorded and transmitted by electronic means and the requirements for transmitting electronic prescriptions. Proposed amendments will require documentation of any medications prescribed in the individual medical record.
§ 5200.43. Fee schedule
The requirement that fee schedules be submitted to the Department for informational purposes is proposed to be deleted to reduce paperwork requirements for providers. The outdated terminology of referring to an individual receiving services as a patient is proposed to be amended to be consistent with other sections of this chapter.
§ 5200.44. Quality assurance program
''Patients'' is proposed to be amended to ''individuals'' for consistency and a requirement to include MMHT services as part of the quality assurance plan is proposed to be added.
§ 5200.45. Physical facility
''Patient'' is proposed to be amended to ''individual.'' Proposed amendments include physical site requirements that recognize the importance of an engaging and culturally-competent environment in the clinic for individuals receiving services. As part of the ten guiding principles of recovery developed by SAMHSA, culture in all its diverse representations are keys in determining a person's unique pathway to recovery. DHHS (2012), ''SAMHSA's Working Definition of Recovery.''
§ 5200.46. Notice of nondiscrimination
''Client'' is proposed to be amended to ''individual'' for consistency with other sections of this proposed rulemaking. Additionally, the nondiscrimination language is proposed to be updated to reflect current terminology addressing nondiscrimination.
§ 5200.48. Waiver of standards
This section is proposed to be amended to allow greater flexibility for the duration and renewal of waivers to be granted when the development of specialty psychiatric clinic services would be severely limited by the standards. The waivers would continue to be subject to approval by the Department.
§ 5200.51. Provider service description
This proposed section requires that licensed outpatient clinics develop a service description for MMHT services that will be provided, including the age range of the population to be served. Prior to the delivery of MMHT, the service description shall be approved by the Department.
§ 5200.52. Treatment planning
This proposed section includes specific elements in the MMHT treatment plan in addition to the requirements in § 5200.31 (relating to treatment planning). The additional elements provide information on the services to be provided, duration of the service, location of the service provision and the professional responsible for the delivery of the services.
§ 5200.53. Discharge
This proposed section identifies discharge planning requirements for MMHT services.
Affected Individuals and Organizations
This proposed rulemaking will affect individuals receiving psychiatric outpatient clinic services by increasing access to needed services, including the ability to receive outpatient services at alternative locations, allowing the use of telepsychiatry, requiring the involvement of individuals receiving services in planning their treatment and expanding the categories of professionals who may provide services by adding advanced practice professionals licensed to prescribe medications in this Commonwealth.
Licensed psychiatric outpatient clinics that are enrolled in the Medical Assistance Program will be affected by this proposed rulemaking. This proposed rulemaking will reduce paperwork requirements, increase the utilization of licensed professionals within their scope of practice and increase access to services in rural areas by allowing use of telepsychiatry. This proposed rulemaking will help maintain the 279 community-based psychiatric outpatient clinic programs and their 783 satellite sites that served approximately 325,851 individuals in Fiscal Year 2013-2014.
Accomplishments and Benefits
This proposed rulemaking will benefit individuals seeking outpatient psychiatric services by increasing access through the use of telepsychiatry, requiring involvement of each individual in the planning of individualized treatment services, expanding the utilization of MMHT, supporting recovery and increasing the role of advance practice professionals licensed to prescribe medication in the clinics.
The NSDUH report published by SAMHSA in 2014 states that mental illness is a major public health concern in the United States as a primary cause of disability. The Agency for Healthcare Research and Quality cites a cost of $57.5 billion in 2006 for mental health care in the United States, equivalent to the cost of cancer care. Much of the economic burden of mental illness is not the cost of care, but the loss of income due to unemployment, expenses for social supports and a range of indirect costs due to a disability that begins early in life. SMI costs the United States $193.2 billion in lost earnings per year. Kessler, R.C. (2008). ''The individual-level and societal-level effects of mental disorders on earnings in the United States: Results from the National Comorbidity Survey Replication,'' American Journal of Psychiatry, 165(6), 703—711.
Mental health is essential to a person's well-being, healthy family and interpersonal relationships, and the ability to live a full and productive life according to the research done by Healthy People 2020. Research has shown that many mental illnesses can be treated successfully and increasing access to community mental health services could substantially reduce the associated morbidity. CDC (2011), ''Mental Illness Surveillance among Adults in the U.S.'' Increasing access to community-based services with early detection, treatment and recovery supports may have significant positive cost implications for the Commonwealth. There is strong consensus in many countries that outpatient clinics offer an efficient way to assess and treat mental illness by providing sites that are accessible to the local population. Thornicroft, G. and Tansella, M. (2003), ''What are the arguments for community-based mental health care?,'' WHO, Health Evidence Network Report. WHO's Mental Health Action Plan 2013—2020 incorporates the overall goal of promoting mental well-being and preventing mental disorders by providing accessible care, enhancing recovery through a comprehensive integrated community-based mental health system.
The consequences of not having community mental health services, including access to psychiatric outpatient services, include increased hospitalization, physical health costs and suicide. Suicide is the tenth leading cause of death in the United States and the second leading cause of death for youth 15 to 24 years of age. Ensuring access to psychiatric outpatient clinic services is a cost-effective resource that can promote mental well-being, support recovery and reduce the utilization of inpatient care.
The psychiatric outpatient clinics will benefit from a decrease in paperwork requirements, thereby increasing psychiatric and other clinical time available to provide direct services, and also the increased ability to provide services in accordance with current industry standards.
Fiscal Impact
No costs to the Commonwealth, local government, service providers or individuals seeking psychiatric outpatient services are anticipated as a result of this proposed rulemaking.
Paperwork Requirements
No additional reporting, paperwork or recordkeeping is required to comply with this proposed rulemaking. Further, requirements regarding documentation of treatment planning are proposed to be reduced, which will result in a decrease in current paperwork requirements for psychiatric outpatient clinic providers.
Effective Date
This proposed rulemaking will be effective upon final-form publication in the Pennsylvania Bulletin.
Public Comment
Interested persons are invited to submit written comments, suggestions or objections regarding this proposed rulemaking to the Department of Human Services, Office of Mental Health and Substance Abuse Programs, Attention: Michelle Rosenberger, Bureau of Policy, Planning and Program Development, Commonwealth Towers, 11th Floor, 303 Walnut Street, P.O. Box 2675, Harrisburg, PA 17105-2675, RA-PWOPCRegs@pa.gov within 30 calendar days after the date of the publication of this proposed rulemaking in the Pennsylvania Bulletin. Reference Regulation No. 14-538 when submitting comments. Persons 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 28, 2017, the Department submitted a copy of this proposed rulemaking and a copy of a Regulatory Analysis Form to the Independent Regulatory Review Commission (IRRC) and to the Chairpersons of the House Committee on Human Services and the Senate Committee on Public Health and Welfare. 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.
THEODORE DALLAS,
SecretaryFiscal Note: 14-538. No fiscal impact; (8) recommends adoption.
Annex A
TITLE 55. HUMAN SERVICES
PART III. MEDICAL ASSISTANCE MANUAL
CHAPTER 1153. OUTPATIENT [PSYCHIATRIC] BEHAVIORAL HEALTH SERVICES
GENERAL PROVISIONS § 1153.1. Policy.
The MA Program provides payment for specific medically necessary psychiatric outpatient clinic services, MMHT services and psychiatric outpatient partial hospitalization services rendered to eligible [recipients] individuals by psychiatric outpatient clinics and psychiatric outpatient partial hospitalization facilities enrolled as providers under the program. Payment for [outpatient psychiatric] behavioral health services is subject to the provisions of this chapter, Chapter 1101 (relating to general provisions) and the limitations established in Chapter 1150 (relating to [the] MA Program payment policies) and the MA Program [fee schedule] Fee Schedule.
§ 1153.2. Definitions.
The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:
Adult—An individual 21 years of age or older.
Adult partial hospitalization program—A program licensed by the Department, Office of Mental Health and Substance Abuse Services, to provide partial hospitalization services to individuals 15 years of age or older.
Children and youth partial hospitalization program—A program licensed by the Department, Office of Mental Health and Substance Abuse Services, to provide partial hospitalization services to individuals 14 years of age or younger.
Clinical staff—A psychiatrist or a mental health professional or mental health worker under the direct supervision of a psychiatrist.
Collateral family psychotherapy—Psychotherapy provided to the family members of [a clinic patient in the absence of that patient] an individual receiving psychiatric outpatient clinic services in the absence of the individual.
Department—The Department of Human Services.
Facility—A mental health establishment, hospital, clinic, institution, center, or other organizational unit or part thereof, the primary function of which is the diagnosis, treatment, care and rehabilitation of individuals with mental illness or emotional disturbance.
Family—A person living alone or the following persons: spouses; parents and their unemancipated minor children and other unemancipated minor children who are related by blood or marriage; or other adults or emancipated minor children living in the household who are dependent upon the head of the household.
Family psychotherapy—Psychotherapy provided to two or more members of a family. At least one family member shall have a diagnosed mental [disorder] illness or emotional disturbance. Sessions shall be [at least 1/2 hour in duration and shall be] conducted by a clinical staff person.
Group psychotherapy—Psychotherapy provided to no less than [two] 2 and no more than [ten] 12 persons with diagnosed mental [disorders for a period of at least 1 hour] illness or emotional disturbance. These sessions shall be conducted by a clinical staff person.
[Home visit—A visit made to an eligible recipient's place of residence, other than a treatment institution or nursing home, for the purpose of observing the patient in the home setting or providing a compensable outpatient psychiatric service.]
Individual psychotherapy—Psychotherapy provided to one person with a diagnosed mental [disorder for a minimum of 1/2 hour] illness or emotional disturbance. These sessions shall be conducted by a clinical staff person.
Inpatient—[A patient] An individual who has been admitted to a treatment institution or an acute care hospital or psychiatric hospital on the recommendation of a physician and is receiving room, board and professional services in the facility on a continuous 24-hour-a-day basis.
Intake—[The first contact with a patient for initiation or renewal of services.] The first contact with an individual for initiation of or readmission to outpatient behavioral health services covered by this chapter.
[Mental disorder—Conditions characterized as mental disorders by the International Classification of Diseases—ICD-9-CM—including mental retardation with associated psychiatric conditions (ICD-9-CM codes 317 to 319) and excluding drug/alcohol conditions (ICD-9-CM codes 291—292.9).]
LPHA—Licensed practitioner of the healing arts—A person who is licensed by the Commonwealth to practice the healing arts. The term is limited to a physician, physician's assistant, certified registered nurse practitioner or psychologist.
MMHT—Mobile Mental Health Treatment—One or more of the following services provided in an individual's residence or approved community site:
(i) Assessment.
(ii) Individual, group or family therapy.
(iii) Medication visits.
Mental health professional—[A person trained in a generally recognized clinical discipline including but not limited to psychiatry, social work, psychology or nursing, rehabilitation or activity therapies who has a graduate degree and clinical experience.] A person who meets one of the following:
(i) Has a graduate degree from a college or university that is accredited by an agency recognized by the United States Department of Education or the Council for Higher Education Accreditation (CHEA) in a generally recognized clinical discipline which includes mental health clinical experience.
(ii) Has an equivalent degree from a foreign college or university that has been evaluated by the Association of International Credential Evaluators, Inc. (AICE) or the National Association of Credential Evaluation Services (NACES). The Department will accept a general equivalency report from the listed evaluator agencies to verify a foreign degree or its equivalency.
(iii) Is licensed in a generally recognized clinical discipline which includes mental health clinical experience.
Mental health worker—[A person who does not have a graduate degree in a clinical discipline but who by training and experience has achieved recognition as a mental health worker, or a person with a graduate degree in a clinical discipline.] A person acting under the direction of a mental health professional to provide services who meets one of the following:
(i) Has a bachelor's degree from a college or university that is accredited by an agency recognized by the United States Department of Education or the CHEA in a recognized clinical discipline including social work, psychology, nursing, rehabilitation or activity therapies.
(ii) Has a graduate degree in a clinical discipline with 12 graduate-level credits in mental health or counseling from a program that is accredited by an agency recognized by the United States Department of Education or the CHEA.
(iii) Has an equivalent degree from a foreign college or university that has been evaluated by the AICE or the NACES. The Department will accept a general equivalency report from the listed evaluator agencies to verify a foreign degree or its equivalency.
Mental illness or emotional disturbance—A mental illness or emotional disturbance that meets the diagnostic criteria within the current version of the Diagnostic and Statistical Manual or the International Classification of Diseases. A mental illness or emotional disturbance is characterized by clinically significant disturbances in an individual's cognition, emotional regulation or behavior that reflects a dysfunction in the psychological, biological or developmental processes underlying mental functioning.
Outpatient—[A person] An individual who is not a resident of a treatment institution and who is receiving covered medical and [psychiatric services at an approved or licensed outpatient psychiatric] behavioral health services from a licensed psychiatric outpatient clinic or partial hospitalization facility which is not providing [him] the individual with room and board and professional services on a continuous 24-hour-a-day basis.
Psychiatric clinic clozapine monitoring and evaluation visit—A [minimum 15-minute] visit for the monitoring and evaluation of [a patient's] an individual's physical and mental condition during the course of treatment with clozapine. The term includes only a visit provided to an eligible [recipient] individual receiving clozapine therapy, and only by a psychiatrist, physician, certified registered nurse practitioner, registered nurse [(RN)] or physician assistant.
Psychiatric clinic medication visit—A [minimum 15-minute] visit only for administration of a drug and evaluation of [a patient's physical and] an individual's physical or mental condition during the course of prescribed medication. This visit is provided to an eligible [recipient] individual only by a psychiatrist, physician, certified registered nurse practitioner, physician's assistant, registered nurse or licensed practical nurse [who is a graduate of a school approved by the State Board of Nursing or who has successfully completed a course in the administration of medication approved by the State Board of Nursing].
Psychiatric evaluation—An initial mental status examination and evaluation of [a patient provided only by a psychiatrist in a face-to-face interview with the patient] an individual provided only by a psychiatrist in a face-to-face interview or using real-time, two-way interactive audio-video transmission with prior written approval from the Department with the individual. It [shall] must include a comprehensive history and evaluation of pertinent diagnostic information necessary to arrive at a diagnosis and treatment plan, recommendations for treatment, or further diagnostic studies or consultation. The history [shall] must include individual, social, family, occupational, drug, medical, and previous psychiatric diagnostic and treatment information.
Psychiatric outpatient clinic [provider]—A facility [approved by the Department, Office of Medical Assistance, and fully approved/licensed] fully licensed by the Department, Office of Mental Health and Substance Abuse Services, to provide specific medical, psychiatric and psychological services for the diagnosis and treatment of mental [disorders] illness or emotional disturbance. [Treatment is provided to eligible Medical Assistance outpatient recipients who are not residents of a treatment institution or receiving similar treatment elsewhere.]
Psychiatric outpatient clinic services—Outpatient medical, psychiatric and psychological services listed in the MA Program Fee Schedule furnished to [a mentally disordered outpatient while the person] an individual with mental illness or emotional disturbance while the individual is not a resident of a treatment institution, provided by or under the supervision of a psychiatrist [in a facility organized and operated to provide medical care to outpatients].
Psychiatric outpatient partial hospitalization provider—A facility [approved by the Department of Human Services, Office of Medical Assistance,] enrolled in the MA Program to provide partial hospitalization services and fully [approved/licensed] licensed by the Department, Office of Mental Health and Substance Abuse Services, to provide psychiatric, medical, psychological and psychosocial services as partial hospitalization for the diagnosis and treatment of mental [disorders] illness and emotional disturbance. [Treatment is provided to eligible MA outpatient recipients who are not residents of a treatment institution or receiving similar treatment elsewhere.]
Psychiatric partial hospitalization—An active outpatient psychiatric day or evening treatment session including medical, psychiatric, psychological[,] and psychosocial treatment listed in the MA Program Fee Schedule. This service shall be provided to [mentally disordered outpatients in a supervised, protective setting for a minimum of 3 hours and a maximum of 6 hours in a 24-hour period] an individual with mental illness or emotional disturbance in a supervised, protective setting. The session shall be provided by a psychiatrist or by psychiatric partial hospitalization personnel under the supervision of a psychiatrist.
Psychologist in preparation for licensure—A person who has completed the educational requirements for licensure and is accruing the required postdegree experience for licensing.
Psychotherapy—The treatment, by psychological means, of the problems of an emotional nature in which a trained person deliberately establishes a professional relationship with [the patient with the object of removing, modifying or retarding] an individual with the objective of removing, modifying or relieving existing symptoms, of mediating disturbed patterns of behavior, and of promoting positive personality growth and development.
Supervision by a psychiatrist—The psychiatrist [personally] provides or orders, guides and oversees compensable medical, psychiatric and psychological services provided to [recipients] individuals by psychiatric outpatient clinic or partial hospitalization personnel as specified in § 1153.52(a) (relating to payment conditions for various services).
Treatment institution—A facility approved or licensed by the Department or its agents that provides [full- or part-time psychiatric treatment services for resident patients with mental disorders—mental retardation residential facilities] full-time psychiatric treatment services for resident individuals with mental illness or emotional disturbance—residential facilities for individuals with intellectual disabilities or community residential rehabilitation services are not considered to be mental health institutions.
COVERED AND NONCOVERED SERVICES § 1153.11. Types of services covered.
Medical Assistance Program coverage for [outpatient] psychiatric outpatient clinics [and], partial hospitalization facilities and MMHT services is limited to professional medical and psychiatric services for the diagnosis and treatment of mental [disorders, including mental retardation] illness and emotional disturbance, including intellectual disabilities, as specified in the MA Program Fee Schedule.
§ 1153.12. Outpatient services.
The [outpatient] psychiatric outpatient clinic services specified in the MA Program Fee Schedule and the outpatient psychiatric partial hospitalization services specified in the MA Program Fee Schedule are covered only when provided by [approved outpatient psychiatric] licensed psychiatric outpatient clinics or psychiatric partial hospitalization facilities when ordered by a psychiatrist. MMHT services specified in the MA Program Fee Schedule are covered only when provided by a licensed psychiatric outpatient clinic that has an approved service description for MMHT. Payment is subject to the conditions and limitations established in this chapter and Chapter 1101 (relating to general provisions).
§ 1153.14. Noncovered services.
Payment will not be made for the following types of services regardless of where or to whom they are provided:
(1) A covered [clinic] psychiatric outpatient clinic, MMHT or partial hospitalization service conducted over the telephone.
(2) Cancelled appointments.
(3) Covered services that have not been rendered.
(4) [A] An MA covered service, including psychiatric [clinic] outpatient clinic, MMHT and partial hospitalization services, provided to inmates of State or county correctional institutions or committed residents of public institutions.
(5) Psychiatric outpatient clinic, MMHT or partial hospitalization services to residents of treatment institutions, such as[, persons] individuals who are also being provided with room or board, or both, and services, on a 24-hour-a-day basis by the same facility or distinct part of a facility or program.
(6) Services delivered at locations other than [approved psychiatric outpatient clinics or partial hospitalization facilities with the exception of home visits under the conditions specified in § 1153.52(d) (relating to payment conditions for various services)] licensed psychiatric outpatient clinics with the exception of MMHT under the conditions specified in § 1153.52(d) (relating to payment conditions for various services) or partial hospitalization facilities.
(7) Vocational rehabilitation, occupational or recreational therapy, referral, information or education services, case management, central intake or records, training, administration, program evaluation, research or social services provided in psychiatric outpatient clinics.
(8) Case management, central intake or records, training, administration, social rehabilitation, program evaluation or research provided in psychiatric outpatient partial hospitalization facilities.
(9) Psychiatric outpatient clinic services, MMHT and psychiatric partial hospitalization provided on the same day to the same [patient] individual.
(10) Covered psychiatric outpatient clinic services, MMHT and psychiatric partial hospitalization services, with the exception of family psychotherapy, provided to persons without a mental [disorder or mental retardation] illness or emotional disturbance or an intellectual disability diagnosis rendered by a psychiatrist in accordance with the current version of the Diagnostic and Statistical Manual or the International Classification of Diseases—[ICD-9-CM, Chapter V, ''Mental Disorders.''] Chapter V, ''Mental, Behavioral, and Neurodevelopmental Disorders.''
(11) [Psychiatric outpatient clinic and psychiatric partial hospitalization services provided to patients with drug/alcohol abuse or dependence problems, such as alcohol dependence and nonde-pendent abuse of drugs, alcohol psychoses, and drug psychoses, unless the patient has a primary diagnosis of a nondrug/alcohol abuse/dependence related mental disorder.] Psychiatric outpatient clinic, MMHT and psychiatric partial hospitalization services provided to individuals with substance-related and addictive disorders, unless the individual has a primary diagnosis of a mental illness or emotional disturbance.
(12) Drugs [and], biologicals and supplies furnished to [psychiatric clinic or psychiatric partial hospitalization patients during a visit to the] an individual receiving services at a psychiatric outpatient clinic or a partial hospitalization facility during a visit to the psychiatric outpatient clinic or facility. These are included in the psychiatric outpatient clinic medication visit fee or partial hospitalization session payment. Separate billings from any source for items and services provided [in the] by the psychiatric outpatient clinic are noncompensable.
(13) Services not specifically included in the MA Program Fee Schedule are noncompensable.
(14) [Home visits] MMHT services not provided in accordance with the conditions specified in § 1153.52(d).
(15) Services provided beyond the [15th] 30th calendar day following intake, without the psychiatrist's review and approval of the initial assessment and treatment plan.
(16) The hours that the [client] individual participates in an education program delivered in the same setting as a children and youth partial hospitalization program unless, in addition to the teacher, a clinical staff person works with the child in the classroom. The Department will reimburse for only that time during which the [client] individual is in direct contact with a clinical staff person.
(17) Group psychotherapy provided in the [patient's] individual's home.
(18) Psychiatric [clinic] outpatient clinic, MMHT and partial hospitalization services provided to nursing home residents on the grounds of the nursing home or under the corporate umbrella of the nursing home.
(19) Electroconvulsive therapy and electroencephalogram provided through MMHT.
(20) MMHT provided on the same day as other home and community-based behavioral health services to the same individual.
(21) MMHT services provided as a substitute for transportation to the psychiatric outpatient clinic.
SCOPE OF BENEFITS § 1153.21. Scope of benefits for [the categorically needy] children under 21 years of age.
[Categorically needy recipients] Children under 21 years of age are eligible for the full range of covered psychiatric outpatient clinic, MMHT and psychiatric partial hospitalization services in the MA Program Fee Schedule.
§ 1153.22. Scope of benefits for [the medically needy] adults 21 years of age or older.
[Medically needy recipients] Adults 21 years of age or older are eligible for the full range of covered psychiatric outpatient clinic, MMHT and psychiatric partial hospitalization services in the MA Program Fee Schedule.
§ 1153.23. [Scope of benefits for State Blind Pension recipients] (Reserved).
[State Blind Pension recipients are eligible for the full range of covered psychiatric outpatient clinic and psychiatric partial hospitalization services in the MA Program fee schedule.]
§ 1153.24. [Scope of benefits for General Assistance recipients] (Reserved).
[General Assistance recipients, age 21 to 65, whose MA benefits are funded solely by State funds, are eligible for medically necessary basic health care benefits as defined in Chapter 1101 (relating to general provisions). See § 1101.31(e) (relating to scope).]
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