reglab/statecodes huggingface dataset:
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 21.7 - Child Mental Health Wraparound Services › Section 21.7-12 - Provider training

Current through July 10, 2024
Authority: IC
				  12-8-6.5-5; IC 12-15
Affected: IC
				  12-13-7-3; IC 12-29; IC
				  25-23.6-10.5; IC
				  25-27.5-5
Sec. 12.
(a) Each
				year an office-authorized CMHW service provider must complete ten (10) hours of
				ongoing training and continuing education in either child mental health or SED
				child-related topics.
(b) The
				provider must keep current all service-related trainings and certifications
				required for a CMHW service provider.
(c) The provider must submit verification of
				compliance with training and service-related certification requirements to the
				office at the time of provider reauthorization.
(d) A service provider's failure to comply
				with CMHW training and service-related certification requirements may result in
				the revocation of the provider's CMHW service provider authorization.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 21.7 - Child Mental Health Wraparound Services › Section 21.7-13 - Provider reauthorization

Current through July 10, 2024
Authority: IC
				  12-8-6.5-5; IC 12-15
Affected: IC
				  12-13-7-3; IC 12-29; IC
				  25-23.6-10.5; IC
				  25-27.5-5
Sec. 13.
(a) To
				ensure continued compliance with provider qualifications and standards for
				providing CMHW services, an office-approved CMHW service provider must reapply
				for authorization according to the following reauthorization schedule:
(1) An accredited agency provider must apply
				for reauthorization:
(A) at least every three
				(3) years following the initial office authorization; or
(B) at the time of the agency
				reaccreditation; whichever date is earlier.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 21.7 - Child Mental Health Wraparound Services › Section 21.7-14 - Provider sanctions

Current through July 10, 2024
Authority: IC 12-8-6.5-5; IC 12-15
Affected: IC 12-13-7-3; IC 12-29; IC 25-23.6-10.5; IC
				  25-27.5-5
Sec. 14.
(a) Under
				405 IAC 1-1.4-4, if a provider
				has violated any provision established under IC 12-15, the OMPP may impose one
				(1) or more of the following sanctions:
(1)
				Deny payment.
(2) Revoke
				authorization as a CMHW services provider.
(3) Assess a fine.
(4) Assess an interest charge.
(5) Require corrective action against an
				agency or a provider.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 21.7 - Child Mental Health Wraparound Services › Section 21.7-15 - Services: general provisions

Current through July 10, 2024
Authority: IC 12-8-6.5-5; IC 12-15
Affected: IC 12-13-7-3; IC 12-29; IC 25-23.6-10.5; IC
				  25-27.5-5
Sec. 15.
(a) All CMHW
				services provided to a member must meet the following requirements:
(1) Be supported by the member's level of
				need.
(2) Be documented in the
				member's plan of care.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 21.7 - Child Mental Health Wraparound Services › Section 21.7-16 - Wraparound facilitation services

Current through July 10, 2024
Authority: IC
				  12-8-6.5-5; IC 12-15
Affected: IC
				  12-13-7-3; IC 12-29; IC
				  25-23.6-10.5; IC
				  25-27.5-5
Sec. 16.
(a)
				Wraparound facilitation services are as follows:
(1) Comprehensive services comprised of a
				variety of specific tasks and activities designed to carry out the wraparound
				process.
(2) A required component
				of the CMHW services program.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 21.7 - Child Mental Health Wraparound Services › Section 21.7-17 - Habilitation services

Current through July 10, 2024
Authority: IC
				  12-8-6.5-5; IC 12-15
Affected: IC
				  12-13-7-3; IC 12-29; IC
				  25-23.6-10.5; IC
				  25-27.5-5
Sec. 17.
(a)
				Habilitation services are provided with the following goals:
(1) Enhancing the member's level of
				functioning, quality of life, and use of social skills.
(2) Building the strengths, resilience, and
				positive outcomes of the member and the member's family.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 21.7 - Child Mental Health Wraparound Services › Section 21.7-18 - Respite care services

Current through July 10, 2024
Authority: IC
				  12-8-6.5-5; IC 12-15
Affected: IC
				  12-13-7-3; IC 12-29; IC
				  25-23.6-10.5; IC
				  25-27.5-5
Sec. 18.
(a) Respite
				care services are:
(1) provided to a member
				unable to care for himself or herself; and
(2) furnished on a short-term basis because
				of the absence, or need for relief, of a person or persons who normally provide
				care for the member.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 21.7 - Child Mental Health Wraparound Services › Section 21.7-19 - Training and support for unpaid caregiver services

Current through July 10, 2024
Authority: IC
				  12-8-6.5-5; IC 12-15
Affected: IC
				  12-13-7-3; IC 12-29; IC
				  25-23.6-10.5; IC
				  25-27.5-5
Sec. 19.
(a) Training
				and support for unpaid caregivers is a service for an individual who is
				providing unpaid support, training, companionship, or supervision for a
				member.
(b) The intent of this
				service is to provide education and supports to assist the caregiver in
				preserving the member's family unit.
(c) Training and support activities must be:
(1) based on the unique needs of the family
				and caregiver; and
(2) identified
				in the plan of care.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 21.7 - Child Mental Health Wraparound Services › Section 21.7-20 - Fair hearings and appeals

Current through July 10, 2024
Authority: IC
				  12-8-6.5-5; IC 12-15
Affected: IC
				  12-13-7-3; IC 12-29; IC
				  25-23.6-10.5; IC
				  25-27.5-5
Sec. 20.
(a) CMHW
				services applicants, members, and their families shall have an opportunity to
				request a fair hearing to appeal a decision of the office regarding CMHW
				services eligibility or a request for services as described in this
				section.
(b) Information concerning
				a member's right to a fair hearing and appeal and how to request such an
				appeal's hearing shall be provided to an applicant, member, or the family of an
				applicant or member at the following times:
(1) Provided to the applicant and the
				applicant's family by the local access site following the office's
				determination of the applicant's eligibility for CMHW services.
(2) Provided to the member and family by the
				wraparound facilitator following the office review of a proposed CMHW services
				plan of care, or updated plan of care, to document the office authorization or
				denial of the requested CMHW services.
(3) Provided to the member and family by the
				wraparound facilitator following the member's reevaluation for CMHW services
				eligibility.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 21.7 - Child Mental Health Wraparound Services › Section 21.7-21 - Complaints and grievances

Current through July 10, 2024
Authority: IC
				  12-8-6.5-5; IC 12-15
Affected: IC
				  12-13-7-3; IC 12-29; IC
				  25-23.6-10.5; IC
				  25-27.5-5
Sec. 21.
(a) An
				applicant, a member, and the family of an applicant or a member shall have the
				right to file a complaint or grievance in writing with the state regarding CMHW
				service providers or CMHW services. All complaints and grievances are accepted
				by the following means:
(1) Delivery to the
				family-consumer section on the DMHA website.
(2) Delivery in-person to a DMHA staff
				member.
(3) Delivery via written
				complaint or e-mail that is submitted to the DMHA.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 21.8 - Behavioral and Primary Health Care Coordination Services › Section 21.8-1 - General provisions

Current through July 10, 2024
Authority: IC
				  12-8-6.5-5; IC 12-15
Affected: IC
				  12-7-2-40.6; IC
				  12-13-7-3; IC
				  12-15-2-3.5; IC
				  12-29-2; IC
				  25-23-1-1; IC
				  25-23.6-10.5; IC
				  25-27.5-5
Sec. 1.
The intent of this rule is to provide BPHC services to
				  individuals with serious mental illness who demonstrate impairment in
				  self-management of health services. Eligibility for services and the provision
				  of services are based upon an individual meeting specific BPHC needs-based and
				  targeting criteria. BPHC services will be:
(1) provided through a state plan;
				and
(2) delivered by service
				provider agencies meeting specific state-defined criteria.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 21.8 - Behavioral and Primary Health Care Coordination Services › Section 21.8-2 - Definitions

Current through July 10, 2024
Authority: IC
				  12-8-6.5-5; IC 12-15
Affected: IC
				  12-7-2-40.6; IC
				  12-13-7-3; IC
				  12-15-2-3.5; IC
				  12-29-2; IC
				  25-23-1-1; IC
				  25-23.6-10.5; IC
				  25-27.5-5
Sec. 2.
(a) The
				definitions in this section apply throughout this rule.
(b) "Applicant" refers to an individual who
				is seeking enrollment in BPHC services.
(c) "Behavioral and primary health care
				coordination services" or "BPHC services" refers to coordination of health care
				services to manage the health care needs of the member including direct
				assistance in gaining access to health services, coordination of care within
				and across systems, oversight of the entire case, and linkage to appropriate
				services.
(d) "Certified community
				health worker" or "CHW" refers to an individual who meets all of the following:
(1) Has completed the CHW office and Indiana
				state department of health state-approved training program.
(2) Receives a passing score on the
				certification exam.
(3) Is
				supervised by a licensed professional or QBHP.
(4) Delivers services as defined at section
				8(a) of this rule.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 21.8 - Behavioral and Primary Health Care Coordination Services › Section 21.8-3 - Applicants and the application process

Current through July 10, 2024
Authority: IC 12-8-6.5-5; IC 12-15
Affected: IC 12-7-2-40.6; IC 12-13-7-3; IC 12-15-2-3.5; IC
				  12-29-2; IC 25-23-1-1; IC 25-23.6-10.5; IC 25-27.5-5
Sec. 3.
(a) In order
				for an individual to receive services under this rule, a BPHC eligible provider
				agency, in collaboration with the applicant, must submit an application in the
				manner required by the office.
(b)
				Each applicant for BPHC services must receive a face-to-face evaluation using
				both the:
(1) office-approved behavioral
				health assessment tool; and
(2)
				application form developed by the office.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 21.8 - Behavioral and Primary Health Care Coordination Services › Section 21.8-4 - Eligibility

Current through July 10, 2024
Authority: IC 12-8-6.5-5; IC 12-15
Affected: IC 12-7-2-40.6; IC 12-13-7-3; IC 12-15-2-3.5; IC
				  12-29-2; IC 25-23-1-1; IC 25-23.6-10.5; IC 25-27.5-5
Sec. 4.
To be eligible for services under this rule, an applicant
				  must meet all of the following:
(1)
				All of the criteria set forth in
				405 IAC 2-1.1-6.
(2) Be nineteen (19) years of age or
				older.
(3) The applicant has been
				diagnosed with a BPHC-eligible primary mental health diagnosis including, but
				not limited to:
(A) schizophrenic
				disorder;
(B) major depressive
				disorder;
(C) bipolar
				disorder;
(D) delusional disorder;
				or
(E) psychotic
				disorder.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 21.8 - Behavioral and Primary Health Care Coordination Services › Section 21.8-5 - IICP authorization period; renewal

Current through July 10, 2024
Authority: IC
				  12-8-6.5-5; IC 12-15
Affected: IC
				  12-7-2-40.6; IC
				  12-13-7-3; IC
				  12-15-2-3.5; IC
				  12-29-2; IC
				  25-23-1-1; IC
				  25-23.6-10.5; IC
				  25-27.5-5
Sec. 5.
(a) A member
				approved to receive BPHC services under this rule shall be eligible for such
				services for up to a six (6) month period commencing from the date of service
				approval and authorization, as long as eligibility and needs-based eligibility
				criteria and other eligibility continue to be met.
(b) A reevaluation will be conducted at least
				every six (6) months and shall include the following:
(1) Conducting a face-to-face holistic
				clinical and biopsychosocial evaluation completed by an office-approved BPHC
				service provider.
(2) Administering
				the office-approved behavioral assessment tool to determine whether the member
				still meets the level of need for intensive community-based services, as
				demonstrated by a rating level of three (3) or higher.
(3) Assessing the member's progress toward
				meeting treatment goals set forth in the IICP.
(4) Documenting that the member continues to
				meet BPHC target group eligibility and needs-based eligibility
				criteria.
(5) Completing an updated
				application.
(6) Completing an
				updated IICP documenting the member's choice of BPHC service
				providers.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 21.8 - Behavioral and Primary Health Care Coordination Services › Section 21.8-6 - Clinical documentation requirements

Current through July 10, 2024
Authority: IC 12-8-6.5-5; IC 12-15
Affected: IC 12-7-2-40.6; IC 12-13-7-3; IC 12-15-2-3.5; IC
				  12-29-2; IC 25-23-1-1; IC 25-23.6-10.5; IC 25-27.5-5
Sec. 6.
(a) To be
				reimbursable under this rule, the BPHC service must be supported by clinical
				documentation that is maintained in the member's clinical record.
(b) The documentation required to support
				billing for BPHC services must meet the following standards:
(1) Reflect progress toward the goals
				reflected in the member's IICP.
(2)
				Be updated with every member encounter when billing is submitted for
				reimbursement.
(3) Be written and
				signed by the agency staff rendering services.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 21.8 - Behavioral and Primary Health Care Coordination Services › Section 21.8-7 - BPHC services; general provisions

Current through July 10, 2024
Authority: IC
				  12-8-6.5-5; IC 12-15
Affected: IC
				  12-7-2-40.6; IC
				  12-13-7-3; IC
				  12-15-2-3.5; IC
				  12-29-2; IC
				  25-23-1-1; IC
				  25-23.6-10.5; IC
				  25-27.5-5
Sec. 7.
(a) All BPHC
				services provided to a member must meet the following requirements:
(1) Be supported by the member's level of
				need.
(2) Be documented in the
				member's IICP.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 21.8 - Behavioral and Primary Health Care Coordination Services › Section 21.8-8 - BPHC activities

Current through July 10, 2024
Authority: IC
				  12-8-6.5-5; IC 12-15
Affected: IC
				  12-7-2-40.6; IC
				  12-13-7-3; IC
				  12-15-2-3.5; IC
				  12-29-2; IC
				  25-23-1-1; IC
				  25-23.6-10.5; IC
				  25-27.5-5
Sec. 8.
(a) BPHC
				reimbursable activities consist of coordination of health care services to
				manage the health care needs of the member. The BPHC services include the
				following reimbursable activities:
(1)
				Logistical support.
(2) Advocacy
				and education to assist individuals in navigating the health care
				system.
(3) Activities that help
				members:
(A) gain access to needed health
				services; and
(B) manage their
				health conditions, including, but not limited to:
(i) adhering to health regimens;
(ii) scheduling and keeping medical
				appointments;
(iii) obtaining and
				maintaining a primary medical provider; and
(iv) facilitating communication across
				medical providers.
(4) Needs assessment.
(5) IICP development.
(6) Referral and linkage.
(7) Coordination of health services across
				systems.
(8) Monitoring and
				follow-up.
(9)
				Evaluation.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 21.8 - Behavioral and Primary Health Care Coordination Services › Section 21.8-9 - BPHC provider agency requirements

Current through July 10, 2024
Authority: IC 12-8-6.5-5; IC 12-15
Affected: IC 12-7-2-40.6; IC 12-13-7-3; IC 12-15-2-3.5; IC
				  12-29-2; IC 25-23-1-1; IC 25-23.6-10.5; IC 25-27.5-5
Sec. 9.
(a) In order
				to deliver the BPHC program under this rule, a provider must be a
				state-certified community mental health center approved by the office as a BPHC
				provider agency.
(b) Any provider
				wishing to apply to become a BPHC provider agency must:
(1) submit a completed BPHC provider agency
				application to the office for review and consideration; and
(2) be enrolled as a provider.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 21.8 - Behavioral and Primary Health Care Coordination Services › Section 21.8-10 - Fair hearings and appeals

Current through July 10, 2024
Authority: IC
				  12-8-6.5-5; IC 12-15
Affected: IC
				  12-7-2-40.6; IC
				  12-13-7-3; IC
				  12-15-2-3.5; IC
				  12-29-2; IC
				  25-23-1-1; IC
				  25-23.6-10.5; IC
				  25-27.5-5
Sec. 10.
(a) The
				following individuals may appeal an adverse agency action:
(1) An applicant.
(2) A member who receives services under this
				rule.
(3) A duly authorized
				representative of:
(A) an applicant;
				or
(B) a recipient.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 21.8 - Behavioral and Primary Health Care Coordination Services › Section 21.8-11 - Complaints and grievances

Current through July 10, 2024
Authority: IC
				  12-8-6.5-5; IC 12-15
Affected: IC
				  12-7-2-40.6; IC
				  12-13-7-3; IC
				  12-15-2-3.5; IC
				  12-29-2; IC
				  25-23-1-1; IC
				  25-23.6-10.5; IC
				  25-27.5-5
Sec. 11.
(a) The
				following individuals may file a written complaint or a written grievance with
				the state or the office:
(1) An
				applicant.
(2) A member.
(3) A duly authorized representative of:
(A) an applicant; or
(B) a member.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 22 - Nursing and Therapy Services › Section 22-1 - Definitions

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2
Affected: IC 12-13-7-3; IC 12-15
Sec. 1.
The following definitions apply throughout this rule:
(1) "Acute medical condition" means a
				condition with an onset within the preceding fourteen (14) days, and sequelae
				of a temporary nature, including, but not limited to, sprains, spasms,
				infection, or joint inflammation.
(2) "Acute rehabilitation condition" means
				medical injury or insult, onset occurring within one (1) year, which results in
				impaired functioning. These conditions may include, but are not limited to,
				head injury, cerebrovascular accident (CVA), or fracture.
(3) "Applied behavioral analysis therapy
				services" or "ABA therapy services" means the design, implementation, and
				evaluation of environmental modification using behavioral stimuli and
				consequences to produce socially significant improvement in human behavior,
				including the direct observation, measurement, and functional analysis of the
				relations between environment and behavior.
(4) "Chronic medical condition or
				rehabilitation condition" means any injury or insult with onset and sequelae
				extending past one (1) year.
(5)
				"Educational in nature" means instruction or training that develops the general
				abilities of the mind and results in learning new material, as opposed to
				restoring or establishing a normal condition.
(6) "Habilitative therapy" means therapy
				addressing chronic medical conditions where further progress can no longer be
				expected to lessen the deterioration of function over time. Habilitative
				therapy includes physical therapy, occupational therapy, respiratory therapy,
				speech-language pathology services, and audiology services provided to members
				for the purpose of maintaining a level of functionality, but not the
				improvement of functionality. Although the development of a habilitation plan
				is considered part of rehabilitation services, the services furnished under a
				habilitation plan are not skilled therapy.
(7) "Licensed or board certified behavior
				analyst" means a behavior analyst with credentialing as a:
(A) board certified behavior analyst -
				doctoral (BCBA-D);
(B) board
				certified behavior analyst (BCBA); or
(C) board certified assistant behavior
				analyst (BCaBA).
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 22 - Nursing and Therapy Services › Section 22-2 - Nursing services; prior authorization requirements

Current through July 10, 2024
Authority: IC 12-15
Affected: IC 12-13-7-3
Sec. 2.
(a) Medicaid
				reimbursement is available for services rendered by registered nurses, licensed
				practical nurses, and home health agencies who are providers, subject to the
				following:
(1) Prior authorization is required
				for all nursing services, except services ordered in writing by a physician
				prior to the recipient's discharge from an inpatient hospital, which may
				continue for a period not to exceed one hundred twenty (120) units within
				thirty (30) days of discharge without prior authorization and except as noted
				in subsection (c). Prior authorization requests may be submitted by an
				authorized representative of the home health agency. The prior authorization
				form must contain the information specified in
				405 IAC 5-3-5. In addition, the
				following information must be submitted with the prior authorization request
				form:
(A) A copy of the written plan of
				treatment, signed by the attending physician.
(B) An estimate of the costs for the
				requested services as ordered by the physician and as set out in the written
				plan of treatment. The cost estimate must be provided on or with the plan of
				treatment and signed by the attending physician.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 22 - Nursing and Therapy Services › Section 22-3 - Certified nurse midwife services

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 3.
Medicaid reimbursement is available for services rendered by
				  a certified nurse midwife. Coverage of certified nurse-midwife services is
				  restricted to services that the nurse midwife is legally authorized to perform,
				  including well-woman gynecological healthcare, family planning, and care to the
				  normal and expanding family throughout pregnancy, labor, delivery, and
				  post-delivery.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 22 - Nursing and Therapy Services › Section 22-4 - Certified nurse practitioner services

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 4.
Medicaid reimbursement is available for medically necessary
				  services or preventative health care services provided by a licensed, certified
				  nurse practitioner within the scope of the applicable license and
				  certification.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 22 - Nursing and Therapy Services › Section 22-5 - Audiology, occupational, and physical therapy and speech pathology; reimbursement

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 5.
Audiology, occupational and physical therapy, and speech
				  pathology may be reimbursed directly to an individual provider by Medicaid.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 22 - Nursing and Therapy Services › Section 22-6 - Occupational, physical, and respiratory therapy and speech pathology; criteria for prior authorization

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2
Affected: IC 12-13-7-3; IC 12-15
Sec. 6.
(a) Prior
				authorization is required for all therapy services with the following
				exceptions:
(1) Initial
				evaluations.
(2) Emergency
				respiratory therapy.
(3) Any
				combination of therapy ordered in writing prior to a member's discharge from an
				inpatient hospital that may continue for a period not to exceed thirty (30)
				units in thirty (30) calendar days.
(4) The deductible and copay for services
				covered by Medicare, Part B.
(5)
				Oxygen equipment and supplies necessary for the delivery of oxygen with the
				exception of concentrators.
(6)
				Therapy services provided by a nursing facility or large private or small
				intermediate care facility for individuals with intellectual disabilities
				(ICF/IID), which are included in the facility's per diem rate.
(7) Respiratory therapy ordered in writing by
				a physician to treat an acute medical condition, except as required in section
				10 of this rule.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 22 - Nursing and Therapy Services › Section 22-7 - Audiology services

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2
Affected: IC 12-13-7-3; IC 12-15
Sec. 7.
(a) Audiology
				services are subject to the following restrictions:
(1) The physician must certify in writing the
				need for audiological assessment or evaluation.
(2) The audiology service must be rendered by
				a licensed audiologist or a person registered for his or her clinical
				fellowship year who is supervised by a licensed audiologist. A registered
				audiology aide can provide services under the direct on-site supervision of a
				licensed audiologist under
				880 IAC 1-1.
(3) When a member is to be fitted with a
				hearing amplification device, by either the audiologist or a registered hearing
				aid specialist, a medical clearance and audiometric test form must be completed
				in accordance with instructions given below and submitted with the request for
				prior authorization. This form must be complete and must include the proper
				signatures, where indicated, before the prior authorization request will be
				reviewed by the department.
(4)
				Initial audiological assessments are limited to one (1) assessment every three
				(3) years per member. If more frequent audiological assessments are necessary,
				prior authorization is required.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 22 - Nursing and Therapy Services › Section 22-8 - Physical therapy services

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2
Affected: IC 12-13-7-3; IC 12-15
Sec. 8.
Physical therapy services are subject to the following
				  restrictions:
(1) The physical therapy
				service must be performed by a licensed physical therapist or certified
				physical therapist's assistant under the direct supervision of a licensed
				physical therapist or physician as defined in
				844 IAC 6-1-2(g)
				 for reimbursement. Only the activities in
				this subdivision related to the therapy can be performed by someone other than
				a licensed therapist or certified physical therapist's assistant who must be
				under the direct supervision of a licensed physical therapist. Payment for the
				following services is included in the Medicaid allowance for the modality
				provided by the licensed therapist and may not be billed separately to
				Medicaid:
(A) Assisting patients in
				preparation for and, as necessary, during and at the conclusion of
				treatment.
(B) Assembling and
				disassembling equipment.
(C)
				Assisting the physical therapist in the performance of appropriate activities
				related to the treatment of the individual patient.
(D) Following established procedures
				pertaining to the care of equipment and supplies.
(E) Preparing, maintaining, and cleaning
				treatment areas and maintaining supportive areas.
(F) Transporting:
(i) patients;
(ii) records;
(iii) equipment; and
(iv) supplies; in accordance with established
				policies and procedures.
(G) Performing established clerical
				procedures.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 22 - Nursing and Therapy Services › Section 22-9 - Speech pathology services

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2
Affected: IC 12-13-7-3; IC 12-15
Sec. 9.
Speech pathology services are subject to the following
				  restrictions:
(1) The speech pathology
				service must be rendered by a licensed speech-language pathologist or a person
				registered for a clinical fellowship year who is supervised by a licensed
				speech-language pathologist. A registered speech-language pathology aide may
				provide services subject to
				880 IAC 1-2.1.
(2) Evaluations and reevaluations are limited
				to three (3) hours of service per evaluation. The initial evaluation does not
				require prior authorization. Any additional reevaluations require prior
				authorization unless they are conducted during the initial thirty (30) days
				after hospital discharge and the discharge orders include speech pathology
				orders. Reevaluations will not be authorized more than one (1) time yearly
				unless documentation indicating significant change in the patient's condition
				is submitted. It is the responsibility of the provider to determine if
				evaluation services have been previously provided.
(3) Group therapy is covered in conjunction
				with, not in addition to, regular individual treatment. Medicaid will not pay
				for group therapy as the only or primary means of treatment.
(4) Speech therapy services provided by a
				nursing facility or large private or small ICF/IID, which are included in the
				facility's established per diem rate, do not require prior
				authorization.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 22 - Nursing and Therapy Services › Section 22-10 - Respiratory therapy services

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 10.
Respiratory therapy services are subject to the following
				  restrictions:
(1) Respiratory therapy
				services will be reimbursed only when performed by a licensed respiratory
				therapist or a certified respiratory therapy technician who is an employee or
				contractor of a hospital, medical agency, or clinic.
(2) The equipment necessary for rendering
				respiratory therapy will be considered part of the provider's capital
				equipment.
(3) Oxygen provided in a
				nursing facility does not require prior authorization if oxygen is ordered in
				writing by a physician.
(4)
				Respiratory therapy given on an emergency basis does not require prior
				authorization.
(5) Respiratory
				therapy services ordered in writing for the acute medical diagnosis of asthma,
				pneumonia, bronchitis, and upper respiratory infection may be provided without
				prior authorization for a period not to exceed fourteen (14) hours on fourteen
				(14) calendar days. If additional services are required after that date, prior
				authorization must be obtained.
(6)
				Respiratory therapy services provided by a nursing facility or large private or
				small ICF/IID, which are included in the facility's established per diem rate,
				do not require prior authorization.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 22 - Nursing and Therapy Services › Section 22-11 - Occupational therapy services

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 11.
Occupational therapy services are subject to the following
				  restrictions:
(1) Occupational therapy
				services must be performed by a licensed occupational therapist or by a
				licensed occupational therapy assistant under the supervision of a licensed
				occupational therapist. An evaluation must be performed by a licensed
				occupational therapist in order for reimbursement to be made.
(2) Evaluations and reevaluations are limited
				to three (3) hours of service per evaluation. The initial evaluation does not
				require prior authorization. Any additional reevaluations require prior
				authorization unless they are conducted during the initial thirty (30) days
				after hospital discharge and the discharge orders include occupational therapy
				orders. Reevaluations will not be authorized more than one (1) time yearly
				unless documentation indicating significant change in the member's condition is
				submitted. It is the responsibility of the provider to determine if evaluation
				services have been previously provided.
(3) General strengthening exercise programs
				for recuperative purposes are not covered by Medicaid.
(4) Passive range of motion services are not
				covered by Medicaid as the only or primary modality of therapy.
(5) Medicaid reimbursement is not available
				for occupational therapy psychiatric services.
(6) Occupational therapy services provided by
				a nursing facility or large private or small ICF/IID, which are included in the
				facility's established per diem rate, do not require prior
				authorization.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 22 - Nursing and Therapy Services › Section 22-12 - Applied behavioral analysis therapy services

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2
Affected: IC 12-13-7-3; IC 12-15
Sec. 12.
(a) ABA
				therapy services shall be available to an individual who:
(1) is eligible for Medicaid
				services;
(2) has been diagnosed as
				having autism spectrum disorder by a qualified provider; and
(3) has a completed diagnostic evaluation.
A qualified provider, when completing such evaluation, shall
				  utilize the most recent version of the American Psychiatric Association's
				  Diagnostic and Statistical Manual of Mental Disorders (DSM) at the time of the
				  evaluation and include a recommended treatment referral for ABA therapy
				  services.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 23 - Vision Care Services › Section 23-1 - Reimbursement limitations

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15; IC
				  25-24-1-4
Sec. 1.
Medicaid reimbursement is available for vision care services
				  as defined in IC
				  25-24-1-4 rendered by a licensed
				  provider within the scope of his or her license subject to the limitations set
				  out in this rule. Optical supplies are covered when prescribed by an
				  ophthalmologist or optometrist when dispensed within the limitations listed in
				  this rule.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 23 - Vision Care Services › Section 23-2 - Initial examinations

Current through July 10, 2024
Authority: IC 12-15
Affected: IC
				  12-13-7-3; IC
				  25-24-1-4
Sec. 2.
(a)
				Reimbursement for the initial vision care examination will be limited to:
(1) one (1) examination per year for a member
				under twenty-one (21) years of age; and
(2) one (1) examination every two (2) years
				for a member twenty-one (21) years of age or older.
If more frequent examination or care is medically necessary,
				  documentation supporting such medically necessary determinations must be
				  maintained in the provider's office. The documentation shall be subject to
				  postpayment review and audit.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 23 - Vision Care Services › Section 23-3 - Covered vision care services

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15; IC
				  25-24-1-4
Sec. 3.
The following services, if medically necessary, may be
				  provided in addition to the initial examination:
(1) Supplemental evaluation.
(2) Multiple pattern fields, including
				Roberts, Harrington, or Flods.
(3)
				Central field study.
(4) Peripheral
				field study.
(5) Tangent screen
				study.
(6) Color field
				study.
(7) Binocular
				ophthalmoscope.
(8) Other
				supplemental testing.
(9) Visual
				skills study.
(10) Clinical
				photography.
(11) Bifocal
				determination.
(12) Trifocal
				determination.
(13) Definitive
				fundus evaluation.
(14)
				Electrophysiology.
(15)
				Gonioscopy.
(16) Out-of-office
				visits.
(17) Neutralization of lens
				or lenses.
(18) Neutralization of
				contact lenses.
(19) Extended
				ophthalmoscopy.
(20) Serial
				tonometry.
(21)
				Refractions.
(22) Office
				visit.
(23) Consultation.
(24) Visual skills testing.
Screening services (excluding EPSDT) for members are not
				  covered by Medicaid, and payment will not be made for such care. All services
				  provided to recipients in long term care facilities must be documented in the
				  recipient medical record that is maintained by the facility.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 23 - Vision Care Services › Section 23-4 - Frames and lenses; limitations

Current through July 10, 2024
Authority: IC 12-15
Affected: IC
				  12-13-7-3; IC
				  25-24-1-4
Sec. 4.
The provision of frames and lenses are subject to the
				  following limitations:
(1)
				Reimbursement will be made for frames, including, but not limited to, plastic
				or metal. The maximum amount reimbursed for frames is twenty dollars ($20) per
				pair except when a more expensive frame is medically necessary. Situations
				where a more expensive frame may be indicated as medically necessary include,
				but are not limited to, the following:
(A)
				Frames to accommodate facial asymmetry or other anomalies of the:
(i) head;
(ii) neck;
(iii) face; or
(iv) nose.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 23 - Vision Care Services › Section 23-5 - Contact lenses

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15; IC
				  25-24-1-4
Sec. 5.
Contact lenses are covered only when documented as medically
				  necessary and are not covered for cosmetic purposes. Medically necessary
				  documentation must be maintained in the provider's office and shall be subject
				  to postpayment review and audit.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 23 - Vision Care Services › Section 23-6 - Prior authorization

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15; IC
				  25-24-1-4
Sec. 6.
Prior authorization is not required for vision care
				  services.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 24 - Pharmacy Services › Section 24-1 - Reimbursement policy

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 1.
(a) This
				section represents the Medicaid medical policy and covered service limitations
				with respect to pharmacy services provided by a pharmacy provider. Medicaid
				reimbursement is available for pharmacy services rendered by pharmacy
				providers, when such services are:
(1)
				provided in accordance with all applicable laws, rules of the office, and
				Medicaid provider manual; and
(2)
				not specifically excluded from coverage by rules of the office.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 24 - Pharmacy Services › Section 24-2 - "Pharmacy services" and "usual and customary charge" defined

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 2.
(a) As used
				in this rule, "pharmacy services" means legend drugs, nonlegend drugs included
				on the Medicaid nonlegend drug formulary developed in coordination with the
				Indiana Medicaid Drug Utilization Review (DUR) board, nutritional supplements,
				food supplements, and infant formulas. Pharmacy services do not include the
				following:
(1) Nonlegend drugs not included
				on the Medicaid nonlegend drug formulary.
(2) Any other products offered for sale or
				rent by a pharmacy provider except legend drugs, nonlegend drugs included on
				the Medicaid nonlegend drug formulary, and nutritional supplements, food
				supplements, and infant formulas.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 24 - Pharmacy Services › Section 24-3 - Coverage of legend drugs

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 3.
(a) A legend
				drug is covered by Medicaid if the drug is:
(1) approved by the United States Food and
				Drug Administration;
(2) not
				designated by the Centers for Medicare and medicaid Services (CMS) as less than
				effective, or identical, related, or similar to a less than effective
				drug;
(3) subject to the terms of a
				rebate agreement between the drug's manufacturer and CMS; and
(4) not specifically excluded from coverage
				by Medicaid.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 24 - Pharmacy Services › Section 24-4 - Reimbursement for legend drugs

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-21-2
Affected: IC 12-13-7-3; IC 12-15
Sec. 4.
(a) The
				office shall reimburse pharmacy providers for covered legend drugs at the
				lowest of the following, as applicable:
(1)
				The National Average Drug Acquisition Cost (NADAC) of the drug as published by
				the Centers for Medicare and Medicaid Services (CMS) pursuant to
				42 U.S.C.
				1396r-8(f), as of the date
				of dispensing, plus any applicable Medicaid professional dispensing
				fee.
(2) The state maximum
				allowable cost (MAC) of the drug as determined by the office as of the date of
				dispensing, plus any applicable Medicaid professional dispensing fee.
(3) The federal upper limit (FUL) of the drug
				as determined by CMS pursuant to
				42 CFR
				447.514, as of the date of dispensing, plus
				any applicable Medicaid professional dispensing fee.
(4) The wholesale acquisition cost (WAC) of
				the drug according to the office's drug database file contracted from a
				nationally recognized source such as Medi-Span or First DataBank, adjusted by a
				percentage as determined by the office through analysis of the dispensing cost
				survey or other methodology approved by CMS, as of the date of dispensing, plus
				any applicable Medicaid professional dispensing fee. The purpose of the
				percentage is to ensure that the applicable WAC rate sufficiently reflects the
				actual acquisition cost of the provider. The WAC shall only be considered if
				there is no applicable NADAC, FUL, or state MAC rate.
(5) The provider's submitted charge,
				representing the provider's usual and customary charge for the drug, as of the
				date of dispensing.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 24 - Pharmacy Services › Section 24-5 - Reimbursement for nonlegend drugs

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 5.
(a) The
				office shall reimburse pharmacy providers for nonlegend (over-the-counter or
				OTC) drugs at the lower of the following:
(1)
				the state over-the-counter maximum allowable cost plus professional dispensing
				fee; or
(2) the provider's
				submitted charge, representing the provider's usual and customary charge for
				the drug, as of the date of dispensing.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 24 - Pharmacy Services › Section 24-6 - Professional dispensing fee

Current through July 10, 2024
Authority: IC 12-15
Affected: IC
				  12-13-7-3
Sec. 6.
(a) For
				purposes of this rule, the Medicaid professional dispensing fee maximum is ten
				dollars and forty-eight cents ($10.48).
(b) A maximum of one (1) Medicaid
				professional dispensing fee per month is allowable per member per drug order
				for legend or nonlegend drugs provided to members residing in Medicaid
				certified long-term care facilities.
(c) The practice of split billing of legend
				or nonlegend drugs, defined as the dispensing of less than the prescribed
				amount of drug solely for the purpose of collecting more Medicaid professional
				dispensing fees than would otherwise be allowed, or to circumvent prior
				authorization criteria, is prohibited. In cases in which the pharmacist's
				professional judgment dictates that a quantity less than the amount prescribed
				be dispensed, the pharmacist should contact the prescribing practitioner for
				authorization to dispense a lesser quantity. The pharmacist must document the
				result of the contact and the pharmacist's rationale for dispensing less than
				the amount prescribed on the prescription or in the pharmacist's records.