Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 35 - REHABILITATIVE PSYCHIATRIC SERVICES › Section 471-35-001 - Introduction

Current through June 17, 2024
The Nebraska Medical Assistance Program (NMAP) covers rehabilitative
	 psychiatric services to rehabilitate clients experiencing severe and persistent
	 mental illnesses in the community and thereby avoid more restrictive levels of
	 care such as inpatient psychiatric hospital or nursing facility. Rehabilitative
	 psychiatric services for children age 20 and younger are covered under EPSDT
	 treatment plans, as described in Chapter 32-000 of this Title. Rehabilitative
	 psychiatric services for adults age 21 and older are covered under the rules
	 and regulations of this chapter. The services must be medically necessary and
	 the most appropriate level of treatment for the individual client. This does
	 not include treatment for a primary substance abuse diagnosis.
001.01 Definition of Severe and Persistent
  Mental Illness
Clients with severe and persistent mental illness must meet the
	 following criteria:
1. The client is
  age 21 and over;
2. The client has
  a primary diagnosis of schizophrenia, major affective disorder, or other major
  mental illness under the current edition of the Diagnostic and Statistical
  Manual of Mental Disorders published by the American Psychiatric Association.
  Developmental disorders, or psychoactive substance use disorders may be
  included if they co-occur with the primary mental illnesses listed
  above;
3. The client has a
  persistent mental illness as demonstrated by the presence of the disorder for
  the last 12 months or which is expected to last 12 months or longer and will
  result in a degree of limitation that seriously interferes with the client's
  ability to function independently in an appropriate and effective manner in two
  of three functional areas: Vocational/Education, Social Skills, Activities of
  Daily Living.
a. Functional limitations in
  the area of
Vocational/Education
abilities are defined
  as:
(1) An inability to be consistently
  employed or an ability to be employed only with extensive supports, except that
  a person who can work but is recurrently unemployed because of acute episodes
  of mental illness is considered vocationally impaired;
(2) Deterioration or decompensation resulting
  in an inability to establish or pursue educational goals within a normal time
  frame or without extensive supports;
(3) An inability to consistently and
  independently carry out home management tasks, including household meal
  preparation, washing clothes, budgeting, and child care tasks and
  responsibilities;
b.
  Functional limitations in the area of
Social Skills
and abilities are defined as:
(1) Repeated
  inappropriate or inadequate social behavior or an ability to behave
  appropriately or adequately only with extensive or consistent support or
  coaching or only in special contexts or situations, such as social groups
  organized by treatment staff; or
(2) Consistent participation in adult
  activities only with extensive support or coaching and when involvement is
  mostly limited to special activities established for persons with mental
  illness or other persons with interpersonal impairments; or
(3) A history of dangerousness to self or
  others.
c. Functional
  limitations in the area of
Activities of Daily Living
are defined as an inability to consistently perform the range of practical
  daily living tasks required for basic adult functioning in the community, in
  three of five areas listed below:
(1)
  Grooming, hygiene, washing of clothes, and meeting nutritional needs;
(2) Care of personal business
  affairs;
(3) Transportation and
  care of residence;
(4) Procurement
  of medical, legal, and housing services; or
(5) Recognition and avoidance of common
  dangers or hazards to self and possessions.
4. The client is at significant risk of
  continuing in a pattern of either institutionalization or living in a severely
  dysfunctional way if needed mental health services are not provided, and this
  pattern has existed for one year or longer and is likely to endure for one year
  or longer; and
5. The client does
  not have a primary diagnosis of substance abuse/substance dependency or
  developmental disabilities.