Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 105 - RESIDENTIAL BEHAVIORAL MANAGEMENT SERVICES IN GROUP SETTINGS › Section 317:30-5-1043 - Coverage by category

Current through Vol. 41, No. 20, July 1, 2024
(a)
Adults.
Residential Behavioral Management Services (RBMS) in group
				  settings are not covered for adults.
(b)
Children.
RBMS in group
				  settings are covered for children as set forth in this subsection.
(1)
Description.
RBMS are
				  provided by Organized Health Care Delivery Systems (OHCDS) for children in the
				  care and custody of the State who have special psychological, behavioral,
				  emotional and social needs that require more intensive care than can be
				  provided in a family or foster home setting. The behavior management services
				  are provided in the least restrictive environment and within a therapeutic
				  milieu. The group setting is restorative in nature, allowing children with
				  emotional and psychological problems to develop the necessary control to
				  function in a less restrictive setting. RBMS are reimbursed in accordance with
				  established rate methodology as described in the Oklahoma Medicaid State Plan.
				  It is expected that RBMS in group settings are an all-inclusive array of
				  treatment services provided in one (1) day. In the case of a child who needs
				  additional specialized services, under the Rehabilitation Option or by a
				  psychologist, prior authorization by the OHCA or designated agent is required.
				  Only specialized rehabilitation or psychological treatment services to address
				  unique, unusual or severe symptoms or disorders will be authorized. If
				  additional services are approved, the OHCDS collaborates with the provider of
				  such services as directed by the OHCA or its agent. Any additional specialized
				  behavioral health services provided to children in state custody are funded in
				  the normal manner. The OHCDS must provide concurrent documentation that these
				  services are not duplicative. The OHCDS determines the need for RBMS.
(2)
Medical necessity
				  criteria.
The following medical necessity criteria must be met for RBMS.
(A) Any Diagnostic and Statistical Manual of
				  Mental Disorders (DSM) primary diagnosis, with the exception of V codes, with a
				  detailed description of the symptoms supporting the diagnosis. A detailed
				  description of the child's emotional, behavioral and psychological condition
				  must be on file.
(B) The child is
				  medically stable and not actively suicidal or homicidal and not in need of
				  substance abuse detoxification services.
(C) It has been determined by the OHCDS that
				  the current disabling symptoms could not have been or have not been manageable
				  in a less intensive treatment program.
(D) Documentation that the child's presenting
				  emotional and/or behavioral problems prevent the child from living in a
				  traditional family home. The child requires the availability of twenty-four
				  (24) hour crisis response/behavior management and intensive clinical
				  interventions from professional staff.
(E) The agency which has permanent or
				  temporary custody of the child agrees to active participation in the child's
				  treatment needs and planning.
(F)
				  All of the medical necessity criteria must also be met for continued stay in
				  residential group settings.
(3)
Treatment components.
(A)
Individual plan of care
				  development.
A comprehensive individualized plan of care for each
				  resident shall be formulated by the provider agency staff within thirty (30)
				  days of admission, for intensive treatment services (ITS) level within
				  seventy-two (72) hours, with documented input from the agency which has
				  permanent or temporary custody of the child and when possible, the parent. This
				  plan must be revised and updated at least every three (3) months, every seven
				  (7) days for ITS, with documented involvement of the agency which has permanent
				  or temporary custody of the child. Documented involvement can be written
				  approval of the individual plan of care by the agency which has permanent or
				  temporary custody of the child and indicated by the signature of the agency
				  case worker or liaison on the individual plan of care. It is acceptable in
				  circumstances where it is necessary to fax a service plan to someone for review
				  and then have him/her fax back his/her signature; however, the provider obtains
				  the original signature for the clinical file within thirty (30) days. No
				  stamped or Xeroxed signatures are allowed. An individual plan of care is
				  considered inherent in the provision of therapy and is not covered as a
				  separate item of behavior management services. The individual plan of care is
				  individualized taking into account the child's age, history, diagnosis,
				  functional levels, and culture. It includes appropriate goals and time limited
				  and measurable objectives. Each member's individual plan of care must also
				  address the provider agency's plans with regard to the provision of services in
				  each of the following areas:
(i) Group
				  therapy;
(ii) Individual therapy;
(iii) Family therapy;
(iv) Alcohol and other drug counseling;
(v) Basic living skills
				  redevelopment;
(vi) Social skills
				  redevelopment;
(vii) Behavior
				  redirection; and
(viii) The
				  provider agency's plan to access appropriate educational placement services.
				  (Any educational costs are excluded from calculation of the daily rate for
				  behavior management services.)
(B)
Individual therapy.
The
				  provider agency must provide individual therapy on a weekly basis with a
				  minimum of one (1) or more sessions totaling one (1) hour or more of treatment
				  per week to children and youth receiving RBMS in group homes. Individual
				  therapy must be age appropriate and the techniques and modalities employed
				  relevant to the goals and objectives of the individual's plan of care.
				  Individual counseling is a face-to-face, one-to-one service, and must be
				  provided in a confidential setting.
(C)
Group therapy.
The provider
				  agency must provide group therapy to children and youth receiving RBMS. Group
				  therapy must be a face-to-face interaction, age appropriate and the techniques
				  and modalities employed relevant to the goals and objectives of the
				  individual's plan of care. The minimum expected occurrence would be one (1)
				  hour per week in group homes. Group size should not exceed six (6) members and
				  group therapy sessions must be provided in a confidential setting. Thirty (30)
				  minutes of individual therapy may be substituted for one (1) hour of group
				  therapy.
(D)
Family
				  therapy.
Family therapy is a face-to-face interaction between the
				  therapist/counselor and family, to facilitate emotional, psychological or
				  behavioral changes and promote successful communication and understanding. The
				  provider agency must provide family therapy as indicated by the resident's
				  individual plan of care. The agency must work with the caretaker to whom the
				  resident will be discharged, as identified by the OHCDS custody worker. The
				  agency must seek to support and enhance the child's relationships with family
				  members (nuclear and appropriate extended), if the custody plan for the child
				  indicates family reunification. The RBMS provider must also seek to involve the
				  child's parents in treatment team meetings, plans and decisions and to keep
				  them informed of the child's progress in the program. Any service provided to
				  the family must have the child as the focus.
(E)
Alcohol and other drug abuse
				  treatment education, prevention, therapy.
The provider agency must
				  provide alcohol and other drug abuse treatment for residents who have emotional
				  or behavioral problems related to substance abuse/chemical dependency, to
				  begin, maintain and enhance recovery from alcoholism, problem drinking, drug
				  abuse, drug dependency addiction or nicotine use and addiction. This service is
				  considered ancillary to any other formal treatment program in which the child
				  participates for treatment and rehabilitation. For residents who have no
				  identifiable alcohol or other drug use, abuse, or dependency, age appropriate
				  education and prevention activities are appropriate. These may include
				  self-esteem enhancement, violence alternatives, communication skills or other
				  skill development curriculums.
(F)
Basic living skills redevelopment.
The provider agency must
				  provide goal-directed activities designed for each resident to restore, retain,
				  and improve those basic skills necessary to independently function in a family
				  or community. Basic living skills redevelopment is age appropriate and relevant
				  to the goals and objectives of the individual plan of care. This may include,
				  but is not limited to food planning and preparation, maintenance of personal
				  hygiene and living environment, household management, personal and household
				  shopping, community awareness and familiarization with community resources,
				  mobility skills, job application and retention skills.
(G)
Social skills redevelopment.
The provider agency must provide goal-directed activities designed for each
				  resident to restore, retain and improve the self-help, communication,
				  socialization, and adaptive skills necessary to reside successfully in home and
				  community based settings. These are age appropriate, culturally sensitive and
				  relevant to the goals of the individual plan of care. For ITS level of care,
				  the minimum skill redevelopment per day is three (3) hours. Any combination of
				  basic living skills and social skills redevelopment that is appropriate to the
				  need and developmental abilities of the child is acceptable.
(H)
Behavior redirection.
The
				  provider agency must be able to provide behavior redirection management by
				  agency staff as needed twenty-four (24) hours a day, seven (7) days per week.
				  The agency must ensure staff availability to respond in a crisis to stabilize
				  residents' behavior and prevent placement disruption. In addition, ITS group
				  homes will be required to provide crisis stabilization interaction and
				  treatment for new residents twenty-four (24) hours a day, seven (7) days a
				  week.
(4)
Providers.
For eligible RBMS agencies to bill the OHCA for
				  services provided by their staff for behavior management therapies (individual,
				  group, family) as of July 1, 2007, providers must have the following
				  qualifications:
(A) Be licensed in the state
				  in which the services are delivered as a licensed psychologist, social worker
				  (clinical specialty only), professional counselor, marriage and family
				  therapist, or behavioral practitioner, alcohol and drug counselor or under
				  Board approved supervision to be licensed in one (1) of the above stated areas;
				  or
(B) Be licensed as an advanced
				  practice registered nurse (APRN) certified in a psychiatric mental health
				  specialty, and licensed as a registered nurse (RN) with a current certification
				  of recognition from the Board of Nursing in the state in which services are
				  provided; and
(C) Demonstrate a
				  general professional or educational background in the following areas:
(i) Case management, assessment and treatment
				  planning;
(ii) Treatment of
				  victims of physical, emotional, and sexual abuse;
(iii) Treatment of children with attachment
				  disorders;
(iv) Treatment of
				  children with hyperactivity or attention deficit disorders;
(v) Treatment methodologies for emotionally
				  disturbed children and youth;
(vi)
				  Normal childhood development and the effect of abuse and/or neglect on
				  childhood development;
(vii)
				  Treatment of children and families with substance abuse and chemical dependency
				  disorders;
(viii) Anger
				  management; and
(ix) Crisis
				  intervention.
(D) Staff
				  providing basic living skills redevelopment, social skills redevelopment, and
				  alcohol and other substance abuse treatment, must meet one (1) of the following
				  areas:
(i) Bachelor's or master's degree in a
				  behavioral health related field including but not limited to, psychology,
				  sociology, criminal justice, school guidance and counseling, social work,
				  occupational therapy, family studies, alcohol and drug; or
(ii) Currently licensed and in good standing
				  as an RN in the state in which services are provided ; or
(iii) Certification as an alcohol and drug
				  counselor to provide substance abuse rehabilitative treatment to those with
				  alcohol and/or other drug dependencies or addictions as a primary or secondary
				  DSM diagnosis; or
(iv) Current
				  certification as a behavioral health case manager from the Oklahoma Department
				  of Mental Health and Substance Abuse (ODMHSAS) and meets OHCA requirements to
				  perform case management services, as described in Oklahoma Administrative Code
				  (OAC)
				  317:30-5-240
				  through
				  317:30-5-249.
(E) Staff providing
				  behavior redirection services must have current certification and required
				  updates in nationally recognized behavior management techniques, such as
				  Controlling Aggressive Patient Environment (CAPE) or MANDT. Additionally, staff
				  providing these services must receive initial and ongoing training in at least
				  one (1) of the following areas:
(i)
				  Trauma-informed methodology;
(ii)
				  Anger management;
(iii) Crisis
				  intervention;
(iv) Normal child
				  and adolescent development and the effect of abuse;
(v) Neglect and/or violence on such
				  development;
(vi) Grief and loss
				  issues for children in out of home placement;
(vii) Interventions with victims of physical,
				  emotional and sexual abuse;
(viii)
				  Care and treatment of children with attachment disorders;
(ix) Care and treatment of children with
				  hyperactive, or attention deficit, or conduct disorders;
(x) Care and treatment of children, youth and
				  families with substance abuse and chemical dependency disorders;
(xi) Passive physical restraint procedures;
				  or
(xii) Procedures for working
				  with delinquents or the Inpatient Mental Health and Substance Abuse Treatment
				  of Minors Act.
(F) In
				  addition, behavior management staff must have access to consultation with an
				  appropriately licensed mental health professional.