Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 107 - Covered Services › Section DHS 107.13 - Mental health services

Current through June 24, 2024
(1) INPATIENT CARE IN A HOSPITAL IMD.
(a)
Covered services.
Inpatient hospital mental health and AODA care shall be covered when prescribed
				by a physician and when provided within a hospital institution for mental
				disease (IMD) which is certified under ss.
				DHS
				105.07 and
				105.21,
				except as provided in par. (b).
(b)
Conditions for coverage of recipients under 21 years of age.
1. 'Definition.' In this paragraph,
				"individual plan of care"or "plan of care" means a written plan developed for
				each recipient under 21 years of age who receives inpatient hospital mental
				health or AODA care in a hospital IMD for the purpose of improving the
				recipient's condition to the extent that inpatient care is no longer
				necessary.
2. 'General conditions.'
				Inpatient hospital mental health and AODA services provided in a hospital IMD
				for recipients under age 21 shall be provided under the direction of a
				physician and, if the recipient was receiving the services immediately before
				reaching age 21, coverage shall extend to the earlier of the following:
a. The date the recipient no longer requires
				the services; or
b. The date the
				recipient reaches age 22.
3. 'Certification of need for services.'
a. For recipients under age 21 receiving
				services in a hospital IMD, a team specified in subd. 3. b. shall certify that
				ambulatory care resources do not meet the treatment needs of the recipient,
				proper treatment of the recipient's psychiatric condition requires services on
				an inpatient basis under the direction of a physician, and the services can
				reasonably be expected to improve the recipient's condition or prevent further
				regression so that the services will be needed in reduced amount or intensity
				or no longer be needed. The certification specified in this subdivision
				satisfies the requirement for physician certification in subd. 7. In this
				subparagraph, "ambulatory care resources" means any covered service except
				hospital inpatient care or care of a resident in a nursing home.
b. Certification under subd. 3. a. shall be
				made for a recipient when the person is admitted to a facility or program by an
				independent team that includes a physician. The team shall have competence in
				diagnosis and treatment of mental illness, preferably in child psychology, and
				have knowledge of the recipient's situation.
c. For a recipient who applies for MA
				eligibility while in a facility or program, the certification shall be made by
				the team described in subd. 5. b. and shall cover any period before application
				for which claims are made.
d. For
				emergency admissions, the certification shall be made by the team specified in
				subd. 5. b. within 14 days after admission.
4. 'Active treatment.' Inpatient psychiatric
				services shall involve active treatment. An individual plan of care described
				in subd. 5. shall be developed and implemented no later than 14 days after
				admission and shall be designed to achieve the recipient's discharge from
				inpatient status at the earliest possible time.
5. 'Individual plan of care.'
a. The individual plan of care shall be based
				on a diagnostic evaluation that includes examination of the medical,
				psychological, social, behavioral and developmental aspects of the recipient's
				situation and reflects the need for inpatient psychiatric care; be developed by
				a team of professionals specified under subd. 5. b. in consultation with the
				recipient and parents, legal guardians or others into whose care the recipient
				will be released after discharge; specify treatment objectives; prescribe an
				integrated program of therapies, activities, and experiences designed to meet
				the objectives; and include, at an appropriate time, post-discharge plans and
				coordination of inpatient services with partial discharge plans and related
				community services to ensure continuity of care with the recipient's family,
				school and community upon discharge.
b. The individual plan of care shall be
				developed by an interdisciplinary team that includes a board-eligible or
				board-certified psychiatrist; a clinical psychologist who has a doctorate and a
				physician licensed to practice medicine or osteopathy; or a physician licensed
				to practice medicine or osteopathy who has specialized training and experience
				in the diagnosis and treatment of mental diseases, and a psychologist who has a
				master's degree in clinical psychology or who is certified by the state. The
				team shall also include a psychiatric social worker, a registered nurse with
				specialized training or one year's experience in treating mentally ill
				individuals, an occupational therapist who is certified by the American
				occupation therapy association and who has specialized training or one year of
				experience in treating mentally ill individuals, or a psychologist who has a
				master's degree in clinical psychology or who has been certified by the state.
				Based on education and experience, preferably including competence in child
				psychiatry, the team shall be capable of assessing the recipient's immediate
				and long-range therapeutic needs, developmental priorities, and personal
				strengths and liabilities; assessing the potential resources of the recipient's
				family; setting treatment objectives; and prescribing therapeutic modalities to
				achieve the plan's objectives.
c.
				The plan shall be reviewed every 30 days by the team specified in subd. 5. b.
				to determine that services being provided are or were required on an inpatient
				basis, and to recommend changes in the plan as indicated by the recipient's
				overall adjustment as an inpatient.
d. The development and review of the plan of
				care under this subdivision shall satisfy the utilization control requirements
				for physician certification and establishment and periodic review of the plan
				of care.
6. 'Evaluation.'
a. Before a recipient is admitted to a
				psychiatric hospital or before payment is authorized for a patient who applies
				for MA, the attending physician or staff physician shall make a medical
				evaluation of each applicant's or recipient's need for care in the hospital,
				and appropriate professional personnel shall make a psychiatric and social
				evaluation of the applicant's or recipient's need for care.
b. Each medical evaluation shall include a
				diagnosis, a summary of present medical findings, medical history, the mental
				and physical status and functional capacity, a prognosis, and a recommendation
				by a physician concerning admission to the psychiatric hospital or concerning
				continued care in the psychiatric hospital for an individual who applies for MA
				while in the hospital.
7.
				'Physician certification.'
a. A physician
				shall certify and recertify for each applicant or recipient that inpatient
				services in a psychiatric hospital are or were needed.
b. The certification shall be made at the
				time of admission or, if an individual applies for assistance while in a
				psychiatric hospital, before the agency authorizes payment.
c. Recertification shall be made at least
				every 60 days after certification.
8. 'Physician's plan of care.'
a. Before a recipient is admitted to a
				psychiatric hospital or before payment is authorized, the attending physician
				or staff physician shall document and sign a written plan of care for the
				recipient or applicant. The physician's plan of care shall include diagnosis,
				symptoms, complaints and complications indicating the need for admission; a
				description of the functional level of the individual; objectives; any orders
				for medications, treatments, restorative and rehabilitative services,
				activities, therapies, social services, diet or special procedures recommended
				for the health and safety of the patient; plans for continuing care, including
				review and modification to the plan of care; and plans for discharge.
b. The attending or staff physician and other
				personnel involved in the recipient's care shall review each plan of care at
				least every 30 days.
9.
				'Record entries.' A written report of each evaluation under subd. 6. and the
				plan of care under subd. 8. shall be entered in the applicant's or recipient's
				record at the time of admission or, if the individual is already in the
				facility, immediately upon completion of the evaluation or
				plan.
(c)
Eligibility for non-institutional services.
Recipients under
				age 22 or over age 64 who are inpatients in a hospital IMD are eligible for MA
				benefits for services not provided through that institution and reimbursed to
				the hospital as hospital services under s.
				DHS
				107.08 and this subsection.
(d)
Patient's account.
Each
				recipient who is a patient in a state, county, or private psychiatric hospital
				shall have an account established for the maintenance of earned or unearned
				money payments received, including social security and SSI payments. The
				account for a patient in a state mental health institute shall be kept in
				accordance with s. 46.07, Stats. The payee for the
				account may be the recipient, if competent, or a legal representative or bank
				officer except that a legal representative employed by a county department of
				social services or the department may not receive payments. If the payee of the
				resident's account is a legally authorized representative, the payee shall
				submit an annual report on the account to the U.S. social security
				administration if social security or SSI payments have been paid into the
				account.
(e)
Professional
				services provided to hospital IMD inpatients.
In addition to meeting
				the conditions for provision of services listed under s.
				DHS 107.08
				(4), including separate billing, the
				following conditions apply to professional services provided to hospital IMD
				inpatients:
1. Diagnostic interviews with the
				recipient's immediate family members shall be covered services. In this
				subdivision, "immediate family members" means parents, guardian, spouse and
				children or, for a child in a foster home, the foster parents;
2. The limitations specified in s.
				DHS
				107.08(3) shall apply; and
3. Electroconvulsive therapy shall be a
				covered service only when provided by a certified psychiatrist in a hospital
				setting.
(f)
Non-covered services.
The following services are not covered
				services:
1. Activities which are primarily
				diversional in nature such as services which act as social or recreational
				outlets for the recipient;
2. Mild
				tranquilizers or sedatives provided solely for the purpose of relieving the
				recipient's anxiety or insomnia;
3.
				Consultation with other providers about the recipient's care;
4. Conditional leave, convalescent leave or
				transfer days from psychiatric hospitals for recipients under the age of
				21;
5. Psychotherapy or AODA
				treatment services when separately billed and performed by masters level
				therapists or AODA counsellors certified under s.
				DHS
				105.22 or
				105.23;
6. Group therapy services or medication
				management for hospital inpatients whether separately billed by an IMD hospital
				or by any other provider as an outpatient claim for professional
				services;
7. Court appearances,
				except when necessary to defend against commitment; and
8. Inpatient services for recipients between
				the ages of 21 and 64 when provided by a hospital IMD, except that services may
				be provided to a 21 year old resident of a hospital IMD if the person was a
				resident of that institution immediately prior to turning 21 and continues to
				be a resident after turning 21. A hospital IMD patient who is 21 to 64 years of
				age may be eligible for MA benefits while on convalescent leave from a hospital
				IMD.
Note:
Subdivision 8 applies only to services for
				  recipients 21 to 64 years of age who are actually residing in a psychiatric
				  hospital or an IMD. Services provided to a recipient who is a patient in one of
				  these facilities but temporarily hospitalized elsewhere for medical treatment
				  or temporarily residing at a rehabilitation facility or another type of medical
				  facility are covered services.
Note:
For more information on non-covered
				  services, see ss.
				  DHS
				  107.03 and
				  107.08
				  (4).