405 IAC 5-21.8-2 - Definitions
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.
(e)
"Certified recovery specialist" or "CRS" refers to an individual who meets all
of the following:
(1) Is maintaining healthy
recovery from mental illness.
(2)
Has completed the CRS office state-approved training program.
(3) Receives a passing score on the
certification exam.
(4) Is
supervised by a licensed professional or QBHP.
(5) Delivers services as defined at section
8(a) of this rule.
(f)
"DMHA" means the division of mental health and addiction.
(g) "Health" means physical and behavioral
health.
(h) "Individualized
integrated care plan" or "IICP" means a treatment plan that meets all of the
following:
(1) Integrates all components and
aspects of care that are:
(A) deemed medically
necessary;
(B)
needs-based;
(C) clinically
indicated; and
(D) provided in the
most appropriate setting to achieve the member's goals.
(2) Includes all indicated medical and
support services needed by the member in order to:
(A) remain in the community;
(B) function at the highest level of
independence possible; and
(C)
achieve goals identified in the IICP.
(3) Reflects the member's desires and
choices.
(i) "Level of
need" means a recommended intensity of services based on a pattern of a
member's needs, as determined using the office-approved behavioral health
assessment tool.
(j) "Licensed
professional" means any of the following persons:
(1) A licensed psychiatrist.
(2) A licensed physician.
(3) A licensed psychologist or a psychologist
endorsed as a health service provider in psychology (HSPP).
(4) A licensed clinical social worker
(LCSW).
(5) A licensed mental
health counselor (LMHC).
(6) A
licensed marriage and family therapist (LMFT).
(7) A licensed clinical addiction counselor
(LCAC), as defined under IC 25-23.6-10.5.
(k) "Medicaid rehabilitation services" means
any medical or remedial service recommended by a physician or other licensed
practitioner of the healing arts, within the scope of that individual's
practice under state law, for:
(1) maximum
reduction of physical or mental health disability; and
(2) restoration to a member's best possible
level of functioning.
(l)
"Member" means a person receiving BPHC services.
(m) "Needs-based eligibility criteria" means
factors used to determine an applicant's need for BPHC services. The applicant
meets the BPHC needs-based eligibility criteria when the following are
demonstrated:
(1) Needs related to management
of the applicant's health.
(2)
Impairment in self-management of the applicant's health services.
(3) A health need that requires assistance
and support in coordinating health treatment.
(4) A recommendation for intensive community
based care based on the uniform office-approved behavioral health assessment
tool as indicated by a rating of three (3) or higher.
(n) "Office-approved behavioral health
assessment tool" means the state designated assessment tool administered by a
qualified individual who is trained and office-certified to administer the tool
in order to assist in determining the level of need and functional impairment
of an applicant or a member.
(o)
"Other behavioral health professional" or "OBHP" means any of the following:
(1) An individual with an associate's or
bachelor's degree, or equivalent behavioral health experience who:
(A) meets minimum competency standards set
forth by a behavioral health service provider; and
(B) is supervised by either a licensed
professional or a QBHP.
(2) A licensed addiction counselor, as
defined under IC 25-23.6-10.5, who is supervised by either a licensed
professional or a QBHP.
(p) "Provider agency" means any
office-approved agency that meets the qualifications and criteria to become a
BPHC provider agency, as required by this rule.
(q) "Provider staff" means any individual
working for an office-approved BPHC provider agency who meets the
qualifications and requirements mandated by the BPHC service being provided, as
defined in this rule.
(r)
"Qualified behavioral health professional" or "QBHP" means any of the
following:
(1) An individual who has had at
least two (2) years of clinical experience treating persons with mental illness
under the supervision of a licensed professional, with such experience
occurring after the completion of a master's degree or a doctoral degree, or
both, in any of the following disciplines from an accredited university:
(A) Psychiatric or mental health nursing,
including a license as a registered nurse in Indiana.
(B) Pastoral counseling.
(C) Rehabilitation counseling.
(2) An individual who:
(A) is supervised by a licensed
professional;
(B) is eligible for
and working toward professional licensure; and
(C) has completed a master's degree or a
doctoral degree, or both, in any of the following disciplines from an
accredited university:
(i) Social work from a
university accredited by the Council on Social Work Education.
(ii) Psychology.
(iii) Mental health counseling.
(iv) Marital and family therapy.
(3) A licensed,
independent practice school psychologist under the supervision of a licensed
professional.
(4) An authorized
health care professional (AHCP) who is either of the following:
(A) A physician assistant with the authority
to prescribe, dispense, and administer drugs and medical devices or services
under an agreement with a supervising physician and subject to the requirements
of IC 25-27.5-5.
(B) A nurse
practitioner or clinical nurse specialist, with prescriptive authority,
performing duties within the scope of that person's license and under the
supervision of, or under a supervisory agreement with, a licensed physician
under IC 25-23-1.
(s) "State evaluation team" means the office
independent evaluation team that will review and assess all evaluation
information and supporting clinical documentation collected for BPHC applicants
and members and will be responsible for making final determinations regarding
the following:
(1) Needs-based and target
group eligibility of applicants for BPHC services.
(2) Authorization for BPHC services for
eligible members.
(3) Continued
eligibility determination for BPHC members.
(4) Appropriate service delivery to BPHC
members as a result of conducting quality improvement reviews of BPHC service
provider agencies.
(t)
"Target group eligibility criteria" means factors used to determine an
applicant's eligibility for BPHC services. To meet the BPHC target group
criteria, an applicant must:
(1) be nineteen
(19) years of age or older; and
(2)
have been diagnosed with an eligible primary mental health diagnosis as defined
at section 4(3) of this rule.
Notes
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