23 Miss. Code. R. 223-6.3 - Covered Services
A. All State Plan
services described in Miss. Admin. Code Part 206 and Part 223 are covered for
Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)-eligible
beneficiaries without regard to service limits when prior authorized by the
Utilization Management/Quality Improvement Organization (UM/QIO).
B. The Division of Medicaid covers
neuropsychological evaluations for EPSDT-eligible beneficiaries when medically
necessary, prior authorized by a UM/QIO, the Division of Medicaid or designee
and conducted by a psychologist trained to administer, score and interpret
neuropsychological instruments, and one (1) or more of the following apply:
1. Other interventions have been unsuccessful
with the beneficiary,
2. Previous
psychological evaluation indicates neuropsychological deficits and supports
justification,
3. The beneficiary
displays evidence of cognitive deficits or brain injury, or
4. Results are used in treatment planning and
placement decisions.
C.
The Division of Medicaid covers developmental evaluations for EPSDT-eligible
beneficiaries when medically necessary, prior authorized by a UM/QIO, the
Division of Medicaid or designee, conducted by a physician or a psychologist
with knowledge and expertise to administer and interpret developmental
evaluation results and uses the results or the following:
1. To assist in treatment planning for a
beneficiary less than three (3) years of age or a beneficiary with a severe
disability, or
2. To confirm the
existence of a major diagnosis.
D. The Division of Medicaid covers day
treatment services for EPSDT eligible beneficiaries when the service and
provider meet the following requirements:
1.
Service components include:
a) Treatment plan
development and review.
b) Skill
building groups such as social skills training, self-esteem building, anger
control, conflict resolution and daily living skills.
2. Certified to operate by the Mississippi
Department of Mental Health (DMH).
3. Included in a care plan approved by one
(1) of the following: a psychiatrist, physician, psychologist, psychiatric
mental health nurse practitioner (PMHNP), physician assistant (PA), licensed
clinical social worker (LCSW), licensed professional counselor (LPC), licensed
marriage and family therapist (LMFT), licensed master social worker (LMSW) or
certified mental health therapist (CMHT).
4. Provided by a psychiatrist, physician,
psychologist, PMHNP, PA, LCSW, LPC, LMFT, LMSW or CMHT.
5. Prior authorized as medically necessary by
the UM/QIO.
E. The
Division of Medicaid covers medically necessary wraparound facilitation as part
of a targeted case management benefit for EPSDT-eligible beneficiaries with a
serious emotional disturbance (SED) that meet the level of care provided in a
psychiatric residential treatment facility (PRTF).
1. Service components include:
a) Engaging the family,
b) Assembling the beneficiary and family team
which includes all of the required entities and individuals as described in the
DMH operational standards for wraparound facilitation.
c) Facilitating the beneficiary and family
team meeting, at a minimum, once every thirty (30) days,
d) Facilitating the development of a
wraparound service plan (WSP) through decisions made by the beneficiary and
family team during the beneficiary and family team meeting, including a plan
for anticipating, preventing and managing crisis,
e) Working with the beneficiary and family
team in identifying providers of services and other community resources to meet
the family and beneficiary's needs,
f) Making necessary referrals for
beneficiaries,
g) Documenting and
maintaining all information regarding the WSP, including revisions and
beneficiary and family team meetings,
h) Presenting WSP for approval to the
beneficiary and family team,
i)
Providing copies of the WSP to the entire team including the beneficiary and
family/guardian,
j) Monitoring the
implementation of the WSP and revising as necessary to achieve
outcomes,
k) Maintaining
communication between all beneficiary and family team members,
l) Evaluating the progress toward needs being
met to ensure the referral behaviors have decreased,
m) Leading the beneficiary and family team to
discuss and ensure the supports and services continue to meet the caregiver and
the beneficiary's needs,
n)
Educating new team members about the wraparound process,
o) Maintaining team cohesiveness,
p) Contact with the beneficiary at least
weekly,
q) Meeting face-to-face
with the beneficiary a minimum of twice per month in addition to family
face-to-face meetings,
r) Meeting
face-to-face with the family a minimum of twice per month in addition to
beneficiary face-to-face meetings,
s) Contact with collateral contacts related
to WSP implementation and/or other care coordination activities at least three
(3) times a week, and
t) Ensuring
medication management and monitoring of beneficiaries medication(s) used in the
treatment of the beneficiary's Serious Emotional Disturbance (SED) occur at a
physician visit every ninety (90) days at a minimum.
2. Wraparound services are provided by a
Certified Wraparound Facilitator.
3. Prior authorized as medically necessary by
the UM/QIO.
F. The
Division of Medicaid covers medically necessary Mississippi Youth Programs
Around the Clock (MYPAC) Therapeutic Services for Early and Periodic Screening,
Diagnosis and Treatment (EPSDT) eligible beneficiaries that require the level
of care provided in a psychiatric residential treatment facility (PRTF).
1. In order to receive MYPAC Therapeutic
Services, beneficiaries must meet DMH requirements for admission.
2. Providers of MYPAC Therapeutic Services
must be certified by DMH to provide MYPAC Therapeutic Services.
3. MYPAC Therapeutic Services must be
provided to beneficiaries based on the beneficiary's needs as identified as a
part of the wraparound plan of care or individual service plan.
4. MYPAC Therapeutic Services are designed to
meet the clinical needs of the beneficiaries and families. Component parts of
MYPAC Therapeutic Services must also be certified by DMH if applicable
certification is available. Services should meet all DMH service provision
requirements. These components include:
a)
Treatment plan development and review which is defined as the development and
review of an overall plan that directs the treatment and support of the person
receiving services by qualified providers.
b) Medication management which includes the
evaluation and monitoring of psychotropic medications, provided by a
psychiatrist, or psychiatric mental health nurse practitioner.
c) Intensive individual therapy defined as
one-on-one therapy for the purpose of treating a mental disorder and family
therapy defined as therapy for the family which is exclusively directed at the
beneficiary's needs and treatment provided in the home.
d) Family therapy involves participation of
non-Medicaid eligible individuals for the direct benefit of the beneficiary.
The service must actively involve the beneficiary in the sense of being
tailored to the beneficiary's individual needs. There may be times when, based
on clinical judgment, the beneficiary is not present during the delivery of the
service, but remains the focus of the service. Must be provided by a master's
level staff.
e) Peer support
services defined as non-clinical activities with a rehabilitation and
resiliency/recovery focus that allow a person receiving mental health services
and/or substance use disorders services and their family members the
opportunity to build skills for coping with and managing psychiatric symptoms,
substance use issues and challenges associated with various disabilities while
directing their own recovery. Must be provided by a certified Peer Support
Specialist.
g) Community Support
Services defined as specific, measurable and individualized that focuses on the
mental health needs of the beneficiary while attempting to restore
beneficiary's ability to succeed in the community. Covered community support
services include:
1) Identification of
strengths which aid the beneficiary in their recovery and the barriers that
will challenge the development of skills necessary for independent functioning
in the community.
2) Individual
therapeutic interventions that directly increase the restoration of skills
needed to accomplish the goals set forth in the Individual Service
Plan.
3) Monitoring and evaluating
the effectiveness of interventions that focus on restoring, retraining and
reorienting, as evidence by symptom reduction and program toward
goals.
4) Psychoeducation regarding
the identification and self-management of the prescribed medication regimen and
communication with the prescribing provider.
5) Direct interventions in deescalating
situations to prevent crisis.
6)
Relapse prevention.
7) Facilitation
of the Individual Service Plan or Recovery Support Plan which includes the
active involvement of the beneficiary and the people identified as important in
the beneficiary's life.
5. Each beneficiary receiving MYPAC
Therapeutic Services must have on file an individualized plan which describes
the following:
a) Services to be
provided,
b) Frequency of service
provision,
c) Who provides each
service and their qualifications,
d) Formal and informal supports available to
the beneficiary and family,
e) Plan
for anticipating, preventing and managing crises, and
f) A discharge or transition plan.
6. If the beneficiary participates
in Targeted Case Management provided as Wraparound Facilitation, the MYPAC
provider agency must be a participating team member and attend the monthly
Child Family Team Meeting.
7. MYPAC
Therapeutic Services must be prior authorized as medically necessary by the
UM/QIO.
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