(A) For the purposes of medicaid
reimbursement, assertive community treatment (ACT) refers to the evidence based
model of delivering comprehensive community based behavioral health services to
adults with certain serious and persistent mental illnesses who have not
benefited from traditional outpatient treatment. The ACT model utilizes a
multidisciplinary team of practitioners to deliver services to eligible
(B) For the purposes
of this rule, collateral contact occurs when the practitioner contacts
individuals who play a significant role in a medicaid recipient's life. The
information gained from the collateral contact can provide insight into
treatment or the basic psychoeducation provided to that collateral contact can
assist with the treatment of the medicaid recipient.
(C) The ACT team is the sole provider to ACT
recipients of outpatient behavioral health services, including level one
outpatient services as defined by the American society of addiction
ACT services include
but are not limited to the following:
Psychiatry and primary care as related to the mental health or substance use
(3) Crisis assessment
assessment and management;
Community based rehabilitative services;
(6) Education, support, and consultation to
families, legal custodians, and significant others who are part of the
recipient's support network.
The desired outcomes of ACT intervention
for medicaid recipients include but are not limited to:
(1) Achieving and maintaining a stable life
in a community based setting;
Reducing the need for inpatient hospital admission and emergency department
(3) Improving mental and
physical health status, and improving life satisfaction.
A medicaid recipient may receive ACT
services when determined by the ODM designated entity to have met all of the
The recipient has a diagnosis
of schizophrenia, bipolar, or major depressive disorder with psychosis, in
accordance with the ICD-10 diagnosis code group list found at
(2) The recipient has a supplemental security
income or social security disability insurance determination or has a score of
two or greater on at least one of the items in the "mental health needs" or
"risk behaviors" sections or a score of three on at least one of the items in
the "life domain function" section of the adult needs and strengths assessment
(ANSA) administered by an individual with a bachelor's degree or higher and
with training in the administration of the assessment; and
The recipient has one or more of the
(a) Two or more admissions to a
psychiatric inpatient hospital setting during the past twelve months;
(b) Two or more occasions of
utilizing psychiatric emergency services during the past twelve months;
(c) Significant difficulty
meeting basic survival needs within the last twenty-four months; or
(d) History within the past two years of
criminal justice involvement including but not limited to arrest,
incarceration, or probation; and
The recipient experiences one or more of
(a) Persistent or recurrent
severe psychiatric symptoms; or
Coexisting substance use disorder of more than six month in duration;
(c) Residing in an inpatient or
supervised residence, but clinically assessed to be able to live in a more
independent living situation if intensive services are provided; or
(d) At risk of psychiatric hospitalization,
institutional or supervised residential placement if more intensive services
are not available; or
(e) Has been
unsuccessful in using traditional office-based outpatient services; and
(5) The recipient is
eighteen years of age or older at the time of ACT enrollment.
Prior authorization of ACT
(1) The provider must submit a
request for prior authorization and receive approval from the ODM designated
entity before ACT services can be rendered. The request for prior authorization
must be accompanied by the appropriate documentation which includes, but is not
limited to, the ANSA results or the documentation that supports the social
security determination. The maximum amount of ACT service which may be prior
authorized at any one time is twelve months.
(2) At the conclusion of the previous ACT
service period, the provider agency may request additional ACT service to be
prior authorized by the ODM designated entity.
(3) The provider may begin submitting claims
for medicaid reimbursement of ACT services for dates of service within the
subsequent calendar month following the date on which prior authorization is
approved by the ODM designated entity.
Disenrollment of a recipient from ACT.
Upon planned or unplanned disenrollment of an ACT recipient, the ACT team shall
document the circumstances regarding disenrollment in the recipient's medical
A planned disenrollment from ACT
occurs when a recipient, or recipient's guardian and ACT team members mutually
agree to the termination of ACT services and transition of the recipient to a
different care setting, provider, or benefit package. A planned disenrollment
is appropriate when:
(a) The recipient has
successfully reached established goals for disenrollment and the recipient
and/or their guardian and ACT team members agree to the discharge from ACT;
(b) The recipient moves outside
the geographic area of the ACT team's responsibility. In such cases, the ACT
team shall arrange to transfer mental health and substance use disorder service
responsibility to another ACT program or other provider wherever the recipient
is moving. The ACT team shall maintain contact with the recipient until the
transfer is complete; or
recipient or their guardian requests a disenrollment; or
(d) The recipient is determined by the ODM
designated entity to no longer meet the eligibility or medical necessity
criteria for ACT.
part of a planned disenrollment, the ACT team shall document that the recipient
has actively participated in disenrollment activities by documenting in the
recipient's medical record the following information:
(a) The reason(s) for the recipient's
disenrollment as stated by both the recipient and the ACT team;
(b) The recipient's progress toward the goals
set forth in the treatment plan;
(c) Documentation that the recipient's
behavioral health care is being linked and transfered to a provider other than
the ACT team;
(d) The signature of
the recipient or their guardian, the ACT team leader, and the psychiatric
recipient's disenrollment from ACT may be unplanned and due to circumstances
(a) The inability of the ACT
team to locate the recipient for more than forty-five days; or
The recipient's incarceration,
hospitalization or admission to a residential substance use disorder treatment
facility. In these circumstances, the primary responsibility for the
recipient's health care is transferred to the aforementioned setting.
(i) The ACT team is expected to maintain
contact with the recipient to assist with transition between settings if the
recipient is likely to be discharged and resume service from the ACT team
within two months.
(ii) If the
recipient's stay is predicted to be longer than two months, the recipient shall
be disenrolled from the ACT team.
(iii) The recipient may be re-enrolled with
the ACT team when discharged from the incarcerated, inpatient or residential
setting. Any re-enrollment shall follow the eligibility determination criteria
described in paragraph (F) of this rule.
(4) Except for services found in paragraph
(O) of this rule, a recipient may not obtain behavioral health services from a
provider other than the ACT team unless the recipient is disenrolled from ACT
(5) The provider must
inform the ODM designated entity of disenrollment within three business days of
the discharge date. The ODM designated entity shall deactivate the
authorization for the ACT service. Failure to timely disenroll the recipient
from ACT may result in claim denial for other mental health or substance use
provider furnishing ACT services must meet both of the following criteria:
Meets the eligibility requirements found
in paragraph (A)(1) or (A)(2) of rule
of the Administrative Code; and
Employs one or more teams of mental health and substance use disorder
practitioners who comprise the ACT treatment team.
Each team must meet the following
fidelity review within the previous twelve months by an independent validation
entity recognized by ODM. In year one of an ACT team's participation with Ohio
medicaid the team must participate in a fidelity review
achieve an average fidelity score of at
on the dartmouth assertive community treatment scale (DACTS)
as determined via
an on-site fidelity review
performed by an independent validation
entity recognized by ODM. The DACTS fidelity scale and protocol can be found at
Fidelity reviews of ACT teams must be
repeated every twelve months from the report date of the previous fidelity
(b) In year three and subsequent
years of ACT team participation with the Ohio medicaid program, each ACT team
must achieve and maintain an average fidelity score of at least 4.0
An ACT team must have documented evidence of
compliance to the requirements stated in paragraph (J) of this
prior to submitting any prior authorization requests for recipients
of ACT services.
team shall have a designated full-time team leader who may serve in that
capacity with only one team.
(a) An ACT team
leader shall have a national provider identification number and be actively
enrolled as an Ohio medicaid provider.
A team leader shall have psychiatric
training and shall hold one of the following valid licenses from the
appropriate Ohio professional licensure board or licensure equivalents for ACT
teams located in other states:
independent social worker.
Licensed independent marriage and family therapist.
(iii) Licensed professional clinical
(v) Physician -
medical doctor, psychiatrist, doctor of osteopathy.
(vi) Clinical nurse specialist
(vii) Certified nurse practitioner.
(viii) Physician assistant.
(ix) Registered nurse.
Team leaders who are licensed in
accordance with paragraph (A)(5) of rule
of the Administrative Code but do not have independent licensure status from
one of the boards referenced in paragraph (A)(5) of rule
of the Administrative Code must receive approval from ODM before the ACT team
to which they are assigned can begin billing Ohio medicaid.
ACT teams that employ peer
recovery supporters must ensure that they meet the criteria and requirements
for the peer recovery support services set forth in rule
of the Administrative Code.
teams must have a caseload no greater than one hundred and twenty and must
maintain an average caseload ratio of one practitioner for every ten ACT
recipients. Upon request from the ODM, the ACT team must provide to the ODM or
its designated entity the ACT team caseload size and composition of medicaid
and non-medicaid enrollees.
ODM reserves the right to suspend or
terminate the payment of ACT services and to require subsequent review of an
ACT team's fidelity performance
if ODM has reason to believe that
the ACT team's fidelity to the DACTS model described in paragraph (J)(1) of
this rule may be in question. ODM may, at its discretion, suspend payment of
ACT medicaid claims from the provider agency employing the ACT team until such
time as ODM receives documentation from its independent validation entity that
the team does meet the fidelity criteria described in paragraph (J)(1) of this
A provider employing an
ACT team may bill up to four ACT units per month per recipient when all
clinical and billing requirements for each unit are met. The billing of ACT
units are subject to the following limits per provider category, per recipient,
(1) Not more than one unit may be
billed per medicaid recipient per month for services rendered by the ACT team
medical prescriber including physician, clinical nurse specialist, certified
nurse practitioner, or physician assistant operating within their respective
scopes of practice.
(2) Not more
than one unit per medicaid recipient per month may be billed for services
rendered by any one of the following ACT team members: psychologist, licensed
independent social worker, licensed social worker, licensed clinical social
worker, licensed professional counselor, licensed professional clinical
counselor, licensed independent clinical counselor, licensed independent
marriage and family therapist, licensed marriage and family therapist, licensed
practical nurse, registered nurse, licensed independent chemical dependency
counselor, licensed chemical dependency counselor II or licensed chemical
dependency counselor III.
more than two units per medicaid recipient per month may be billed by an ACT
team member not listed in paragraph (L)(1) or (L)(2) of this rule. This unit
category includes: psychology assistant, psychology intern, psychology trainee,
social worker assistant, social worker trainee, marriage and family therapist
trainee, counselor trainee, chemical dependency counselor assistant, qualified
mental health specialist (QMHS), including QMHS with three or more years of
experience, and peer recovery supporter.
The medicaid payment rates for ACT are
stated in the appendix to rule
of the Administrative Code. Payment for services provided by authorized ACT
teams is only available for dates of services on or after January 1,
(N) ACT teams shall maintain
regular contact and deliver all medically necessary outpatient mental health
and substance use disorder services and supports to ACT recipients enrolled
with their team.
However, with the exception
provided in paragraph (O) of this rule, only services and supports rendered in
person, face-to-face, by an ACT team member are billable to Ohio Medicaid
according to the requirements stated in paragraph (L) of this rule. While ACT
teams are encouraged to utilize the delivery of services and supports via
telephone or secure video conference, these services and supports are not
billable to the Ohio medicaid program.
(O) Services rendered by the ACT team medical
prescriber, including physician, clinical nurse specialist, certified nurse
practitioner, or physician assistant, are billable when rendered to an ACT
face-to-face or via a case
specific consultation with another member of the ACT team regarding the medical
aspects of the ACT recipient's treatment plan. The ACT team medical prescriber
must have at least one face-to-face contact
with each ACT recipient every three months. (P)
When a recipient is enrolled on an ACT
team, no other medicaid community behavioral health services, as defined in
Chapter 5160-27 of the Administrative Code, are eligible for reimbursement
Supported employment as identified
on a recipient's specialized recovery services program treatment plan if
applicable, as described in rule
of the Administrative Code.
Substance use disorder services that are not considered part of the benefit
package encompassed under level one of the american society of addiction
medicine (ASAM) as defined in rule
of the Administrative Code. Prior authorization from the ODM designated entity
(3) Crisis services
furnished by a provider other than the billing provider agency employing the
Documentation requirements for ACT.
Documentation in the recipient's medical record of the services provided by the
ACT team must meet the requirements stated in this paragraph as well as those
stated in rules
of the Administrative Code.
ACT team must develop a specific treatment plan for each enrolled recipient.
The treatment plan must, at a minimum, meet the requirements of rule
of the Administrative Code plus the following additional requirements:
(a) The treatment plan shall be
individualized based on the recipient's needs, strengths, and preferences and
shall set measurable long-term and short-term goals and specify approaches and
interventions necessary for the recipient to achieve the recipient goals. The
treatment plan shall also identify who will carry out the approaches and
plan shall address, at a minimum, the following key areas:
(i) Psychiatric illness or symptom
(ii) Stable, safe, and
Activities of daily living.
Daily structure and activities, including employment if appropriate.
(v) Family and social
treatment plan shall be reviewed and revised by a member of the ACT team with
the recipient whenever a change is needed in the recipient's course of
treatment or at least every six months. In conjunction with a treatment plan
review, the ACT team member shall prepare a summary of the recipient's
progress, goal attainment, effectiveness of the intervention and recipient's
satisfaction with the ACT team interventions since enactment of the previous
(d) The treatment
plan, and all subsequent revisions of it, shall be reviewed and signed by the
recipient and the ACT team practitioner.
The following activities performed by
members of the ACT team are not eligible for reimbursement:
(1) Time spent attending or participating in
Services provided to teach academic subjects or as a substitute for educational
personnel, including but not limited to a teacher, teacher's aide, or an
services for the recipient to acquire, retain, and improve the self-help,
socialization, and adaptive skills necessary to reside successfully in
(4) Child care
services or services provided as a substitute for the parent or other
individuals responsible for providing care and supervision.
(5) Respite care.
(6) Transportation for the recipient or
(7) Services provided to
children, spouse, parents, or siblings of the eligible recipient under
treatment or others in the eligible recipient's life to address problems not
directly related to the eligible recipient's issues and not listed in the
eligible recipient's ACT treatment plan.
(8) Art, movement, dance, or drama
(9) Services provided to
collaterals of the recipient.
Contacts that are not medically necessary.
(11) Any service outside the responsibility
of the ACT team.
training and supported employment services, unless the recipient is enrolled in
the specialized recovery services program as described in rule
of the Administrative Code.
Crisis intervention provided by the provider agency employing the ACT