Wis. Admin. Code Department of Health Services DHS 107.13 - Mental health services
(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 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).
(2) OUTPATIENT PSYCHOTHERAPY SERVICES.
(a)
Covered services. Except
as provided in par. (b), outpatient psychotherapy services shall be covered
services when provided by a provider certified under s.
DHS
105.22, and when the following conditions are met:
1. A strength-based assessment, including
differential diagnostic examination, is performed by a certified psychotherapy
provider. A physician's prescription is not necessary to perform the
assessment. The assessment shall include:
a.
The recipient's presenting problem.
b. Diagnosis established from the current
Diagnostic and Statistical Manual of Mental Disorders including all 5 axes or,
for children up to age four, the current Diagnostic Classification of Mental
Health and Developmental Disorders of Infancy and Early Childhood.
c. The recipient's symptoms which support the
given diagnosis.
d. The recipient's
strengths, and current and past psychological, social, and physiological data;
information related to school or vocational, medical, and cognitive function;
past and present trauma; and substance abuse.
e. The recipient's unique perspective and own
words about how he or she views his or her recovery, experience, challenges,
strengths, needs, recovery goals, priorities, preferences, values and
lifestyle, areas of functional impairment, and family and community
support.
f. Barriers and strengths
to the recipient's progress and independent functioning.
g. Necessary consultation to clarify the
diagnosis and treatment.
3. Psychotherapy is furnished by:
a. A provider who is a licensed physician,
licensed psychologist, or a licensed and certified advanced practice nurse
prescriber who is individually certified under s.
DHS 105.22 (1) (a), (b),
or (bm) and who is working in an outpatient
mental health clinic certified under s.
DHS
105.22 or in private practice.
b. A provider under s.
DHS 105.22
(3) who is working in an outpatient mental
health clinic that is certified under s.
DHS
105.22 to participate in MA.
4. Psychotherapy is performed only in any of
the following:
a. The office of a provider for
providers who may bill directly.
b.
A hospital outpatient mental health clinic on the hospital's physical
premises.
c. An outpatient mental
health clinic.
d. A nursing
home.
e. A school.
f. A hospital.
g. The home.
h. Via telehealth when the provider is in a
location that ensures privacy and confidentiality of recipient information and
communications.
5. The
provider who performs psychotherapy shall engage in contact with the recipient
in person, via real-time interactive audio-visual telehealth, or real-time
interactive audio-only telehealth for at least 5/6 of the time for which
reimbursement is claimed under MA.
(c)
Other limitations.
1. Collateral interviews shall be limited to
members of the recipient's immediate family. These are parents, spouse and
children or, for children in foster care, foster parents.
2. No more than one provider may be
reimbursed for the same psychotherapy session, unless the session involves a
couple, family group or is a group therapy session. In this subdivision, "group
therapy session" means a session not conducted in a hospital for an inpatient
recipient at which there are more than one but not more than 10 individuals
receiving psychotherapy services together from one or 2 providers. Under no
circumstances may more than 2 providers be reimbursed for the same
session.
3. Emergency psychotherapy
may be performed by a provider for a recipient without a prescription for
treatment or prior authorization when the provider has reason to believe that
the recipient may immediately injure himself or herself or any other person. A
prescription for the emergency treatment shall be obtained within 48 hours of
the time the emergency treatment was provided, excluding weekends and holidays.
Services shall be incorporated within the limits described in par. (b) and this
paragraph, and subsequent treatment may be provided if par. (b) is
followed.
4. Strength-based
assessment, including a differential diagnostic evaluation for mental health,
day treatment and substance abuse services shall be limited to 8 hours every
calendar year per recipient as a unique procedure before prior authorization is
required.
5. Services under this
subsection are not reimbursable if the recipient is receiving community support
program services under sub. (6) or psychosocial services provided through a
community-based psychosocial service program under sub. (7).
6. Professional psychotherapy services
provided to hospital inpatients in general hospitals, other than group therapy
and medication management, are not considered inpatient services. Reimbursement
shall be made to the psychiatrist, psychologist, or advanced practice nurse
prescriber billing providers certified under s.
DHS 105.22 (1) (a), (b),
or (bm) who provide mental health
professional services to hospital inpatients in accordance with requirements of
this subsection.
(d)
Non-covered services. All of the following services are not
covered services:
1. Collateral interviews
with persons not stipulated in par. (c) 1., and consultations, except as
provided in s. 49.45 (29y), Stats., and s.
DHS 107.06 (4)
(d).
2. Psychotherapy for individuals with the
primary diagnosis of developmental disabilities, including intellectual
disabilities, except when they experience psychological problems that
necessitate psychotherapeutic intervention.
3. For individuals age 21 and over,
psychotherapy provided in a person's home.
Note: Section 49.45 (45), Stats., provides for in-home community mental health and alcohol and other drug abuse (AODA) services for individuals age 21 and over. However, these services are available to an individual only if the county, city, town or village in which the individual resides elects to make the services available and agrees to pay the non-federal share of the cost of those services.
4. Self-referrals. For purposes of this
paragraph, "self-referral" means that a provider refers a recipient to an
agency in which the provider has a direct financial interest, or to himself or
herself acting as a practitioner in private practice.
5. Court appearances except when necessary to
defend against commitment.
Note: For more information on non-covered services, see s. DHS 107.03.
(2m) The goals of psychotherapy and specific
objectives to meet those goals shall be documented in the recipient's recovery
and treatment plan that is based on the strength-based assessment. In the
recovery and treatment plan, the signs of improved functioning that will be
used to measure progress towards specific objectives at identified intervals,
agreed upon by the provider and recipient shall be documented. A mental health
diagnosis and medications for mental health issues used by the recipient shall
be documented in the recovery and treatment plan.
(3) ALCOHOL AND OTHER DRUG ABUSE OUTPATIENT
TREATMENT SERVICES.
(a)
Covered
services. Outpatient alcohol and drug abuse treatment services shall
be covered when prescribed by a physician, provided by a provider who meets the
requirements of s.
DHS
105.23, and when the following conditions are met:
1. The treatment services furnished are AODA
treatment services;
2. Before being
enrolled in an alcohol or drug abuse treatment program, the recipient receives
a complete medical evaluation, including diagnosis, summary of present medical
findings, medical history and explicit recommendations by the physician for
participation in the alcohol or other drug abuse treatment program. A medical
evaluation performed for this purpose within 60 days prior to enrollment shall
be valid for reenrollment;
3. The
supervising physician or psychologist develops a treatment plan which relates
to behavior and personality changes being sought and to the expected outcome of
treatment;
5. AODA treatment
services are performed only in the office of the provider, a hospital or
hospital outpatient clinic, an outpatient facility, a nursing home or a school
or by telehealth when functionally equivalent to services provided in
person;
6. The provider who
performs AODA treatment services shall engage in contact with the recipient in
person, via real-time interactive audio-visual telehealth, or real-time
interactive audio-only telehealth for at least 5/6 of the time for which
reimbursement is claimed.
(c)
Other limitations.
1. No more than one provider may be
reimbursed for the same AODA treatment session, unless the session involves a
couple, a family group or is a group session. In this paragraph, "group
session" means a session not conducted in a hospital for an inpatient recipient
at which there are more than one but not more than 10 recipients receiving
services together from one or 2 providers. No more than 2 providers may be
reimbursed for the same session. No recipient may be held responsible for
charges for services in excess of MA coverage under this paragraph.
2. Services under this subsection are not
reimbursable if the recipient is receiving community support program services
under sub. (6).
3. Professional
AODA treatment services other than group therapy and medication management
provided to hospital inpatients in general or to inpatients in IMDs are not
considered inpatient services. Reimbursement shall be made to the psychiatrist
or psychologist billing provider certified under s.
DHS 105.22 (1) (a) or
(b) or
105.23 who provides AODA treatment
services to hospital inpatients in accordance with requirements under this
subsection.
4. Medical
detoxification services are not considered inpatient services if provided
outside an inpatient general hospital or IMD.
(d)
Non-covered services.
The following services are not covered services:
1. Collateral interviews and consultations,
except as provided in s.
DHS 107.06 (4)
(d);
2. Court appearances except when necessary to
defend against commitment; and
3.
Detoxification provided in a social setting, as described in s.
DHS
75.58, is not a covered service.
Note: For more information on non-covered services, see s. DHS 107.03.
(3m) ALCOHOL AND OTHER DRUG ABUSE DAY
TREATMENT SERVICES.
(a)
Covered
services. Alcohol and other drug abuse day treatment services shall be
covered when prescribed by a physician, provided by a provider certified under
s.
DHS
105.25 and performed according to the recipient's
treatment program in a non-residential, medically supervised setting, and when
the following conditions are met:
1. An
initial assessment is performed by qualified medical professionals under s.
DHS 75.24
(11) for a potential participant. Services
under this section shall be covered if the assessment concludes that AODA day
treatment is medically necessary and that the recipient is able to benefit from
treatment;
2. A treatment plan
based on the initial assessment is developed by the interdisciplinary team in
consultation with the medical professionals who conducted the initial
assessment and in collaboration with the recipient;
3. The supervising physician or psychologist
approves the recipient's written treatment plan;
4. The treatment plan includes measurable
individual goals, treatment modes to be used to achieve these goals and
descriptions of expected treatment outcomes; and
5. The interdisciplinary team monitors the
recipient's progress, adjusting the treatment plan as required.
(b)
Prior
authorization.
1. All AODA day
treatment services except the initial assessment shall be prior
authorized.
2. Any recommendation
by the county human services department under s.
46.23, Stats., or the county
community programs department under s.
51.42, Stats., shall be
considered in review and approval of the prior authorization request.
3. Department representatives who review and
approve prior authorization requests shall meet the same minimum training
requirements as those mandated for AODA day treatment providers under s.
DHS
105.25.
(c)
Other limitations.
1. AODA day treatment services in excess of 5
hours per day are not reimbursable under MA.
2. AODA day treatment services may not be
billed as psychotherapy, AODA outpatient treatment, case management,
occupational therapy or any other service modality except AODA day
treatment.
3. Reimbursement for
AODA day treatment services may not include time devoted to meals, rest
periods, transportation, recreation or entertainment.
4. Reimbursement for AODA day treatment
assessment for a recipient is limited to 3 hours in a calendar year. Additional
assessment hours shall be counted towards the mental health outpatient dollar
or hour limit under sub. (2) (a) 6. before prior authorization is required or
the AODA outpatient dollar or hour limit under sub. (3) (a) 4. before prior
authorization is required.
(d)
Non-covered services.
The following are not covered services:
1.
Collateral interviews and consultations, except as provided in s.
DHS 107.06(4)
(d);
2. Time spent in the AODA day treatment
setting by affected family members of the recipient;
3. AODA day treatment services which are
primarily recreation-oriented or which are provided in non-medically supervised
settings. These include but are not limited to sports activities, exercise
groups, and activities such as crafts, leisure time, social hours, trips to
community activities and tours;
4.
Services provided to an AODA day treatment recipient which are primarily social
or only educational in nature. Educational sessions are covered as long as
these sessions are part of an overall treatment program and include group
processing of the information provided;
5. Prevention or education programs provided
as an outreach service or as case-finding; and
6. AODA day treatment provided in person in
the recipient's home.
(4) MENTAL HEALTH DAY TREATMENT OR DAY
HOSPITAL SERVICES.
(a)
Covered
services. Day treatment or day hospital services are covered services
when prescribed by a physician, when provided by a provider who meets the
requirements of s.
DHS
105.24, and when the following conditions are met:
1. Before becoming involved in a day
treatment program, the recipient is evaluated through the use of the functional
assessment scale provided by the department to determine the medical necessity
for day treatment and the person's ability to benefit from it;
2. The supervising psychiatrist approves,
signs and dates a written treatment plan for each recipient and reviews and
signs the plan no less frequently than once every 60 days. The treatment plan
shall be based on the initial evaluation and shall include the individual
goals, the treatment modalities including identification of the specific group
or groups to be used to achieve these goals and the expected outcome of
treatment;
3. Up to 90 hours of day
treatment services in a calendar year may be reimbursed without prior
authorization. Psychotherapy services or occupational therapy services provided
as component parts of a person's day treatment package may not be billed
separately, but shall be billed and reimbursed as part of the day treatment
program;
4. Day treatment or day
hospital services provided to recipients with inpatient status in a hospital
are limited to 20 hours per inpatient admission and shall only be available to
patients scheduled for discharge to prepare them for discharge;
5. Reimbursement is not made for day
treatment services provided in excess of 5 hours in any day or in excess of 120
hours in any month;
6. Day
treatment services are covered only for the chronically mentally ill and
acutely mentally ill who have a need for day treatment and an ability to
benefit from the service, as measured by the functional assessment scale
provided by the department; and
7.
Billing for day treatment is submitted by the provider. Day treatment services
shall be billed as such, and not as psychotherapy, occupational therapy or any
other service modality.
8. The
groups shall be led by a qualified professional staff member, as defined under
s.
DHS 105.24 (1) (b)
4. a., and the staff member shall be present
throughout the group sessions and shall perform or direct the
service.
(b)
Services requiring prior authorization.
1. Providers shall obtain authorization from
the department before providing the following services, as a condition for
coverage of these services:
a. Day treatment
services provided beyond 90 hours of service in a calendar year;
b. All day treatment or day hospital services
provided to recipients with inpatient status in a nursing home. Only those
patients scheduled for discharge are eligible for day treatment. No more than
40 hours of service in a calendar year may be authorized for a recipient
residing in a nursing home;
c. All
day treatment services provided to recipients who are concurrently receiving
psychotherapy, occupational therapy or AODA services;
d. All day treatment services in excess of 90
hours provided to recipients who are diagnosed as acutely mentally
ill.
2. The prior
authorization request shall include:
a. The
name, address, and MA number of the recipient;
b. The name, address, and provider number of
the provider of the service and of the billing provider;
c. A photocopy of the physician's original
prescription for treatment;
d. A
copy of the treatment plan and the expected outcome of treatment;
e. A statement of the estimated additional
dates of service necessary and total cost; and
f. The demographic and client information
form from the initial and most recent functional assessment. The assessment
shall have been conducted within 3 months prior to the authorization
request.
3. The
department's decision on a prior authorization request shall be communicated to
the provider in writing. If the request is denied, the department shall provide
the recipient with a separate notification of the denial.
(c)
Other limitations.
1. All assessment hours beyond 6 hours in a
calendar year shall be considered part of the treatment hours and shall become
subject to the relevant prior authorization limits. Day treatment assessment
hours shall be considered part of the 6 hour per 2-year mental health
evaluation limit.
2. Reimbursement
for day treatment services shall be limited to actual treatment time and may
not include time devoted to meals, rest periods, transportation, recreation or
entertainment.
3. Reimbursement for
day treatment services shall be limited to no more than 2 series of day
treatment services in one calendar year related to separate episodes of acute
mental illness. All day treatment services in excess of 90 hours in a calendar
year provided to a recipient who is acutely mentally ill shall be
prior-authorized.
4. Services under
this subsection are not reimbursable if the recipient is receiving community
support program services under sub. (6) or psychosocial services provided
through a community-based psychosocial service program under sub.
(7).
(d)
Non-covered services. The following services are not covered
services:
1. Day treatment services which are
primarily recreation-oriented and which are provided in non-medically
supervised settings such as 24 hour day camps, or other social service
programs. These include sports activities, exercise groups, activities such as
craft hours, leisure time, social hours, meal or snack time, trips to community
activities and tours;
2. Day
treatment services which are primarily social or educational in nature, in
addition to having recreational programming. These shall be considered
non-medical services and therefore non-covered services regardless of the age
group served;
3. Consultation with
other providers or service agency staff regarding the care or progress of a
recipient;
4. Prevention or
education programs provided as an outreach service, case-finding, and reading
groups;
5. Aftercare programs,
provided independently or operated by or under contract to boards;
6. Medical or AODA day treatment for
recipients with a primary diagnosis of alcohol or other drug abuse;
7. Day treatment provided in person in the
recipient's home; and
8. Court
appearances except when necessary to defend against commitment.
Note: For more information on non-covered services, see s. DHS 107.03.
(6) COMMUNITY SUPPORT PROGRAM (CSP) SERVICES.
(a)
Covered services.
Community support program (CSP) services shall be covered services when
prescribed by a physician and provided by a provider certified under s.
DHS
105.255 for recipients who can benefit from the
services. These non-institutional services make medical treatment and related
care and rehabilitative services available to enable a recipient to better
manage the symptoms of his or her illness, to increase the likelihood of the
recipient's independent, effective functioning in the community and to reduce
the incidence and duration of institutional treatment otherwise brought about
by mental illness. Services covered are as follows:
1. Initial assessment. At the time of
admission, the recipient, upon a psychiatrist's order, shall receive an initial
assessment conducted by a psychiatrist and appropriate professional personnel
to determine the need for CSP care;
2. In-depth assessment. Within one month
following the recipient's admission to a CSP, a psychiatrist and a treatment
team shall perform an in-depth assessment to include all of the following
areas:
a. Evaluation of psychiatric
symptomology and mental status;
b.
Use of drugs and alcohol;
c.
Evaluation of vocational, educational and social functioning;
d. Ability to live independently;
e. Evaluation of physical health, including
dental health;
f. Assessment of
family relationships; and
g.
Identification of other specific problems or needs;
3. Treatment plan. A comprehensive written
treatment plan shall be developed for each recipient and approved by a
psychiatrist. The plan shall be developed by the treatment team with the
participation of the recipient or recipient's guardian and, as appropriate, the
recipient's family. Based on the initial and in-depth assessments, the
treatment plan shall specify short-term and long-term treatment and restorative
goals, the services required to meet these goals and the CSP staff or other
agencies providing treatment and psychosocial rehabilitation services. The
treatment plan shall be reviewed by the psychiatrist and the treatment team at
least every 30 days to monitor the recipient's progress and status;
4. Treatment services, as follows:
a. Family, individual and group
psychotherapy;
b. Symptom
management or supportive psychotherapy;
c. Medication prescription, administration
and monitoring;
d. Crisis
intervention on a 24-hour basis, including short-term emergency care at home or
elsewhere in the community; and
e.
Psychiatric and psychological evaluations;
5. Psychological rehabilitation services as
follows;
a. Employment-related services. These
services consist of counseling the recipient to identify behaviors which
interfere with seeking and maintaining employment; development of interventions
to alleviate problem behaviors; and supportive services to assist the recipient
with grooming, personal hygiene, acquiring appropriate work clothing, daily
preparation for work, on-the-job support and crisis assistance;
b. Social and recreational skill training.
This training consists of group or individual counseling and other activities
to facilitate appropriate behaviors, and assistance given the recipient to
modify behaviors which interfere with family relationships and making
friends;
c. Assistance with and
supervision of activities of daily living. These services consist of aiding the
recipient in solving everyday problems; assisting the recipient in performing
household tasks such as cleaning, cooking, grocery shopping and laundry;
assisting the recipient to develop and improve money management skills; and
assisting the recipient in using available transportation;
d. Other support services. These services
consist of helping the recipient obtain necessary medical, dental, legal and
financial services and living accommodations; providing direct assistance to
ensure that the recipient obtains necessary government entitlements and
services, and counseling the recipient in appropriately relating to neighbors,
landlords, medical personnel and other personal contacts; and
6. Case management in the form of
ongoing monitoring and service coordination activities described in s.
DHS 107.32 (1)
(d).
(b)
Other limitations.
1. Mental health services under s.
DHS 107.13 (2) and
(4) are not reimbursable for recipients
receiving CSP services.
2. An
initial assessment shall be reimbursed only when the recipient is first
admitted to the CSP and following discharge from a hospital after a short-term
stay.
3. Group therapy is limited
to no more than 10 persons in a group. No more than 2 professionals shall be
reimbursed for a single session of group therapy. Mental health technicians
shall not be reimbursed for group therapy.
4. Reimbursement is not available for a
person participating in the program under this subsection if the person is also
participating in the program under sub. (7).
(c)
Non-covered services.
The following CSP services are not covered services:
1. Case management services provided under s.
DHS
107.32 by a provider not certified under s.
DHS
105.255 to provide CSP services;
2. Services provided to a resident of an
intermediate care facility, skilled nursing facility or an institution for
mental diseases, or to a hospital patient unless the services are performed to
prepare the recipient for discharge from the facility to reside in the
community;
3. Services related to
specific job-seeking, job placement and work activities;
4. Services performed by
volunteers;
5. Services which are
primarily recreation-oriented; and
6. Legal advocacy performed by an attorney or
paralegal.
(7) PSYCHOSOCIAL SERVICES PROVIDED THROUGH A
COMMUNITY-BASED PSYCHOSOCIAL SERVICE PROGRAM.
(a)
Covered services.
Psychosocial services provided through a community-based psychosocial service
program shall be covered services when authorized by a mental health
professional under s.
DHS
36.15 for recipients determined to have a need for the
services under s.
DHS
36.14. These non-institutional services must fall
within the definition of "rehabilitative services" under
42 CFR
440.130 (d) and must be
described in a service plan under s.
DHS
36.17. Covered services include assessment under s.
DHS
36.16 and service planning and review under s.
DHS
36.17.
(b)
Other limitations.
1. Mental
health services under s.
DHS 107.13 (2) and
(4) are not reimbursable for recipients
receiving services under this subsection.
2. Group psychotherapy is limited to no more
than 10 persons in a group. No more than 2 professionals shall be reimbursed
for a single session of group psychotherapy. Mental health technicians shall
not be reimbursed for group psychotherapy.
3. Reimbursement is not available for a
person participating in the program under this subsection if the person is also
participating in the program under sub. (6).
(c)
Non-covered services.
The following are not covered services under this subsection:
1. Case management services provided under s.
DHS
107.32 by a provider not certified under s.
DHS
105.257 to provide services under this
section.
2. Services provided to a
resident of an intermediate care facility, skilled nursing facility or an
institution for mental diseases, or to a hospital patient unless the services
are performed to prepare the recipient for discharge from the facility to
reside in the community.
3.
Services performed by volunteers, except that out-of-pocket expenses incurred
by volunteers in performing services may be covered.
4. Services that are not rehabilitative,
including services that are primarily recreation-oriented.
5. Legal advocacy performed by an attorney or
paralegal.
Notes
For more information on non-covered services, see s. DHS 107.03.
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
(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).
(2) OUTPATIENT PSYCHOTHERAPY SERVICES.
(a) Covered services. Except as provided in par. (b), outpatient psychotherapy services shall be covered services when provided by a provider certified under s. DHS 105.22, and when the following conditions are met:
1. A strength-based assessment, including differential diagnostic examination, is performed by a certified psychotherapy provider. A physician's prescription is not necessary to perform the assessment. The assessment shall include:
a. The recipient's presenting problem.
b. Diagnosis established from the current Diagnostic and Statistical Manual of Mental Disorders including all 5 axes or, for children up to age four, the current Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood.
c. The recipient's symptoms which support the given diagnosis.
d. The recipient's strengths, and current and past psychological, social, and physiological data; information related to school or vocational, medical, and cognitive function; past and present trauma; and substance abuse.
e. The recipient's unique perspective and own words about how he or she views his or her recovery, experience, challenges, strengths, needs, recovery goals, priorities, preferences, values and lifestyle, areas of functional impairment, and family and community support.
f. Barriers and strengths to the recipient's progress and independent functioning.
g. Necessary consultation to clarify the diagnosis and treatment.
3. Psychotherapy is furnished by:
a. A provider who is a licensed physician, licensed psychologist, or a licensed and certified advanced practice nurse prescriber who is individually certified under s. DHS 105.22 (1) (a), (b), or (bm) and who is working in an outpatient mental health clinic certified under s. DHS 105.22 or in private practice.
b. A provider under s. DHS 105.22(3) who is working in an outpatient mental health clinic that is certified under s. DHS 105.22 to participate in MA.
4. Psychotherapy is performed only in any of the following:
a. The office of a provider for providers who may bill directly.
b. A hospital outpatient mental health clinic on the hospital's physical premises.
c. An outpatient mental health clinic.
d. A nursing home.
e. A school.
f. A hospital.
g. The home.
h. Via telehealth when the provider is in a location that ensures privacy and confidentiality of recipient information and communications.
5. The provider who performs psychotherapy shall engage in contact with the recipient in person, via real-time interactive audio-visual telehealth, or real-time interactive audio-only telehealth for at least 5/6 of the time for which reimbursement is claimed under MA.
(c) Other limitations.
1. Collateral interviews shall be limited to members of the recipient's immediate family. These are parents, spouse and children or, for children in foster care, foster parents.
2. No more than one provider may be reimbursed for the same psychotherapy session, unless the session involves a couple, family group or is a group therapy session. In this subdivision, "group therapy session" means a session not conducted in a hospital for an inpatient recipient at which there are more than one but not more than 10 individuals receiving psychotherapy services together from one or 2 providers. Under no circumstances may more than 2 providers be reimbursed for the same session.
3. Emergency psychotherapy may be performed by a provider for a recipient without a prescription for treatment or prior authorization when the provider has reason to believe that the recipient may immediately injure himself or herself or any other person. A prescription for the emergency treatment shall be obtained within 48 hours of the time the emergency treatment was provided, excluding weekends and holidays. Services shall be incorporated within the limits described in par. (b) and this paragraph, and subsequent treatment may be provided if par. (b) is followed.
4. Strength-based assessment, including a differential diagnostic evaluation for mental health, day treatment and substance abuse services shall be limited to 8 hours every calendar year per recipient as a unique procedure before prior authorization is required.
5. Services under this subsection are not reimbursable if the recipient is receiving community support program services under sub. (6) or psychosocial services provided through a community-based psychosocial service program under sub. (7).
6. Professional psychotherapy services provided to hospital inpatients in general hospitals, other than group therapy and medication management, are not considered inpatient services. Reimbursement shall be made to the psychiatrist, psychologist, or advanced practice nurse prescriber billing providers certified under s. DHS 105.22 (1) (a), (b), or (bm) who provide mental health professional services to hospital inpatients in accordance with requirements of this subsection.
(d) Non-covered services. All of the following services are not covered services:
1. Collateral interviews with persons not stipulated in par. (c) 1., and consultations, except as provided in s. 49.45 (29y), Stats., and s. DHS 107.06 (4) (d).
2. Psychotherapy for individuals with the primary diagnosis of developmental disabilities, including intellectual disabilities, except when they experience psychological problems that necessitate psychotherapeutic intervention.
3. For individuals age 21 and over, psychotherapy provided in a person's home.
Note: Section 49.45 (45), Stats., provides for in-home community mental health and alcohol and other drug abuse (AODA) services for individuals age 21 and over. However, these services are available to an individual only if the county, city, town or village in which the individual resides elects to make the services available and agrees to pay the non-federal share of the cost of those services.
4. Self-referrals. For purposes of this paragraph, "self-referral" means that a provider refers a recipient to an agency in which the provider has a direct financial interest, or to himself or herself acting as a practitioner in private practice.
5. Court appearances except when necessary to defend against commitment.
Note: For more information on non-covered services, see s. DHS 107.03.
(2m) The goals of psychotherapy and specific objectives to meet those goals shall be documented in the recipient's recovery and treatment plan that is based on the strength-based assessment. In the recovery and treatment plan, the signs of improved functioning that will be used to measure progress towards specific objectives at identified intervals, agreed upon by the provider and recipient shall be documented. A mental health diagnosis and medications for mental health issues used by the recipient shall be documented in the recovery and treatment plan.
(3) ALCOHOL AND OTHER DRUG ABUSE OUTPATIENT TREATMENT SERVICES.
(a) Covered services. Outpatient alcohol and drug abuse treatment services shall be covered when prescribed by a physician, provided by a provider who meets the requirements of s. DHS 105.23, and when the following conditions are met:
1. The treatment services furnished are AODA treatment services;
2. Before being enrolled in an alcohol or drug abuse treatment program, the recipient receives a complete medical evaluation, including diagnosis, summary of present medical findings, medical history and explicit recommendations by the physician for participation in the alcohol or other drug abuse treatment program. A medical evaluation performed for this purpose within 60 days prior to enrollment shall be valid for reenrollment;
3. The supervising physician or psychologist develops a treatment plan which relates to behavior and personality changes being sought and to the expected outcome of treatment;
5. AODA treatment services are performed only in the office of the provider, a hospital or hospital outpatient clinic, an outpatient facility, a nursing home or a school or by telehealth when functionally equivalent to services provided in person;
6. The provider who performs AODA treatment services shall engage in contact with the recipient in person, via real-time interactive audio-visual telehealth, or real-time interactive audio-only telehealth for at least 5/6 of the time for which reimbursement is claimed.
(c) Other limitations.
1. No more than one provider may be reimbursed for the same AODA treatment session, unless the session involves a couple, a family group or is a group session. In this paragraph, "group session" means a session not conducted in a hospital for an inpatient recipient at which there are more than one but not more than 10 recipients receiving services together from one or 2 providers. No more than 2 providers may be reimbursed for the same session. No recipient may be held responsible for charges for services in excess of MA coverage under this paragraph.
2. Services under this subsection are not reimbursable if the recipient is receiving community support program services under sub. (6).
3. Professional AODA treatment services other than group therapy and medication management provided to hospital inpatients in general or to inpatients in IMDs are not considered inpatient services. Reimbursement shall be made to the psychiatrist or psychologist billing provider certified under s. DHS 105.22 (1) (a) or (b) or 105.23 who provides AODA treatment services to hospital inpatients in accordance with requirements under this subsection.
4. Medical detoxification services are not considered inpatient services if provided outside an inpatient general hospital or IMD.
(d) Non-covered services. The following services are not covered services:
1. Collateral interviews and consultations, except as provided in s. DHS 107.06 (4) (d);
2. Court appearances except when necessary to defend against commitment; and
3. Detoxification provided in a social setting, as described in s. DHS 75.58, is not a covered service.
Note: For more information on non-covered services, see s. DHS 107.03.
(3m) ALCOHOL AND OTHER DRUG ABUSE DAY TREATMENT SERVICES.
(a) Covered services. Alcohol and other drug abuse day treatment services shall be covered when prescribed by a physician, provided by a provider certified under s. DHS 105.25 and performed according to the recipient's treatment program in a non-residential, medically supervised setting, and when the following conditions are met:
1. An initial assessment is performed by qualified medical professionals under s. DHS 75.24(11) for a potential participant. Services under this section shall be covered if the assessment concludes that AODA day treatment is medically necessary and that the recipient is able to benefit from treatment;
2. A treatment plan based on the initial assessment is developed by the interdisciplinary team in consultation with the medical professionals who conducted the initial assessment and in collaboration with the recipient;
3. The supervising physician or psychologist approves the recipient's written treatment plan;
4. The treatment plan includes measurable individual goals, treatment modes to be used to achieve these goals and descriptions of expected treatment outcomes; and
5. The interdisciplinary team monitors the recipient's progress, adjusting the treatment plan as required.
(b) Prior authorization.
1. All AODA day treatment services except the initial assessment shall be prior authorized.
2. Any recommendation by the county human services department under s. 46.23, Stats., or the county community programs department under s. 51.42, Stats., shall be considered in review and approval of the prior authorization request.
3. Department representatives who review and approve prior authorization requests shall meet the same minimum training requirements as those mandated for AODA day treatment providers under s. DHS 105.25.
(c) Other limitations.
1. AODA day treatment services in excess of 5 hours per day are not reimbursable under MA.
2. AODA day treatment services may not be billed as psychotherapy, AODA outpatient treatment, case management, occupational therapy or any other service modality except AODA day treatment.
3. Reimbursement for AODA day treatment services may not include time devoted to meals, rest periods, transportation, recreation or entertainment.
4. Reimbursement for AODA day treatment assessment for a recipient is limited to 3 hours in a calendar year. Additional assessment hours shall be counted towards the mental health outpatient dollar or hour limit under sub. (2) (a) 6. before prior authorization is required or the AODA outpatient dollar or hour limit under sub. (3) (a) 4. before prior authorization is required.
(d) Non-covered services. The following are not covered services:
1. Collateral interviews and consultations, except as provided in s. DHS 107.06(4) (d);
2. Time spent in the AODA day treatment setting by affected family members of the recipient;
3. AODA day treatment services which are primarily recreation-oriented or which are provided in non-medically supervised settings. These include but are not limited to sports activities, exercise groups, and activities such as crafts, leisure time, social hours, trips to community activities and tours;
4. Services provided to an AODA day treatment recipient which are primarily social or only educational in nature. Educational sessions are covered as long as these sessions are part of an overall treatment program and include group processing of the information provided;
5. Prevention or education programs provided as an outreach service or as case-finding; and
6. AODA day treatment provided in person in the recipient's home.
(4) MENTAL HEALTH DAY TREATMENT OR DAY HOSPITAL SERVICES.
(a) Covered services. Day treatment or day hospital services are covered services when prescribed by a physician, when provided by a provider who meets the requirements of s. DHS 105.24, and when the following conditions are met:
1. Before becoming involved in a day treatment program, the recipient is evaluated through the use of the functional assessment scale provided by the department to determine the medical necessity for day treatment and the person's ability to benefit from it;
2. The supervising psychiatrist approves, signs and dates a written treatment plan for each recipient and reviews and signs the plan no less frequently than once every 60 days. The treatment plan shall be based on the initial evaluation and shall include the individual goals, the treatment modalities including identification of the specific group or groups to be used to achieve these goals and the expected outcome of treatment;
3. Up to 90 hours of day treatment services in a calendar year may be reimbursed without prior authorization. Psychotherapy services or occupational therapy services provided as component parts of a person's day treatment package may not be billed separately, but shall be billed and reimbursed as part of the day treatment program;
4. Day treatment or day hospital services provided to recipients with inpatient status in a hospital are limited to 20 hours per inpatient admission and shall only be available to patients scheduled for discharge to prepare them for discharge;
5. Reimbursement is not made for day treatment services provided in excess of 5 hours in any day or in excess of 120 hours in any month;
6. Day treatment services are covered only for the chronically mentally ill and acutely mentally ill who have a need for day treatment and an ability to benefit from the service, as measured by the functional assessment scale provided by the department; and
7. Billing for day treatment is submitted by the provider. Day treatment services shall be billed as such, and not as psychotherapy, occupational therapy or any other service modality.
8. The groups shall be led by a qualified professional staff member, as defined under s. DHS 105.24 (1) (b) 4. a., and the staff member shall be present throughout the group sessions and shall perform or direct the service.
(b) Services requiring prior authorization.
1. Providers shall obtain authorization from the department before providing the following services, as a condition for coverage of these services:
a. Day treatment services provided beyond 90 hours of service in a calendar year;
b. All day treatment or day hospital services provided to recipients with inpatient status in a nursing home. Only those patients scheduled for discharge are eligible for day treatment. No more than 40 hours of service in a calendar year may be authorized for a recipient residing in a nursing home;
c. All day treatment services provided to recipients who are concurrently receiving psychotherapy, occupational therapy or AODA services;
d. All day treatment services in excess of 90 hours provided to recipients who are diagnosed as acutely mentally ill.
2. The prior authorization request shall include:
a. The name, address, and MA number of the recipient;
b. The name, address, and provider number of the provider of the service and of the billing provider;
c. A photocopy of the physician's original prescription for treatment;
d. A copy of the treatment plan and the expected outcome of treatment;
e. A statement of the estimated additional dates of service necessary and total cost; and
f. The demographic and client information form from the initial and most recent functional assessment. The assessment shall have been conducted within 3 months prior to the authorization request.
3. The department's decision on a prior authorization request shall be communicated to the provider in writing. If the request is denied, the department shall provide the recipient with a separate notification of the denial.
(c) Other limitations.
1. All assessment hours beyond 6 hours in a calendar year shall be considered part of the treatment hours and shall become subject to the relevant prior authorization limits. Day treatment assessment hours shall be considered part of the 6 hour per 2-year mental health evaluation limit.
2. Reimbursement for day treatment services shall be limited to actual treatment time and may not include time devoted to meals, rest periods, transportation, recreation or entertainment.
3. Reimbursement for day treatment services shall be limited to no more than 2 series of day treatment services in one calendar year related to separate episodes of acute mental illness. All day treatment services in excess of 90 hours in a calendar year provided to a recipient who is acutely mentally ill shall be prior-authorized.
4. Services under this subsection are not reimbursable if the recipient is receiving community support program services under sub. (6) or psychosocial services provided through a community-based psychosocial service program under sub. (7).
(d) Non-covered services. The following services are not covered services:
1. Day treatment services which are primarily recreation-oriented and which are provided in non-medically supervised settings such as 24 hour day camps, or other social service programs. These include sports activities, exercise groups, activities such as craft hours, leisure time, social hours, meal or snack time, trips to community activities and tours;
2. Day treatment services which are primarily social or educational in nature, in addition to having recreational programming. These shall be considered non-medical services and therefore non-covered services regardless of the age group served;
3. Consultation with other providers or service agency staff regarding the care or progress of a recipient;
4. Prevention or education programs provided as an outreach service, case-finding, and reading groups;
5. Aftercare programs, provided independently or operated by or under contract to boards;
6. Medical or AODA day treatment for recipients with a primary diagnosis of alcohol or other drug abuse;
7. Day treatment provided in person in the recipient's home; and
8. Court appearances except when necessary to defend against commitment.
Note: For more information on non-covered services, see s. DHS 107.03.
(6) COMMUNITY SUPPORT PROGRAM (CSP) SERVICES.
(a) Covered services. Community support program (CSP) services shall be covered services when prescribed by a physician and provided by a provider certified under s. DHS 105.255 for recipients who can benefit from the services. These non-institutional services make medical treatment and related care and rehabilitative services available to enable a recipient to better manage the symptoms of his or her illness, to increase the likelihood of the recipient's independent, effective functioning in the community and to reduce the incidence and duration of institutional treatment otherwise brought about by mental illness. Services covered are as follows:
1. Initial assessment. At the time of admission, the recipient, upon a psychiatrist's order, shall receive an initial assessment conducted by a psychiatrist and appropriate professional personnel to determine the need for CSP care;
2. In-depth assessment. Within one month following the recipient's admission to a CSP, a psychiatrist and a treatment team shall perform an in-depth assessment to include all of the following areas:
a. Evaluation of psychiatric symptomology and mental status;
b. Use of drugs and alcohol;
c. Evaluation of vocational, educational and social functioning;
d. Ability to live independently;
e. Evaluation of physical health, including dental health;
f. Assessment of family relationships; and
g. Identification of other specific problems or needs;
3. Treatment plan. A comprehensive written treatment plan shall be developed for each recipient and approved by a psychiatrist. The plan shall be developed by the treatment team with the participation of the recipient or recipient's guardian and, as appropriate, the recipient's family. Based on the initial and in-depth assessments, the treatment plan shall specify short-term and long-term treatment and restorative goals, the services required to meet these goals and the CSP staff or other agencies providing treatment and psychosocial rehabilitation services. The treatment plan shall be reviewed by the psychiatrist and the treatment team at least every 30 days to monitor the recipient's progress and status;
4. Treatment services, as follows:
a. Family, individual and group psychotherapy;
b. Symptom management or supportive psychotherapy;
c. Medication prescription, administration and monitoring;
d. Crisis intervention on a 24-hour basis, including short-term emergency care at home or elsewhere in the community; and
e. Psychiatric and psychological evaluations;
5. Psychological rehabilitation services as follows;
a. Employment-related services. These services consist of counseling the recipient to identify behaviors which interfere with seeking and maintaining employment; development of interventions to alleviate problem behaviors; and supportive services to assist the recipient with grooming, personal hygiene, acquiring appropriate work clothing, daily preparation for work, on-the-job support and crisis assistance;
b. Social and recreational skill training. This training consists of group or individual counseling and other activities to facilitate appropriate behaviors, and assistance given the recipient to modify behaviors which interfere with family relationships and making friends;
c. Assistance with and supervision of activities of daily living. These services consist of aiding the recipient in solving everyday problems; assisting the recipient in performing household tasks such as cleaning, cooking, grocery shopping and laundry; assisting the recipient to develop and improve money management skills; and assisting the recipient in using available transportation;
d. Other support services. These services consist of helping the recipient obtain necessary medical, dental, legal and financial services and living accommodations; providing direct assistance to ensure that the recipient obtains necessary government entitlements and services, and counseling the recipient in appropriately relating to neighbors, landlords, medical personnel and other personal contacts; and
6. Case management in the form of ongoing monitoring and service coordination activities described in s. DHS 107.32 (1) (d).
(b) Other limitations.
1. Mental health services under s. DHS 107.13(2) and (4) are not reimbursable for recipients receiving CSP services.
2. An initial assessment shall be reimbursed only when the recipient is first admitted to the CSP and following discharge from a hospital after a short-term stay.
3. Group therapy is limited to no more than 10 persons in a group. No more than 2 professionals shall be reimbursed for a single session of group therapy. Mental health technicians shall not be reimbursed for group therapy.
4. Reimbursement is not available for a person participating in the program under this subsection if the person is also participating in the program under sub. (7).
(c) Non-covered services. The following CSP services are not covered services:
1. Case management services provided under s. DHS 107.32 by a provider not certified under s. DHS 105.255 to provide CSP services;
2. Services provided to a resident of an intermediate care facility, skilled nursing facility or an institution for mental diseases, or to a hospital patient unless the services are performed to prepare the recipient for discharge from the facility to reside in the community;
3. Services related to specific job-seeking, job placement and work activities;
4. Services performed by volunteers;
5. Services which are primarily recreation-oriented; and
6. Legal advocacy performed by an attorney or paralegal.
(7) PSYCHOSOCIAL SERVICES PROVIDED THROUGH A COMMUNITY-BASED PSYCHOSOCIAL SERVICE PROGRAM.
(a) Covered services. Psychosocial services provided through a community-based psychosocial service program shall be covered services when authorized by a mental health professional under s. DHS 36.15 for recipients determined to have a need for the services under s. DHS 36.14. These non-institutional services must fall within the definition of "rehabilitative services" under 42 CFR 440.130 (d) and must be described in a service plan under s. DHS 36.17. Covered services include assessment under s. DHS 36.16 and service planning and review under s. DHS 36.17.
(b) Other limitations.
1. Mental health services under s. DHS 107.13 (2) and (4) are not reimbursable for recipients receiving services under this subsection.
2. Group psychotherapy is limited to no more than 10 persons in a group. No more than 2 professionals shall be reimbursed for a single session of group psychotherapy. Mental health technicians shall not be reimbursed for group psychotherapy.
3. Reimbursement is not available for a person participating in the program under this subsection if the person is also participating in the program under sub. (6).
(c) Non-covered services. The following are not covered services under this subsection:
1. Case management services provided under s. DHS 107.32 by a provider not certified under s. DHS 105.257 to provide services under this section.
2. Services provided to a resident of an intermediate care facility, skilled nursing facility or an institution for mental diseases, or to a hospital patient unless the services are performed to prepare the recipient for discharge from the facility to reside in the community.
3. Services performed by volunteers, except that out-of-pocket expenses incurred by volunteers in performing services may be covered.
4. Services that are not rehabilitative, including services that are primarily recreation-oriented.
5. Legal advocacy performed by an attorney or paralegal.
Notes
For more information on non-covered services, see s. DHS 107.03.