2015 FLORIDA MEDICAID LEVEL OF CARE GUIDELINES

LEVEL OF CARE: 23-HOUR CRISIS OBSERVATION Description: The primary objective of this level of care is for prompt evaluation and or stabilization of participants presenting with acute psychiatric symptoms or distress. Duration of services may not exceed 23 hours, by which time stabilization and or determination of the appropriate level of care will be made. This service is to be provided in a secure and protected, medically staffed and psychiatrically supervised care environment. Criteria  An indication of actual or potential danger to self as evidenced by severe suicidal intent or a recent attempt with continued intent as evidenced by the circumstances of the attempt, the participant’s statements, or extreme feelings of hopelessness and helplessness 

Indication of actual or potential danger to others as evident by a current threat.

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Loss of impulse control leading to life threatening behavior and /or psychiatric symptoms that require immediate stabilization in a structured, psychiatrically monitored treatment setting

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The participant demonstrates a considerable incapacitating or debilitating disturbance in mood/thought/or behavior interfering with activities of daily living to the extent that immediate stabilization is required.

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Command auditory/visual hallucinations or delusions leading to suicidal and or homicidal intent.

Exclusions  The participant can be safely treated in a less restrictive treatment setting. 

Threat/assaultive behavior is not accompanied by a psychiatric diagnosis.

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Presence of any condition of sufficient severity to require acute inpatient psychiatric treatment.

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The primary problem is social, economic or one of physical health without a concurrent major psychiatric episode meeting the criteria for this level of care.

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Admission is being used as an alternative to possible imprisonment.

Discharge Criteria  Treatment goals and objectives have been substantially met. 

Length of stay at this level of care has surpassed the maximum 23-hour length of stay and a plan for continuation of services at another level of care has been established.

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Support systems allowing the participant to be maintained safely in a less restrictive treatment environment have been thoroughly explored and secured.

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The participant, family or guardian is competent but non-participatory in treatment or in following the program rules and regulations. The non-participation is of such a degree that treatment at this level of care is rendered ineffective or unsafe, despite numerous attempts to address these issues.

STATEWIDE INPATIENT PSYCHIATRIC PROGRAMS (SIPP) Description: The primary objective of this level of care is for residential placement for children and youth which can include mental health targeted case management services up to 180 days prior to discharge from

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residential placement. All SIPP services require prior authorization. In addition, all children and/or youth admitted to residential placement must have a “suitability evaluation” completed prior to admission. The purpose of the suitability evaluation is to determine appropriateness of residential treatment. The suitability assessment can be achieved in two different ways: 1. The family, guardian, or guardian ad litem can obtain the suitability assessment and letter from a psychologist or psychiatrist, licensed to practice in the State of Florida, recommending the residential care; or 2. The multidisciplinary team can request and refer a family for a suitability assessment at the point that residential treatment level of care has been identified as the appropriate setting to treat the individual’s condition. As per ss.394.455(2),(24), F.S., the suitability assessment must be completed by a psychiatrist or psychiatrist licensed to practice in the State of Florida with experience or training in treating children’s disorders. Criteria 

The child or youth has been examined and assessed for suitability for residential treatment by a psychologist or psychiatrist licensed to practice in the State of Florida.

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The child has an emotional disturbance as defined in ss.394.492(5),F.S. or a serious emotional disturbance as defined in ss.394.492(6),F.S. o ss.394.492(5),,F.S.: “Child or adolescent who has an emotional disturbance” means a person under 18 years of age who is diagnosed with a mental, emotional, or behavioral disorder of sufficient duration to meet one of the diagnostic categories specified in the most recent edition of the Diagnostic and Statistical Manual of the American Psychiatric Association, but who does not exhibit behaviors that substantially interfere with or limit his or her role or ability to function in the family, school, or community. The emotional disturbance must not be considered to be a temporary response to a stressful situation. The term does not include a child or adolescent who meets the criteria for involuntary placement under s. 394.467(1).” o

394.492(6),F.S: “Child or adolescent who has a serious emotional disturbance or mental illness” means a person under 18 years of age who: (a) Is diagnosed as having a mental, emotional, or behavioral disorder that meets one of the diagnostic categories specified in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association; and (b) Exhibits behaviors that substantially interfere with or limit his or her role or ability to function in the family, school, or community, which behaviors are not considered to be a temporary response to a stressful situation.”

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The emotional disturbance or serious emotional disturbance requires treatment in a residential treatment center

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All available treatment that is less restrictive than residential treatment has been considered or is unavailable

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The treatment provided in the residential treatment center is reasonably likely to resolve the child’s presenting problems as identified by the evaluation

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The provider is qualified by staff, program and equipment to give the care and treatment required by the child’s condition, age and cognitive ability.

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The participant is under the age of 18; and

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The nature, purpose, and expected length of treatment have been explained to the child, the child’s parent or guardian, and/or guardian ad litem.

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In addition, ALL of the following must be met:

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The participant is NOT at imminent risk of serious harm to self or others; Within 48 hours of admission, the following will occur: o A treatment plan is developed, by the psychiatrist, multidisciplinary team, and when possible the child or youth o A plan is developed to provide the child or youth with an appropriate educational program o Determine the estimated length of stay and develop a preliminary discharge plan o The participant’s family / social support will participate in treatment as clinically appropriate and available o Visits with the treating psychiatrist occur, at a minimum, twice a week o Treatment in a Residential Treatment Center is not for the purpose of providing custodial care. Custodial care in a Residential Treatment Center is defined as clinical or non-clinical services that will not cure, or which are provided during periods when the participant’s mental health condition is not changing, or does not require trained clinical personnel to safely deliver services. Custodial care includes the following:  The participant’s presenting signs and symptoms have been stabilized,  resolved, or a baseline level of functioning has been achieved;  The participant is not responding to treatment or otherwise is not  improving;  The intensity of active treatment provided in a residential setting is no  longer required or services can be safely provided in a less intensive setting.

Exclusions • The participant is 18 years of age or older; • A suitability assessment has not been completed; • The participant does not have an emotional disturbance as defined in ss.394.492(5),F.S. or a serious emotional disturbance as defined in ss.394.492(6),F.S.; • The emotional disturbance or serious emotional disturbance does NOT require treatment in a residential treatment center; • All available treatment that is less restrictive than residential treatment has NOT been considered or there is alternative treatment available that will treat the participant’s condition; • The treatment provided in the residential treatment center is NOT reasonably likely to resolve the child’s presenting problems as identified by the evaluation; • The provider is NOT qualified by staff, program and equipment to give the care and treatment required by the child’s condition, age and cognitive ability; • The nature, purpose, and expected length of treatment have NOT been explained to the child, the child’s parent or guardian, and/or guardian ad litem; • The residential treatment is being rendered as custodial care Discharge Criteria The participant is considered appropriate for discharge when: • The participant turns 18 years of age; • The participant’s presenting signs and symptoms have been stabilized, resolved, or a baseline level of functioning has been achieved; • The participant’s condition is stable to transition to a less restrictive environment; • The expected length of treatment has been met and further treatment at this level of care is not medically necessary; • The multidisciplinary team determines that the participant has met stated objectives and treatment goals; • The attending physician determines that the participant is stable for discharge; • Continued treatment at this level would be custodial in nature Services  1001Residential treatment-psychiatric

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LEVEL OF CARE: ASSESSMENT SERVICES Description: a comprehensive evaluation that investigates the participant’s clinical status including the presenting problem, history of the present illness, previous psychiatric history, physical history, relevant personal, and family history, personal strengths and a brief metal status exam. This examination concludes with a summary of findings, diagnostic formulation and treatment recommendations. Criteria  The evaluation should be conducted at the onset of illness or when the participant first presents for treatment 

It may be utilized again if an extended treatment hiatus occurs, marked change in mental status occurs or admission or readmission to an inpatient setting

Exclusions  A psychiatric evaluation is not considered necessary when the participant has a previously established diagnosis of organic brain disorder unless there has been a change in mental status requiring an evaluation to rule out additional psychiatric processes that may respond favorably to treatment 

A maximum of two psychiatric evaluations per participant per fiscal year

Services  H2000 HP comprehensive multidisciplinary evaluation/psychiatric evaluation by physician.  H2000 HP GT comprehensive multidisciplinary evaluation/psychiatric evaluation by physician (Telemedicine)  H2000 HO comprehensive multidisciplinary evaluation/ psychiatric evaluation by non-physician.

LEVEL OF CARE: LIMITED FUNCTIONAL ASSESSMENT Description: This assessment is restricted to the administration of the Multnomah Community Ability Scale (MCAS), Functional Assessment Rating Scale (FARS), and the Children’s Functional Assessment Rating Scale (CFARS) or any other functional assessment required by the Department of Children and Families (DCF). Criteria  The assessment must be provided by an individual who has been authorized by DCF to administer the assessment. 

A copy of the assessment must be placed in the participant’s clinical record.

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This service does not require authorization in the treatment plan

Exclusions  Medicaid reimburses a maximum of 3 limited functional assessments per participant per fiscal year. Services  H0031 mental health assessment by non-physician/limited functional assessment, mental health.  H0031 mental health assessment by non-physician/limited functional assessment, mental health (Telemedicine)  H0001 Limited functional assessment by non-physician, substance abuse  H0001 GT Limited functional assessment by a non-physician, substance abuse (Telemedicine)

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LEVEL OF CARE: BRIEF BEHAVIORAL HEALTH STATUS EXAMINATION Description: A brief clinical, psychiatric, diagnostic, or evaluative interview to assess behavioral stability or treatment status. Criteria  Examination documentation must include the purpose of the exam, setting, mental status of the participant, findings, and plan. Must be provided, at a minimum, by a licensed practitioner of the healing arts or master’s level certified addictions professional Exclusions  Medicaid reimburses a maximum of 10 quarter hour units annually, per participant, per fiscal year. 

Services  H2010 HO comprehensive multidisciplinary evaluation/brief behavioral health status exam.  H2010 HO GT comprehensive multidisciplinary evaluation/brief behavioral health status exam (Telemedicine)  H0001 HO In-depth assessment, new patient, substance abuse  H0001 HO GT In-depth assessment, new patient, substance abuse (Telemedicine)  H0001 TS In-depth assessment, established patient, substance abuse  H0001 TS GT In-depth assessment, established patient, substance abuse (Telemedicine)  H0001 HN Bio-psychosocial evaluation, substance abuse  H0001 HN GT Bio-psychosocial evaluation, substance abuse (Telemedicine)  H0001 Limited functional assessment, substance abuse  H0001 GT Limited functional assessment, substance abuse (Telemedicine)  T1023 HE Behavioral health medical screening, mental health  T1023 HF Behavioral health medical screening, substance abuse

LEVEL OF CARE: IN-DEPTH ASSESSMENT Description: A diagnostic tool for gathering information to establish or support a diagnosis, to provide the basis for the development of or modification to the treatment plan and the development of discharge criteria. The assessment must include an integrated summary. The summary is written to evaluate, integrate, and interpret from a broad perspective, history and assessment information collected. The summary identifies and prioritizes the participant’s service needs, establishes a diagnosis, provided and evaluation of the efficacy of past interventions, and helps to establish discharge criteria. Criteria  The participant must meet one of the following criteria to receive the assessment 

The participant has a documented history of being in need of a level of treatment beyond outpatient individual or group therapy or medication management

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The participant has been identified as high risk (step down from inpatient treatment)

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The participant has been receiving intensive services for 6 months or longer and for whom the documentation supports a lack of significant progress

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The participant has been identified through the utilization management process as being a high risk / high utilizer.

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The participant is in the infants 0–5 age group and is reportedly exhibiting symptoms of an emotional or behavioral nature that is atypical for the child’s age and/or development.

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Exclusions  A master’s level practitioner must provide the assessment and integrated summary. 

Medicaid reimburses one in depth assessment, per participant, per fiscal year.

Services  H0031 HO mental health assessment by non-physician, master’s degree/in depth assessment, new patient, mental health.  H0031 HO GT mental health assessment by non-physician, master’s degree/in depth assessment, new patient, mental health (Telemedicine).  H0031 TS mental health assessment by non-physician, follow up services/in depth assessment established patient, mental health.  H0031 TS GT mental health assessment by non-physician, follow up services/in depth assessment established patient, mental health (Telemedicine).  H0001 HO In-depth assessment, new patient, substance abuse  H0001 HO GT In-depth assessment, new patient, substance abuse (Telemedicine)  H0001 TS In-depth assessment, established patient, substance abuse  H0001 TS GT In-depth assessment, established patient, substance abuse (Telemedicine)  H0001 HN Bio-psychosocial evaluation, substance abuse  H0001 HN GT Bio-psychosocial evaluation, substance abuse (Telemedicine)  H0001 Limited functional assessment by a non-physician, substance abuse  H0001 GT Limited functional assessment by a non-physician, substance abuse (Telemedicine)  T1023 HE Behavioral health medical screening, mental health  T1023 HF Behavioral health medical screening, substance abuse

LEVEL OF CARE: BIO-PSYCHOSOCIAL EVALUATION Description: The evaluation describes the biological, psychological and social factors that may have contributed to the participant’s need for services. The evaluation includes a brief mental status exam and preliminary service recommendations. Criteria  The evaluation must be reviewed, signed and dated by a master’s level practitioner or bachelor’s level certified addictions professional. 

The review must include clinical impressions, a provisional diagnosis and a statement by the reviewer that indicates concurrence or alternative recommendations regarding treatment.

Exclusions  Medicaid reimburses 1 bio-psychosocial evaluation, per participant, per fiscal year. Services  H0031 HN mental health assessment bachelor degree/ bio psychosocial evaluation, mental health.  H0031 HN GT mental health assessment bachelor degree/ bio psychosocial evaluation, mental health (Telemedicine)

LEVEL OF CARE: REVIEW OF RECORDS (PSYCHIATRIC REVIEW) Description: Includes the review of participant records, psychiatric reports, psychometric / projective tests, clinical and psychological evaluation date for diagnostic use in evaluating and planning for the participant. A written report must be done by the individual rendering services and must be included in the participant’s medical record.

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Criteria  A psychiatrist or other physician, or psychiatric ARNP, at a minimum, must render psychiatric review of records. Exclusions  The review does not include a review of the provider agency’s own records except for psychological testing and other evaluations or evaluative data used to explicitly to address documented diagnostic questions. 

Medicaid reimburses a maximum of 2 psychiatric reviews of records, per participant, per fiscal year.

Services  H2000: comprehensive multidisciplinary evaluation/psychiatric review of records.

LEVEL OF CARE: PSYCHOLOGICAL TESTING Description: Assessment, evaluation, and diagnosis of the participant’s mental status or psychological condition through use of standardized testing materials Criteria A participant is eligible to receive psychological testing only under the following circumstances: 

At the onset of illness or suspected illness or when the participant first presents for treatment.

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Testing may be repeated if an extended hiatus in treatment or a marked change in status occurs.

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The participant is being considered for admission or readmission to an inpatient treatment program.

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There is documented difficulty determining a diagnosis or where there are divergent diagnostic impressions.

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To gather additional information to evaluate or redirect treatment efforts.

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A written report based upon test results must be done by the individual rendering services and must be included the participant’s medical record for all evaluation and testing services listed in the evaluation and testing section.

Exclusions  Testing must be provided by an individual practitioner within the scope of professional licensure, training, protocols, and competence and in accordance with applicable statutes. 

Medicaid reimburses a maximum of 40 quarter hour units of psychological testing, per participant, per fiscal year.

Services  H2019 therapeutic behavioral services, per 15 minutes/psychological testing.

LEVEL OF CARE: BRIEF INDIVIDUAL MEDICAL PSYCHOTHERAPY Description: A treatment activity designed to reduce maladaptive behaviors related to the participant’s behavioral health disorder, to maximize behavioral self-control, or to restore normalized functioning and more appropriate interpersonal relationships. Includes insight oriented, cognitive behavioral or supportive therapy. Criteria

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Therapy must be provided, at a minimum, by a psychiatrist, physician, physician assistant, or psychiatric ARNP.

Exclusions  Medicaid reimburses a maximum of 16 quarter hour units, per participant, per fiscal year. Services  H2010 HE comprehensive medication services/brief individual medical psychotherapy, mental health  H2010 HE GT comprehensive medication services/brief individual medical psychotherapy, mental health. Telemedicine)  H2010 HF comprehensive medication services/brief individual medical psychotherapy, substance abuse  H2010 HF GT comprehensive medication services/brief individual medical psychotherapy, substance abuse (Telemedicine)

LEVEL OF CARE: GROUP MEDICAL THERAPY Description: A treatment activity designed to reduce maladaptive behaviors, maximize behavioral self-control, or to restore normalized functioning, reality orientation, and emotional adjustment, thus enabling improved functioning and more appropriate interpersonal and social relationships. This service includes continuing medical diagnostic evaluation and drug management, when indicated, and may include insight oriented, cognitive behavioral, or supportive therapy Criteria  Therapy must be personally rendered by a psychiatrist or psychiatric ARNP. 

Group therapy documentation must include the group topic, assessment of the group. Level of participation, findings and plan.

Exclusions  The size of the group cannot exceed 10 participants. 

Medicaid reimburses a maximum of 18 quarter hour units of group medical therapy, per participant, per fiscal year.

Services  H2010 HQ comprehensive medication services, group setting/group medical therapy

TELEMEDICINE LEVEL OF CARE CLINICAL CRITERIA Description: The American Telemedicine Association defines telemedicine as the “use of medical information exchanged from one site to another via electronic communications for the health and education of the patient or health care provider and for the purpose of improving patient care, treatment, and services.” The federal Centers for Medicare and Medicaid Services (CMS) prefer the term “telehealth” to describe real-time, bi-directional communication between a patient and remote health care provider. Criteria Services must be real-time, interactive, two-way communication that is not audio-only, not written-only, and includes the use of audio and video equipment. Covered locations, or “spoke” sites, are limited to physician offices, hospital inpatient and outpatient settings, and community behavioral health centers. The spoke site is not reimbursed unless the provider performs separate service for the recipient at the spoke site on the same day as telemedicine service. Providers utilizing telemedicine must implement technical written policies and procedures for telemedicine

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systems that comply with the Health Insurance Portability and Accountability Act privacy regulations as well as applicable state and federal laws that pertain to patient privacy. Policies and procedures must also address the technical safeguards required by Title 45, Code of Federal Regulations, section 164.312, where applicable. NOTE: The medical necessity criteria and service limitations for individual services apply as per the handbook, even if services are rendered via Telemedicine. Exclusions 

Email

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Facsimile

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Phone without separate video capability.

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Transfer of data from one site to another through the use of a camera or similar device that records (stores) an image that is sent (forwarded) via telecommunication to another site for consultation.

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Video cell phone conversations, such as FaceTime® and/or Skype® calls, are not covered.

Services  H2000 HP GT Psychiatric evaluation by physician 

H2010 GT Brief behavioral health status exam

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H0031 H0 GT In-depth assessment, new patient, mental health

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H0031 TS GT In-depth assessment, established patient, mental health

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H0001 H0 GT In-depth assessment, new patient, substance abuse

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H0001 TS GT In-depth assessment, established patient, substance abuse

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H0031 HN GT Bio-psychosocial evaluation, mental health

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H0001 HN GT Bio-psychosocial evaluation, substance abuse

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H0031 GT Limited functional assessment, mental health

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H0001 GT Limited functional assessment, substance abuse

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T1015 GT Medication management

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H2010 HE GT Brief individual medical psychotherapy, mental health

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H2010 HF GT Brief individual medical psychotherapy, substance abuse

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H0046 GT Behavioral health-related medical services; verbal interaction, mental health

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H0047 GT Behavioral health-related medical services; verbal interaction, substance abuse

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H2019 HR GT Individual and family therapy

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LEVEL OF CARE: PET THERAPY/ANIMAL ASSISTED THERAPY CLINICAL CRITERIA Description: The American Veterinary Medical Association (AVMA) defines Animal-assisted therapy (AAT) or Pet Therapy as a goal directed intervention where an animal meeting specific criteria becomes an active and integral part of the treatment process for the identified individual. The AVMA clearly indicates that the delivery of animal-assisted therapy is by a health or human service provider working within the scope of his / her profession. The goal of this treatment modality is to promote improvement in functioning across various aspects of an individual’s life, including: physical, social, emotional, or cognitive function. There are a variety of settings where this therapy is available, including group or individual in nature. The process is documented and evaluated. Criteria Pet therapy is to have rehabilitative effect, alone or in concert with other evidence-based therapies, measured as quantifiable improvements in functional status and/or materially sustained progress towards reducing a gap between chronological age and mental age. For services to meet criteria, the following applies: A referral is made by a treating behavioral health physician Be rehabilitative in nature Be provided by a pet and its handler that has been trained, evaluated and certified by a pet therapy certification organization such as the Foundation for Pet-Provided Therapy or the American Kennel Club. Exclusion   

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Services are rendered with a primary recreational focus Services are not rehabilitative in nature Services are not rendered in coordination with other evidence-based therapies Services are not likely to evidence quantifiable improvements In functional status Services are not likely to impact the reduction of an existing gap between chronological age and mental age Services are rendered without the recommendation by a treating behavioral health physician Services are rendered by a non-qualified practitioner/organization

LEVEL OF CARE: ART THERAPY CLINICAL CRITERIA Description: The American Art Therapy Association defines Art Therapy as the use of “a creative process to improve and enhance the physical, mental and emotional wellbeing of individuals of all ages. Criteria The goal of Art Therapy is to resolve conflicts and problems, develop interpersonal skills, manage behavior, reduce stress, and increase self-esteem and awareness.” These goals provide benefits for the individual in terms of: 

Improving communication

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Stabilizing mood

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Resolving conflicts and problems

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Promoting interpersonal growth and skills development

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Developing coping and anger-management strategies

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Improving self-esteem and confidence

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A referral is made by a treating behavioral health physician

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Be rehabilitative in nature

Art therapy is to have rehabilitative effect, alone or in concert with other evidence-based therapies, measured as quantifiable improvements in functional status and/or materially sustained progress towards reducing a gap between chronological age and mental age. Exclusion        

Services are rendered with a primary recreational focus Services are not rehabilitative in nature Services are not rendered in coordination with other evidence-based therapies Services are not likely to evidence quantifiable improvements In functional status Services are not likely to impact the reduction of an existing gap between chronological age and mental age Services are rendered without the recommendation by a treating behavioral health physician Services are rendered by a non-qualified practitioner/organization Services are rendered to an individual who is not likely to benefit from the treatment with evidence of improved communication, stabilization of mood, enhanced interpersonal growth and skills development, and/or facilitate coping skills development.

LEVEL OF CARE: BEHAVIORAL HEALTH SCREENING Description: a face-to-face assessment of physical status, a brief history, and decision-making of low complexity. Criteria The assessment must include at a minimum:  Vital signs. 

Medication concerns and possible side effects.

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Brief mental status assessment.

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Plan for follow up.

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The results of the examination must be included in the participant’s medical record.

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The service must be provided, at a minimum by a psychiatrist, physician, physician assistant, ARNP or registered nurse.

Exclusion  Medicaid reimburses 2 behavioral health-screening services, per participant, per fiscal year.

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Services  T1023 HE screening to determine appropriateness of consideration of an individual for participation in a specified program, project or treatment protocol per encounter, mental health. Behavioral health screening.  T1023 HF screening to determine appropriateness of consideration of an individual for participation in a specified program, project or treatment protocol per encounter, substance abuse  H0001 HO In-depth assessment, new patient, substance abuse  H0001 HO GT In-depth assessment, new patient, substance abuse (Telemedicine)  H0001 TS In-depth assessment, established patient, substance abuse  H0001 TS GT In-depth assessment, established patient, substance abuse (Telemedicine)  H0001 HN Bio-psychosocial evaluation, substance abuse  H0001 HN GT Bio-psychosocial evaluation, substance abuse (Telemedicine)  H0001 Limited functional assessment by a non-physician, substance abuse  H0001 GT Limited functional assessment by a non-physician, substance abuse (Telemedicine)

LEVEL OF CARE: BEHAVIORAL HEALTH SERVICES Description: A verbal interaction (15-minute minimum between the provider and the participant. This service must be directly related to the participant’s behavioral health disorder or to monitoring side effects associated with medication (specimen collection, taking vitals, and administering injections) Criteria  Documentation for each service must describe the need and the participant’s interaction. 

Verbal interaction must be provided by a Physician’s assistant, ARNP or RN.

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The monitoring of possible medication side effects must be provided by an individual qualified by licensure, training, protocols and competence and within purview of statutes applicable to his/her profession.

Exclusion  A behavioral health service is not reimbursable on the same day for the participant as behavioral health screening services. Services  H0046 mental health services not otherwise specified/behavioral health services, verbal interaction, mental health.  H0046 GT Behavioral health-related medical services; verbal interaction, mental health (Telemedicine)  

H0047 Behavioral health-related medical services; verbal interaction, substance abuse. H0047 GT Behavioral health-related medical services; verbal interaction, substance abuse (Telemedicine)

LEVEL OF CARE: CASE MANAGEMENT SERVICES Description: Case management involves the accessing, linking, coordinating and monitoring of services aimed at assisting members in coping with psychosocial stressors. These services, provided by multiple providers, will enable the individual to participate fully in family and community activities. Instrumental to this coordination is the creation of an individualized care plan which reflects the participant’s strengths, personal goals, obtaining individualized services, facilitating linkages to community based resources, and reviewing the progress made over the course of care.

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Admission Criteria  The participant meets at least one of the following requirements: o o o o o

Is awaiting admission to or has been discharged from a State mental Hospital. Has been discharged from a mental health residential treatment facility. Has had more than one admission to a crisis stabilization unit, short-term residential treatment facility, inpatient psychiatric unit, or any combination of these facilities within a 12-month period. Is at risk of institutionalization for mental health reasons. Is experiencing long-term or acute episodes of mental impairment that may put him/her at risk or requiring more intensive services.

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The participant presents with an axis I diagnosis or a behavioral condition associated with an axis II condition.

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The individual has a disability that requires advocacy for and coordination of services to maintain or improve level of functioning.

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Family/individual requires assistance with obtaining, coordination necessary treatment, rehabilitation and social services without which they would likely require a more restrictive level of care.

Continued Care  The participant continues to meet criteria for case management services. 

The participant has made some progress toward more independent functioning, but evidences an ongoing inability to obtain or coordinate services without program support at this time.

Exclusions  Ongoing services are for the primary purpose of providing support that can be obtained through other services or a lower level of care. 

The participant does not meet criteria for case management services.

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When dealing with a child the family refuses services and the child continues to live within the family home.

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The participant chooses to no longer participate in the program.

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Severity of symptoms requires a more intensive level of care/treatment intervention.

Discharge Criteria  The participant no longer meets criteria for or requires program services. 

The individual/family are non-participatory with the program.

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The participant requires a more restrictive level of care.

Case Management  T1017 (TARGETED CASE MANAGEMENT FOR ADULTS).  T1017HA (TARGETED CASE MANAGEMENT FOR CHILDREN BIRTH TO 17).  T1017HK (INTENSIVE TEAM TARGETED CASE MANAGEMENT ADULTS).

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LEVEL OF CARE: CLUBHOUSE SERVICES Description: A place where people who have a mental illness come to rebuild their lives. Clubhouse services are structured, community-based group services provided in a group rehabilitation service setting. These services include a range of social, educational, pre-vocational and transitional employment. Every opportunity provided is the result of the efforts of the participant and staff who work together to achieve shared goals. These services are designed to assist the participant to eliminate the functional, interpersonal and environmental barriers created by their disabilities and to restore social skills for independent living and effective life management. Criteria  The participant must have a psychiatric diagnosis and be at least 16 years old. 

A referral from a psychiatrist, psychiatric ARNP, or licensed practitioner of the healing arts.

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A weekly progress note that describes what activities were performed to enhance/support the participant’s functioning.

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A monthly progress note at the end of each month that reflects how the services are linked to the goals and objectives of the participant’s treatment plan.

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Documentation describes the participant’ progress relative to the treatment plan.

Exclusion  Medicaid reimburses services for a maximum of 1920 quarter hour units annually, per participant, per fiscal year. 

These units count against psychosocial rehabilitation units of service.

Services  H2030 mental health clubhouse, per 15 minutes.

LEVEL OF CARE: PSYCHOSOCIAL REHABILITATION Description: Services combine daily medication use, independent living and social skills training, support to clients and their families, housing, pre-vocational and transitional employment rehabilitation training, social support and network enhancement, structured activities to restore participant to a higher level of functioning and diminish tendencies towards isolation and withdrawal. Services are intended to restore a participant’s skills and abilities essential for independent living. This differs from counseling/therapy in that it concentrates less upon the amelioration of symptoms and more upon restoring functional capabilities. Criteria  Services are appropriate for participants exhibiting psychiatric, behavioral or cognitive symptoms or clinical conditions of sufficient severity to bring about a significant impairment in day to day personal, social, pre-vocational and educational functioning. 

The participant is diagnosed with a mental health disorder associated with psychiatric, behavioral or cognitive symptoms or clinical conditions of sufficient severity to bring about a significant impairment in functioning.

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Participation in psychosocial rehabilitation services is not solely for the purpose of satisfying legal requirements for treatment or services.

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Services rendered to participants will be designed to assist the recipient to compensate for or eliminate

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functional deficits and interpersonal and environmental barriers created by their disabilities, and to restore skills for independent living and effective life management. 

Daily documentation describes what activities the rehabilitation counselor did to enhance/support the participant’s skills of daily life management.

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Monthly documentation reflects how the services are linked to the goals and objectives of the participant’s treatment plan, and describes the participant’s progress relative to the treatment plan.

Exclusion  Medicaid reimburses a maximum of 1920 units of psychosocial rehabilitation services, per participant, per fiscal year. 

The participant has received behavioral health day services on the same day as psychosocial rehabilitation services.

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Based on the submitted clinical information by the rendering practitioner(s) and review by a board certified psychiatrist, the participant is not an appropriate candidate for services as evidenced by his/her inability to restore a higher level of functioning, or compensate for/eliminate functional deficits that are barriers for independent living. The provider has the opportunity to speak with the Medical Director to provide additional information as well.

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The participant’s sole purpose for participation in psychosocial rehabilitation services is to satisfy court/legal requirements.

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The participant does not have a valid Axis I mental health diagnosis as the primary purpose for treatment.

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The participant meets criteria for day treatment services, but participation in psychosocial rehabilitation services is unlikely to impact the participant’s ability to function more independently in the community.

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Despite an extended period of services at this level, the member has failed to make or sustain gains toward independent living and effective life management.

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These units count against clubhouse service units.

Services  H2017 psychosocial rehab services, per 15 minutes.

LEVEL OF CARE: ADULT DAY TREATMENT Description: Provides a coordinated set of individualized therapeutic services to participants with psychiatric disorders who may be able to function only partially in a school, work, and or home environment and need the additional structured activities of this level of care. Active family involvement is important unless contraindicated. Frequency should be based upon individual needs. Day treatment is for participants who need more active or inclusive services than is typically available through traditional outpatient mental health services. Day treatment leads to the attainment of specific goals through detailed therapeutic interventions within a designated timeframe and allows for transitioning of the participant to an outpatient level of care and to other necessary supports, or other structured activities. Admission Criteria  The participant presents with symptoms associated with a diagnosis that requires and can be reasonably expected to respond to a therapeutic intervention.

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

Exacerbation or persistence of a longstanding psychiatric disorder results in symptoms of thought, mood, behavior or perception that significantly limit functioning.

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Treatment planning should be individualized and specifically state what benefits the participant can reasonable expect to obtain. The participant requires structure for activities of daily living.

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The participant is seen as able to master more intricate personal and interpersonal life skills.

Continued Care  The participant’s condition continues to meet admission criteria at this level of care and participant is actively involved in the plan of care and treatment activities. 

Progress in relation to specific symptoms or impairments is clearly evident and can be described in objective terms, but goals of treatment have not yet been achieved or adjustments in the treatment plan to address lack of progress are apparent.

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Care is rendered in a clinically appropriate manner and focused on the participant’s behavioral and functional outcomes as indicated in the treatment plan.

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All services and treatment are carefully structured to achieve optimum results in the most time efficient manner possible consistent with sound clinical practices.

Exclusions  The participant’s condition requires placement in a more restrictive level of care due to an increase in symptoms or can be managed in a less restrictive level of care due to a decrease in the severity of symptoms. 

The primary focus is social, economic, or one of physical health without a concurrent psychiatric episode meeting criteria for this level of care.



Admission is being used as an alternative to imprisonment.

Discharge Criteria  The participant has been able to achieve stated treatment goals and thus no longer meets the admission criteria. Treatment can now be provided in a less intensive level of care. 

The participant has shown an increase in symptom severity and thus requires services which are beyond the scope of the current treatment option.

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Non-participation in treatment is of such a degree that treatment has been rendered ineffective or unsafe even with documented attempts to address this issue.

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The participant is not making progress towards obtaining treatment goals and there is no reasonable expectation of improvement at this level of care.

Services  H2012 behavioral health day treatment, per hour/day services mental health.  H2012 HF behavioral health day treatment, per hour/day services substance abuse.

LEVEL OF CARE: CRISIS STABILIZATION / INPATIENT HOSPITALIZATION Description: The most intensive level of psychiatric care. Twenty four hour skilled psychiatric nursing care, daily medical care, and a structure treatment milieu are required due to the participant’s clinical presentation. Typically, the individual poses a significant risk to self or others or shows severe psychosocial dysfunction.

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Admission Criteria The participant exhibits one of the following:  The participant has attempted suicide or displays severe suicidal ideation with a specific plan of selfharm. 

Assaultive threats or behaviors, resulting from an axis I diagnosis, with clear risk of escalation.

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A recent history of violence resulting from an axis I or II diagnosis.

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Significant risk taking or poor impulse control resulting in danger to self or others.

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Command /bizarre behavior or psychomotor agitation or retardation that interferes with activities of daily living. These symptoms are of such a degree that the participant would not be able to function at a less intensive level of care.

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Disorientation or memory impairment which is due to an axis I diagnosis and endangers the wellbeing of the participant or others in the community.

Exclusion Criteria  The participant can be safely maintained and treated in a less restrictive level of care. 

The participant exhibits serious and persistent mental illness and is not in an acute exacerbation of the illness. A member whose baseline functioning does not show any improvement.

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The primary problem is social, economic, or one of physical health without a concurrent major psychiatric episode meeting criteria for this level of care.

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Admission is being used as an alternative to imprisonment.

Continued Care  The participant’s condition continues to meet admission criteria for inpatient care, acute treatment interventions have not been exhausted and no less restrictive level of care would be adequate. 

All services and treatment are carefully structured to achieve optimal results in the most time proficient manner possible consistent with sound clinical practices.

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The participant is active in the plan of care and treatment to the extent possible given the current psychiatric symptoms.

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Progress in relation to specific symptoms or impairments is clearly evident and can be described in objective terms but goals of treatment have not yet been achieved, or adjustments in the treatment plan to address lack of progress and or psychiatric/medical complications are evident

Discharge Criteria  Treatment goals and objectives have been substantially met or continuing care can be implemented in a less restrictive level of care. 

The participant, family of guardian is competent but non-participatory in treatment or in following program rules/regulations. The non-participant is of such a degree that treatment at this level of care is rendered ineffective or unsafe, despite multiple attempts to address this issue.

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The participant is not making progress towards treatment goals and there is no reasonable expectation of progress at this level of care due to chronicity.

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LEVEL OF CARE: INTENSIVE CASE MANAGEMENT Description: Intensive case management provides for the assignment of a single fixed point of accountability for the participant that ensures the coordination of services that will enable the participant to live in the least restrictive environment possible while increasing adaptive capabilities of the participants. Services include the development of a highly individualized and integrated care plan. Admission Criteria  The participant is enrolled in a Department of Children and Families adult mental health target population. 

The participant meets at least one of the following requirements: o o o

o

The participant has resided in a State Mental facility for at least 6 months in the past 36 months. The participant resides in the community and has had two or more admissions to a State Mental hospital in the past 36 months. The participant resides in the community and has had three or more admissions to a crisis stabilization unit (CSU), short-term residential facility, inpatient psychiatric unit, or any combination of these facilities in the past 12 months. The participant resides in the community and, due to a mental illness, exhibits behavior or symptoms that could result in long-term hospitalization if frequent interventions for a period of time were not provided.

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The participant cannot be maintained in a less restrictive treatment setting without case management services.

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Individual/family requires assistance in obtaining and coordinating treatment, rehabilitation and social services, without which the participant would likely require a more restrictive level of care.

Continued Care  The participant continues to meet criteria for this intensity of service. 

Behaviors and/or symptoms demonstrate the continued need for the service.

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Individual/family actively participates in the development and implementation of the treatment plan.

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Continued inability to obtain or coordinate services without program supports will lead to the need for more restrictive treatment in the absence of continued services.

Discharge Criteria  The participant has demonstrated the ability to remain out of the hospital for 3 months and/or the ability to maintain adherence with treatment plan and consent of referring agency. 

The goals have been substantially met and the participant shows the ability to be able to access needed services/supports and sustain activities of daily living.

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The member can be treated at a lower level of care or least restrictive setting.

LEVEL OF CARE: MEDICATION MANAGEMENT Description: The provision of a prescription, and ongoing medical monitoring. The sole service rendered by a qualified provider, is the evaluation of the need for psychotropic medication.

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Admission Criteria  There is a need for prescribing and monitoring of psychotropic medications. Continued Care  Progress in relation to specific symptoms or impairments is clearly evident and can be described in objective terms, but goals of treatment have not yet been achieved, or adjustments in the treatment plan to address lack of progress are evident. 

All services and treatment are carefully structured to achieve optimal results in the most time efficient manner possible, consistent with sound clinical practices.

Discharge Criteria  The participant no longer requires psychotropic medication. 

Consent for treatment has been withdrawn.



Non-participation is of such degree that treatment at this level of care is rendered ineffective or unsafe, in spite of multiple attempts to address the non-compliance issues.

Services  T1015 clinic visit, all inclusive, medication management.  T1015 HF Behavioral health related medical services, medical procedures, substance abuse  T1015 HE Behavioral health related medical services, medical procedures, mental health

LEVEL OF CARE: OUTPATIENT SERVICES Description: Therapeutic services which are provided in an office, clinic setting, home or other location appropriate to the provision of psychotherapy or counseling. Services focus on the restoration, enhancement and /or maintenance of the participant’s level of functioning and the lessening of symptoms which significantly interfere with functioning in at least one are of the participant’s daily functioning. The goals, frequency and length of treatment will vary according to the needs of the participant and the response to treatment. Treatment can be seen as falling into 1 of 3 possible categories based upon the clinical information. 1. Situational: This is usually a brief clinical intervention (1-10 sessions) which has as a focus the resolution of a current life crisis, or adjustment to an external stressor. 2. Symptom Based: This type of intervention can be of an intermediate duration (1-20 sessions) and is focused on the reduction of symptoms associated with an axis I or II diagnosis and may include psychopharmacological measures. 3. Intricate: This intervention is to be considered for participants who have tried less restrictive clinical interventions which has been unsuccessful in controlling symptom severity. This approach may require the use of longer term therapy and medication management. Schedules or intermittent contact with a treatment provider is necessary to maintain the participant’s current level of functioning and to prevent the possible need for more restrictive treatment interventions. Admission Criteria  The participant has a chronic mental illness (schizophrenia) or a refractory condition (personality disorder) which by history has required inpatient treatment. 

The participant shows symptoms which are consistent with an axis I diagnosis and can be reasonably expected to respond to therapeutic interventions. These symptoms are significant and interfere with the participant’s ability to function on a daily basis.

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The belief exists that the participant has the ability to make significant progress towards treatment goals or treatment is necessary to maintain the current level of functioning.

Continued Care  Improvement in relation to specific symptoms or impairments is clearly evident and can be described in objective terms, but goals of treatment have not yet been achieved, or adjustments in the treatment plan to address lack of progress are evident. 

All services and treatment are carefully structured to achieve optimal results in the most time efficient manner possible consistent with established clinical practices.

Exclusions  Treatment is designed to address goals other that relief of symptoms associated with an axis I or II diagnosis. 

The primary problem is social, educational, economic, one of physical health without concurrent major psychiatric episode meeting criteria for this level of care.

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Admission is being used as an alternative to imprisonment.

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The participant requires a level of care beyond the scope of current services.

Discharge Criteria  The treatment goals/objective have been substantially met. 

Non-participation is of such a degree that treatment at this level of care is rendered ineffective or unsafe, despite multiple attempts to address this issue.

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The participant is not making progress towards treatment goals and there is no reasonable expectation of improvement at this level of care.

Services  H2019 HQ therapeutic behavioral services, per 15 minutes, group setting/group therapy  H2019 HR therapeutic behavioral services, per 15 minutes, family/couple with client present/individual and family therapy.  H2019 HR GT Individual and family therapy (Telemedicine)

LEVEL OF CARE: TARGETED CASE MANAGEMENT Description: Specialized case management is intended to be used in a wide variety of circumstances; short term intervention to transition a participant from one level of care to another. This form of case managed may also be used with participants and their families, who need temporary assistance obtaining services. Admission Criteria  The participant meets at least one of the following requirements: o o o o

Has had more than one admission to a crisis stabilization unit, short-term residential treatment facility, inpatient psychiatric unit, or any combination of these facilities Is at risk of institutionalization for mental health reasons Is experiencing long-term or acute episodes of mental impairment that may put him/her at risk or requiring more intensive services Is experiencing apparent distress due to current environmental factors which require short-term intervention to transition the participant to a less restrictive level of care.

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The participant presents with an axis I diagnosis or a behavioral condition associated with an axis II condition which is severe enough that, in the absence of intervention, the condition would require treatment at a more restrictive level.

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The individual has a disability that requires advocacy for and coordination of services to transition to a lower level of care.

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Family/individual requires assistance with obtaining, coordination necessary treatment, rehabilitation and social services without which they would likely require a more restrictive level of care.

Continued Care  The participant continues to meet criteria for specialized case management services. 

The participant has made some progress toward more independent functioning, but evidences an ongoing inability to obtain or coordinate services without program support at this time.

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The treatment plan clearly defines the expected treatment goals and the time frame for achieving these specific activities.

Exclusions  The participant has an axis I diagnosis which is not reasonably expected to improve or successfully respond to therapeutic interventions. The member is unable to show any positive improvement given their baseline behavior. 

Ongoing services are for the primary purpose of providing support which can be obtained through other services or a lower level of care.

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The participant does not meet criteria for specialized case management services.

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The participant can be effectively treated at a less restrictive level of care.

Discharge Criteria  The goals of the care coordination have been successfully achieved. 

The participant can be treated a less restrictive level of care.

LEVEL OF CARE: THERAPEUTIC BEHAVIORAL ON SITE SERVICES Description: An intensive family based treatment intervention that is delivered where the child is living, working, or participating in educational activities and designed to stabilize family functioning and preserve the safety of the child, family, community and maintaining the child within the home setting. Service components include comprehensive assessment of family structure, roles, and dynamics, crisis intervention, service coordination, and the teaching, accessing tangible resources and modeling of family skills. Intensity of treatment depends upon the clinical needs of the family unit. Admission Criteria  A member demonstrates psychological symptoms which are consistent with and axis I diagnosis and which requires, and is likely to respond to, therapeutic interventions. 

The identified participant and family have complex needs that in the absence of intervention at this level will require a more intensive, restrictive behavioral health placement.

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Family functioning is seriously disrupted and threatens the wellbeing of the individual, family, community,

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or continued in-home placement. 

The family has the ability and willingness to actively take part in this intervention.

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There are multiple systemic problems that require in-home intervention several hours a week and/or traditional, office based interventions have been ineffective in the stabilization of family functioning.

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The services are intended to maintain the child/adolescent in the home.

Continued Care  Progress in relation to specific symptoms/impairments/dysfunction is clearly evident and can be described in objective terms, but goals of treatment have not yet been achieved or adjustments in the treatment plan to address the lack of progress is evident. 

The participant continues to meet admission criteria and there is active planning for transition to a less restrictive level of care.

Exclusions  Consent is not obtained for this intervention. 

The family is not willing to or does not have the ability to actively take part in this intervention.

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The home environment is not safe/stable enough to allow staff to appropriately intervene.

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The family based modification can be accomplished using a less restrictive intervention.

Discharge Criteria The family is not making progress towards goals and there is no reasonable expectation of improvement at this level. 

The family no longer has the ability/willingness to participate in this intervention.

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Treatment goals have been substantially met.

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The participant can be effectively treated at a lower level of care.

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Despite an extended period of services at this level, the member has failed to make or sustain gains as delineated in the treatment objectives.

Services for Children and Adolescents  H2019 HM therapeutic behavioral services, per 15 minutes/less than bachelor degree level/onsite services, behavior management.  H2019 HN therapeutic behavioral services, per 15 minutes onsite services, behavior management.  H2019 HO therapeutic behavioral services, per 15 minutes/masters level/onsite services, behavior management, per 15 minutes.

LEVEL OF CARE: TREATMENT PLAN DEVELOPMENT AND MODIFICATION Description: A structured, goal directed schedule of services developed jointly by the participant and the treatment team. If the participants age or clinical condition preclude participant in the development of the plan an explanation must be provided. The plan must contain written treatment-related goals and measurable objectives.

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Criteria The treatment plan must contain the following elements:  Specific diagnosis codes. 

Goals that are focused on the participant’s strengths and abilities.

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Measurable objectives and target dates.

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Services to be provided.

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Frequency of treatment interventions.

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An addendum may be used to make changes to the treatment plan in lieu of rewriting the entire plan.

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The addendum must be signed and dated by the treating practitioner and the participant.

Exclusion  Medicaid reimburses 1 treatment plan development, per provider, per fiscal year with a maximum total of 2 per participant per fiscal year. Services  H0032 mental health service plan development by non-physician/treatment plan development, new and established patient mental health.  T1007 Treatment Plan development, new and established patient, substance abuse

LEVEL OF CARE: TREATMENT PLAN REVIEW Description: A process conducted to ensure that treatment goals, objectives and services continue to be appropriate to the participant’s needs and to assess the participant’s progress and continued need for services. Criteria  A formal review of the treatment plan must be conducted at least every 6 months. The plan may be reviewed more often when significant changes occur. 

During the plan review, activities, notations of discussions, findings, conclusions, and recommendations must be documented. The written documentation must be included in the participant’s medical record upon completion of the plan review activities.



If the assessment indicates that the goals/objectives have not been met, documentation must reflect the treatment team’s re-assessment of services and justification if no changes were made.

Exclusion  Medicaid reimburses a maximum of 4 plan reviews per participant per fiscal year Services  H0032 TS mental health service plan development by non-physician/treatment plan development, follow up service.  T1007 TS Treatment Plan review, substance abuse

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LEVEL OF CARE: MEDICATION-ASSISTED TREATMENT SERVICES Description: Services for medication-assisted treatment is reimbursed for opioid addiction treatment by a program licensed by the state and certified by the Federal Substance Abuse and Mental Health Services Administration (SAMHSA), in accordance with state and federal regulations. Recipients receiving methadone treatment can be prescribed take-home doses after 30 days of treatment, if it is clinically indicated. In order to qualify for take-home doses, it must be documented that a recipient is participating in a methadone maintenance regimen, in addition to meeting the conditions outlined in Rule 65D-30.014, F.A.C. Criteria Medication-assisted treatment services must be provided under the supervision of a physician or a psychiatrist. Medication-assisted treatment must be provided by one of the following qualified practitioners:  Physician  Psychiatrist  PPA  Physician assistant  Psychiatric ARNP  ARNP  Psychiatric nurse  Registered nurse  Licensed practical nurse  Medical assistant Exclusion  Medicaid reimburses medication-assisted treatment services 52 times, per recipient, per state fiscal year. The service is billed one time per seven days. This service is not reimbursable using any other procedure code. Services  H0020 medication-assisted treatment services 52 times/year.

LEVEL OF CARE: SPECIALIZED THERAPEUTIC SERVICES; COMPREHENSIVE BEHAVIORAL HEALTH ASSESSMENTS, SPECIALIZED THERAPEUTIC FOSTER CARE, AND THERAPEUTIC GROUP HOME SERVICES Description: Specialized therapeutic services include comprehensive behavioral health assessments, specialized therapeutic foster care, and therapeutic group home services provided to recipients under the age of 21 years with mental health, substance use, and co-occurring mental health and substance use disorders. The intent of specialized therapeutic services is the maximum reduction of the recipient’s disability and restoration to the best possible functional level. Services must be diagnostically relevant and medically necessary. Specialized therapeutic foster care and therapeutic group home services must be included in an individualized treatment plan that has been approved by a treating practitioner. Services are treatment events that correspond with Medicaid procedure codes. Services are not the same as interventions.

LEVEL OF CARE: COMPREHENSIVE BEHAVIORAL HEALTH ASSESSMENTS Description: A comprehensive behavioral health assessment is an in-depth and detailed assessment of the recipient’s emotional, social, behavioral, and developmental functioning. For those settings in which the recipient routinely participates, a comprehensive behavioral health assessment must include direct observation of the recipient in the following settings:

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• Home • School or child care • Work site • Community Comprehensive behavioral health assessment components requiring face-to-face contact cannot be provided using telemedicine. This service requires prior authorization. Eligibility Criteria  To receive a comprehensive behavioral health assessment, a recipient must be under the age of 21 years and meet all of the following criteria: o Be a victim of abuse or neglect o Have been determined by the Department of Children and Families (DCF) or their designee to require o out-of-home care or be placed in shelter status 

Or the recipient must meet all of the following criteria: o Have committed acts of juvenile delinquency o Be suffering from an emotional disturbance or a serious emotional disturbance o Be at risk for placement in a residential setting

Services  H0031HA Comprehensive Behavioral Health Assessment / 1x per state fiscal year (July 1 through June 30) per recipient. Reimbursement is limited to a total of 20 hours per recipient per fiscal year. The assessment is reimbursed on the date that the report is completed.

LEVEL OF CARE: SPECIALIZED THERAPEUTIC FOSTER CARE SERVICES Description: Specialized therapeutic foster care services are intensive treatment services provided to recipients under the age of 21 years with emotional disturbances who reside in a state licensed foster home. Specialized therapeutic foster care services are appropriate for long-term treatment and short-term crisis intervention. The goal of specialized therapeutic foster care is to enable a recipient to manage and to work toward resolution of emotional, behavioral, or psychiatric problems in a highly supportive, individualized, and flexible home setting. Specialized therapeutic foster care services incorporate clinical treatment services, which are behavioral, psychological, and psychosocial in orientation. Services must include clinical interventions by the specialized therapeutic foster parent(s), a primary clinician, and a psychiatrist. A specialized therapeutic foster parent must be available 24 hours per day to respond to crises or to provide special therapeutic interventions. There are two levels of specialized therapeutic foster care, which are differentiated by the supervision and training of the foster parents and intensity of programming required. Specialized therapeutic foster care levels are intended to support, promote competency, and enhance participation in normal, age-appropriate activities of recipients who present moderate to serious emotional or behavior management problems. Programming and interventions are tailored to the age and diagnosis of the recipients. Specialized therapeutic foster care services are offered at Level I or Level II, with crisis intervention available at both levels.

LEVEL OF CARE: SPECIALIZED THERAPEUTIC FOSTER LEVEL I Description: Level I specialized therapeutic foster care is for recipients with a history of abuse or neglect, or delinquent behavior, and who have an emotional disturbance or serious emotional disturbance. Level I specialized therapeutic foster care is characterized by close supervision of the recipient within a specialized therapeutic foster home. Services to the recipient must include clinical interventions by the specialized therapeutic foster parent(s), a primary clinician, and a psychiatrist.

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This service requires prior authorization. Eligibility Criteria  Level I specialized therapeutic foster care is for recipients with a history of abuse or neglect, or delinquent behavior, and who have an emotional disturbance or serious emotional disturbance, of sufficient duration to meet one of the diagnostic categories specified in the most recent edition of the Diagnostic and Statistical Manual of the American Psychiatric Association. The emotional disturbance must not be considered to be a temporary response to a stressful situation. 

The recipient must qualify for foster care and must meet at least one of the following criteria: o o

Requires admission to a psychiatric hospital, a crisis stabilization unit, or a residential treatment center without specialized therapeutic foster care. Within the last two years, been admitted to one of these treatment settings.

Exclusion  Medicaid does not reimburse for specialize therapeutic services for treatment of a cognitive deficit severe enough to prohibit the service from being of benefit to the recipient. 

The following are services and supports not reimbursed under specialized therapeutic services: o

o o o o o o o o o o

o o o o

Services provided to a recipient on the day of admission into the Statewide Inpatient Psychiatric Program (SIPP). However, community behavioral health services are reimbursable on the day of discharge. Case management services. Partial hospitalization. Services rendered to individuals residing in an institution for mental diseases. Services rendered to institutionalized individuals, as defined in 42 CFR 435.1009. Room and board expenditures. Basic childcare programs for developmental delays, preschool, or enrichment programs. Education services. Travel time. Activities performed to maintain and review records for facility utilization, continuous quality improvement, recipient eligibility status processing, and staff training purposes. Activities (other than record reviews, services with family member or other interested persons that benefit the recipient, or services performed using telemedicine) that are not performed face-to-face with the recipient. Services rendered by a recipient’s relative. Services rendered by unpaid interns or volunteers. Services paid for by another funding source. Escorting or transporting a recipient to and from a service site.

Services  S5145 Specialized Therapeutic Foster Care, Level I / per day Aftercare Planning The recipient and the treating staff should collaborate to develop the recipient’s individualized formal aftercare plan. A formal aftercare plan should include community resources, activities, services, and supports that will be utilized to help the recipient sustain gains achieved during treatment. Discharge Criteria

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The recipient and the treating staff should collaborate to develop the individualized, measurable discharge criteria. The recipient’s progress toward meeting the discharge criteria should be addressed throughout the course of treatment as part of the treatment plan review.

LEVEL OF CARE: SPECIALIZED THERAPEUTIC FOSTER LEVEL II Description: Level II specialized therapeutic foster care is characterized by the need for more frequent contact between the specialized therapeutic foster parents, the recipient, primary clinician, and the psychiatrist as a result of the recipient exhibiting the maladaptive behaviors listed below. Level II specialized therapeutic foster care is intended to provide a high degree of structure, support, supervision, and clinical intervention. This service requires prior authorization.

Eligibility Criteria A recipient requiring Level II specialized therapeutic foster care must meet the following criteria: • Meet the criteria of Level I specialized therapeutic foster care. • Be exhibiting more severe maladaptive behaviors such as: o Destruction of property o Physical aggression toward people or animals o Self-inflicted injuries o Suicidal ideations or gestures o An inability to perform activities of daily and community living due to psychiatric symptoms The recipient must require the availability of highly trained specialized therapeutic foster parents as evidenced by at least one of the behaviors or deficits listed above. Exclusion  Medicaid does not reimburse for specialize therapeutic services for treatment of a cognitive deficit severe enough to prohibit the service from being of benefit to the recipient. 

The following are services and supports not reimbursed under specialized therapeutic services: • Services provided to a recipient on the day of admission into the Statewide Inpatient Psychiatric Program (SIPP). However, community behavioral health services are reimbursable on the day of discharge. • Case management services. • Partial hospitalization. • Services rendered to individuals residing in an institution for mental diseases. • Services rendered to institutionalized individuals, as defined in 42 CFR 435.1009. • Room and board expenditures. • Basic childcare programs for developmental delays, preschool, or enrichment programs. • Education services. • Travel time. • Activities performed to maintain and review records for facility utilization, continuous quality improvement, recipient eligibility status processing, and staff training purposes. • Activities (other than record reviews, services with family member or other interested persons that benefit the recipient, or services performed using telemedicine) that are not performed face-to-face with the recipient. • Services rendered by a recipient’s relative. • Services rendered by unpaid interns or volunteers. • Services paid for by another funding source. • Escorting or transporting a recipient to and from a service site.

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Services  S5145 HE Specialized Therapeutic Foster Care, Level II /per day Aftercare Planning The recipient and the treating staff should collaborate to develop the recipient’s individualized formal aftercare plan. A formal aftercare plan should include community resources, activities, services, and supports that will be utilized to help the recipient sustain gains achieved during treatment. Discharge Criteria The recipient and the treating staff should collaborate to develop the individualized, measurable discharge criteria. The recipient’s progress toward meeting the discharge criteria should be addressed throughout the course of treatment as part of the treatment plan review.

LEVEL OF CARE: SPECIALIZED THERAPEUTIC FOSTER FOR CRISIS INTERVENTION Description: Specialized therapeutic foster care services may be used for a maximum of 30 days for crisis intervention for a recipient for whom services must occur immediately in order to stabilize a behavioral, emotional, or psychiatric crisis. Any exception to this length of stay must be approved in writing by the multidisciplinary team. A comprehensive behavioral health assessment must be initiated within 10 working days of crisis intervention services for any recipient who has not had a comprehensive behavioral health assessment in the past year. This service requires prior authorization. Eligibility Criteria The recipient must be in foster care or delinquent and must be determined by the multidisciplinary team to meet Level I or Level II criteria. An Authorization for Crisis Intervention form, found in the appendices, must be completed and a copy placed in the recipient’s clinical record by the provider. For recipients who are enrolled in managed care, the plan must authorize approval for crisis intervention services. Exclusion  Medicaid does not reimburse for specialize therapeutic services for treatment of a cognitive deficit severe enough to prohibit the service from being of benefit to the recipient. 

The following are services and supports not reimbursed under specialized therapeutic services: • Services provided to a recipient on the day of admission into the Statewide Inpatient Psychiatric Program (SIPP). However, community behavioral health services are reimbursable on the day of discharge. • Case management services. • Partial hospitalization. • Services rendered to individuals residing in an institution for mental diseases. • Services rendered to institutionalized individuals, as defined in 42 CFR 435.1009. • Room and board expenditures. • Basic childcare programs for developmental delays, preschool, or enrichment programs. • Education services. • Travel time. • Activities performed to maintain and review records for facility utilization, continuous quality improvement, recipient eligibility status processing, and staff training purposes. • Activities (other than record reviews, services with family member or other interested persons that benefit the recipient, or services performed using telemedicine) that are not performed face-to-face with the recipient.

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• Services rendered by a recipient’s relative. • Services rendered by unpaid interns or volunteers. • Services paid for by another funding source. • Escorting or transporting a recipient to and from a service site. Services  S5145 HK Specialized Therapeutic Foster Care, Crisis Intervention /per day Aftercare Planning The recipient and the treating staff should collaborate to develop the recipient’s individualized formal aftercare plan. A formal aftercare plan should include community resources, activities, services, and supports that will be utilized to help the recipient sustain gains achieved during treatment. Discharge Criteria The recipient and the treating staff should collaborate to develop the individualized, measurable discharge criteria. The recipient’s progress toward meeting the discharge criteria should be addressed throughout the course of treatment as part of the treatment plan review.

LEVEL OF CARE: THERAPEUTIC GROUP CARE SERVICES Description: Therapeutic group care services are community-based, psychiatric residential treatment services designed for recipients under the age of 21 years with moderate to severe emotional disturbances. They are provided in a licensed residential group home setting serving no more than 12 recipients under the age of 21 years. Therapeutic group care services are intended to support, promote, and enhance competency and participation in normal age-appropriate activities of recipients who present moderate to severe psychiatric, emotional, or behavior management problems related to a psychiatric diagnosis. Programming and interventions are highly individualized and tailored to the age and diagnosis of the recipient. Therapeutic group care is intended to provide a high degree of structure, support, supervision, and clinical intervention in a homelike setting. Therapeutic group care services are a component within Florida Medicaid’s behavioral health system of care for recipients under the age of 21 years. They are appropriate for recipients under the age of 21 years who are ready to transition from a more restrictive residential treatment program or for those who require more intensive community-based treatment to avoid placement in a more restrictive residential treatment setting. The recipient’s primary diagnosis and level of functioning are the reasons for treatment and the focus of the interventions and services provided. Generally, these services include psychiatric and therapy services, therapeutic supervision, and the teaching of problem solving skills, behavior strategies, normalization activities, and other treatment modalities, as authorized in the treatment plan. This service requires prior authorization. Eligibility Criteria  The multidisciplinary team, using the Authorization for Therapeutic Group Care Services, found in the appendices of the Specialized Therapeutic Services and Limitations Handbook, March 201, must confirm that the recipient is appropriate for therapeutic group care placement by a licensed clinical psychologist, per section 490, F.S., or a board certified psychiatrist in compliance with section 394.4781 or 39.407, F.S., and has an emotional disturbance or serious emotional disturbance, of sufficient duration to meet one of the diagnostic categories specified in the most recent edition of the Diagnostic and Statistical Manual of the American Psychiatric Association. The emotional disturbance must not be considered to be a temporary response to a stressful situation. Exclusion  Medicaid does not reimburse for specialize therapeutic services for treatment of a cognitive deficit severe enough to prohibit the service from being of benefit to the recipient.

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The following are services and supports not reimbursed under specialized therapeutic services: • Services provided to a recipient on the day of admission into the Statewide Inpatient Psychiatric Program (SIPP). However, community behavioral health services are reimbursable on the day of discharge. • Case management services. • Partial hospitalization. • Services rendered to individuals residing in an institution for mental diseases. • Services rendered to institutionalized individuals, as defined in 42 CFR 435.1009. • Room and board expenditures. • Basic childcare programs for developmental delays, preschool, or enrichment programs. • Education services. • Travel time. • Activities performed to maintain and review records for facility utilization, continuous quality improvement, recipient eligibility status processing, and staff training purposes. • Activities (other than record reviews, services with family member or other interested persons that benefit the recipient, or services performed using telemedicine) that are not performed face-to-face with the recipient. • Services rendered by a recipient’s relative. • Services rendered by unpaid interns or volunteers. • Services paid for by another funding source. • Escorting or transporting a recipient to and from a service site.

Services  H0019 Therapeutic Group Care Services / per day Aftercare Planning The recipient and the treating staff should collaborate to develop the recipient’s individualized formal aftercare plan. A formal aftercare plan should include community resources, activities, services, and supports that will be utilized to help the recipient sustain gains achieved during treatment. Discharge Criteria The recipient and the treating staff should collaborate to develop the individualized, measurable discharge criteria. The recipient’s progress toward meeting the discharge criteria should be addressed throughout the course of treatment as part of the treatment plan review.

LEVEL OF CARE: BEHAVIORAL HEALTH OVERLAY SERVICES Description: Behavioral health overlay services include mental health, substance abuse, and supportive services designed to meet the behavioral health treatment needs of recipients in the care of Medicaid enrolled, certified agencies under contract with the Department of Children and Families, Child Welfare and Community-Based Care organization. The intent of behavioral health overlay services is the maximum reduction of the recipient’s disability and restoration to the best possible functional level in order to avoid a more intensive level of care. Services must be diagnostically relevant and medically necessary. Services must be included in an individualized treatment plan that has been approved by a treating practitioner. Behavioral health overlay services include the following components:  Therapy  Behavior management  Therapeutic support This service requires prior authorization. Eligibility Criteria The recipient must meet the diagnostic eligibility criterion described in Section A and also meet at least one of the risk factors in Section B.

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Section A: Diagnostic Criterion 

A person under the age of 21 years who is diagnosed with a mental, emotional, or behavioral disorder of sufficient duration to meet one of the diagnostic categories specified in the most recent edition of the Diagnostic and Statistical Manual of the American Psychiatric Association. The emotional disturbance must not be considered to be a temporary response to a stressful situation.

Section B: Risk Factors 

The recipient must be at risk due to one of the following factors in the last 12 months: o o o o o

Has exhibited suicidal gestures or attempts, or self-injurious behavior or current ideation related to suicidal or self-injurious behavior, and is not currently in need of acute care. Has exhibited physical aggression or violent behavior toward people, animals, or property; this risk may also be evidenced by current threats of such aggression. Has run away from home or placements or threatened to run away on one or more occasions. Has had an occurrence of sexual aggression. Has experienced trauma.

The recipient’s risk factor(s) must be documented and detailed on the Certification of Eligibility and reflected in the recipient’s treatment plan. Exclusion  Medicaid does not reimburse for behavioral health overlay services for treatment of a cognitive deficit severe enough to prohibit the service from being of benefit to the recipient. 

Medicaid will not reimburse for behavioral health overlay services when a recipient is absent because he or she is in a Department of Juvenile Justice detention center placement.

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The following are services and supports not reimbursed under behavioral health overlay services: • Services provided to a recipient on the day of admission into a statewide inpatient psychiatric program. However, community behavioral health services are reimbursable on the day of discharge. • Case management services. • Partial hospitalization. • Services rendered to individuals residing in an institution for mental diseases. • Services rendered to institutionalized individuals, as defined in 42 CFR 435.1009. • Room and board expenditures. • Travel time. • Education services. • Activities performed to maintain and review records for facility utilization, continuous quality improvement, recipient eligibility status processing, and staff training purposes. • Activities (other than record reviews, services with family member or other interested person that benefit the recipient, or services performed using telemedicine) that are not performed face-to-face with the recipient. • Services rendered by a recipient’s relative. • Services rendered by unpaid interns or volunteers. • Services paid for by another funding source. • Escorting or transporting a recipient to and from a service site.

Services

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H2020 HA Behavioral Health Overlay Services/ per day

Aftercare Planning The recipient and the treating staff should collaborate to develop the recipient’s individualized formal aftercare plan. A formal aftercare plan should include community resources, activities, services, and supports that will be utilized to help the recipient sustain gains achieved during treatment.

Discharge Criteria The recipient and the treating staff should collaborate to develop the individualized, measurable discharge criteria. The recipient’s progress toward meeting the discharge criteria should be addressed throughout the course of treatment as part of the treatment plan review. REFERENCES 1. Mental Health Targeted Case Management Coverage and Limitations Handbook, the Community Mental Health Services Coverage and Limitations Handbook or herein, subsequently referred to as the Community Behavioral Health Services Coverage and Limitations Handbook, March, 2014, Specialized Therapeutic Services Coverage And Limitations Handbook, March 2014, Behavioral Health Overlay Services Coverage And Limitations Handbook Agency For Health Care Administration, March 2014 and specific service requirements as described in the general service requirements. 2. 2014 MMA Medicaid Contract.

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