Part 1.
DEPARTMENT OF STATE HEALTH SERVICES
Chapter 412.
LOCAL MENTAL HEALTH AUTHORITY RESPONSIBILITIES
Subchapter I. MENTAL HEALTH CASE MANAGEMENT SERVICES
25 TAC §§412.403, 412.405 - 412.408, 412.410 - 412.413, 412.415 - 412.417
The Executive Commissioner of the Health and Human Services
Commission (commission), on behalf of the Department of State Health Services
(department), adopts amendments to §§412.403, 412.405 - 412.408,
412.410 - 412.413, and 412.415 - 412.417, concerning mental health case management
services. The amendments to §§412.403, 412.406 - 412.408, and 412.412
are adopted with changes to the proposed text as published in the April 14,
2006, issue of the
Texas Register
(31 TexReg
3171). The amendments to §§412.405, 412.410, 412.411, 412.413, and
412.415 - 412.417 are adopted without changes and the sections will not be
republished.
BACKGROUND AND PURPOSE
This subchapter describes requirements for the provision of mental health
case management services (MH case management services) funded by or through
the department.
The amendments include the addition of language that either better explains
terms already included in the definitions, or adds newly defined terms, providing
clarification for providers and others who are impacted by these rules.
Several new requirements are added to §412.411, relating to Staff
Training. These additional requirements are intended to highlight and emphasize
that case managers and case manager supervisors must not only comply with
the provisions in this subsection, but also with standards and requirements
found in other rules of the department. Such other rules include the requirements
of Chapter 412, Subchapter G of this title (relating to Mental Health Community
Services Standards), Chapter 404, Subchapter E of this title (relating to
Rights of Persons Receiving Mental Health Services), and Chapter 414, Subchapter
L of this title (relating to Abuse, Neglect, and Exploitation in Local Authorities
and Community Centers).
Certain language is moved from §412.405, relating to Eligibility for
MH Case Management Services, to §412.413, relating to Medicaid Reimbursement.
These changes are to more accurately reflect that, although an individual
may meet the basic eligibility criteria for MH case management services, circumstances
sometimes exist in which those services are not reimbursable under Medicaid.
Moving the language to the section concerning Medicaid reimbursement is intended
to assist readers in understanding this distinction.
The amendments also remove all references to the Texas Department of Mental
Health and Mental Retardation and replace them with the new agency name, the
Department of State Health Services.
Government Code, §2001.039, requires that each state agency review
and consider for re-adoption each rule adopted by that agency pursuant to
the Government Code, Chapter 2001 (Administrative Procedure Act). Sections
412.401 - 412.417 have been reviewed and the department has determined that
reasons for adopting the sections continue to exist because rules on this
subject are needed. Sections 412.401, 412.402, 412.404, 412.409 and 412.414
were opened for public comment in the proposed preamble without changes and
are readopted without changes. No comments were received concerning these
sections and they are readopted without changes.
SECTION-BY-SECTION SUMMARY
In addition to certain grammatical and formatting changes, as well as changing
the references to the "Texas Department of Mental Health and Mental Retardation"
to the "Department of State Health Services" in §412.403 and §412.417,
the following amendments are adopted.
Amendments to §412.403 add language to the definition of "CSSP or
community services specialist" to require the CSSP staff to possess demonstrated
competency in the provision and documentation of case management services
in accordance with the subchapter and with the case management billing guidelines.
Amendments also add the following new definitions: "family partner", "intensive
case management", "routine case management", and "strengths-based". Amendments
were also made to the definitions of "department," "staff member," "uniform
assessment", "utilization management guideline", and "wraparound planning",
for clarification and a better understanding of these terms as they are used
in this subchapter. The definitions are renumbered to accommodate the additions.
Section 412.405, relating to Eligibility for MH Case Management Services,
is amended by deleting subsection (b) and moving it to §412.413 of this
title (relating to Medicaid Reimbursement), as it more accurately refers to
the availability of Medicaid reimbursement than to eligibility for the services.
Section 412.406, relating to Establishing Type, Amount, and Duration of
MH Case Management Services, is amended to require the department or its designee
to notify the individual seeking services or the individual's legally authorized
representative, not later than seven business days after a determination has
been made, whether a request for MH case management services has been authorized
or denied. Sections 412.406 and 412.408, relating to Service Limitations,
is amended by deleting references to the section title, "Exhibits", and replacing
it with "Guidelines".
Section 412.407, relating to MH Case Management Services, is amended to
clarify that an assessment of unmet needs involves discussing what those needs
are with the individual, establishing time frames for meeting outcomes, explaining
the availability of services and providing case management offsite if it is
necessary to facilitate linkage to a needed service.
Section 412.410 is amended by grammatical changes only.
Section 412.411, relating to Staff Training, is amended by the addition
of language requiring case managers and supervisors of case managers to receive
training and demonstrate competency in the requirements of this subchapter,
as well as the requirements of Chapter 412, Subchapter G of this title (relating
to Mental Health Community Services Standards), Chapter 404, Subchapter E
of this title (relating to Rights of Persons Receiving Mental Health Services),
and Chapter 414, Subchapter L of this title (relating to Abuse, Neglect, and
Exploitation in Local Authorities and Community Centers). The section is also
amended to provide that case managers and case manager supervisors must receive
training and demonstrate competency in developing and implementing a case
management plan when providing intensive case management services to a child
or adolescent.
Section 412.412, relating to Documentation of MH Case Management Services,
is amended to reflect the expectation that not only are service provision
events to be documented, but attempts to provide the service are expected
to be documented as well by the case manager. Additionally, the section is
amended to require the case manager to document referrals made and the disposition
of those referrals.
Section 412.413, relating to Medicaid Reimbursement, is amended by the
addition of language indicating that the department will not reimburse a provider
for Medicaid MH case management services provided in excess of eight hours.
The section is also amended by the addition of a new subsection (f), the text
of which is being deleted from §412.405(b) of this title, relating to
Eligibility for MH Case Management Services. This change is intended to clarify
that the language more accurately refers to the availability of Medicaid reimbursement
than to eligibility for the services, and to assist readers in better understanding
the distinction between an individual's eligibility for services and a provider's
ability to be reimbursed, under Medicaid, for providing those services.
Section 412.415 is renamed as "Guidelines". In addition, the text of the
rule is amended by changing references to "exhibits" to "guidelines", and
by correcting the department's address for purposes of obtaining copies of
any of the guidelines.
Section 412.416 is amended by making corrections and additions to the rules
referenced in the subchapter.
COMMENTS
The department, on behalf of the commission, has reviewed and prepared
responses to the comments received regarding the proposed rules during the
comment period, which the commission has reviewed and accepts. The commenters
were individuals, associations, and/or groups, including the following: Advocacy,
Inc., MHMR of Tarrant County, a consumer, and program staff. The commenters
generally supported the rules, but some implicitly or explicitly suggested
changes as discussed in the summary of comments.
Comment: Concerning §412.406(e)(4), one commenter requested that the
time limit for consumer notification of eligibility determination be lengthened
to 14 days.
Response: The commission agrees that providers need sufficient time to
notify consumers of eligibility determinations, but the commission disagrees
with the suggestion that 14 days is needed. In order to reduce the burden
on the provider while ensuring that people who are seeking services are provided
with eligibility notification in a timely manner, the rule has been changed
to require that notification be provided to the consumer within seven business
days.
Comment: Concerning §412.407(c), one commenter requested clarification
of how Intensive Case Management differs from the "coordination services"
described in 25 TAC, §419.459(c)(2).
Response: The commission disagrees that intensive mental health case management
services needs further clarification. The "coordination services" set forth
in 25 TAC, §419.459(c)(2) are a component service of Psychosocial Rehabilitation.
As such, the rehabilitative "coordination services" have as their principle
focus assisting the service recipient in learning the skills required to coordinate
services for him or herself. In contrast, Intensive Case Management, as set
forth in §412.407(c), is not a rehabilitative service and does not have
a focus on the development of skills and abilities. Intensive case management
is intended to ensure that recipients are effectively linked to services that
are appropriate to the individual's needs. No change was made to the rule
as a result of this comment.
Comment: Concerning §412.411, one commenter made the suggestion that
case managers who are providing intensive case management services to a child
or adolescent should have training in wraparound services.
Response: The commission agrees that such training is important and §412.411(a)(14)
specifically requires that case managers who are providing services to children
and adolescents receive training in the wraparound planning process that is
approved by the department. No change was made to the rule as a result of
this comment.
Comment: Concerning the rules in general, one commenter stated that the
changes to the rules are positive changes that will provide the opportunity
for more cost-effective recovery opportunities for consumers.
Response: The commission agrees with the commenter and notes that these
services were specifically developed with a view toward maximizing recovery.
No change was made to the rules as a result of this comment.
The department staff on behalf of the commission provided comments and
the commission has reviewed and agrees to the following changes.
Change: Concerning §412.403(19), the word "are" was deleted after
the word "but" to correct the grammar.
Change: Concerning §412.403(27), the definition of "staff member"
was inadvertently changed to include "a volunteer" in the proposed rule, when
the intent was to retain the original definition which excluded volunteers.
The rule as proposed is being changed to correct this inadvertent error.
Change: Concerning §412.403(30), the verb "developed" was inadvertently
omitted and has been inserted in the definition.
Change: Concerning §412.406(a), references to "Exhibits" were intended
to be replaced with "Guidelines" in the proposed rule, but one such reference
was not changed. This correction is being made to the rule, and paragraph
numbers are added to the adopted cross-references for clarity.
Change: Concerning §412.407(c)(6), the word "process" was inadvertently
left out of the term "wraparound process planning", and is being inserted.
Change: Concerning §412.408(b), the specific paragraph number is added
to the cross-reference to §412.415 for of clarity.
Change: Concerning §412.412(a), changes are made in order to clarify
that consistent documentation is required for services provided to individuals,
whether through face-to-face contact or not. The subsection is renumbered
to accommodate new and deleted text.
LEGAL CERTIFICATION
The Department of State Health Services, General Counsel, Cathy Campbell,
certifies that the rules, as adopted, have been reviewed by legal counsel
and found to be a valid exercise of the agencies' legal authority.
STATUTORY AUTHORITY
The adopted amendments are authorized by Health and Safety Code, §534.052,
which requires the adoption of rules necessary and appropriate to ensure the
adequate provision of community based mental health services through a local
mental health authority; Health and Safety Code, §534.053, which requires
the department to ensure that case management services are available in each
local mental health authority service area; and Government Code, §531.0055,
and Health and Safety Code, §1001.075, which authorize the Executive
Commissioner of the Health and Human Services Commission to adopt rules and
policies necessary for the operation and provision of health and human services
by the department and for the administration of Health and Safety Code, Chapter
1001.
§412.403.Definitions.
The following words and terms, when used in this chapter, have the
following meanings, unless the context clearly indicates otherwise:
(1)
Adolescent--An individual who is at least 13 years of age,
but younger than 18 years of age.
(2)
Adult--An individual who is 18 years of age or older.
(3)
Business day--Any day except a Saturday, Sunday, or legal
holiday listed in the Texas Government Code, §662.021.
(4)
Case manager--A staff member who provides MH case management
services.
(5)
Child--An individual who is at least three years of age,
but younger than 13 years of age.
(6)
Community-based--Provided in an individual's community.
(7)
CMHC or community mental health center--An entity established
in accordance with the Texas Health and Safety Code, §534.001, as a community
mental health center or a community mental health and mental retardation center.
(8)
CSSP or community services specialist--A staff member who,
as of August 31, 2004:
(A)
has received:
(i)
a high school diploma; or
(ii)
a high school equivalency certificate issued in accordance
with the law of the issuing state; and
(B)
has had three continuous years of documented full time
experience in the provision of MH case management services; and
(C)
has demonstrated competency in the provision and documentation
of MH case management services in accordance with this subchapter and the
MH Case Management Billing Guidelines.
(9)
Crisis--A situation in which:
(A)
because of a mental health condition:
(i)
the individual presents an immediate danger to self or
others: or
(ii)
the individual's mental or physical health is at risk
of serious deterioration; or
(B)
an individual believes that he or she presents an immediate
danger to self or others or that his or her mental or physical health is at
risk of serious deterioration.
(10)
Day--A calendar day, unless otherwise specified.
(11)
Department--Department of State Health Services.
(12)
Employee--A staff member who receives a W2 Wage and Tax
Statement from a provider.
(13)
Family partner--Experienced parent (i.e. parent of an
individual with a serious emotional disturbance) who provides peer mentoring,
education, and support to the caregivers of a child who is receiving mental
health community services.
(14)
Individual--A person seeking or receiving MH case management
services.
(15)
IMD or institution for mental diseases--Based on 42 CFR §435.1009,
a hospital, nursing facility, or other institution of more than 16 beds that
is primarily engaged in providing psychiatric diagnosis, treatment, or care
of individuals with mental illness, including medical attention, nursing care,
and related services.
(16)
Intensive case management--In conjunction with wraparound
process planning, this is a focused intervention of coordinating community-based
services that assist a child or adolescent in gaining access to necessary
care and services appropriate to the individual's needs. It also includes
monitoring service effectiveness and proactive crisis planning and management.
(17)
LAR or legally authorized representative--A person authorized
by law to act on behalf of a child or adolescent with regard to a matter described
in this subchapter, and who may be a parent, guardian, or managing conservator.
(18)
LOC or level of care--A designation given to the department's
standardized packages of mental health services, based on the uniform assessment
and the utilization management guidelines, which specify the type, amount,
and duration of MH case management services to be provided to an individual.
(19)
Life domains--Areas of life in which a child or adolescent
has unmet needs, including but not limited to safety, health, emotional, psychological,
social, educational, cultural, and legal.
(20)
MH case management plan--A written document developed
by a case manager, in collaboration with the individual and the individual's
LAR or primary caregiver, that identifies services needed by the individual
and sets forth a plan for how the individual may gain access to the identified
services.
(21)
Mental health (MH) case management services--Services
to assist an individual in gaining and coordinating access to necessary care
and services appropriate to the individual's needs.
(22)
Primary caregiver--A person 18 years of age or older who
has actual care, control, and possession of a child or adolescent.
(23)
Provider--An entity that has an agreement with the department
to provide general revenue-funded MH case management services, Medicaid-funded
MH case management services, or both.
(24)
QMHP-CS or qualified mental health professional-community
services--A staff member who meets the definition of a QMHP-CS set forth in
Subchapter G of this chapter (relating to Mental Health Services Standards).
(25)
Routine case management--Primarily site-based services
that assist an adult, child or adolescent in gaining and coordinating access
to necessary care and services appropriate to the individual's needs.
(26)
Site-based--Provided at a case manager's work site.
(27)
Staff member--Personnel of a provider including a full-time
and part-time employee, contractor, intern, but excluding a volunteer.
(28)
Strengths-based--Concept used in wraparound planning that
identifies, builds on and enhances the capabilities, knowledge, skills and
assets of the child and family, their community, and other team members. The
focus is on increasing functional strengths and assets rather than on the
elimination of deficits.
(29)
Uniform assessment--An assessment tool adopted by the
department that includes the Adult Texas Recommended Assessment Guidelines,
the Texas Implementation of Medication Algorithms scales for adults, and the
Children and Adolescent Texas Recommended Assessment Guidelines.
(30)
Utilization management guidelines--Guidelines developed
by the department that establish the type, amount, and duration of MH case
management services for each LOC.
(31)
Wraparound process planning--A philosophy of care that
includes a definable planning process involving the child and family that
results in a unique set of community services and natural supports individualized
for that child and family to achieve a positive set of outcomes. Wraparound
process planning is for a child or adolescent:
(A)
with serious emotional disturbance;
(B)
who has multiple, complex needs;
(C)
who may have placement issues; and
(D)
who is authorized for a LOC inclusive of intensive case
management.
§412.406.Establishing Type, Amount, and Duration of MH Case Management Services.
(a)
The department or its designee will make the initial determination
of an individual's LOC using the uniform assessment which is referenced in §412.415(1)
of this title (relating to Guidelines); and the utilization management guidelines
which are referenced in §412.415(2) of this title. If the LOC includes
MH case management services, the department or its designee will authorize
the individual to receive either routine or intensive MH case management services.
(b)
A provider must:
(1)
ensure that a QMHP-CS administers the uniform assessment
to the individual at intervals specified by the department and applies the
utilization management guidelines to obtain a recommended LOC for the individual;
and
(2)
clinically evaluate the needs of the individual to determine
if the amount of MH case management services associated with the recommended
LOC is sufficient to meet those needs.
(c)
If the provider determines that the amount of MH case management
services associated with the recommended LOC is sufficient to meet the individual's
needs, the provider must submit to the department or its designee a request
for service authorization in accordance with the recommended LOC.
(d)
If the provider determines that the amount of MH case management
services associated with the recommended LOC is not sufficient to meet the
individual's needs, the provider must submit to the department or its designee:
(1)
a request for an authorization of an LOC that is sufficient
to meet the individual's need or a request for authorization of additional
units of service; and
(2)
clinical justification for the request.
(e)
Upon receipt of a request submitted in accordance with
subsection (c) or (d) of this section, the department or its designee will:
(1)
review the documentation submitted by the provider;
(2)
based on the review of documentation and an evaluation
of available resources, authorize or deny an LOC for the individual, and if
authorized, it will authorize the individual to receive either routine or
intensive MH case management services;
(3)
if applicable, authorize or deny a request for additional
units of service; and
(4)
communicate to the individual or LAR, no longer than 7
business days after the determination has been made, whether the service has
been authorized or denied.
§412.407.MH Case Management Services.
(a)
MH case management services assist an individual in gaining
and coordinating access to necessary care and services appropriate to the
individual's needs. There are two types of MH case management services:
(1)
routine MH case management, for an adult, a child, or adolescent,
which is primarily site-based; and
(2)
intensive MH case management, for a child or adolescent,
which is primarily community-based.
(b)
A case manager assigned to an individual who is authorized
to receive routine MH case management services must:
(1)
meet face-to-face with the individual, and the individual's
LAR or primary caregiver if individual is a child or adolescent, within 14
days after the case manager is assigned to the individual in accordance with §412.404(c)
of this title (relating to Provider Requirements), or document why the meeting
did not occur;
(2)
meet face-to-face with the individual upon the request
of the individual, the LAR, or the primary caregiver at the case manager's
work site or document why the meeting did not occur;
(3)
assist the individual in identifying the individual's immediate
need in gaining access to a community resource that may address that need;
(4)
document the identified need and the assistance given to
address the identified need; and
(5)
if notified that the individual is in crisis, coordinate
with the appropriate providers of emergency services to respond to the crisis,
as described in §412.314 of this title (relating to Crisis Services).
(c)
A case manager assigned to an individual who is authorized
to receive intensive MH case management services must:
(1)
meet face-to-face with the individual and the individual's
LAR or primary caregiver within seven days after the case manager is assigned
to the individual or within seven days after discharge from an inpatient psychiatric
setting, whichever is later, or document the reasons the meeting did not occur;
(2)
meet face-to-face with the individual and the individual's
LAR or primary caregiver in accordance with the individual's MH case management
plan or document why the meeting did not occur;
(3)
meet face-to-face with the individual and the individual's
LAR or primary caregiver upon notification of a clinically significant change
in the individual's functioning, life status, or service needs or document
why the meeting did not occur;
(4)
meet face-to-face with the individual and the individual's
LAR or primary caregiver at the request of the individual, the LAR, or primary
caregiver or document why the meeting did not occur;
(5)
gather information about the individual's strengths and
service needs across life domains from relevant sources, including:
(A)
the individual;
(B)
the individual's LAR or primary caregiver;
(C)
other agencies and organizations providing services to
the individual;
(D)
the individual's clinical record; and
(E)
other sources identified by the individual or LAR or primary
caregiver;
(6)
utilize wraparound process planning to develop an MH case
management plan that addresses the individual's unmet needs across life domains
and that includes:
(A)
a prioritized list of the individual's unmet needs which
includes a discussion of the priorities and needs expressed by the individual
and the individual's LAR;
(B)
a description of the objective and measurable outcomes
for each of the unmet needs as well as a projected time frame for each outcome;
(C)
a description of the actions the individual, the case manager,
and other designated people will take to achieve those outcomes;
(D)
a list of the necessary services and service providers
and the availability of the services;
(E)
a description of the MH case management services to be
provided by the case manager; and
(F)
a statement of the maximum period of time between face-to-face
contacts with the individual, and the individual's LAR or primary caregiver,
determined in accordance with the utilization management guidelines;
(7)
assist the individual in gaining access to the needed services
and service providers including:
(A)
making referrals to potential service providers;
(B)
initiating contact with potential service providers;
(C)
arranging, and if necessary to facilitate linkage, accompanying
the individual to initial meetings and non-routine appointments;
(D)
arranging transportation to ensure the individual's attendance;
(E)
advocating with service providers; and
(F)
providing relevant information to service providers;
(8)
monitor the individual's progress toward the outcomes set
forth in the MH case management plan including;
(A)
gathering information from the individual, current service
providers, and other resources;
(B)
reviewing pertinent documentation, including the individual's
clinical records, and assessments;
(C)
ensuring the MH case management plan was implemented as
agreed upon;
(D)
ensuring needed services were provided;
(E)
determining if progress toward the desired outcomes was
made;
(F)
identifying barriers to accessing services or to obtaining
maximum benefit from services;
(G)
advocating for the modification of services to address
changes in the needs or status of the individual;
(H)
identifying emerging unmet service needs;
(I)
determining if the MH case management plan needs to be
modified to address the individual's unmet service needs more adequately;
and
(J)
revising the MH case management plan as necessary to address
the individual's unmet service needs;
(9)
upon notification that the individual is in crisis, coordinate
with the appropriate providers of emergency services to respond to the crisis,
as described in §412.314 of this title; and
(10)
recognize that the LAR is authorized to act on behalf
of the child or adolescent.
(d)
A case manager must notify an individual in writing of
the process for making a complaint to the client rights officers of the provider
and the department if the individual expresses dissatisfaction with:
(1)
scheduling meetings with the case manager; or
(2)
his or her MH case management plan or the treatment planning
process.
§412.408.Service Limitations.
(a)
A case manager may not provide MH case management services
to his or her child, parent, spouse, mother-in-law, father-in-law, son-in-law,
daughter-in-law, stepchild, stepparent, grandchild, or sibling.
(b)
Activities that do not constitute MH case management services
are identified in the department's MH Case Management Services Billing Guidelines,
referenced in §412.415(3) of this title (relating to Guidelines).
§412.412.Documentation of MH Case Management Services.
(a)
A case manager must document the provision of MH case management
services, as well as attempts to provide MH case management services, as follows:
(1)
if the service involves face-to-face contact with the individual,
document:
(A)
the date of the contact;
(B)
start and stop time of the contact;
(C)
a description of the MH case management service provided;
(D)
the individual's response to the services being provided;
(E)
if the individual is receiving intensive MH case management
services, the progress or lack of progress in addressing the individual's
outcomes as identified in the MH case management plan; and
(F)
the case manager's signature and credentials of QMHP-CS
or CSSP;
(2)
if the service does not involve face-to-face contact with
the individual, document:
(A)
the date(s) of the contact;
(B)
a description of the MH case management service provided;
(C)
the case manager's signature and credentials of QMHP-CS
or CSSP;
(3)
if the service involves face-to-face or telephone contact
with someone other than the individual, document:
(A)
the date of the contact;
(B)
the person with whom the contact was made;
(C)
a description of the MH Case management service provided;
(D)
the outcome of the service; and
(E)
the case manager's signature and credentials of QMHP-CS
or CSSP.
(4)
A case manager must document referrals made and the disposition
of each referral.
(b)
The provider must retain documentation in compliance with
applicable federal and state laws, rules, and regulations.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of
the Secretary of State on July 28, 2006.
TRD-200603977
Cathy Campbell
General Counsel
Department of State Health Services
Effective date: September 1, 2006
Proposal publication date: April 14, 2006
For further information, please call: (512) 458-7111 x6972
The Executive Commissioner of the Health and Human Services Commission
(commission), on behalf of the Department of State Health Services (department),
adopts amendments to §§419.451 - 419.459 and 419.461 - 419.470,
and the repeal of §419.460, concerning Rehabilitative Counseling and
Psychotherapy. The amendments to §§419.453, 419.454, 419.457, 419.465,
and 419.469 are adopted with changes to the proposed text as published in
the April 14, 2006, issue of the
Texas Register
(31
TexReg 3177). The amendments to §§419.451, 419.452, 419.455, 419.456,
419.458, 419.459, 419.461 - 419.464, 419.466 - 419.468, 419.470, and the repeal
of §419.460 are adopted without changes and the sections will not be
republished.
BACKGROUND AND PURPOSE
This subchapter describes requirements for the provision of mental health
rehabilitative services. During the 79th Texas legislative session, the legislature
appropriated funds to restore the general counseling benefit to all Medicaid
recipients, resulting in an amendment to the Medicaid State Plan. Due to the
restoration of the general counseling benefit to all Medicaid recipients,
the adopted amendments and repeal include the repeal of §419.460 of this
title (relating to Rehabilitative Counseling and Psychotherapy), thus removing
the rehabilitative counseling and psychotherapy benefit from the array of
rehabilitative services. This change will avoid any duplication of the service
that could result in double billing by providers.
Amendments include removal of the word "Medicaid" from the title of the
subchapter and from various provisions throughout the affected sections, to
reflect that the subchapter applies to all mental health (MH) rehabilitative
services, not just Medicaid rehabilitative services. In addition, throughout
the rules, all references to the department are changed from the "Texas Department
of Mental Health and Mental Retardation" to the "Department of State Health
Services".
Another change is the addition of skills training and development in a
group modality (as opposed to one-to-one), to reflect the current understanding,
described in recently published scientific literature, that providing this
service in a group modality is effective in treating children and adolescents.
Certain language is moved from §419.455, relating to Eligibility,
to §419.465, relating to Medicaid Reimbursement. These changes more accurately
reflect the fact that, although an individual may meet the basic eligibility
criteria for MH Rehabilitative Services, circumstances sometimes exist in
which those services are not reimbursable under Medicaid. Moving the language
to the section concerning Medicaid reimbursement is intended to clarify this
distinction.
The amendments also require that psychosocial rehabilitative services be
provided by members of a clearly defined therapeutic team, and the role and
function of that team is described. New language is also adopted to better
define and clarify the components of "coordination services," as that term
is used in this subchapter.
Additionally, Government Code, §2001.039, requires that each state
agency review and consider for re-adoption each rule adopted by that agency
pursuant to the Government Code, Chapter 2001 (Administrative Procedure Act).
Sections 419.451-419.470 have been reviewed and the department has determined
that reasons for adopting the sections continue to exist because rules on
this subject are needed with the exception of §419.460, which is being
repealed, as it is no longer necessary.
SECTION-BY-SECTION SUMMARY
Certain grammatical and formatting changes have been made throughout the
rules, as well as removal of the word, "Medicaid," from §§419.451-419.456,
419.458, 419.459, 419.461-419.467, and 419.470. References in §419.453
to the Texas Department of Mental Health and Mental Retardation (TDMHMR),
and in §419.468 to the division of Behavioral Health Services, are changed
to the Department of State Health Services. A reference in §419.470 to
TDMHMR or the applicable council is changed to the State Health Services Council.
In addition to these changes, the following amendments are adopted.
Section 419.453, relating to Definitions, is amended by revising the definition
of the term, "Medicaid provider". A separate definition of the term, "provider",
is added as a newly defined term. Also, within the definition of "MH rehabilitative
services", the term, "psychosocial rehabilitation services", is changed to
"psychosocial rehabilitative services". In addition, the definition of "MH
rehabilitative services" is amended by deleting rehabilitative counseling
and psychotherapy from the list of enumerated services that are within the
array of available rehabilitative services as a result of the restoration
of the general counseling benefit to all Medicaid recipients.
Also in §419.453, the definition of "peer provider" is amended by
changing the requirement that a peer provider has at least one cumulative
year of receiving mental health services "from or through the department"
to a requirement that the person has at least one cumulative year of receiving
mental health services "for a disorder that is treated in the target population
for Texas". This change recognizes that a person may qualify to serve as a
peer provider as a result of receiving mental health services outside of Texas,
as long as they were treated for a disorder that falls within the target population
for Texas. The definition of "peer provider" is also amended by removing the
requirement that the person "has demonstrated competency in the provision
and documentation of Medicaid MH rehabilitative services in accordance with
this subchapter and the Medicaid MH Rehabilitative Services Billing Guidelines".
This requirement is deleted because it would not be realistic to expect that
an individual who is otherwise qualified to serve as a peer provider would
be in a position to demonstrate such competence without having first served
as a peer provider or in some other capacity as a provider of MH rehabilitative
services. Such a requirement would in most, if not all, instances prevent
an individual from ever qualifying to serve as a peer provider.
Amendments to §419.455, relating to Eligibility, include the renumbering
of paragraph (1) of this section and the deletion of text which is moved to §419.465
of this title (relating to Medicaid Reimbursement) to more accurately refer
to the availability of Medicaid reimbursement rather than to eligibility for
the service.
Amendments to §419.456, relating to Service Authorization and Treatment
Plan, include the addition of language in subsection (b)(1)(B) of that section,
to require that the medical necessity of crisis intervention services be documented.
Also, subsection (d)(2) is amended by adding language to require that, at
the time a treatment plan is reviewed, the provider must solicit input from
the individual, or from the legally authorized representative (LAR) or primary
caregiver of a child or adolescent, regarding the services received to date
and whether the services received have led to improvement and/or if there
are other services to address unmet needs. This new language replaces language
currently in the rule, which is less specific and requires only that input
be solicited regarding satisfaction with the services provided. The new language
recognizes that while there may be satisfaction with a particular service,
it does not mean that the individual or the individual's LAR or primary caregiver
believes that the individual's needs have been fully met.
Section 419.457, relating to Crisis Intervention Services, is amended to
clarify that the rehabilitative counseling and psychotherapy benefit has been
removed from the array of rehabilitative services. The publication of proposed
amendments reflected the intent to delete subsection (a)(6) in order to avoid
confusion. As discussed under the "comments" section of this preamble, department
staff determined that the potential for confusion could be eliminated by changing
the word "guidance", which was thought to imply counseling, rather than deleting
the entire subsection.
Section 419.458, relating to Medication Training and Support Services,
is amended by the addition of language clarifying that medication training
and support services consists of instruction and guidance based on curricula
promulgated by the department, including the patient/family education program
guidelines referenced in §419.468(3) of this title (relating to Guidelines).
Amendments to §419.459 include changing the name of the title to Psychosocial
Rehabilitative Services, and changing all references to psychosocial rehabilitation
services to psychosocial rehabilitative services. In addition, subsection
(b)(1) is amended to require that psychosocial rehabilitative services must
be provided by members of a clearly defined therapeutic team, and the role
and function of that team is described. Subsection (b)(3) is also amended
to require that the therapeutic team be constituted and organized in a manner
that ensures that "every member of the team is knowledgeable of the needs
and of the services available to the specific individuals assigned to the
team". Finally, amendments to subsection (c)(2) more fully describe and clarify
the components of "coordination services", as that term is used in this subchapter.
Section 419.460, relating to Rehabilitative Counseling and Psychotherapy,
is repealed because the general rehabilitative counseling and psychotherapy
service was restored as a benefit to Medicaid recipients, effective December
1, 2005.
Amendments to §419.461, relating to Skills Training and Development
Services, include the deletion of subsection (b)(3) and (4) of this section,
which now allows providers to provide skills training and development to a
child or adolescent in a group setting. The section is also amended by the
addition of language indicating that skills training and development services
may be provided to an adult, child, adolescent, LAR, or primary caregiver
of a child or adolescent. The section is also amended by the deletion of subsection
(b)(9) of this section, which requires that skills training and development
services provided to an LAR or primary caregiver of a child or adolescent
must be provided by either a qualified mental health professional-community
service (QMHP-CS) or a community services specialist (CSSP).
Section 419.462, relating to Day Programs for Acute Needs, is amended to
include the addition of a new component of symptom management training, which
involves providing assistance and training to individuals in recognizing and
reducing their symptoms. The new component involves training in ways to avoid
symptomatic episodes.
Section 419.463(a)(7), relating to Documentation Requirements, is amended
to remove the reference to LPHA because the service that required an LPHA,
Rehabilitative Counseling and Psychotherapy, has been removed.
Adopted amendments to §419.464, relating to Staff Member Training,
include the addition of language to subsection (a)(2)(B) of this section,
clarifying that staff must be trained on skills training curricula that has
been reviewed and approved by the department.
Amendments to §419.465, relating to Medicaid Reimbursement, clarify
that a provider may only bill for medically necessary services to Medicaid-eligible
individuals, and further clarify that with the exception of crisis intervention
services and psychosocial rehabilitative services provided in a crisis situation,
the department will not reimburse a Medicaid provider for any combination
of MH rehabilitative services delivered in excess of 8 hours per individual
per day. The amended rule clarifies that crisis services must be provided
to the individual until the crisis is resolved. The section is also amended
by the addition of language that is being deleted from §419.455 of this
title (relating to Eligibility), as it more accurately refers to the availability
of Medicaid reimbursement than to eligibility for the services.
Section 419.468 is renamed as "Guidelines". In addition, the text of the
rule is amended by changing references to "exhibits" to "guidelines", and
by correcting the department's address for purposes of obtaining copies of
any of the guidelines.
Section 419.469, relating to References, is amended by making corrections
and additions to the rules referenced in the subchapter.
Section 419.470, relating to Distribution, includes the addition of language
requiring distribution of this subchapter to the members of the State Health
Services Council, and also requiring it be made available by the chief executive
officer of each provider to all staff members who deliver MH rehabilitative
services.
COMMENTS
The department, on behalf of the commission, has reviewed and prepared
responses to the comments received regarding the proposed rules during the
comment period, which the commission has reviewed and accepts. The commenters
were individuals, associations, and/or groups, including Advocacy, Inc., Central
Counties Center for MHMR, and MHMR of Tarrant County. The commenters generally
supported the rules, but some implicitly or explicitly suggested changes as
discussed in the summary of comments.
Comment: Concerning §419.456, one commenter expressed support for
consumers having a say in their treatment, and that "treatment planning should
be directed by consumer need and choice".
Response: The commission agrees that consumers should have a say in their
treatment, and notes that §419.456(a)(1)(B) specifically requires treatment
plans be developed in collaboration with the person receiving the services.
No change was made to the rule as a result of this comment.
Comment: Concerning §419.458, one commenter noted that the rule requires
rehabilitative Medication Training and Support Services to be based on curricula
promulgated by the department or other departmentally approved materials.
The commenter asked where instructions on assisting an individual in learning
self-administration of medication are found in these materials.
Response: The commission notes that materials related to this question
can be found in Session III of the education groups set forth in the Peer
Facilitator Guide at the following URL: www.dshs.state.tx.us/mhprograms/PtEd.shtm.
No change was made to the rule as a result of this comment.
Comment: Concerning §419.459(c)(2), one commenter requested clarification
of how "coordination services" differs from Intensive Case Management, as
described in 25 TAC, §412.407(c).
Response: The commission disagrees that the terms need further clarification
in the rules and points out that "coordination services", referenced in §419.459(c)(2),
are a component service of Psychosocial Rehabilitation. As such, the rehabilitative
"coordination services" have as their principle focus assisting the service
recipient in learning the skills required to coordinate services for him or
herself. In contrast, Intensive Case Management, as set forth in 25 TAC, §412.407(c),
is not a rehabilitative service and does not have a focus on the development
of skills and abilities. Intensive case management is intended to ensure that
recipients are effectively linked to services that are appropriate to the
individual's needs. No change was made to the rule as a result of this comment.
Comment: Concerning the rules in general, one commenter generally noted
that there is nothing in the Mental Health Rehabilitative Services rules that
specifies the services to be provided to children and adolescents, and suggested
that such services needed to be defined in the rules. The commenter indicated
that the state is obligated to provide Medicaid eligible children with all
medically necessary covered services determined necessary to treat their medical
condition. The commenter stated that all medically necessary services for
children that are listed in the department's Resiliency and Disease Management
packages for children and adolescents should be set forth in the rule.
Response: The commission disagrees with the commenter, noting that the
purpose of the rule subchapter is to describe the requirements for the provision
of mental health rehabilitative services provided by entities that contract
with the department. For each type of service described, the rules specify
which services are considered to be clinically appropriate for adults, children
and adolescents. A complete listing of all services that may be determined
medically necessary and, therefore, available to Medicaid-eligible children
and adolescents goes beyond the scope and purpose of this rule subchapter.
No changes were made to the rules as a result of this comment.
Comment: Concerning the rules in general, one commenter generally noted
about the rules in the subchapter that peer supports have resulted in positive
outcomes and recommended the continuation of peer support and consumer driven
services.
Response: The commission agrees with the commenter and points out that
the rules maintain the option for the delivery of certain services by peer
providers and also broaden the definition of peer provider in such a way as
to allow individuals who have received services in other systems of care to
also be included. No changes were made to the rules as a result of this comment.
Comment: Concerning the rules in general, one commenter stated that the
changes to the rules are positive and will provide the opportunity for more
cost-effective recovery opportunities for consumers. The commenter also noted
that these changes will increase consumer choice and allow more consumers
to be served.
Response: The commission agrees with the commenter and notes that these
services were specifically developed with a view toward maximizing recovery
and improving the efficiency of service delivery. No changes were made to
the rules as a result of this comment.
The following changes were made as a result of comments from department
staff to provide greater clarity to the rules.
Change: Concerning §419.453(16), language is added to clarify that
the size of groups comprised of LARs and/or primary caregivers are limited
to the same numbers as groups for children and adolescents.
Change: Concerning §419.453(39), language is added to clarify that
Medicaid providers are also included within the definition.
Change: Concerning §419.453(43), deletion of the term "Medicaid" was
inadvertently overlooked in the proposed rules. This term is being deleted
to clarify that the definition of "Staff member" applies to all providers
covered by this subchapter.
Change: Concerning §419.454(a), an error in the subsection's number
of a cross-reference is corrected from §412.304(a)(4) to §412.304(a)(5).
Change: Concerning §419.457(a)(6), the entire subsection was proposed
for deletion in the publication of proposed amendments under the mistaken
belief that it was necessary to be consistent with the deletion of §419.460,
relating to Rehabilitative Counseling and Psychotherapy, and to avoid any
potential for confusion. After further consideration by department staff,
the proposed deletion of this entire subsection is determined to be unnecessary,
because any potential for confusion is remedied simply by changing the word
"guidance" to "instruction".
Change: Concerning §419.465(b)(1), the words "combination of" that
preceded "MH rehabilitative services" are deleted as unnecessary and to add
clarity to the rule.
Change: Concerning §419.465(b)(1)(E), the subparagraph was divided
into two subparagraphs, (E) and a new (F), for clarity.
Change: Concerning §419.469(13), it is amended to reflect the correct
name of the cross-referenced rule.
LEGAL CERTIFICATION
The Department of State Health Services, General Counsel, Cathy Campbell,
certifies that the rules, as adopted, have been reviewed by legal counsel
and found to be a valid exercise of the agencies' legal authority.
Subchapter L. MENTAL HEALTH REHABILITATIVE SERVICES
25 TAC §§419.451 - 419.459, 419.461 - 419.470
STATUTORY AUTHORITY
The adopted amendments are authorized by Health and Safety Code, §534.052,
which requires the adoption of rules necessary and appropriate to ensure the
adequate provision of community based mental health services through a local
mental health authority; Health and Safety Code, §534.053, which requires
the department to ensure that psychosocial rehabilitation programs are available
in each local mental health authority service area; and Government Code, §531.0055,
and Health and Safety Code, §1001.075, which authorize the Executive
Commissioner of the Health and Human Services Commission to adopt rules and
policies necessary for the operation and provision of health and human services
by the department and for the administration of Health and Safety Code, Chapter
1001.
§419.453.Definitions.
The following words and terms, when used in this subchapter, have the
following meanings, unless the context clearly indicates otherwise:
(1)
Adolescent--An individual who is at least 13 years of age,
but younger than 18 years of age.
(2)
Adult--An individual who is 18 years of age or older.
(3)
Advanced practice nurse--A staff member who is a registered
nurse approved by the Texas State Board of Nurse Examiners to practice as
an advanced practice nurse, in accordance with Texas Occupations Code, Chapter
301. The term is synonymous with "advanced nurse practitioner."
(4)
Arrangement--A contract between a provider and a person
or entity for the provision of MH rehabilitative services.
(5)
Authorization period--The duration for which the provider
has obtained authorization in accordance with §419.456(a) of this title
(relating to Service Authorization and Treatment Plan).
(6)
Business day--Any day except a Saturday, Sunday, or legal
holiday listed in Texas Government Code, §662.021.
(7)
CFR--The Code of Federal Regulations.
(8)
Child--An individual who is at least three years of age,
but younger than 13 years of age.
(9)
Crisis--A situation in which:
(A)
because of a mental health condition:
(i)
an individual presents an immediate danger to self or others;
or
(ii)
an individual's mental or physical health is at risk of
serious deterioration; or
(B)
an individual believes that he or she presents an immediate
danger to self or others or that his or her mental or physical health is at
risk of serious deterioration.
(10)
CSSP or community services specialist--A staff member
who, as of August 30, 2004:
(A)
has received:
(i)
a high school diploma; or
(ii)
a high school equivalency certificate issued in accordance
with the law of the issuing state;
(B)
has had three continuous years of documented full-time
experience in the provision of MH rehabilitative services; and
(C)
has demonstrated competency in the provision and documentation
of MH rehabilitative services in accordance with this subchapter and the MH
Rehabilitative Services Billing Guidelines.
(11)
CSU or crisis stabilization unit--A crisis stabilization
unit licensed under Chapter 577, of the Texas Health and Safety Code and Chapter
134 of this title (relating to Private Psychiatric Hospitals and Crisis Stabilization
Units).
(12)
Day--Calendar day, unless otherwise specified.
(13)
Department--Department of State Health Services.
(14)
Direct clinical supervision--An LPHA's interaction with
a peer provider to ensure that MH rehabilitative services provided by the
peer provider are clinically appropriate and in compliance with this subchapter
by:
(A)
conducting a documented face-to-face meeting with the peer
provider at regularly scheduled intervals; and
(B)
conducting, at least monthly, a documented face-to-face
observation of the peer provider providing MH rehabilitative services.
(15)
Face-to-face--Within the physical presence of another
person.
(16)
Group--A service delivery modality involving two to eight
individuals (for adults), or two to six individuals (for children and adolescents
or their legally authorized representatives (LARs) or primary caregivers),
and at least one staff member.
(17)
IMD or institution for mental diseases--Based on 42 CFR §435.1009,
a hospital, nursing facility, or other institution of more than 16 beds that
is primarily engaged in providing diagnosis, treatment, or care of individuals
with mental illness, including medical attention, nursing care, and related
services.
(18)
Individual--A person seeking or receiving MH rehabilitative
services.
(19)
In-vivo--The individual's natural environment (e.g., the
individual's residence, work place, or school).
(20)
LAR or legally authorized representative--A person authorized
by law to act on behalf of a child or adolescent with regard to a matter described
in this subchapter, and who may be a parent, guardian, or managing conservator.
(21)
Licensed marriage and family therapist--An individual
who is licensed as a licensed marriage and family therapist by the Texas State
Board of Examiners of Marriage and Family Therapists in accordance with Texas
Occupations Code, Chapter 502.
(22)
Licensed medical personnel--A staff member who is:
(A)
a physician;
(B)
a physician assistant;
(C)
an RN;
(D)
an LVN; or
(E)
a pharmacist.
(23)
Licensed professional counselor--A person who is licensed
as a licensed professional counselor by the Texas State Board of Examiners
of Professional Counselors in accordance with Texas Occupations Code, Chapter
503.
(24)
LOC or level of care--A designation given to the department's
standardized packages of MH rehabilitative services, based on the uniform
assessment and utilization management guidelines referenced in §419.468
of this title (relating to Guidelines), which specify the type, amount, and
duration of MH rehabilitative services to be provided to an individual.
(25)
LPHA or licensed practitioner of the healing arts--A staff
member who is:
(A)
a physician;
(B)
a licensed professional counselor;
(C)
a licensed clinical social worker (formally a licensed
master social worker-advanced clinical practitioner) as determined by the
Texas State Board of Social Work Examiners in accordance with Texas Occupations
Code, Chapter 505;
(D)
a psychologist;
(E)
an advanced practice nurse recognized by the Board of Nurse
Examiners for the State of Texas as a clinical nurse specialist in psych/mental
health or nurse practitioner in psych/mental health; or
(F)
a licensed marriage and family therapist.
(26)
LVN or vocational nurse--A person who is licensed as a
vocational nurse by the Texas Board of Nurse Examiners in accordance with
Texas Occupations Code, Chapter 301 or, prior to February 1, 2004, was licensed
as a licensed vocational nurse by the Texas Board of Nurse Examiners in accordance
with Texas Occupations Code, Chapter 302, and whose license has not yet expired.
(27)
Master's level professional--A staff member who has completed
a master's degree that is a prerequisite for licensure as one of the professionals
listed in the definition of LPHA and is actively pursuing such licensure.
(28)
Mental health (MH) rehabilitative services--Services that:
(A)
are individualized age-appropriate training and instructional
guidance that address an individual's functional deficits due to severe and
persistent mental illness or serious emotional disturbance;
(B)
are designed to improve or maintain the individual's ability
to remain in the community as a fully integrated and functioning member of
that community; and
(C)
consist of the following services:
(i)
crisis intervention services;
(ii)
medication training and support services;
(iii)
psychosocial rehabilitative services which consist of
the following component services:
(I)
independent living services;
(II)
coordination services;
(III)
employment related services;
(IV)
housing related services;
(V)
medication related services; and
(VI)
crisis related services;
(iv)
skills training and development services; and
(v)
day programs for acute needs which consist of the following
component services;
(I)
psychiatric nursing services;
(II)
pharmacological instruction;
(III)
symptom management training; and
(IV)
functional skills training.
(29)
Medicaid provider--A Medicaid-enrolled provider with which
the department has a Medicaid provider agreement to provide MH rehabilitative
services under the State's Medicaid Program.
(30)
Medical necessity--The need for a service that:
(A)
is reasonable and necessary for the diagnosis or treatment
of a mental health disorder or a mental health and substance use disorder
in order to improve or maintain an individual's level of functioning;
(B)
is in accordance with professionally accepted clinical
guidelines and standards of practice in behavioral health care;
(C)
is furnished in the most appropriate and least restrictive
setting in which the service can be safely provided;
(D)
is provided at a level that is safe and appropriate for
the individual's needs and facilitates the individual's recovery; and
(E)
could not be omitted without adversely affecting the individual's
mental or physical health or the quality of care rendered.
(31)
Nursing services--Services provided or delegated by an
RN acting within the scope of his or her practice, as described in Texas Occupations
Code, Chapter 301.
(32)
On-site--A location operated by a provider or a person
or entity under arrangement with the provider at which MH rehabilitative services
are provided, such as a clinic, clubhouse, or office.
(33)
Peer provider--A staff member who:
(A)
has received:
(i)
a high school diploma; or
(ii)
a high school equivalency certificate issued in accordance
with the law of the issuing state;
(B)
has at least one cumulative year of receiving mental health
services for a disorder that is treated in the target population for Texas;
and
(C)
is under the direct clinical supervision of an LPHA.
(34)
Pharmacist--A person who is licensed as a pharmacist by
the Texas State Board of Pharmacy in accordance with Texas Occupations Code,
Chapter 558.
(35)
Physician--A staff member who is:
(A)
licensed as a physician by the Texas State Board of Medical
Examiners in accordance with Texas Occupations Code, Chapter 155 (medical
doctor or doctor of osteopathy); or
(B)
authorized to perform medical acts under an institutional
permit at a Texas postgraduate training program approved by the Accreditation
Council on Graduate Medical Education, the American Osteopathic Association,
or the Texas State Board of Medical Examiners.
(36)
Physician assistant--A person who is licensed as a physician
assistant by the Texas State Board of Physician Assistant Examiners in accordance
with Texas Occupations Code, Chapter 204.
(37)
Primary caregiver--A person 18 years of age or older who
has actual care, control, and possession of a child or adolescent.
(38)
Problem-solving--The use of specific steps and strategies
to analyze and evaluate a problematic situation in order to determine a course
of action to resolve the problematic situation.
(39)
Provider--An entity with which the department has a contractual
agreement for the provision of MH Rehabilitative Services, including a Medicaid
provider.
(40)
Psychologist--A person who is licensed as a psychologist
by the Texas State Board of Examiners of Psychologists in accordance with
Texas Occupations Code, Chapter 501.
(41)
QMHP-CS or qualified mental health professional-community
services--A staff member who meets the definition of a QMHP-CS set forth in
Chapter 412, Subchapter G of this title (relating to Mental Health Community
Services Standards).
(42)
RN or registered nurse--A staff member who is licensed
as a registered nurse by the Texas State Board of Nurse Examiners in accordance
with Texas Occupations Code, Chapter 301.
(43)
Staff member--Personnel of a provider including a full-time
and part-time employee, contractor, intern, and a volunteer.
(44)
Therapeutic team--A group of staff members who work together
in a coordinated manner for the purpose of providing comprehensive mental
health services to an individual.
(45)
Uniform assessment--An assessment tool adopted by the
department that includes the Adult Texas Recommended Assessment Guidelines,
the Texas Implementation of Medication Algorithms Scales for Adults, and the
Children and Adolescent Texas Recommended Assessment Guidelines.
(46)
Utilization management guidelines--Guidelines developed
by the department that establish the type, amount, and duration of MH rehabilitative
services for each LOC.
§419.454.General Requirements for Providers of MH Rehabilitative Services.
(a)
Compliance with MH community standards. In addition to
complying with this subchapter, a provider must also comply with Chapter 412,
Subchapter G of this title (relating to Mental Health Community Services Standards)
in the provision of MH rehabilitative services, as described in §412.304(a)(5)
and (b)(4) of this title (relating to Responsibility for Compliance).
(b)
Staff supervision and oversight. A provider must develop
policies and procedures for the supervision and oversight of CSSPs and peer
providers.
(c)
Service provision under arrangement.
(1)
A provider may choose to have any MH rehabilitative service
provided by a person or entity under arrangement.
(2)
A provider must ensure that if MH rehabilitative services
are provided under arrangement, then the person or entity delivering the MH
rehabilitative services under arrangement complies with all applicable federal
and state laws, rules, and regulations, and any provider manuals and policy
clarification letters promulgated by the department.
(d)
Prohibitions against discrimination and retaliation.
(1)
A provider may not discriminate against an individual based
on race, color, national origin, religion, sex, age, disability, co-occurring
disorder or political affiliation. A provider may not deny MH rehabilitative
services to an individual based on sexual orientation.
(2)
A provider must ensure that an individual's refusal of
any service offered by the provider does not preclude the individual from
accessing a needed MH rehabilitative service.
§419.457.Crisis Intervention Services.
(a)
Description. Crisis intervention services are interventions
provided in response to a crisis in order to reduce symptoms of severe and
persistent mental illness or serious emotional disturbance and to prevent
admission of an individual to a more restrictive environment. Crisis intervention
services include:
(1)
an assessment of dangerousness of the individual to self
or others;
(2)
the coordination of emergency care services in accordance
with §412.314 of this title (relating to Crisis Services);
(3)
behavior skills training to assist the individual in reducing
stress and managing symptoms;
(4)
problem-solving;
(5)
reality orientation to help the individual identify and
manage their symptoms of mental illness; and
(6)
providing instruction and structure to the individual in
adapting to and coping with stressors.
(b)
Conditions.
(1)
Crisis intervention services may be provided to:
(A)
an adult; or
(B)
a child or adolescent.
(2)
Crisis intervention services must be provided one-to-one.
(3)
Crisis intervention services may be provided:
(A)
on-site; or
(B)
in-vivo.
(4)
Crisis intervention services must be provided by a QMHP-CS.
(5)
Crisis intervention services may not be provided to an
individual who is currently admitted to a CSU.
(6)
Crisis intervention services may be provided to an individual
without first obtaining authorization from the department or its designee
in accordance with §419.456 of this title (relating to Service Authorization
and Treatment Plan).
(7)
Crisis intervention services may be provided without a
treatment plan described in §419.456(b) of this title.
§419.465.Medicaid Reimbursement.
(a)
Billable and non-billable activities.
(1)
A Medicaid provider may only bill for medically necessary
MH rehabilitative services that are provided face-to-face to:
(A)
a Medicaid-eligible individual; or
(B)
the LAR or primary caregiver of a Medicaid-eligible child
or adolescent.
(2)
The cost of the following activities are included in the
Medicaid MH rehabilitative services reimbursement rate(s) and may not be directly
billed by the Medicaid provider:
(A)
developing and revising the treatment plan and interventions
that are appropriate to an individual's needs;
(B)
staffing and team meetings to discuss the provision of
MH rehabilitative services to a specific individual;
(C)
monitoring and evaluating outcomes of interventions, including
contacts with a person other than the individual;
(D)
documenting the provision of MH rehabilitative services;
(E)
a staff member traveling to and from a location to provide
MH rehabilitative services;
(F)
all services provided within a day program for acute needs
that are delivered by a staff member, including services delivered in response
to a crisis or an episode of acute psychiatric symptoms; and
(G)
administering the uniform assessment to individuals who
are receiving psychosocial rehabilitative services.
(b)
Non-reimbursable activities.
(1)
The department will not reimburse a Medicaid provider for
any MH rehabilitative services provided to an individual who is:
(A)
a resident of an intermediate care facility for persons
with mental retardation as described in 42 CFR §440.150;
(B)
a resident in an IMD;
(C)
an inmate of a public institution as defined in 42 CFR §435.1009;
(D)
a resident in a Medicaid-certified nursing facility unless
the individual has been determined through a pre-admission screening and annual
resident review assessment to be eligible for the specialized service of MH
rehabilitative services;
(E)
a patient in a general medical hospital; or
(F)
not Medicaid-eligible.
(2)
With the exception of crisis intervention services and
psychosocial rehabilitative services that are being provided in a crisis situation,
the department will not reimburse a Medicaid provider for any combination
of MH rehabilitative services delivered in excess of 8 hours per individual
per day. In addition, the department will not reimburse a Medicaid provider
for more than:
(A)
two hours per individual per day of medication training
and support services;
(B)
four hours per individual per day of psychosocial rehabilitative
services when the psychosocial rehabilitative services are being provided
in non-crisis situations;
(C)
four hours per individual per day of skills training and
development services;
(D)
six hours per individual per day of day programs for acute
needs; and
(E)
crisis services should be provided until resolution of
the crisis.
(3)
The department will not reimburse a Medicaid provider for:
(A)
a MH rehabilitative service that is not included in the
individual's treatment plan (except for crisis intervention services documented
in accordance with §419.456(b) of this title (relating to Service Authorization
and Treatment Plan) and psychosocial rehabilitative services provided in a
crisis situation;
(B)
a MH rehabilitative service that is not authorized in accordance
with §419.456 of this title (except for crisis intervention services
documented in accordance with §419.456(b) of this title);
(C)
a MH rehabilitative service provided in excess of the amount
authorized in accordance with §419.456(a)(1) of this title;
(D)
a MH rehabilitative service provided outside of the duration
authorized in accordance with §419.456(b) of this title;
(E)
a psychosocial rehabilitative service provided to an individual
receiving MH case management services in accordance with Chapter 412, Subchapter
I of this title (relating to Mental Health Case Management Services);
(F)
a MH rehabilitative service that is not documented in accordance
with §419.462 of this title (relating to Documentation Requirements);
(G)
a MH rehabilitative service provided to an individual who
does not meet the eligibility criteria as described in §419.455 of this
title (relating to Eligibility);
(H)
a MH rehabilitative service provided to an individual who
does not have a current uniform assessment (except for crisis intervention
services documented in accordance with §419.456(b) of this title);
(I)
a MH rehabilitative service provided to an individual who
is not present, awake, and participating during such service; and
(J)
any other activity or service identified as non-reimbursable
in the department's MH Rehabilitative Services Billing Guidelines, referenced
in §419.468 of this title (relating to Guidelines).
(c)
Services provided same time and same day.
(1)
If a Medicaid provider provides more than one MH rehabilitative
service to an individual at the same time and on the same day, the Medicaid
provider may bill for only one of the services provided.
(2)
A Medicaid provider may bill for a MH rehabilitative service
provided to a child or adolescent's LAR or primary caregiver at the same time
and on the same day the child or adolescent is receiving another MH rehabilitative
service only if the staff member providing the service to the LAR or primary
caregiver is different from the staff member providing the service to the
child or adolescent.
(d)
Services provided before a fair hearing. If the provision
of a MH rehabilitative service is continued prior to a fair hearing decision
being rendered, as required by Texas Administrative Code, Title 1, §357.7
(relating to Maintaining Benefits or Services), the Medicaid provider may
bill for such service.
§419.469.References.
The following laws and rules are referenced in this subchapter:
(1)
Texas Administrative Code, Title 1, Chapter 357 (relating
to Medical Fair Hearings);
(2)
Texas Administrative Code, Title 1, §357.7 (relating
to Maintaining Benefits or Services);
(3)
Texas Health and Safety Code, Chapters 573, 574, and 577;
and §§534.001 and 534.053(a)(1)-(7);
(4)
Texas Code of Criminal Procedure, Article 17.032 and Article
42.12, §11(d);
(5)
Texas Government Code, §662.021;
(6)
Texas Occupations Code, Chapters 155, 204, 301, 302, 501,
502, 503, 505, and 558;
(7)
42 CFR, §435.1009 and §440.150;
(8)
Chapter 134 of this title (relating to Private Psychiatric
Hospitals and Crisis Stabilization Units);
(9)
Chapter 404, Subchapter E of this title (relating to Rights
of Persons Receiving Mental Health Services);
(10)
Chapter 411, Subchapter N of this title (relating to Standards
for Services to Individuals with Co-Occurring Psychiatric and Substance Use
Disorders (COPSD));
(11)
Chapter 412, Subchapter G of this title (relating to Mental
Health Community Services Standards);
(12)
Section 412.314 of this title (relating to Crisis Services);
(13)
Section 412.315 of this title (relating to Assessment
and Treatment Planning);
(14)
Chapter 412, Subchapter I of this title (relating to Mental
Health Case Management Services);
(15)
Chapter 414, Subchapter L of this title (relating to Abuse,
Neglect, and Exploitation in Local Authorities and Community Centers); and
(16)
Section 414.504(g) of this title (relating to Pre-employment
and Pre-assignment Clearance).
This agency hereby certifies that the adoption has been
reviewed by legal counsel and found to be a valid exercise of the agency's
legal authority.
Filed with the Office of
the Secretary of State on July 28, 2006.
TRD-200603978
Cathy Campbell
General Counsel
Department of State Health Services
Effective date: September 1, 2006
Proposal publication date: April 14, 2006
For further information, please call: (512) 458-7111 x6972
25 TAC §419.460
STATUTORY AUTHORITY
The adopted repeal is authorized by Health and Safety Code, §534.052,
which requires the adoption of rules necessary and appropriate to ensure the
adequate provision of community based mental health services through a local
mental health authority; Health and Safety Code, §534.053, which requires
the department to ensure that psychosocial rehabilitation programs are available
in each local mental health authority service area; and Government Code, §531.0055,
and Health and Safety Code, §1001.075, which authorize the Executive
Commissioner of the Health and Human Services Commission to adopt rules and
policies necessary for the operation and provision of health and human services
by the department and for the administration of Health and Safety Code, Chapter
1001.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed
with the Office of the Secretary of State on July 28, 2006.
TRD-200603979
Cathy Campbell
General Counsel
Department of State Health Services
Effective date: September 1, 2006
Proposal publication date: April 14, 2006
For further information, please call: (512) 458-7111 x6972
Chapter 571.
HEALTH PLANNING AND RESOURCE DEVELOPMENT
Subchapter B. HEALTH INFORMATION TECHNOLOGY ADVISORY COMMITTEE
Chapter 419.
MENTAL HEALTH SERVICES--MEDICAID STATE OPERATING AGENCY RESPONSIBILITIES
Subchapter L. MEDICAID MENTAL HEALTH REHABILITATIVE SERVICES
Part 6.
STATEWIDE HEALTH COORDINATING COUNCIL