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Oregon Bulletin

July 1, 2013

Oregon Health Authority, Addictions and Mental Health Division: Mental Health Services, Chapter 309

Rule Caption: Standards For The Approval of Providers of Non-Inpatient Mental Health Treatment Services

Adm. Order No.: MHS 4-2013

Filed with Sec. of State: 6-5-2013

Certified to be Effective: 6-5-13

Notice Publication Date: 5-1-2013

Rules Repealed: 309-039-0700, 309-039-0710, 309-039-0720, 309-039-0730, 309-039-0740, 309-039-0750, 309-039-0760, 309-039-0770, 309-039-0780, 309-039-0790

Subject: These rules prescribe standards and procedures for implementation of a registration pilot project in Jackson and Josephine counties. This pilot project has ended and these rules need to be repealed.

Rules Coordinator: Nola Russell—(503) 945-7652


 

Rule Caption: Permanent amendments to OAR 309-016 entitled Medicaid Payment For Rehabilitative Mental Health Services.

Adm. Order No.: MHS 5-2013

Filed with Sec. of State: 6-5-2013

Certified to be Effective: 6-5-13

Notice Publication Date: 5-1-2013

Rules Adopted: 309-016-0825, 309-016-0830, 309-016-0835, 309-016-0837, 309-016-0840, 309-016-0845, 309-016-0850, 309-016-0855

Rules Amended: 309-016-0605

Rules Repealed: 309-016-0825(T)

Subject: These rules specify standards for authorized appropriate reimbursement of Medicaid or State Children’s Health Plan funded addictions and mental health services and supports. The requirements set forth here in OAR 309-016 must be met in order for Medicaid payment to have been made appropriately.

Rules Coordinator: Nola Russell—(503) 945-7652

309-016-0605

Definitions

(1) “Action” means:

(a) The denial, limitation or restriction of a requested covered services including the type or level of service;

(b) The reduction, suspension or termination of a previously authorized service; or

(c) The failure to provide services in a timely manner, as defined by the Addictions and Mental Health Division of the Oregon Health Authority.

(2) “Active Treatment” means a service provided as prescribed in a professionally developed and supervised Individual Services and Supports Plan to address or improve a condition.

(3) “Addictions and Mental Health Division” means the Division of the Oregon Health Authority responsible for the administration of addictions and mental health services provided in Oregon or to its residents.

(4) “Allowable Cost” means the cost of treatment services based on cost finding principles found in the appropriate OMB Circular such as “Cost Principles for Non-Profit Organization” (OMB Circular A-122) or “Cost Principles for State, Local, and Indian Tribal Governments” (OMB Circular A-87) and including allowable costs incurred for interest on the acquisition of buildings and improvements thereon.

(5) “Appeal” means a request by an Individual or their representative to review an Action as defined in this rule.

(6) “Assertive Community Treatment” (ACT) means an evidence-based practice which utilizes a highly integrated, trans-disciplinary team to deliver comprehensive and effective services to individuals with serious mental illness who have needs that have not been well met by traditional approaches to delivering services.

(7) “Certificate of Approval” means the document awarded by the Division signifying that a specific, named organization is judged by the Division to operate in compliance with applicable rules. A “Certificate of Approval” for mental health services is valid only when signed by the Deputy Director of the Division of Mental Health Services and, in the case of a subcontract provider of a CMHP, the CMHP director.

(8) “Certification of Need” means the procedures established by the Division to certify in writing a child’s need for psychiatric residential treatment services.

(9) “Child” or “Children” means a person under the age of 18. An individual with Medicaid eligibility, who is in need of services specific to children, adolescents, or young adults in transition, will be considered a child until age 21 for purposes of these rules.

(10) “Children, Adults and Families” (CAF) means the Division serving as Oregon’s child welfare agency.

(11) “Clean Claim(s)” means a claim that can be processed without obtaining additional information from the provider of the service or from a third party. It includes a claim with errors originating in the State’s claims system. It does not include a claim from a provider who is under investigation for fraud or abuse, or a claim under review for medical necessity.

(12) “Commission on Accreditation of Rehabilitation” (CARF) means an organization that accredits behavioral health care and community providers based on the current edition of the “CARF Behavioral Health” standards manual.

(13) “Community Mental Health Program” (CMHP) means an entity that is responsible for planning and delivery of services for persons with substance use disorders, mental health diagnosis, or developmental disabilities, operated in a specific geographic area of the state under an intergovernmental agreement or direct contract with the Division.

(14) “Complaint” means an expression of dissatisfaction from an Individual or their representative to a Practitioner or Provider about any matter other than an Action.

(15) “Council on Accreditation of Services for Families and Children Facilities” (COA) means an organization that accredits behavioral health care and social service programs based on the current edition of the COA “Standards for Behavioral Health Care Services and Community Support and Education Services Manual.”

(16) “Disabling Mental Illness” means a mental illness that substantially limits functioning in one or more major life activity.

(17) “Division” means the Addictions and Mental Health Division of the Oregon Health Authority.

(18) “Division of Medical Assistance Programs” (DMAP) means the Division of the Oregon Health Authority responsible for coordinating the medical assistance programs within the State of Oregon including the Oregon Health Plan (OHP) Medicaid demonstration, the State Children’s Health Insurance Program (SCHIP -Title XXI), and several other programs.

(19) “DMAP/AMH” means the Division of Medical Assistance or Addictions and Mental Health Division. Both DMAP and AMH have delegated responsibilities for the administration of Medicaid funded addictions and mental health services and supports. A lead agency will be identified to each entity involved in any process when the delegation of such is necessary.

(20) “Diagnostic and Statistical Manual” (DSM) means the current edition of the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association.

(21) “Fidelity Review” means an on-site assessment utilizing a standardized, reliable, and valid evaluation tool to determine the degree to which an evidence-based practice is being implemented. Fidelity reviews include staff interviews, consumer and family member interviews, observation of service provision, review of program data, and/or chart reviews as necessary for the practice being reviewed.

(22) “Grievance System” means the overall system in which an Individual can express dissatisfaction and that expression acted on if necessary. The Grievance System includes a Complaint process, and Appeals process and access to the Division of Medical Assistance Programs Administrative Hearing process.

(23) “Habilitation Services” means services designed to help an individual attain or maintain their maximal level of independence, including the individual’s acceptance of a current residence and the prevention of unnecessary changes in residence. Services are provided in order to assist an individual to acquire, retain or improve skills in one or more of the following areas: assistance with activities of daily living, cooking, home maintenance, recreation, community inclusion and mobility, money management, shopping, community survival skills, communication, self-help, socialization, and adaptive skills necessary to reside successfully in home and community-based settings.

(24) “Individual” means any person being considered for or receiving services and supports.

(25) “Individual Service and Support Plan” (ISSP) means a comprehensive plan for services and supports provided to or coordinated for an individual and his or her family, as applicable, that is reflective of the assessment and the desired outcomes of service.

(26) “Interdisciplinary Team” means the group of people designated to advise in the planning and provision of services and supports to individuals receiving Intensive Treatment Services (ITS) and Enhanced Care Services (ECS) and may include multiple disciplines or agencies. For ITS programs, the composition of the interdisciplinary team must be consistent with the requirements of 42 CFR Part 441.156.

(27) “Joint Commission, The” (TJC) means the commission which accredits psychiatric residential treatment facilities according to its current edition of the “Comprehensive Accreditation Manual for Hospitals” and the “Comprehensive Accreditation Manual for Behavioral Health Care.”

(28) “Letter of Approval” means the document awarded to service providers under OAR 309-012-0010 which states that the provider is in compliance with applicable administrative rules of the Division. Letters of Approval issued for mental health services are obsolete upon their expiration date, or upon the effective date of 309-012-0140, whichever is later.

(29) “Licensed Medical Practitioner” (LMP) means a person who meets the following minimum qualifications as documented by the LMHA or designee:

(a) Physician licensed to practice in the State of Oregon; or

(b) Nurse practitioner licensed to practice in the State of Oregon; or

(c) Physician’s Assistant licensed to practice in the State of Oregon.

(d) In addition, whose training, experience and competence demonstrate the ability to conduct a mental health assessment and provide medication management.

(e) For ICTS and ITS providers, a “Licensed Medical Practitioner” or “LMP” means a board-certified or board-eligible child and adolescent psychiatrist licensed to practice in the State of Oregon.

(30) “Local Mental Health Authority” (LMHA) means one of the following entities:

(a) The board of county commissioners of one or more counties that establishes or operates a Community Mental Health Program (CMHP);

(b) The tribal council, in the case of a federally recognized tribe of Native Americans that elects to enter into an agreement to provide mental health services; or

(c) A regional local mental health authority comprised of two or more boards of county commissioners.

(31) “Medicaid” means the federal grant-in-aid program to state governments to provide medical assistance to eligible persons, under Title XIX of the Social Security Act.

(32) “Medicaid Management Information System” The mechanized claims processing and information retrieval system that all states are required to have according to section 1903(a)(3) of the Social Security Act and defined in regulation at 42 CFR 433.111. All states operate an MMIS to support Medicaid business functions and maintain information in such areas as provider enrollment; client eligibility, including third party liability; benefit package maintenance; managed care enrollment; claims processing; and prior authorization.

(33) “Medically Appropriate” means services and medical supplies required for prevention, diagnosis or treatment of a physical or mental health condition, or injuries, and which are:

(a) Consistent with the symptoms of a health condition or treatment of a health condition;

(b) Appropriate with regard to standards of good health practice and generally recognized by the relevant scientific community and professional standards of care as effective;

(c) Not solely for the convenience of an individual or a provider of the service or medical supplies; and

(d) The most cost effective of the alternative levels of medical services or medical supplies that can be safely provided to an individual.

(34) “National Provider Identifier” (NPI) means a unique 10-digit identifier mandated by the Administrative Simplification provisions of the federal Health Insurance Portability and Accountability Act (HIPAA) for all healthcare providers that is good for the life of the provider.

(35) “Non-Contiguous Area Provider” means a provider located more than 75 miles from Oregon and enrolled with the Division.

(36) “Plan of Care” (POC) means a tool within the Medicaid Management Information System used to authorize certain Medicaid funded services for Individuals.

(37) “Provider” means an organizational entity, or qualified person, that is operated by or contractually affiliated with, a community mental health program, or contracted directly with the Division, for the direct delivery of addictions, problem gambling or mental health services and supports.

(38) “Psychiatric Residential Treatment Facility” means facilities that are structured residential treatment environments with daily 24-hour supervision and active psychiatric treatment, Psychiatric Residential Treatment Services (PRTS), Secure Children’s Inpatient Treatment Programs (SCIP), Secure Adolescent Inpatient Treatment Programs (SAIP), and Sub-acute psychiatric treatment for children who require active treatment for a diagnosed mental health condition in a 24-hour residential setting.

(39) “Psychiatric Residential Treatment Services” means services delivered in a PRTF that include 24-hour supervision for children who have serious psychiatric, emotional or acute mental health conditions that require intensive therapeutic counseling and activity and intensive staff supervision, support and assistance.

(40) “Qualified Mental Health Associate” (QMHA) means a person delivering services under the direct supervision of a Qualified Mental Health Professional (QMHP) and meeting the following minimum qualifications as documented by the LMHA or designee:

(a) A bachelor’s degree in a behavioral sciences field; or

(b) A combination of at least three year’s relevant work, education, training or experience; and

(c) Has the competencies necessary to:

(A) Communicate effectively;

(B) Understand mental health assessment, treatment and service terminology and to apply the concepts; and

(C) Provide psychosocial skills development and to implement interventions prescribed on a Treatment Plan within the scope of his or her practice.

(41) “Qualified Mental Health Professional” (QMHP) means a Licensed Medical Practitioner (LMP) or any other person meeting the following minimum qualifications as documented by the LMHA or designee:

(a) Graduate degree in psychology;

(b) Bachelor’s degree in nursing and licensed by the State of Oregon;

(c) Graduate degree in social work;

(d) Graduate degree in a behavioral science field;

(e) Graduate degree in recreational, art, or music therapy; or

(f) Bachelor’s degree in occupational therapy and licensed by the State of Oregon; and

(g) Whose education and experience demonstrates the competencies to identify precipitating events; gather histories of mental and physical disabilities, alcohol and drug use, past mental health services and criminal justice contacts; assess family, social and work relationships; conduct a mental status examination; document a multiaxial DSM diagnosis; write and supervise a Treatment Plan; conduct a Comprehensive Mental Health Assessment; and provide individual, family, and/or group therapy within the scope of his or her practice.

(42) “Representative” means a person who acts on behalf of an individual at the individual’s request with respect to a grievance, including, but not limited to a relative, friend, employee of the Division, attorney or legal guardian.

(43) “Residential Alcohol and Other Drug Treatment Program” means a publicly or privately operated program as defined in ORS 430.010 that provides assessment, treatment, rehabilitation and twenty four hour observation and monitoring for individuals with alcohol and other drug dependence, consistent with Level III of American Society of Addiction Medicine (ASAM) PPC-2R.

(44) “Supported Employment” (SE) means an evidence-based practice which provides services and supports to enable individuals with a serious mental illness to obtain and maintain competitive employment.

(45) “System Of Care” means the comprehensive array of mental health and other necessary services which are organized to meet the multiple and changing needs of children with severe emotional disorders and their families.

(46) “Usual and Customary Charge” means the lesser of the following unless prohibited from billing by federal statute or regulation:

(a) The Provider’s charge per unit of service for the majority of non-medical assistance users of the same service based on the preceding month’s charges;

(b) The Provider’s lowest charge per unit of service on the same date that is advertised, quoted or posted. The lesser of these applies regardless of the payment source or means of payment;

(c) Where the Provider has established a written sliding fee scale based upon income for individuals and families with income equal to or less than 200% of the federal poverty level, the fees paid by these individuals and families are not considered in determining the usual charge. Any amounts charged to Third Party Resources (TPR) are to be considered.

Stat. Auth.: ORS 413.042 & 430.640
Stats. Implemented: ORS 413.042, 414.025, 414.065, 430.640, 430.705, 430.715
Hist.: MHS 8-2010(Temp), f. 6-15-10, cert. ef. 7-1-10 thru 8-28-10; MHS 11-2010, f. & cert. ef. 8-25-10; MHS 14-2011(Temp), f. 12-29-11, cert. ef. 1-1-12 thru 6-28-12; MHS 7-2012(Temp), f. & cert. ef. 5-17-12 thru 11-11-12; MHS 10-2012, f. & cert. ef. 6-19-12; MHS 12-2012(Temp), f. 6-27-12, cert. ef. 7-1-12 thru 12-27-12; MHS 14-2012, f. & cert. ef. 11-5-12; MHS 5-2013, f. & cert. ef. 6-5-13

309-016-0825

Supported Employment (SE) Overview

(1) Supported Employment is an evidence-based practice for individuals with serious mental illness.

(2) Supported Employment is characterized by:

(a) Emphasis on competitive employment;

(b) Every person who is interested in work is eligible for services regardless of symptoms, substance use disorders, treatment decisions, or any other issue;

(c) Employment services are integrated with mental health treatment;

(d) Individuals have access to personalized benefits planning;

(e) Job search begins soon after a person expresses interest in working; and

(f) Client preferences for jobs, and preferences for service delivery, are honored.

(3) Supported Employment services include, but are not limited to:

(a) Job development;

(b) Supervision and job training;

(c) On-the-job visitation;

(d) Consultation with the employer;

(e) Job coaching;

(f) Counseling;

(g) Skills training; and/or

(h) Transportation.

Stat. Auth.: ORS 414.032, 414.615, 414.625 & 414.651
Stats. Implemented: ORS 414.610 - 414.685
Hist.: MHS 1-2013(Temp), f. & cert. ef. 1-7-13 thru 7-1-13; MHS 5-2013, f. & cert. ef. 6-5-13

309-016-0830

Supported Employment Providers

(1) To be eligible for Medicaid reimbursement, SE services must be provided by a Qualified SE Provider.

(2) To become a Qualified SE Provider, an agency must provide the evidence-based practice of Individual Placement and Support Supported Employment (IPS SE), and submit a copy to AMH of a fidelity review conducted by a Fidelity Reviewer approved by AMH, which resulted in a score of 100 or better.

(3) Providers implementing IPS SE may become a Provisionally Qualified SE Provider by submitting a request to AMH with a letter of support which indicates receipt of technical assistance and training from an AMH approved IPS SE Trainer. Medicaid reimbursements to a Provisionally Qualified SE Provided end after 12 months. This option is intended only for providers initiating supported employment services.

Stat. Auth.: ORS 413.042, 430.640
Stats. Implemented: ORS 413.042, 414.025, 414.065, 430.640, 430.705, 430.715
Hist.: MHS 5-2013, f. & cert. ef. 6-5-13

309-016-0835

Supported Employment Fidelity Requirements

(1) In order to maintain designation as a Qualified SE Provider, a provider must submit to AMH an annual fidelity review report, conducted by an AMH approved reviewer, which indicates a minimum score of 100.

(2) Qualified SE Providers achieving a fidelity score of 115 or higher are eligible to extend their review period to every 18 months.

(3) Fidelity reviews will be conducted utilizing the most current Dartmouth College IPS Fidelity Scale available at www.oregon.gov/oha/amh.

Stat. Auth.: ORS 413.042, 430.640
Stats. Implemented: ORS 413.042, 414.025, 414.065, 430.640, 430.705, 430.715
Hist.: MHS 5-2013, f. & cert. ef. 6-5-13

309-016-0837

Failure to Meet Fidelity Standards

If a Qualified SE Provider does not receive a minimum score of 100 on a fidelity review, the following shall occur:

(1) Technical assistance shall be made available for a period of 90-days to address problem areas identified in the fidelity review.

(2) At the end of the 90-day period, a follow-up review will be conducted by an AMH approved reviewer.

(c) The provider shall forward a copy of the amended fidelity review report to AMH.

(3) If the 90-day re-review results in a score of less than 100, the agency’s designation as a Qualified SE Provider may be suspended for up to one calendar year.

Stat. Auth.: ORS 413.042, 430.640
Stats. Implemented: ORS 413.042, 414.025, 414.065, 430.640, 430.705, 430.715
Hist.: MHS 5-2013, f. & cert. ef. 6-5-13

309-016-0840

Assertive Community Treatment (ACT) Overview

(1) ACT is an evidence-based practice for individuals with a serious mental illness.

(2) ACT is characterized by:

(a) A team approach;

(b) In vivo services;

(c) A caseload of approximately 10:1;

(d) Time-unlimited services;

(e) Flexible service delivery;

(f) A fixed point of responsibility; and

(g) 24/7 crisis availability

(3) ACT services include, but are not limited to:

(a) Hospital discharge planning;

(b) Case management;

(c) Symptom management;

(d) Psychiatry services;

(e) Nursing services;

(f) Co-occurring substance use disorder services;

(g) Vocational services;

(h) Life skills training; and/or

(i) Peer support services.

Stat. Auth.: ORS 413.042, 430.640
Stats. Implemented: ORS 413.042, 414.025, 414.065, 430.640, 430.705, 430.715
Hist.: MHS 5-2013, f. & cert. ef. 6-5-13

309-016-0845

ACT Providers

(1) To be eligible for Medicaid reimbursement, ACT services must be provided by a Qualified ACT Provider.

(2) To become a Qualified ACT Provider, an agency must provide the evidence-based practice of ACT, and submit to AMH a copy of a fidelity review conducted by an AMH approved ACT Fidelity Reviewer, with a minimum score of 114.

(3) Agencies may become a Provisionally Qualified ACT Provider by submitting to AMH a request, with a letter of support which indicates receipt of technical assistance and training from an AMH approved ACT Trainer. Provisional ability to receive Medicaid reimbursement will end after 12 months. This option is intended only for providers initiating ACT services.

Stat. Auth.: ORS 413.042, 430.640
Stats. Implemented: ORS 413.042, 414.025, 414.065, 430.640, 430.705, 430.715
Hist.: MHT 5-2013, f. & cert. ef. 6-5-13

309-016-0850

ACT Fidelity Requirements

(1) In order to maintain designation as a Qualified ACT Provider, an agency must submit to AMH an annual fidelity review report by an AMH approved reviewer, with a minimum score of 114.

(2) Qualified Providers achieving a fidelity score of 128 or better are eligible to extend their review period to every 18 months.

(3) Fidelity reviews will be conducted utilizing the Substance Abuse and Mental Health Services ACT Toolkit Fidelity Scale, available at www.oregon.gov/oha/amh

(4) Providers approved by AMH to bill Medicaid for ACT services prior to January 1, 2013, will be deemed Qualified ACT Providers through July 1, 2014. In order to maintain their designation as a Qualified ACT Provider, these providers must submit to AMH, prior to July 1, 2014, a copy of a fidelity review conducted by an AMH approved ACT Fidelity Reviewer with a minimum score of 114.

Stat. Auth.: ORS 413.042, 430.640
Stats. Implemented: ORS 413.042, 414.025, 414.065, 430.640, 430.705, 430.715
Hist.: MHS 5-2013, f. & cert. ef. 6-5-13

309-016-0855

Failure to Meet Fidelity Standards

If a Qualified ACT Provider does not receive a minimum score of 114 on a fidelity review, the following shall occur:

(1) Technical assistance shall be made available for a period of 90-days to address problem areas identified in the fidelity review.

(2) At the end of the 90-day period, a follow-up review will be conducted by an AMH approved reviewer.

(3) The provider shall forward a copy of the amended fidelity review report to AMH.

(4) If the 90-day re-review results in a score of less than 114, the agency’s designation as a Qualified ACT Provider may be suspended for up to one calendar year.

Stat. Auth.: ORS 413.042, 430.640
Stats. Implemented: ORS 413.042, 414.025, 414.065, 430.640, 430.705, 430.715
Hist.: MHS 5-2013, f. & cert. ef. 6-5-13

Notes
1.) This online version of the OREGON BULLETIN is provided for convenience of reference and enhanced access. The official, record copy of this publication is contained in the original Administrative Orders and Rulemaking Notices filed with the Secretary of State, Archives Division. Discrepancies, if any, are satisfied in favor of the original versions. Use the OAR Revision Cumulative Index found in the Oregon Bulletin to access a numerical list of rulemaking actions after November 15, 2012.

2.) Copyright 2013 Oregon Secretary of State: Terms and Conditions of Use

Oregon Secretary of State • 136 State Capitol • Salem, OR 97310-0722
Phone: (503) 986-1523 • Fax: (503) 986-1616 • oregon.sos@state.or.us

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