Wyo. Code R. 048-0037-13
Medicaid
Chapter 13: Mental Health Services
Effective Date: 04/07/2015 to 12/17/2015
Rule Type: Superceded Rules & Regulations
Reference Number: 048.0037.13.04072015
Section 1. Authority. This Chapter is promulgated by the Department of Health pursuant to the Medical Assistance and Services Act at W.S. § 42-4-104 and the Wyoming Administrative Procedures Act at W.S. § 16-3-102.
Section 2. Purpose and Applicability.
(a) This Chapter establishes the scope of mental health and substance abuse treatment services covered by Medicaid when provided by certified community mental health centers, certified substance abuse treatment centers, licensed psychologists, licensed Advanced Practitioners of Nursing with a specialty area of psychiatric/mental health, or licensed mental health professionals, as well as the methods and standards for reimbursing providers of such services. It shall apply to all such services provided on or after its effective date.
(b) The requirements of Title XIX of the Social Security Act, 42 C.F.R. §440.130, §440.40(b), § 440.169, and the Medicaid State Plan also apply to Medicaid and are incorporated by this reference, and may be cross-referenced throughout this Chapter where applicable. This incorporation by reference is effective as of the effective date of this Chapter, and does not include any later amendments or editions of the incorporated matter. The incorporated rules and regulations may be viewed at http://www.ecfr.gov/cgi-bin/ECFR, www.ssa.gov, and http://www.health.wyo.gov/healthcarefin/medicaid/spa.html or may be obtained at cost from the Department.
Section 3. Definitions. Except as otherwise specified in Chapter 1, or as defined herein, the terminology used in this Chapter is the standard terminology and has the standard meaning used in accounting, mental health care, substance abuse care, Medicaid and Medicare.
(a) "Certified center." A community mental health or substance abuse treatment agency that is certified by the Division of Behavioral Health, Division of Healthcare Financing, or both.
(b) "Clinical Professional." An individual who is licensed as a:
(i) Licensed Addictions Therapist;
(ii) Licensed Advanced Practitioner of Nursing with a specialty area of psychiatric/mental health (APRN);
(iii) Licensed Clinical Social Worker; (iv) Licensed Marriage and Family Therapist; (v) Licensed Physician; (vi) Licensed Professional Counselor; (vii) Licensed Psychiatric Nurse (Master level); or (viii) Licensed Psychologist.
(c) "Clinical staff." An individual who is a:
(i) Certified addictions practitioner (CAP), certified by the Mental Health Professions Licensing Board pursuant to the Mental Health Professions Practice Act (Wyo. Stat. §§ 33-38-101 through -113) to practice under the supervision of a licensed and qualified clinical supervisor;
(ii) Certified addictions practitioner assistant (CAPA), certified by the Mental Health Professions Licensing Board pursuant to the Mental Health Professions Practice Act (Wyo. Stat. §§ 33-38-101 through -113), or similar authority in another State, to practice under the supervision of a licensed and qualified clinical supervisor;
(iii) Certified Peer Specialist (CPS) who has a general equivalency diploma (GED) or high school diploma, meets the criteria and supervision requirements of a Mental Health Technician, is certified by the Division of Behavioral Health as a peer specialist, and is working under the documented, scheduled supervision of a licensed mental health professional;
(iv) Certified Social Worker (CSW) or a Certified Mental Health Worker (CMHW), certified by the Mental Health Professions Licensing Board pursuant to the Mental Health Professions Practice Act (Wyo. Stat. §§ 33-38-101 through -113), or similar authority in another State, to practice under the supervision of a qualified clinical supervisor licensed in the state of Wyoming;
(v) Licensed Practical Nurse (LPN) who is performing nursing duties within the scope of practice as defined by the Wyoming Board of Nursing Rules, Chapter III-Standards of Nursing Practice;
(vi) Mental Health Assistant (MHA) who has achieved a bachelor's degree in a human relations discipline as specified in the Wyoming Standards for the Operation of Community Mental Health and Substance Abuse Programs who is working under the documented, scheduled supervision of a licensed mental health professional;
(vii) Mental Health Technician (MHT) who has a general equivalent diploma, a high school diploma, or a higher degree in an other than human relations discipline and who is working under the documented, scheduled supervision of a licensed mental health professional;
(viii) Provisional licensee who is provisionally licensed by the Mental Health Professions Licensing Board pursuant to the Mental Health Professions Practice Act (Wyo. Stat. §§ 33-38-101 through -113), or similar authority in another State, to practice under the supervision of a licensed and qualified clinical supervisor. This includes student interns who meet the qualifications required by their respective Board and are practicing and billing under the direct supervision of a licensed and qualified clinical supervisor; or
(ix) Registered Nurse (RN) who is performing nursing duties within the scope of practice as defined by the Wyoming Board of Nursing Rules, Chapter III-Standards of Nursing Practice.
(d) "Collateral contact." An individual involved in the client's care. This individual may be a family member, guardian, healthcare professional or person who is a knowledgeable source of information about the client's situation and serves to support or corroborate information provided by the client.
(a) "Payments only to providers." No certified center, licensed psychologist, APRN, or licensed mental health professional that furnishes services to a client shall receive Medicaid reimbursement unless the certified center, licensed psychologist, APRN, or licensed mental health professional is enrolled with Medicaid.
(b) "Compliance with Chapter 3." A certified center, licensed psychologist, APRN, or licensed mental health professional that wishes to receive Medicaid reimbursement for services furnished to a client shall meet the provider participation requirements of Chapter 3.
(a) A certified center which wishes to receive Medicaid reimbursement for furnishing covered services to clients must:
(i) Be certified by the Division of Behavioral Health and meet Medicaid enrollment requirements; and (i) Have an internal quality assurance plan that meets Medicaid requirements as established in section 10.
(b) Case management services. All members of a certified center's staff who provide case management services must:
(i) Be employed by, or under contract with, a certified center; and
(ii) Be a clinical professional or clinical staff.
(c) Individual rehabilitative services (IRS). All members of the staff who provide IRS must:
(i) Be eighteen (18) years of age or older;
(ii) Be employed by, or under contract with, a certified center;
(iii) Complete a basic training program which includes non-violent behavior management; and
(iv) Have a general equivalency diploma, high school diploma, or higher.
(v) Be supervised by the client's primary therapist as evidenced by co-signature of the primary therapist on each IRS progress note.
(d) Mental health center services. All members of a certified center's staff who provide mental health center services must:
(i) Be employed by, or under contract with, a certified center; and
(ii) Be a clinical professional or clinical staff per the requirements of the specific service provided.
(a) All covered services must be:
(i) Furnished to a client or collateral contact and must be for the direct and exclusive benefit of the client;
(ii) Furnished pursuant to a treatment plan, updated and signed by a clinical professional at least every ninety (90) days that lists the type, frequency, and duration of each service to be provided with the exception of the initial clinical assessment; and:
(iii) Documented by providing a legible progress note in the client's medical record. Each progress note must contain a hand written or electronic signature and credentials of the provider and shall specify:
(A) Service type and setting (if outside of the office);
(B) Begin and end times; and
(C) Client progress towards goals identified in their current
treatment plan.
(b) The following are covered services when furnished by a certified center:
(i) Clinical assessment;
(ii) Office-based individual and family therapy;
(iii) Community-based individual and family therapy;
(iv) Psychosocial rehabilitation (day treatment);
(v) Intensive outpatient program (IOP);
(vi) Group therapy;
(vii) Comprehensive medication services;
(viii) Individual rehabilitative services (IRS);
(ix) Certified peer specialist services;
(x) Targeted case management provided to clients twenty-one (21) years of age and older; and
(xi) Ongoing case management provided to clients less than twenty-one (21) years of age.
(c) The following are covered services when furnished by a licensed psychologist, APRN, or licensed mental health professional:
(i) Clinical assessment;
(ii) Office-based individual and family therapy services;
(iii) Community-based individual and family therapy;
(iv) Group therapy;
(v) Ongoing case management services provided to clients under twenty-one (21) years of age; and
(vi) Additional services as specified in Medicaid policy manuals and provider bulletins. These services provided by licensed psychologists or APRNs may include psychological testing, psychotherapy and evaluation and management services.
Section 7. Excluded Services. The following services are excluded:
(a) Clinical services not provided face-to-face or via a telehealth modality, other than collateral contacts necessary to develop or implement a treatment plan;
(b) Education, public education, public relations, and speaking engagements;
(c) Day care;
(d) Driving while under the influence (DUI) classes;
(e) Missed appointment;
(f) Psychological testing done for the sole purpose of education diagnosis, school or institution admission or placement;
(g) Record-keeping time unless allowed by a specific service code;
(h) Recreation and socialization without an active clinical treatment component as specified in the individual client's treatment plan;
(i) Remedial or other formal education;
(j) Residential room, board, or care;
(k) Substance abuse or mental health disorder prevention services;
(l) Support groups such as AA or NA;
(m) Time spent preparing records or reports; except:
(i) Up to three (3) hours for a licensed psychologist to prepare a formal report of test findings; and
(ii) Time spent completing reports, forms, and correspondence regarding case management services as specified in a client's treatment plan.
(n) Vocational services;
(o) Services provided to a client with:
(i) Sole DSM diagnosis of intellectual or cognitive disability;
(ii) DSM diagnosis of factitious disorder;
(iii) DSM Axis I diagnosis of any ICD-9 "V" code or ICD-10 "Z" code unless the client's medical record contains a written statement signed by the affiliated clinical professional explaining why the treatment of a condition that is not classified as a mental disorder is medically necessary;
(p) Services provided by a school psychologist.
(q) Services provided by a provisionally licensed or certified mental health professional who has not obtained full licensure.
Section 8. Limited Services for Nursing Home Residents. Medicaid reimbursement for services provided to a client in a nursing facility is limited to:
(a) Clinical assessment;
(b) Community-based individual and family therapy; and
(c) Group therapy.
Section 9. Prior Authorization. Prior authorization of mental health services and substance abuse treatment services shall be governed by the prior authorization requirements of Chapter 3.
Section 10. Quality Assurance for Centers.
(a) Each certified center shall have a quality assurance plan that meets the standards specified by the Department and has been approved by the Department. The plan shall include:
(i) Utilization and quality review criteria to review and evaluate the appropriateness of the services provided;
(ii) Standards for completeness review and clinical record keeping; and
(iii) Definitions of critical incidents which require professional review and review procedures.
(b) The Department shall develop standards for quality assurance programs to supplement those contained in this Chapter.
(i) In developing quality assurance standards, the Department shall consider:
(A) Types of services provided in certified centers;
(B) Potential for over-utilization of the services; and
(C) Availability of alternative treatments which meet the therapeutic needs of clients.
(ii) The Department shall disseminate its quality assurance standards, as well as any modifications to those standards, to providers through Provider Manuals or bulletins.
(c) Quality assurance committee. The quality assurance plan must include a quality assurance committee that:
(i) Consists of clinical staff, including non-supervisory clinical staff; and
(ii) Conducts utilization review and critical incident review, unless another body is designated for critical incident reviews. The committee shall:
(A) Review annually at least ten percent (10%) of all Medicaid cases, including one (1) case that involves each member of the clinical staff and a proportionate number of mental health and substance abuse treatment cases;
(B) Document the results of all reviews and all committee activities;
(C) Document in each clinical record reviewed the type of review, the date of the review, and the person(s) involved in the review;
(D) Exclude an individual that is the primary or co-therapist from conducting the review;
(E) Prepare an annual report of all reviews, including recommendations for appropriate corrective activities. Submit a copy of the annual report to Medicaid, within thirty (30) days after its completion;
(F) Make available to the certified center staff and governing body a summary of the annual report; and
(G) Such other activities as specified by the Department.
Section 11. Submission and Payment of Claims. Payment and submission of claims shall be pursuant to Chapter 3.
Section 12. Third Party Liability. Claims for which third party liability exists shall be submitted in accordance with Chapter 35.
Section 13. Audits. Audits shall be subject to the provisions of Chapter 16.
Section 14. Recovery of Overpayments. The Department shall recover overpayments pursuant to Chapter 16.
Section 15. Reconsideration. A provider may request reconsideration of the decision to recover overpayments pursuant to Chapter 16.
Section 16. Disposition of Recovered Funds. The Department shall dispose of recovered funds pursuant to the provisions of Chapter 16.
Section 17. Interpretation of Chapter.
(a) The order in which the provisions of this Chapter appear is not to be construed to mean any one provision is more or less important than any other provision.
(b) The text of this Chapter shall control the titles of its various provisions.
Section 18. Superseding Effect. This Chapter supersedes all prior rules and policy statements issued by the Department, including manuals and bulletins, which are inconsistent with this Chapter.
Section 19. Severability. If any portion of this Chapter is found to be invalid or unenforceable, the remainder shall continue in full force.