(A) For the purposes of medicaid
reimbursement, assertive community treatment (ACT) refers to the evidence based
model of delivering comprehensive community based behavioral health services to
adults with certain serious and persistent mental illnesses who have not
benefited from traditional outpatient treatment. The ACT model utilizes a
multidisciplinary team of practitioners to deliver services to eligible
individuals.
(B) For the purposes of this rule,
collateral contact occurs when the practitioner contacts individuals who play a
significant role in a medicaid recipient's life. The information gained
from the collateral contact can provide insight into treatment or the basic
psychoeducation provided to that collateral contact can assist with the
treatment of the medicaid recipient.
(C) The ACT team is the sole provider to ACT recipients of
outpatient behavioral health services, including level one outpatient services
as defined by the American society of addiction medicine.
(D) ACT services include but are not limited to the
following:
(1) Psychiatry and
primary care as related to the mental health or substance use disorder
diagnoses;
(2) Service
coordination;
(3) Crisis assessment and
intervention;
(4) Symptom assessment
and management;
(5) Community based
rehabilitative services;
(6) Education, support,
and consultation to families, legal custodians, and significant others who are
part of the recipient's support network.
(E) The desired outcomes of ACT intervention for medicaid
recipients include but are not limited to:
(1) Achieving and
maintaining a stable life in a community based setting;
(2) Reducing the need for
inpatient hospital admission and emergency department visits;
(3) Improving mental and
physical health status, and improving life satisfaction.
(F) A medicaid recipient may receive ACT services when determined
by the ODM designated entity to have met all of the following:
(1) The recipient has a
diagnosis of schizophrenia, bipolar, or major depressive disorder with
psychosis, in accordance with the ICD-10 diagnosis code group list found at
https://bh.medicaid.ohio.gov/manuals;
(2) The recipient has a
supplemental security income or social security disability insurance
determination or has a score of two or greater on at least one of the items in
the "mental health needs" or "risk behaviors" sections or a
score of three on at least one of the items in the "life domain
function" section of the adult needs and strengths assessment (ANSA)
administered by an individual with a bachelor's degree or higher and with
training in the administration of the assessment; and
(3) The recipient has one
or more of the following:
(a) Two or more admissions to a psychiatric inpatient hospital
setting during the past twelve months; or
(b) Two or more occasions of utilizing psychiatric emergency
services during the past twelve months; or
(c) Significant difficulty meeting basic survival needs within
the last twenty-four months; or
(d) History within the past two years of criminal justice
involvement including but not limited to arrest, incarceration, or probation;
and
(4) The recipient
experiences one or more of the following:
(a) Persistent or recurrent severe psychiatric symptoms;
or
(b) Coexisting substance use disorder of more than six month in
duration; or
(c) Residing in an inpatient or supervised residence, but
clinically assessed to be able to live in a more independent living situation
if intensive services are provided; or
(d) At risk of psychiatric hospitalization, institutional or
supervised residential placement if more intensive services are not available;
or
(e) Has been unsuccessful in using traditional office-based
outpatient services; and
(5) The recipient is eighteen years of
age or older at the time of ACT enrollment.
(G) Prior authorization of ACT services.
(1) The provider must
submit a request for prior authorization and receive approval from the ODM
designated entity before ACT services can be rendered. The request for prior
authorization must be accompanied by the appropriate documentation which
includes, but is not limited to, the ANSA results or the documentation that
supports the social security determination. The maximum amount of ACT service
which may be prior authorized at any one time is twelve months.
(2) At the conclusion of
the previous ACT service period, the provider agency may request additional ACT
service to be prior authorized by the ODM designated entity.
(3) The provider may
begin submitting claims for medicaid reimbursement of ACT services for dates of
service within the subsequent calendar month following the date on which prior
authorization is approved by the ODM designated entity.
(H) Disenrollment of a recipient from ACT. Upon planned or
unplanned disenrollment of an ACT recipient, the ACT team shall document the
circumstances regarding disenrollment in the recipient's medical record.
(1) A planned
disenrollment from ACT occurs when a recipient, or recipient's guardian
and ACT team members mutually agree to the termination of ACT services and
transition of the recipient to a different care setting, provider, or benefit
package. A planned disenrollment is appropriate when:
(a) The recipient has successfully reached established goals for
disenrollment and the recipient and/or their guardian and ACT team members
agree to the discharge from ACT; or
(b) The recipient moves outside the geographic area of the ACT
team's responsibility. In such cases, the ACT team shall arrange to
transfer mental health and substance use disorder service responsibility to
another ACT program or other provider wherever the recipient is moving. The ACT
team shall maintain contact with the recipient until the transfer is complete;
or
(c) The recipient or their guardian requests a disenrollment;
or
(d) The recipient is determined by the ODM designated entity to
no longer meet the eligibility or medical necessity criteria for
ACT.
(2) As part of a planned
disenrollment, the ACT team shall document that the recipient has actively
participated in disenrollment activities by documenting in the recipient's
medical record the following information:
(a) The reason(s) for the recipient's disenrollment as
stated by both the recipient and the ACT team;
(b) The recipient's progress toward the goals set forth in
the treatment plan;
(c) Documentation that the recipient's behavioral health
care is being linked and transfered to a provider other than the ACT
team;
(d) The signature of the recipient or their guardian, the ACT
team leader, and the psychiatric prescriber.
(3) A recipient's
disenrollment from ACT may be unplanned and due to circumstances facilitated
by:
(a) The inability of the ACT team to locate the recipient for
more than forty-five days; or
(b) The recipient's incarceration, hospitalization or
admission to a residential substance use disorder treatment facility. In these
circumstances, the primary responsibility for the recipient's health care
is transferred to the aforementioned setting.
(i) The ACT team is
expected to maintain contact with the recipient to assist with transition
between settings if the recipient is likely to be discharged and resume service
from the ACT team within two months.
(ii) If the
recipient's stay is predicted to be longer than two months, the recipient
shall be disenrolled from the ACT team.
(iii) The recipient may
be re-enrolled with the ACT team when discharged from the incarcerated,
inpatient or residential setting. Any re-enrollment shall follow the
eligibility determination criteria described in paragraph (F) of this
rule.
(4) Except for services
found in paragraph (O) of this rule, a recipient may not obtain behavioral
health services from a provider other than the ACT team unless the recipient is
disenrolled from ACT services.
(5) The provider must
inform the ODM designated entity of disenrollment within three business days of
the discharge date. The ODM designated entity shall deactivate the
authorization for the ACT service. Failure to timely dis-enroll the recipient
from ACT may result in claim denial for other mental health or substance use
disorder services.
(I) A provider furnishing ACT services must meet both of the
following criteria:
(1) Meets the
eligibility requirements found in paragraph (A)(1) or (A)(2) of rule 5160-27-01
of the Administrative Code; and
(2) Employs one or more
teams of mental health and substance use disorder practitioners who comprise
the ACT treatment team.
(J) Each team must meet the following
criteria:
(1) Completed a fidelity
review within the previous twelve months by an independent validation entity
recognized by ODM. In year one of an ACT team's participation with Ohio
medicaid the team must participate in a fidelity review based on the dartmouth
assertive community treatment scale (DACTS) and performed by an independent
validation entity recognized by ODM. The DACTS fidelity scale and protocol can
be found at www.medicaid.ohio.gov.
(a) Fidelity reviews of ACT teams must be repeated every twelve
months from the report date of the previous fidelity review.
(b) An ACT team must have documented evidence of compliance
to the requirements stated in paragraph (J) of this rule prior to submitting
any prior authorization requests for recipients of ACT services.
(2) Each team shall have
a designated full-time team leader who may serve in that capacity with only one
team.
(a) An ACT team leader shall have a national provider
identification number and be actively enrolled as an Ohio medicaid
provider.
(b) A team leader shall have psychiatric training and shall hold
one of the following valid licenses from the appropriate Ohio professional
licensure board or licensure equivalents for ACT teams located in other
states:
(i) Licensed independent
social worker.
(ii) Licensed independent
marriage and family therapist.
(iii) Licensed
professional clinical counselor.
(iv) Licensed
psychologist.
(v) Physician
medical doctor, psychiatrist, doctor of osteopathy.
(vi) Clinical nurse
specialist
(vii) Certified nurse
practitioner.
(viii) Physician
assistant.
(ix) Registered
nurse.
(c) Team leaders who are licensed in accordance with paragraph
(A)(5) of rule 5160-27-01 of the Administrative Code but do not have
independent licensure status from one of the boards referenced in paragraph
(A)(5) of rule 5160-27-01 of the Administrative Code must receive approval from
ODM before the ACT team to which they are assigned can begin billing Ohio
medicaid.
(3) ACT teams that employ
peer recovery supporters must ensure that they meet the criteria and
requirements for the peer recovery support services set forth in rule
5160-43-09 of the Administrative Code.
(4) ACT teams must have a
caseload no greater than one hundred and twenty and must maintain an average
caseload ratio of one practitioner for every ten ACT recipients. Upon request
from the ODM, the ACT team must provide to the ODM or its designated entity the
ACT team caseload size and composition of medicaid and non-medicaid
enrollees.
(K) ODM reserves the right to suspend or terminate the payment of
ACT services and to require subsequent review of an ACT team's fidelity
performance if ODM has reason to believe that the ACT team's fidelity to
the DACTS model described in paragraph (J)(1) of this rule may be in question.
ODM may, at its discretion, suspend payment of ACT medicaid claims from the
provider agency employing the ACT team until such time as ODM receives
documentation from its independent validation entity that the team does meet
the fidelity criteria described in paragraph (J)(1) of this rule.
(L) A provider employing an ACT team may bill up to four ACT
units per month per recipient when all clinical and billing requirements for
each unit are met. The billing of ACT units are subject to the following limits
per provider category, per recipient, per month:
(1) Not more than one
unit may be billed per medicaid recipient per month for services rendered by
the ACT team medical prescriber including physician, clinical nurse specialist,
certified nurse practitioner, or physician assistant operating within their
respective scopes of practice.
(2) Not more than one
unit per medicaid recipient per month may be billed for services rendered by
any one of the following ACT team members: psychologist, licensed independent
social worker, licensed social worker, licensed clinical social worker,
licensed professional counselor, licensed professional clinical counselor,
licensed independent clinical counselor, licensed independent marriage and
family therapist, licensed marriage and family therapist, licensed practical
nurse, registered nurse, licensed independent chemical dependency counselor,
licensed chemical dependency counselor II or licensed chemical dependency
counselor III.
(3) Not more than two
units per medicaid recipient per month may be billed by an ACT team member not
listed in paragraph (L)(1) or (L)(2) of this rule. This unit category includes:
psychology assistant, psychology intern, psychology trainee, social worker
assistant, social worker trainee, marriage and family therapist trainee,
counselor trainee, chemical dependency counselor assistant, qualified mental
health specialist (QMHS), including QMHS with three or more years of
experience, and peer recovery supporter.
(M) The medicaid payment rates for ACT are stated in the appendix
to rule 5160-27-03 of the Administrative Code. Payment for services provided by
authorized ACT teams is only available for dates of services on or after
January 1, 2018.
(N) ACT teams shall maintain regular contact and deliver all
medically necessary outpatient mental health and substance use disorder
services and supports to ACT recipients enrolled with their team.
(O) Services rendered by the ACT team
medical prescriber, including physician, clinical nurse specialist, certified
nurse practitioner, or physician assistant, are billable when rendered to an
ACT recipient or via a case specific consultation with another member of the
ACT team regarding the medical aspects of the ACT recipient's treatment
plan. The ACT team medical prescriber must have at least one contact with each
ACT recipient every three months.
(P) When a recipient is enrolled on an ACT team, no other
medicaid community behavioral health services, as defined in Chapter 5160-27 of
the Administrative Code, are eligible for reimbursement except:
(1) Supported employment
as identified on a recipient's specialized recovery services program
treatment plan if applicable, as described in rule 5160-43-01 of the
Administrative Code.
(2) Substance use
disorder services that are not considered part of the benefit package
encompassed under level one of the american society of addiction medicine
(ASAM) as defined in rule 5160-27-09 of the Administrative Code. Prior
authorization from the ODM designated entity is required.
(3) Crisis services
furnished by a provider other than the billing provider agency employing the
ACT team.
(Q) Documentation requirements for ACT.
(1) Documentation in the
recipient's medical record of the services provided by the ACT team must
meet the requirements stated in this paragraph as well as those stated in rules
5160-1-27 and 5160-8-05 of the Administrative Code.
(2) The ACT team must
develop a specific treatment plan for each enrolled recipient. The treatment
plan must, at a minimum, meet the requirements of rule 5160-8-05 of the
Administrative Code plus the following additional requirements:
(a) The treatment plan shall be individualized based on the
recipient's needs, strengths, and preferences and shall set measurable
long-term and short-term goals and specify approaches and interventions
necessary for the recipient to achieve the recipient goals. The treatment plan
shall also identify who will carry out the approaches and
interventions.
(b) The treatment plan shall address, at a minimum, the following
key areas:
(i) Psychiatric illness
or symptom reduction.
(ii) Stable, safe, and
affordable housing.
(iii) Activities of daily
living.
(iv) Daily structure and
activities, including employment if appropriate.
(v) Family and social
relationships.
(c) The treatment plan shall be reviewed and revised by a member
of the ACT team with the recipient whenever a change is needed in the
recipient's course of treatment or at least every six months. In
conjunction with a treatment plan review, the ACT team member shall prepare a
summary of the recipient's progress, goal attainment, effectiveness of the
intervention and recipient's satisfaction with the ACT team interventions
since enactment of the previous treatment plan.
(d) The treatment plan, and all subsequent revisions of it, shall
be reviewed and signed by the recipient and the ACT team
practitioner.
(R) The following activities performed by members of the ACT team
are not eligible for reimbursement:
(1) Time spent attending
or participating in recreational activities.
(2) Services provided to
teach academic subjects or as a substitute for educational personnel, including
but not limited to a teacher, teacher's aide, or an academic
tutor.
(3) Habilitative services
for the recipient to acquire, retain, and improve the self-help, socialization,
and adaptive skills necessary to reside successfully in community
settings.
(4) Child care services
or services provided as a substitute for the parent or other individuals
responsible for providing care and supervision.
(5) Respite
care.
(6) Transportation for
the recipient or family.
(7) Services provided to
children, spouse, parents, or siblings of the eligible recipient under
treatment or others in the eligible recipient's life to address problems
not directly related to the eligible recipient's issues and not listed in
the eligible recipient's ACT treatment plan.
(8) Art, movement, dance,
or drama therapies.
(9) Services provided to
collaterals of the recipient.
(10) Contacts that are
not medically necessary.
(11) Any service outside
the responsibility of the ACT team.
(12) Vocational training and supported
employment services, unless the recipient is enrolled in the specialized
recovery services program as described in rule 5160-43-01 of the Administrative
Code.
(13) Crisis intervention provided by the
provider agency employing the ACT team.
