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New Rules for Medicaid-Funded Behavioral Health Services for Kids

Overview

There are significant changes to rules governing the delivery of mental health services to children and adolescents under Pennsylvania's Medicaid program. The state Office of Mental Health and Substance Abuse Services (OMHSAS) has established new regulations for Intensive Behavioral Health Services (IBHS) that replace Behavioral Health Rehabilitation Services (BHRS) for the delivery of child and adolescent services in the home, school, and community. The new regulations (Title 55, Chapters 1155 and 5240) become effective January 17, 2020.

IBHS support children, youth, and young adults with mental, emotional, and behavioral health needs. IBHS include a wide array of services that can meet the needs of these individuals in their homes, schools, and communities. There are three categories: 1) Individual services; 2) Applied Behavior Analysis (ABA); and 3) Group services. Detailed information about each of these three categories is detailed below.

The changes include increased requirements for staff training, supervision, and credentialing. These new regulations were built from needs identified, during a years-long process, by community stakeholders (including school district principals, provider agencies, and consumers) during targeted focused groups for improved access and quality of care for children, youth, and young adults.

The state has created a DHS/Health Choices IBHS website with information regarding IBHS and the ongoing implementation, including the IBHS Regulations, the IBHS Preamble, upcoming regional training information and registration, as well as important IBHS forms.

1. Applied Behavioral Analysis (ABA)

One of the changes that has drawn the greatest attention is that Applied Behavioral Analysis (ABA) is covered as a distinct service. Previously it was covered under generic Behavior Health Rehabilitation Services (also known as wraparound). There had been no regulations governing the coverage, just a series of PA state bulletins. From 2016, the state Office of Mental Health Services and a group of stakeholders, including PHLP, worked on regulations that would codify coverage of ABA as a distinct service. Providers can begin providing and billing for services as set out below; they will be required to comply with the new regulations starting January 17, 2020. Below are some of the key provisions affecting families seeking ABA services under Medical Assistance.

How to Obtain ABA Under Pennsylvania Medicaid

Step 1: Written Order (i.e. prescription)
The process begins with a written order from physician, licensed psychologist, certified registered nurse practitioner, or physician assistant supervised by a physician. The written order must be based on a face-to-face interaction with the youth. The order must be written within 12 months prior to the initiation of services. The initiation of services is the first day an individual service or group service is provided.  The order can be written for a child or adolescent with any behavioral health disorder or diagnosis in the DSM or ICD; not just autism spectrum disorders.  The written order must include: 

  • All clinical information supporting need for ABA services;
  • The maximum hours of each service per month;
  • The setting(s) where ABA is to be provided; and
  • The level of goal achievement at which point services can be reduced (titrated) 

 

Step 2:  Assessment (formerly the “Psych Eval”)

  • This no longer needs to be done by psychiatrist of psychologist. It must be done by an individual qualified to provide behavioral analytic or behavior consultation services (see below for required qualifications).
  • The assessment must be face-to-face with child/youth and parent, legal guardian, or caregiver “as appropriate.”
  • It must be completed within 30 days of initiation of ABA services but before completing the treatment plan so services can begin before assessment is completed.
  • It provides specifics for treatment delivery, including the number of hours of each service needed at each location.
  • The signature of the family is not required on the assessment.
  • If progress towards goals in treatment plan have not been made within 90 days, another assessment is needed in order to revise the treatment plan.


Step 3:  Individual Treatment Plan (ITP)

  • The Individual Treatment Plan (ITP) must be based on the assessment and developed within 45 days of initiation of ABA services.
  • The ITP is completed by an individual who is qualified to provide behavioral analytic or behavior consultation services (see below for required qualifications)- typically someone who works for the ABA service provider from whom services are being sought.
  • Individual Treatment Plan must be signed by the youth or their parent/legal guardian and must include the following:
    • Service type, settings and number of hours of each service and in each setting;
    • Specific measurable goals & timelines for completion;
    • Whether and how parent, legal guardian or caregiver training, support and participation is needed to achieve the identified goals (Note: the regulations do not require that a parent or other caregiver be present while ABA is being provided- that is determined by the Individual Treatment Plan);
    • The Interagency Service Planning Team is meeting no longer necessary.
       

Step 4: Submission to Insurer

The Written Order, Assessment, and Individual Treatment Plan are submitted to the youth’s Behavioral Health Managed Care Organization (BH-MCO) for review. The BH-MCO decides whether to approve the services requested in the treatment plan. If approved, the provider can bill for services. If denied, the family can appeal the decision.

 

ABA Services Covered
ABA is comprised of a variety of models that use observation, data collection, and analysis of that data to develop techniques to produce socially significant improvement in behavior and improve skills or functioning. The regulations do not recognize any specific types or models of ABA. It is left up to the ABA professionals and family to determine, by way of the individual treatment plan, which model is most appropriate for the child. Instead, the regulations specify the qualifications and roles of various professionals who can provide ABA under Medicaid.

a. Behavior Analytic Services

  • Consists of clinical direction of services, development and revision of individual treatment plan, oversight of the treatment plan, consultation with the treatment team, and engaging in functional analysis. 
  • Staff qualification is a Board-Certified Behavior Analyst (BCBA) who is also a licensed behavior specialist; licensed psychologist; licensed professional counselor, marriage and family therapist, clinical social worker, social worker; or certified registered nurse practitioner.


b. Behavior Consultation 

  • Services are the same as behavior analytic services except they do not include doing functional analysis.
  • Staff qualification is not a BCBA, but must include one of the licenses above plus one of the following qualifications:
    • A Board-Certified Assistant Behavior Analyst (BCaBA);
    • One year full time provision of ABA + 12 college credits in ABA; or
    • One year full time provision of ABA under the supervision of a BCBA + 40 hours of ABA training approved by DHS or the Behavior Analyst Certification Board
       

c. Assistant Behavior Consultation

  • Services consist of assisting an individual who provides behavior analytic services or behavior consultation—ABA services and providing face-to-face behavioral interventions.
  • Staff qualifications:
    • Must meet the licensure requirements for behavior specialist except they don’t yet have 1000 hours of in-person clinical experience; or
    • Certified as a Board-Certified Assistant Behavior Analyst (BCaBA), with a bachelor’s degree in psychology, social work, counseling, education or a related field; or
    • Must have a minimum of six months of experience in providing ABA services, a bachelor's degree in psychology, social work, counseling, education or a related field, and a minimum of 12 credits in ABA from a college or university
       

d. Behavioral Health Technician (BHT-ABA)

  • These services consist of implementing the individual treatment plan. They take the place of the TSS.
  • Staff qualifications, effective July 1, 2020:
    • Certified as a Board-Certified Assistant Behavior Analyst (BCaBA); or
    • Certified as a Registered Behavior Technician (RBT); or
    • Certified as a Board-certified autism technician (BCAT); or
    • High school diploma/GED + have completed a 40-hour training covering the RBT Task List as evidenced by a certification that includes the name of the trainer, who is certified as a BCBA or BCaBA; or
    • Minimum of two (2) years of experience in providing ABA services and a minimum of 40 hours of training related to ABA approved by the Department or provided by a continuing education provider-approved by the Behavior Analyst Certification Board;
    • A college degree is not required.
       

2. Individual Services

Individual Services are provided one-to-one to children, youth, and young adults (under age 21) (hereafter referred to as youth) with mental, emotional, and behavioral health needs. These services can be provided with Behavior Consultation (BC) Services, Mobile Therapy (MT) Services and/or Behavioral Health Technician (BHT) Services. BC services include an assessment of the youth’s behavioral needs, development of an Individual Treatment Plan (ITP) which includes interventions to be used and when and where they occur. The youth’s ITP should be developed with the youth (as appropriate), family members, and other providers and school personnel as indicated. BC services can be provided in the home, school, or other community settings based on the needs of the youth. BC services replace BSC (Behavior Specialist Consultant) that were a part of BHRS.

Mobile Therapy (MT) services can also include an assessment and development of the ITP, if not already done by a BC. MT can include individual therapy, family therapy, assistance with crisis stabilization, and assistance with other problems encountered by the youth and/or family. MT services are similar to the MT services that were a part of BHRS.
BHT services are used to implement the youth’s ITP. BHT services replace TSS (Therapeutic Staff Support) services that were a part of BHRS.

3. Group Services

Group services are intensive therapeutic interventions that are provided in a group format. They can be provided in school or community settings such as a daycare or afterschool program. Group services include group and family psychotherapy, design of psychoeducational group activities, clinical direction of group services, creation and revision of the ITP, and oversight of the ITP implementation and consultation with the treatment team. IBHS regulations do not include a staff to client ratio for group services but providers of group services must identify that ratio in their service description to OMHSAS. Parent-Child Interaction Therapy (PCIT) can be provided as a group service. Examples of group services include Group Applied Behavior Analysis, School-Based Programs, After-School Programs, and Summer Therapeutic Activities Programs.

 

How to Obtain Individual and Group Services under Medicaid

Step 1: Written Order (i.e. prescription)

The process begins with a written order. Professionals qualified to write the order include a physician, licensed psychologist, certified registered nurse practitioner, physician assistant, licensed social worker, licensed professional counselor, and licensed family therapist. The written order must be based on a face-to-face interaction with the youth. The order must be written within 12 months of initiation of services. The initiation of services is the first day an individual service or group service is provided. The written order must include:

  • A behavioral health disorder or diagnosis listed in the most recent DSM or ICD; or
  • One or more orders for IBHS for the youth and includes the following:
    • Clinical information to support the medical necessity of the service ordered;
    • The maximum number of hours of each service per month;
    • Setting(s) where services are to be provided; and
    • The measurable improvements in the identified therapeutic needs indicating when services may be reduced, changed, or terminated.
       

Step 2: The Assessment
Once there is a written order, an assessment must be completed in the home or community-based setting. The qualifications of the professional administering the assessment depend on the service prescribed. An individual qualified to provide behavior consultation (BC) services or mobile therapy (MT) services must complete an assessment for individual services. A graduate-level professional must complete an assessment for group services.

The assessment must provide information on the youth and family’s strengths, existing and needed supports, and clinical information that includes the following:

  • Treatment history;
  • Medical history;
  • Developmental history;
  • Family structure and history;
  • Educational history;
  • Social history;
  • Trauma history; and
  • Other relevant clinical information.
     

The assessment must also include the child's level of developmental, cognitive, communicative, social, and behavioral functioning across the home, school, and other community settings. The cultural, language, or communication needs and preferences of the youth and the parent, legal guardian, or caregiver should also be included in the assessment.
The assessment provides specifics for what services are needed, in what setting, and in what amount. If the assessment indicates the youth needs more services than the maximum indicated in the written order, the assessor and the prescriber should discuss why. For the youth to receive more services than indicated in the written order, a new written order must be done.

Step 3: Individual Treatment Plan (ITP)
An individual treatment plan must be developed from the information in the written order and assessment within 30 days of the initiation of individual services or group services. An ITP for individual services is a detailed written plan of treatment services specifically tailored to address a youth's therapeutic needs that contains the type, amount, frequency, setting and duration of services to be provided and the specific goals, objectives and interventions for the service.

  • For Individual Services, the ITP must be developed in collaboration with the youth’s parent, legal guardian, or caregiver as appropriate and include:
    • Service type and the number of hours of each service; 
    • Whether and how parent, legal guardian, or caregiver participation is needed to achieve the identified goals and objectives;
    • Safety plan to prevent a crisis, a crisis intervention plan, and a transition plan; 
    • Specific goals, objectives, and interventions to address the identified therapeutic needs with definable and measurable outcomes;
    • Time frames to complete each goal; 
    • Settings where services may be provided; and
    • Number of hours of service at each setting.
       
  • For Group Services: The ITP must be developed with the youth and parent, legal guardian, or caretaker as appropriate and include the following:
    (1) Specific goals and objectives to address the identified therapeutic needs with definable and measurable outcomes.
    (2) Whether and how parent, legal guardian, or caregiver participation is needed to achieve the identified goals and objectives.
    (3) Structured therapeutic activities, community integration activities, and individual interventions to address identified therapeutic needs for the child, youth, or young adult to function at home, school, or in the community.
    (4) Time frames to complete each goal.
    (5) Settings where group services may be provided.
    (6) Number of hours that group services will be provided to the child, youth, or young adult.
     
  • For Individual Services and Group Services, the ITP shall be reviewed and updated at least every 6 months or if one of the following occurs
    • (1) The child, youth, or young adult has made sufficient progress to require that the ITP be updated.
      • (8) The child, youth, or young adult experiences a change in living situation that results in a change of the child's, youth's, or young adult's primary caregivers.
         
      • (7) A staff person, primary care physician, other treating clinician, case manager, or other professional involved in the child's, youth's, or young adult's services provides a reason an update is needed.
      • (6) The ITP is no longer clinically appropriate for the child, youth or young adult.
      • (5) The child, youth, or young adult experiences a crisis event.
      • (4) A parent, legal guardian, or caregiver of the child or youth requests an update.
      • (3) The youth or young adult requests an update.
      • (2) The child, youth, or young adult has not made significant progress towards the goals identified in the ITP within 90 days from the initiation of the services.

Evidenced Based Therapies (EBT) can be provided through Individual Services and Group Services. EBT are behavioral health interventions that use scientifically established methods. More of EBT can be found in the state’s Family Fact Sheet and in the IBHS regulations.

Step 4: Submission to Insurer

The Written Order, Assessment, and Individual Treatment Plan are submitted to the youth’s Behavioral Health Managed Care Organization (BH-MCO) for review. The BH-MCO decides whether to approve the services requested in the treatment plan. If approved, the provider can bill for services. If denied, the family can appeal the decision.

Conclusion

For children and youth currently receiving BHRS, providers will work with families as they transition to IBHS. OMHSAS is committed to no disruption in services for those youth now receiving BHRS. Families who experience BHRS service disruptions should contact their Medicaid Behavioral Health Managed Care Organization (BH-MCO) or call PHLP’s Helpline at 1-800-274-3258 for free legal assistance.