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4. Services provided to an AODA day treatment recipient which are primarily social or only educational in nature. Educational sessions are covered as long as these sessions are part of an overall treatment program and include group processing of the information provided;
5. Prevention or education programs provided as an outreach service or as case-finding; and
6. AODA day treatment provided in person in the recipient’s home.
(4)Mental health day treatment or day hospital services.
(a) Covered services. Day treatment or day hospital services are covered services when prescribed by a physician, when provided by a provider who meets the requirements of s. DHS 105.24, and when the following conditions are met:
1. Before becoming involved in a day treatment program, the recipient is evaluated through the use of the functional assessment scale provided by the department to determine the medical necessity for day treatment and the person’s ability to benefit from it;
2. The supervising psychiatrist approves, signs and dates a written treatment plan for each recipient and reviews and signs the plan no less frequently than once every 60 days. The treatment plan shall be based on the initial evaluation and shall include the individual goals, the treatment modalities including identification of the specific group or groups to be used to achieve these goals and the expected outcome of treatment;
3. Up to 90 hours of day treatment services in a calendar year may be reimbursed without prior authorization. Psychotherapy services or occupational therapy services provided as component parts of a person’s day treatment package may not be billed separately, but shall be billed and reimbursed as part of the day treatment program;
4. Day treatment or day hospital services provided to recipients with inpatient status in a hospital are limited to 20 hours per inpatient admission and shall only be available to patients scheduled for discharge to prepare them for discharge;
5. Reimbursement is not made for day treatment services provided in excess of 5 hours in any day or in excess of 120 hours in any month;
6. Day treatment services are covered only for the chronically mentally ill and acutely mentally ill who have a need for day treatment and an ability to benefit from the service, as measured by the functional assessment scale provided by the department; and
7. Billing for day treatment is submitted by the provider. Day treatment services shall be billed as such, and not as psychotherapy, occupational therapy or any other service modality.
8. The groups shall be led by a qualified professional staff member, as defined under s. DHS 105.24 (1) (b) 4. a., and the staff member shall be present throughout the group sessions and shall perform or direct the service.
(b) Services requiring prior authorization.
1. Providers shall obtain authorization from the department before providing the following services, as a condition for coverage of these services:
a. Day treatment services provided beyond 90 hours of service in a calendar year;
b. All day treatment or day hospital services provided to recipients with inpatient status in a nursing home. Only those patients scheduled for discharge are eligible for day treatment. No more than 40 hours of service in a calendar year may be authorized for a recipient residing in a nursing home;
c. All day treatment services provided to recipients who are concurrently receiving psychotherapy, occupational therapy or AODA services;
d. All day treatment services in excess of 90 hours provided to recipients who are diagnosed as acutely mentally ill.
2. The prior authorization request shall include:
a. The name, address, and MA number of the recipient;
b. The name, address, and provider number of the provider of the service and of the billing provider;
c. A photocopy of the physician’s original prescription for treatment;
d. A copy of the treatment plan and the expected outcome of treatment;
e. A statement of the estimated additional dates of service necessary and total cost; and
f. The demographic and client information form from the initial and most recent functional assessment. The assessment shall have been conducted within 3 months prior to the authorization request.
3. The department’s decision on a prior authorization request shall be communicated to the provider in writing. If the request is denied, the department shall provide the recipient with a separate notification of the denial.
(c) Other limitations.
1. All assessment hours beyond 6 hours in a calendar year shall be considered part of the treatment hours and shall become subject to the relevant prior authorization limits. Day treatment assessment hours shall be considered part of the 6 hour per 2-year mental health evaluation limit.
2. Reimbursement for day treatment services shall be limited to actual treatment time and may not include time devoted to meals, rest periods, transportation, recreation or entertainment.
3. Reimbursement for day treatment services shall be limited to no more than 2 series of day treatment services in one calendar year related to separate episodes of acute mental illness. All day treatment services in excess of 90 hours in a calendar year provided to a recipient who is acutely mentally ill shall be prior-authorized.
4. Services under this subsection are not reimbursable if the recipient is receiving community support program services under sub. (6) or psychosocial services provided through a community-based psychosocial service program under sub. (7).
(d) Non-covered services. The following services are not covered services:
1. Day treatment services which are primarily recreation-oriented and which are provided in non-medically supervised settings such as 24 hour day camps, or other social service programs. These include sports activities, exercise groups, activities such as craft hours, leisure time, social hours, meal or snack time, trips to community activities and tours;
2. Day treatment services which are primarily social or educational in nature, in addition to having recreational programming. These shall be considered non-medical services and therefore non-covered services regardless of the age group served;
3. Consultation with other providers or service agency staff regarding the care or progress of a recipient;
4. Prevention or education programs provided as an outreach service, case-finding, and reading groups;
5. Aftercare programs, provided independently or operated by or under contract to boards;
6. Medical or AODA day treatment for recipients with a primary diagnosis of alcohol or other drug abuse;
7. Day treatment provided in person in the recipient’s home; and
8. Court appearances except when necessary to defend against commitment.
Note: For more information on non-covered services, see s. DHS 107.03.
(6)Community support program (CSP) services.
(a) Covered services. Community support program (CSP) services shall be covered services when prescribed by a physician and provided by a provider certified under s. DHS 105.255 for recipients who can benefit from the services. These non-institutional services make medical treatment and related care and rehabilitative services available to enable a recipient to better manage the symptoms of his or her illness, to increase the likelihood of the recipient’s independent, effective functioning in the community and to reduce the incidence and duration of institutional treatment otherwise brought about by mental illness. Services covered are as follows:
1. Initial assessment. At the time of admission, the recipient, upon a psychiatrist’s order, shall receive an initial assessment conducted by a psychiatrist and appropriate professional personnel to determine the need for CSP care;
2. In-depth assessment. Within one month following the recipient’s admission to a CSP, a psychiatrist and a treatment team shall perform an in-depth assessment to include all of the following areas:
a. Evaluation of psychiatric symptomology and mental status;
b. Use of drugs and alcohol;
c. Evaluation of vocational, educational and social functioning;
d. Ability to live independently;
e. Evaluation of physical health, including dental health;
f. Assessment of family relationships; and
g. Identification of other specific problems or needs;
3. Treatment plan. A comprehensive written treatment plan shall be developed for each recipient and approved by a psychiatrist. The plan shall be developed by the treatment team with the participation of the recipient or recipient’s guardian and, as appropriate, the recipient’s family. Based on the initial and in-depth assessments, the treatment plan shall specify short-term and long-term treatment and restorative goals, the services required to meet these goals and the CSP staff or other agencies providing treatment and psychosocial rehabilitation services. The treatment plan shall be reviewed by the psychiatrist and the treatment team at least every 30 days to monitor the recipient’s progress and status;
4. Treatment services, as follows:
a. Family, individual and group psychotherapy;
b. Symptom management or supportive psychotherapy;
c. Medication prescription, administration and monitoring;
d. Crisis intervention on a 24-hour basis, including short-term emergency care at home or elsewhere in the community; and
e. Psychiatric and psychological evaluations;
5. Psychological rehabilitation services as follows;
a. Employment-related services. These services consist of counseling the recipient to identify behaviors which interfere with seeking and maintaining employment; development of interventions to alleviate problem behaviors; and supportive services to assist the recipient with grooming, personal hygiene, acquiring appropriate work clothing, daily preparation for work, on-the-job support and crisis assistance;
b. Social and recreational skill training. This training consists of group or individual counseling and other activities to facilitate appropriate behaviors, and assistance given the recipient to modify behaviors which interfere with family relationships and making friends;
c. Assistance with and supervision of activities of daily living. These services consist of aiding the recipient in solving everyday problems; assisting the recipient in performing household tasks such as cleaning, cooking, grocery shopping and laundry; assisting the recipient to develop and improve money management skills; and assisting the recipient in using available transportation;
d. Other support services. These services consist of helping the recipient obtain necessary medical, dental, legal and financial services and living accommodations; providing direct assistance to ensure that the recipient obtains necessary government entitlements and services, and counseling the recipient in appropriately relating to neighbors, landlords, medical personnel and other personal contacts; and
6. Case management in the form of ongoing monitoring and service coordination activities described in s. DHS 107.32 (1) (d).
(b) Other limitations.
1. Mental health services under s. DHS 107.13 (2) and (4) are not reimbursable for recipients receiving CSP services.
2. An initial assessment shall be reimbursed only when the recipient is first admitted to the CSP and following discharge from a hospital after a short-term stay.
3. Group therapy is limited to no more than 10 persons in a group. No more than 2 professionals shall be reimbursed for a single session of group therapy. Mental health technicians shall not be reimbursed for group therapy.
4. Reimbursement is not available for a person participating in the program under this subsection if the person is also participating in the program under sub. (7).
(c) Non-covered services. The following CSP services are not covered services:
1. Case management services provided under s. DHS 107.32 by a provider not certified under s. DHS 105.255 to provide CSP services;
2. Services provided to a resident of an intermediate care facility, skilled nursing facility or an institution for mental diseases, or to a hospital patient unless the services are performed to prepare the recipient for discharge from the facility to reside in the community;
3. Services related to specific job-seeking, job placement and work activities;
4. Services performed by volunteers;
5. Services which are primarily recreation-oriented; and
6. Legal advocacy performed by an attorney or paralegal.
(7)Psychosocial services provided through a community-based psychosocial service program.
(a) Covered services. Psychosocial services provided through a community-based psychosocial service program shall be covered services when authorized by a mental health professional under s. DHS 36.15 for recipients determined to have a need for the services under s. DHS 36.14. These non-institutional services must fall within the definition of “rehabilitative services” under 42 CFR 440.130 (d) and must be described in a service plan under s. DHS 36.17. Covered services include assessment under s. DHS 36.16 and service planning and review under s. DHS 36.17.
(b) Other limitations.
1. Mental health services under s. DHS 107.13 (2) and (4) are not reimbursable for recipients receiving services under this subsection.
2. Group psychotherapy is limited to no more than 10 persons in a group. No more than 2 professionals shall be reimbursed for a single session of group psychotherapy. Mental health technicians shall not be reimbursed for group psychotherapy.
3. Reimbursement is not available for a person participating in the program under this subsection if the person is also participating in the program under sub. (6).
(c) Non-covered services. The following are not covered services under this subsection:
1. Case management services provided under s. DHS 107.32 by a provider not certified under s. DHS 105.257 to provide services under this section.
2. Services provided to a resident of an intermediate care facility, skilled nursing facility or an institution for mental diseases, or to a hospital patient unless the services are performed to prepare the recipient for discharge from the facility to reside in the community.
3. Services performed by volunteers, except that out-of-pocket expenses incurred by volunteers in performing services may be covered.
4. Services that are not rehabilitative, including services that are primarily recreation-oriented.
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Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published.