Chapter DHS 107

DHS 107.13(3)(d)3. 3. Detoxification provided in a social setting, as described in s. DHS 75.58, is not a covered service.

DHS 107.13 Note Note: For more information on non-covered services, see s. DHS 107.03.

DHS 107.13(3m) (3m) Alcohol and other drug abuse day treatment services.

DHS 107.13(3m)(a) (a) Covered services. Alcohol and other drug abuse day treatment services shall be covered when prescribed by a physician, provided by a provider certified under s. DHS 105.25 and performed according to the recipient’s treatment program in a non-residential, medically supervised setting, and when the following conditions are met:

DHS 107.13(3m)(a)1. 1. An initial assessment is performed by qualified medical professionals under s. DHS 75.24 (11) for a potential participant. Services under this section shall be covered if the assessment concludes that AODA day treatment is medically necessary and that the recipient is able to benefit from treatment;

DHS 107.13(3m)(a)2. 2. A treatment plan based on the initial assessment is developed by the interdisciplinary team in consultation with the medical professionals who conducted the initial assessment and in collaboration with the recipient;

DHS 107.13(3m)(a)3. 3. The supervising physician or psychologist approves the recipient’s written treatment plan;

DHS 107.13(3m)(a)4. 4. The treatment plan includes measurable individual goals, treatment modes to be used to achieve these goals and descriptions of expected treatment outcomes; and

DHS 107.13(3m)(a)5. 5. The interdisciplinary team monitors the recipient’s progress, adjusting the treatment plan as required.

DHS 107.13(3m)(b) (b) Prior authorization.

DHS 107.13(3m)(b)1. 1. All AODA day treatment services except the initial assessment shall be prior authorized.

DHS 107.13(3m)(b)2. 2. Any recommendation by the county human services department under s. 46.23, Stats., or the county community programs department under s. 51.42, Stats., shall be considered in review and approval of the prior authorization request.

DHS 107.13(3m)(b)3. 3. Department representatives who review and approve prior authorization requests shall meet the same minimum training requirements as those mandated for AODA day treatment providers under s. DHS 105.25.

DHS 107.13(3m)(c) (c) Other limitations.

DHS 107.13(3m)(c)1. 1. AODA day treatment services in excess of 5 hours per day are not reimbursable under MA.

DHS 107.13(3m)(c)2. 2. AODA day treatment services may not be billed as psychotherapy, AODA outpatient treatment, case management, occupational therapy or any other service modality except AODA day treatment.

DHS 107.13(3m)(c)3. 3. Reimbursement for AODA day treatment services may not include time devoted to meals, rest periods, transportation, recreation or entertainment.

DHS 107.13(3m)(c)4. 4. Reimbursement for AODA day treatment assessment for a recipient is limited to 3 hours in a calendar year. Additional assessment hours shall be counted towards the mental health outpatient dollar or hour limit under sub. (2) (a) 6. before prior authorization is required or the AODA outpatient dollar or hour limit under sub. (3) (a) 4. before prior authorization is required.

DHS 107.13(3m)(d) (d) Non-covered services. The following are not covered services:

DHS 107.13(3m)(d)1. 1. Collateral interviews and consultations, except as provided in s. DHS 107.06 (4) (d);

DHS 107.13(3m)(d)2. 2. Time spent in the AODA day treatment setting by affected family members of the recipient;

DHS 107.13(3m)(d)3. 3. AODA day treatment services which are primarily recreation-oriented or which are provided in non-medically supervised settings. These include but are not limited to sports activities, exercise groups, and activities such as crafts, leisure time, social hours, trips to community activities and tours;

DHS 107.13(3m)(d)4. 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;

DHS 107.13(3m)(d)5. 5. Prevention or education programs provided as an outreach service or as case-finding; and

DHS 107.13(3m)(d)6. 6. AODA day treatment provided in person in the recipient’s home.

DHS 107.13(4) (4) Mental health day treatment or day hospital services.

DHS 107.13(4)(a) (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:

DHS 107.13(4)(a)1. 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;

DHS 107.13(4)(a)2. 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;

DHS 107.13(4)(a)3. 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;

DHS 107.13(4)(a)4. 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;

DHS 107.13(4)(a)5. 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;

DHS 107.13(4)(a)6. 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

DHS 107.13(4)(a)7. 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.

DHS 107.13(4)(a)8. 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.

DHS 107.13(4)(b) (b) Services requiring prior authorization.

DHS 107.13(4)(b)1. 1. Providers shall obtain authorization from the department before providing the following services, as a condition for coverage of these services:

DHS 107.13(4)(b)1.a. a. Day treatment services provided beyond 90 hours of service in a calendar year;

DHS 107.13(4)(b)1.b. 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;

DHS 107.13(4)(b)1.c. c. All day treatment services provided to recipients who are concurrently receiving psychotherapy, occupational therapy or AODA services;

DHS 107.13(4)(b)1.d. d. All day treatment services in excess of 90 hours provided to recipients who are diagnosed as acutely mentally ill.

DHS 107.13(4)(b)2. 2. The prior authorization request shall include:

DHS 107.13(4)(b)2.a. a. The name, address, and MA number of the recipient;

DHS 107.13(4)(b)2.b. b. The name, address, and provider number of the provider of the service and of the billing provider;

DHS 107.13(4)(b)2.c. c. A photocopy of the physician’s original prescription for treatment;

DHS 107.13(4)(b)2.d. d. A copy of the treatment plan and the expected outcome of treatment;

DHS 107.13(4)(b)2.e. e. A statement of the estimated additional dates of service necessary and total cost; and

DHS 107.13(4)(b)2.f. 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.

DHS 107.13(4)(b)3. 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.

DHS 107.13(4)(c) (c) Other limitations.

DHS 107.13(4)(c)1. 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.

DHS 107.13(4)(c)2. 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.

DHS 107.13(4)(c)3. 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.

DHS 107.13(4)(c)4. 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).

DHS 107.13(4)(d) (d) Non-covered services. The following services are not covered services:

DHS 107.13(4)(d)1. 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;

DHS 107.13(4)(d)2. 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;

DHS 107.13(4)(d)3. 3. Consultation with other providers or service agency staff regarding the care or progress of a recipient;

DHS 107.13(4)(d)4. 4. Prevention or education programs provided as an outreach service, case-finding, and reading groups;

DHS 107.13(4)(d)5. 5. Aftercare programs, provided independently or operated by or under contract to boards;

DHS 107.13(4)(d)6. 6. Medical or AODA day treatment for recipients with a primary diagnosis of alcohol or other drug abuse;

DHS 107.13(4)(d)7. 7. Day treatment provided in person in the recipient’s home; and

DHS 107.13(4)(d)8. 8. Court appearances except when necessary to defend against commitment.

DHS 107.13 Note Note: For more information on non-covered services, see s. DHS 107.03.

DHS 107.13(6) (6) Community support program (CSP) services.

DHS 107.13(6)(a) (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:

DHS 107.13(6)(a)1. 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;

DHS 107.13(6)(a)2. 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:

DHS 107.13(6)(a)2.a. a. Evaluation of psychiatric symptomology and mental status;

DHS 107.13(6)(a)2.b. b. Use of drugs and alcohol;

DHS 107.13(6)(a)2.c. c. Evaluation of vocational, educational and social functioning;

DHS 107.13(6)(a)2.d. d. Ability to live independently;

DHS 107.13(6)(a)2.e. e. Evaluation of physical health, including dental health;

DHS 107.13(6)(a)2.f. f. Assessment of family relationships; and

DHS 107.13(6)(a)2.g. g. Identification of other specific problems or needs;

DHS 107.13(6)(a)3. 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;

DHS 107.13(6)(a)4. 4. Treatment services, as follows:

DHS 107.13(6)(a)4.a. a. Family, individual and group psychotherapy;

DHS 107.13(6)(a)4.b. b. Symptom management or supportive psychotherapy;

DHS 107.13(6)(a)4.c. c. Medication prescription, administration and monitoring;

DHS 107.13(6)(a)4.d. d. Crisis intervention on a 24-hour basis, including short-term emergency care at home or elsewhere in the community; and

DHS 107.13(6)(a)4.e. e. Psychiatric and psychological evaluations;

DHS 107.13(6)(a)5. 5. Psychological rehabilitation services as follows;

DHS 107.13(6)(a)5.a. 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;

DHS 107.13(6)(a)5.b. 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;

DHS 107.13(6)(a)5.c. 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;

DHS 107.13(6)(a)5.d. 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

DHS 107.13(6)(a)6. 6. Case management in the form of ongoing monitoring and service coordination activities described in s. DHS 107.32 (1) (d).

DHS 107.13(6)(b) (b) Other limitations.