Rehabilitative Services Policy

Intensive Supervision Day Treatment Program

Introduction

The Intensive Supervision Day Treatment Program provides comprehensive services that are designed to provide the support and/or services necessary to provide positive outcomes relative to the return of the recipient to the home and/or preventing placement

Covered Services

The following table lists all covered services for Intensive Supervision Day Treatment. The table shows the procedure code, service description, if the service requires prior authorization (Y-yes or N-no).

Supervision Day Treatment

Procedure CodeDescriptionPA

X0361Intensive Supervision Day TreatmentN

Limitations

Limited to comprehensive services provided by those agencies under contract with and licensed by the Rhode Island Department of Children, Youth and Families.

Lead Investigations Program

Introduction

The Lead Investigations Program provides services designed to determine the source of the lead in children with elevated lead levels as determined by the RI Department of Health.

Covered Services

Services are covered for both categorically and medically needy Medicaid recipients.

When billing for lead investigation services, always use diagnosis code 984 (toxic effects, lead and compound).

The following table lists all covered services under the Lead Investigation Program. The table shows the procedure code, service description, if the service requires prior authorization (Y-yes or N-no).

Lead Investigations Program

Procedure CodeDescriptionPA

X0272Environmental Assessment: Lead Program - 1 UnitN

X0655Medical Case Management: Lead Program - Minimum of 1 Unit; Maximum of 12 UnitsN

X0271Non - Medical Case Management: Lead ProgramN

Limitations

Medical Case Management (X0655) cannot be billed for individuals who are enrolled in a managed care program.

Provider Participation

Lead Investigation Program services are only covered for children from birth to 20 years of age.

Provider participation is limited to the RI Department of Health.

Patient Liability

There is no recipient co-pay or patient liability for lead investigation services.

Participating providers are exempt from billing any third party resources, including Medicare, for lead investigation services provided to Medicaid recipients

Medicare/Medicaid Crossover

The Medicaid Program reimbursement for crossover claims is always capped by the established Medicaid Program allowed amount, regardless of coinsurance or deductible amounts. The standard calculation for crossover payments is as follows:

The Medicaid Program will pay the lesser of:

The difference between the Medicaid Program allowed amount and the Medicare Payment (Medicaid Program allowed minus Medicare paid); or
The Medicare coinsurance and deductible up to the Medicaid Program allowed amount, calculated as follows: (Medicare coinsurance/deductible plus Medicare paid) - (Medicaid program allowed).

RIACT-I Team

Introduction

RIACT-I is a self-contained program that is the fixed point of responsibility for providing the treatment, rehabilitation and support services to identified consumers with severe and persistent mental illness. Using an integrated service approach, the RIACT-I merges clinical and rehabilitation staff expertise (e.g., psychiatric, substance abuse, employment) within a single service delivery team supervised by a qualified program director. Accordingly, there are minimal referrals of consumers to other program entities for treatment, rehabilitation and support services.

Covered Services

Both categorically and medically needy Medicaid recipients are eligible to participate in this program.

The following table lists all covered services for the RIACT-I. The table shows the procedure code, service description and if the service requires prior authorization (Y-yes or N-no).

RIACT-I Team

Procedure CodeDescriptionPA

H0040Assertive Community Treatment Program, Per DiemN

Provider Participation

RIACT-I must be certified by MHRH, Division of Mental Health and Management Services, prior to billing for RIACT-I services. This certification is considered additional to any other requirement for participation in the Mental Health Medical Assistance Program.

Complete program and certification requirements are contained in the RIACT-I Standards. Both documents are available from the Medicaid Project Officer.

Certification, if awarded, will be for a period of two years. It is the responsibility of the Provider to apply for re-certification at least sixty (60) days before the current certification expires.

Reimbursement

RIACT-I Team staff will usually provide the bulk of the everyday services required by RIACT-I clients. Therefore, providers are prohibited from billing the Mental Health Medical Assistance Program for any costs over and above the RIACT-I per diem, with the following exceptions:

It is permissible to bill for infrequent Crisis Intervention Services provided by CMHC Emergency Services staff as long as all of the appropriate requirements are met.
It is permissible to bill separately for any services above and beyond the normal levels of RIACT-I service provisions that are specifically required to maintain an individual or Clozaril

Provider Participation Guidelines

To participate in the Rhode Island Medicaid Program, providers must meet the following requirements:

Providers must be located and be performing services in Rhode Island (except for border communities).
Providers must be licensed by the Rhode Island Department of Health to provide services.

Provider Recertification

Providers are periodically recertified by the Rhode Island Department of Health (RIDOH). Providers obtain license renewal through RIDOH and then forward a copy of the renewal documentation to DXC Technology. DXC Technology should receive this information at least five business days prior to the expiration date of the license. Failure to do so will result in suspension from the program.

A provider may appeal to the RIDOH if the facility does not meet the recertification criteria. If the appeal to RIDOH is not successful, the provider may then appeal to the Centers for Medicare and Medicaid (CMS).

Provider Reimbursement

Providers must bill the Medicaid Program at the same usual and customary rate as charged to the general public. Rates discounted to specific groups (such as Senior Citizens) must be billed at the same discounted rate to Medicaid. Payments to providers will not exceed the maximum reimbursement rate of the Medicaid Program.

Psychiatric Rehabilitation Day Program

Introduction

A Psychiatric Rehabilitation Day Program may be composed of one or more focused component programs as defined below.

Program Components Defined

Medication Program

A program providing for the prescription and administration of medication, primarily psychotropic in nature, for the purpose of mitigating or eliminating symptoms of mental illness. This program includes periodic medication reviews which will examine as required:

The reason for prescribing each medication.
Whether the medication is effective in treating the client.
Whether the prescribed dosage is the minimum required to effectively treat the client.
Any signs of side effects and the treatment prescribed to address the side effects.
All medication that the client is currently taking, including those of a non-psychotropic nature, to ensure that the mixture of medications is reasonable and safe.

Structured Therapeutic Program

A program that may include one or more of the following as determined to be medically necessary by inclusion in the client's individual treatment plan as approved by a physician or other licensed practitioner of the healing arts:

Development and maintenance of necessary community and daily living skills including grooming, personal hygiene, cooking, nutrition, health and mental health education, money management and maintenance of the living environment
Development of appropriate personal support networks
Structured socialization activities to enhance tendencies towards language skills necessary to enable the client to function independently
Training in appropriate use of community services
Physical therapy
Expressive therapy
Occupational therapy

Covered Services

Services are covered for both categorically and medically needy Medicaid recipients.

The following table lists all covered services for the Psychiatric Rehabilitation Day Program. The table shows the procedure code, service description and if the service requires prior authorization (Y-yes or N-no).

Psychiatric Rehabilitation Day Program

Procedure CodeDescriptionPA

X0343Day Program-Mentally Ill/Structured Therapy Units (STU)N

X0343 PMSTU with Physician Med VisitN

X0343 RMSTU with RN Med VisitN

Limitations

Program and program staff must comply with the rules, regulations and standards for licensing of Mental Health Facilities and Programs.

Residential Treatment Program - Adults

Introduction

The Residential Treatment Program for Adults is a twenty-four hour, supervised treatment program that is designed to provide the necessary support to and address the treatment, rehabilitation, and individual care needs of mentally ill individuals residing in facilities with less than 17 beds. Services that are covered under this program include, but are not limited to, counseling (individual, group and family), medication (education, administration and monitoring), and skill assessment and development.

Covered Services

Both categorically and medically needy Medicaid recipients are eligible to participate in this program.

The following table lists all covered services for the Residential Treatment Programs. The table shows the procedure code, service description and if the service requires prior authorization (Y-yes or N-no).

Procedure CodeDescriptionPA

X0341Adult MH Residential ServiceN

Limitations

Eligible Medicaid recipients must be adults, age 18 or older, to participate in the Residential Treatment Program for Adults.

Residential Treatment Program - Children

Introduction

The Residential Treatment Program for Children is a twenty-four hour, supervised treatment program that is designed to provide the necessary support to and address the special needs of a child or adolescent to either prevent or minimize the need for long-term residential or hospital psychiatric care. Services that are covered under this program include, but are not limited to: assessment and evaluation; family therapy; medical treatment; counseling and psychotherapy; group therapy; and intervention with child welfare, juvenile justice, local police and other systems affecting youths.

Covered Services

Both categorically and medically needy Medicaid recipients are eligible to participate in this program.

Residential Treatment Program

Procedure CodeDescriptionPA

X0350Residential Child Program - IY

X0351Residential Child Program - IIY

X0352Residential Child Program - IIIY

X0353Residential Child Program - IVY

X0354Residential Child Program- VY

X0355Residential Child Program - VIY

Limitations

Eligible recipients must be between birth and age 17.

Provider participation is limited to residential treatment programs designated as alternative living programs or residential counseling programs under contract with and licensed by DCYF.