20130904-IR-405130211PRA Adds 405 IAC 5-21.7 pertaining to child mental health wraparound (CMHW) services and matters related to CMHW services to provide definitions, reimbursement for CMHW services, eligibility criteria, pr...

TITLE 405 OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES

Proposed Rule LSA Document #13-211

DIGEST

Adds 405 IAC 5-21.7 pertaining to child mental health wraparound (CMHW) services and matters related to CMHW services to provide definitions, reimbursement for CMHW services, eligibility criteria, program standards, and provider types that may provide CMHW services. Effective 30 days after filing with the Publisher.

405 IAC 5-21.7

SECTION 1. 405 IAC 5-21.7 IS ADDED TO READ AS FOLLOWS:

Rule 21.7. Child Mental Health Wraparound Services

405 IAC 5-21.7-1 General provisions

Authority: IC 12-8-6.5-5; IC 12-15

Affected: IC 12-13-7-3; IC 12-29; IC 25-23.6-10.5; IC 25-27.5-5

Sec. 1. (a) This rule provides child mental health wraparound (CMHW) services, which are intensive, home and community-based intervention services provided according to a systems of care philosophy within a wraparound model of service delivery.

(b) The CMHW service program includes the delivery of coordinated, highly individualized wraparound services and interventions that do the following:

(1) Address the participant's unique needs.

(2) Build upon the strengths of the participant and the participant's family or support group.

(3) Assist the participant and the participant's family in achieving positive outcomes in their lives.

(c) CMHW services are provided by qualified, specially trained service providers who engage the participant and the participant's family in an assessment and treatment planning process characterized by the formation of a child and family wraparound team (team).

(d) The team is developed by the participant and family to provide the support and resources needed to assist in developing and implementing an individualized plan of care.

(e) Members of the child and family team are selected by the participant and family and may include, but are not limited to, the following:

(1) The participant and family who will lead the treatment planning process.

(2) The wraparound facilitator who will coordinate service delivery and assist the participant and the participant's family in linking with community and natural supports.

(3) The CMHW and non-CMHW service providers, who will provide the participant and the participant's family with resources and supports in the treatment process.

(4) Any individual whom the participant and the participant's family select to support or assist them in implementation of the CMHW services plan of care.

(f) The CMHW services program will make available to the participant an array of interventions, which may include, but are not limited to, the following:

(1) Behavioral health and support services.

(2) Crisis planning and intervention.

(3) Parent coaching and education.

(4) Community resources and supports.

(g) The state's purposes for providing CMHW services are to:

(1) serve eligible participants with serious emotional disturbances; and

(2) enable them to benefit from receiving intensive wraparound services within their home and community with natural family supports.

(h) CMHW services available for eligible participants include the following:

(1) Wraparound facilitation.

(2) Habilitation.

(3) Respite care.

(4) Training and support for unpaid caregivers.

(i) CMHW services will be administered, evaluated, and monitored by the following:

(1) The OMPP as the state Medicaid agency.

(2) The DMHA as the state operating agency.

(3) Contracted entities of the state agencies in subdivisions (1) and (2), as required to administer the CMHW services program in accordance with this rule.

(Office of the Secretary of Family and Social Services; 405 IAC 5-21.7-1)

405 IAC 5-21.7-2 Definitions

Authority: IC 12-8-6.5-5; IC 12-15

Affected: IC 12-13-7-3; IC 12-29; IC 25-23.6-10.5; IC 25-27.5-5

Sec. 2. (a) The definitions in this article apply throughout this rule.

(b) "Access site" means a DMHA-certified agency that will provide CMHW services applicants and families the following:

(1) Information about CMHW services and eligibility criteria.

(2) Assistance in applying for CMHW services.

(3) Linkage to the most appropriate services, based upon an applicant's identified needs.

(c) "Applicant" refers to a child who is assessed for meeting eligibility criteria for enrollment in CMHW services.

(d) "Behavioral health assessment tool" means a state designated, individually appropriate assessment tool that is:

(1) approved by the DMHA; and

(2) administered by a qualified individual who is trained and certified by the DMHA to administer the tool.

(e) "Behavioral recommendation" means a recommended intensity of behavioral health services that is derived from administration of the DMHA-approved behavioral health assessment tool, as follows:

(1) The recommendation is based on an algorithm derived from the patterns of assessment ratings, in multiple life domains, from administration of the assessment tool with the applicant or participant and family member.

(2) This algorithm does the following:

(A) Implements the criteria for a level of need.

(B) Indicates the appropriate intensity of behavioral health services recommended for the participant.

(f) "Child and family wraparound team" or "team" means a wraparound treatment team or support team developed as follows:

(1) By a participant enrolled in CMHW services and the participant's family.

(2) To assist a participant and the participant's family in developing and implementing an individualized plan of care.

(g) "Child mental health wraparound" or "CMHW" services mean intensive, home and community-based, behavioral health wraparound services and interventions that meet the following requirements:

(1) The services are recommended by a physician or other licensed professional, within the scope of his or her practice.

(2) The services and interventions are intended for the:

(A) treatment of a mental health disability; and

(B) restoration of a participant's best possible functional level.

(3) The services include clinical and supportive behavioral health services provided for eligible participants who are:

(A) living with their family in the community; and

(B) at risk of an out-of-home placement, due to their mental illness and the disruptive patterns of their behavior.

(4) The services are provided in accordance with wraparound principles and a system of care philosophy.

(h) "CMHW service provider" means a service provider or agency that:

(1) has successfully completed CMHW services provider certification and training; and

(2) meets all qualifications and standards required by the OMPP and the DMHA.

(i) "Corrective action" means an action imposed upon the provider by the DMHA or the OMPP for noncompliance with CMHW services policies and procedures.

(j) "Crisis plan" means a plan of action prepared by the participant, the participant's family, and the team that specifies the following:

(1) Potential crises the participant may experience.

(2) The planned interventions and resources available to the participant and family to assist in deescalating a crisis situation.

(k) "DMHA" refers to the Indiana division of mental health and addiction, which is responsible for operating the CMHW services program. For purposes of this rule, use of the term "the DMHA" includes the following:

(1) Staff hired by the DMHA.

(2) An entity under contract with the DMHA to provide a service or to complete administrative tasks or functions assigned by the DMHA and required under this rule.

(l) "Eligibility determination form" means the written notice provided to the access site, documenting a DMHA determination regarding the meeting of eligibility for level of need and participation in the CMHW services program by an applicant or participant. The access site shall share this information with the applicant or participant, including the following information that accompanies the eligibility determination form:

(1) Approval or denial of the applicant's or participant's level of care or eligibility to participate in the CMHW services program.

(2) CMHW services approved or denied by the DMHA.

(3) The effective dates and reasons for the action or actions taken.

(4) The applicant's or participant's appeal and fair hearing rights and procedural information.

(m) "Family" refers to the legal guardian or caretaker responsible for the care of a participant.

(n) "Licensed professional" means any of the following persons:

(1) A licensed psychiatrist.

(2) A licensed physician.

(3) A licensed psychologist or a psychologist endorsed as a health service provider in psychology (HSPP).

(4) A licensed clinical social worker (LCSW).

(5) A licensed mental health counselor (LMHC).

(6) A licensed marriage and family therapist (LMFT).

(7) A licensed clinical addiction counselor (LCAC), as defined under IC 25-23.6-10.5.

(o) "OMPP" refers to the office of Medicaid policy and planning that is responsible for oversight of the CMHW services program. For purposes of this rule, the use of the term includes the following:

(1) Staff hired by the OMPP.

(2) Contract entities working on behalf of the OMPP to provide services or to complete administrative tasks or functions required under this rule.

(p) "Participant" means a person receiving CMHW services.

(q) "Plan of care" means the individualized treatment plan that integrates all components and aspects of care, including services that are deemed medically necessary or clinically indicated and all medical and behavioral support services and interventions needed to assist the participant in the following:

(1) To remain in the home or community.

(2) To function at the highest level of independence possible.

(3) To achieve treatment goals.

(r) "Qualified professional" means a provider who is a licensed professional as defined in this subsection or supervised by a licensed professional.

(s) "Qualifying SED work experience" means work directly with the SED population in a way that builds functional skills, such as the following:

(1) Group counseling, one-on-one counseling, provision of skills training, or provision of therapeutic recreational activities.

(2) The provision of therapeutic foster care, or work in a capacity that may not involve mental health care, but where the work is targeted at a defined SED population.

(3) Experience in case management, therapy, or skills training, in conjunction with a mental health center is also considered as qualifying SED work experience.

(t) "Seriously emotionally disturbed" or "SED" refers to severe functional impairments due to a mental illness, as defined in 440 IAC 8-2-4.

(u) "System of care" refers to a comprehensive spectrum of mental health and other necessary services that are organized into a coordinated network to meet the multiple and changing needs of children and their families, and includes the following concepts regarding care delivery:

(1) Family-driven and child-guided.

(2) Individualized and community-based.

(3) Culturally and linguistically competent.

(v) "The state" refers to the state agencies responsible for administration and operation of CMHW services as defined in this rule.

(w) "Unpaid caregiver" means a person, family member, neighbor, friend, co-worker, or companion who provides uncompensated care, training, guidance, companionship, or support to an enrolled CMHW services participant.

(x) "Wraparound facilitator" means an individual who facilitates and supervises the delivery of wraparound services for a CMHW services participant.

(y) "Wraparound model of service delivery" means a practice model that is a team-based process for planning and implementing formal and informal services, interventions, and supports for children with complex needs. Services are provided in a manner that is consistent with and guided by a system of care philosophy that builds on the collective action of a committed group of family, friends, community, professionals, and cross-system supports mobilizing resources and talents from a variety of sources resulting in the creation of a plan of care that is the best fit for the family vision and story, team mission, strengths, underlying needs, resources, and strategies.

(Office of the Secretary of Family and Social Services; 405 IAC 5-21.7-2)

405 IAC 5-21.7-3 Applicants and the application process

Authority: IC 12-8-6.5-5; IC 12-15

Affected: IC 12-13-7-3; IC 12-29; IC 25-23.6-10.5; IC 25-27.5-5

Sec. 3. (a) The purpose of the application process is to provide families with a means to explore whether their child may be eligible for and benefit from CMHW services.

(b) A referral application for CMHW services must be made in the manner required by the OMPP and the DMHA.

(c) Access sites, which are DMHA-approved CMHW service agencies, provide a local point of access in order for applicants and their families to complete the CMHW services application process that includes the following:

(1) Completion of the CMHW services application.

(2) A face-to-face evaluation and administration of the behavioral health assessment tool to assist the DMHA in determining whether an applicant meets the eligibility and needs-based criteria for enrollment in CMHW services.

(d) The DMHA, which makes the final eligibility determination for all applicants for CMHW services, shall do the following:

(1) Review the applicant's application, evaluation, and behavioral health assessment tool findings.

(2) Notify the access site regarding the DMHA eligibility determination with an eligibility determination form.

(e) The eligibility determination form shall include the following, as applicable:

(1) Approval of the applicant for enrollment in CMHW services, if the eligibility and needs-based criteria are met.

(2) Denial of the applicant for enrollment in CMHW services if either the eligibility criteria or the needs-based criteria is not met.

(3) Initial DMHA-approved plan of care.

(f) The access site shall do the following:

(1) Notify the family regarding the DMHA approval or denial of the applicant for the CMHW services program.

(2) Provide the family with information regarding the family's rights, including information regarding how to appeal the DMHA eligibility determination, if so desired.

(Office of the Secretary of Family and Social Services; 405 IAC 5-21.7-3)

405 IAC 5-21.7-4 Independent assessment and evaluation

Authority: IC 12-8-6.5-5; IC 12-15

Affected: IC 12-13-7-3; IC 12-29; IC 25-23.6-10.5; IC 25-27.5-5

Sec. 4. (a) Each applicant completing the application process for CMHW services shall undergo a face-to-face assessment and evaluation by an access site.

(b) The purpose of the assessment and evaluation is to determine whether an applicant meets the CMHW services eligibility and needs-based criteria.

(c) The assessment shall include administration of the DMHA-approved behavioral assessment tool in order to:

(1) assess an applicant's strengths, needs, and functional impairment or impairments; and

(2) assist in determining an applicant's level of need for CMHW services, based upon the assessment results and algorithm for a behavioral recommendation.

(d) The assessment or evaluation and clinical documentation gathered by the access site and submitted to the DMHA for review and determination of an applicant's eligibility will include, but are not limited to, the following:

(1) Current and historical behavioral health needs, including treatment history and confirmation of mental health diagnoses.

(2) Evaluation findings and behavioral recommendation from administration of the DMHA-approved behavioral assessment tool.

(3) Assessment of an applicant's functional strengths and needs.

(4) Assessment of the strengths and needs of the family.

(5) Documentation of an applicant's meeting target group and financial eligibility criteria.

(6) Documentation demonstrating that the applicant does not meet CMHW services exclusionary criteria.

(7) Information about the individual's current and historical health status and needs.

(8) Information to satisfy the state's data collection requirements.

(9) Any additional information or documentation needed to support a determination that the applicant meets eligibility and needs-based criteria required to access CMHW services.

(Office of the Secretary of Family and Social Services; 405 IAC 5-21.7-4)

405 IAC 5-21.7-5 Eligibility and needs-based criteria

Authority: IC 12-8-6.5-5; IC 12-15

Affected: IC 12-13-7-3; IC 12-29; IC 25-23.6-10.5; IC 25-27.5-5

Sec. 5. (a) To be enrolled in the CMHW services program, the applicant must meet the following target group eligibility criteria:

(1) The applicant meets age criteria, which is six (6) through seventeen (17) years of age.

(2) The applicant meets the criteria for two (2) or more DSM-IV-TR (or subsequent revision) diagnoses.

(3) The applicant does not meet any of the following CMHW services exclusionary criteria:

(A) Primary substance abuse disorder.

(B) Primary or secondary pervasive developmental disorder (autism spectrum disorder).

(C) Primary attention deficit hyperactivity disorder.

(D) Intellectual disability or disabilities.

(E) Dual diagnosis of serious emotional disturbance and intellectual disabilities.

(b) In addition to meeting the target group eligibility criteria, the applicant must also meet CMHW services needs-based criteria, which include the following:

(1) The applicant is experiencing significant emotional or functional impairments, or both, that impact the level of functioning at home or in the community, as a result of a mental illness, and supported by a behavioral recommendation of a 4, 5, or 6 from the administered DMHA-approved behavioral assessment tool.

(2) The applicant that meets a 4, 5, or 6 behavioral recommendation on the behavioral assessment tool must also demonstrate dysfunctional patterns of behavior due to one (1) or more of the following behavioral or emotional needs identified on the behavioral assessment tool:

(A) Adjustment to trauma.

(B) Psychosis.

(C) Debilitating anxiety.

(D) Conduct problems.

(E) Sexual aggression.

(F) Fire-setting.

(3) The applicant demonstrates significant needs in at least one (1) of the family or caregiver areas, as indicated on the DMHA-approved behavioral assessment tool, which results in a negative impact on the applicant's mental illness:

(A) Mental health.

(B) Supervision issues.

(C) Family stress.

(D) Substance abuse.

(4) The applicant does not meet any of the following exclusionary criteria:

(A) The applicant is at imminent risk of harm to himself or herself or to others.

(B) The applicant is identified as feasibly unable to receive intensive community-based services without compromising his or her safety, or the safety of others.

(Office of the Secretary of Family and Social Services; 405 IAC 5-21.7-5)

405 IAC 5-21.7-6 Individualized plan of care

Authority: IC 12-8-6.5-5; IC 12-15

Affected: IC 12-13-7-3; IC 12-29; IC 25-23.6-10.5; IC 25-27.5-5

Sec. 6. (a) The plan of care is an individualized treatment plan that integrates all components and aspects of care, including services, interventions, and supports that are deemed medically necessary or clinically indicated.

(b) The plan of care must include all indicated medical and behavioral support services needed by a participant in order to assist the participant in the following:

(1) Remaining in the home or community.

(2) Functioning at the highest level of independence possible.

(3) Achieving treatment goals.

(c) The CMHW services plan of care developed within the team, with participant and family input and inclusion, must meet the following criteria:

(1) Be developed for each participant based upon the participant's unique strengths and needs, as ascertained in the evaluation or assessment.

(2) Reflect the participant's and the family's preferences and choices for services and providers.

(3) Contain goals that delineate the following:

(A) Clear objectives.

(B) Resources, including the child and family team member or members that will assist the participant in meeting each goal.

(C) Service duration and frequency, based upon the participant's level of need and functional impairments.

(d) In addition to the plan of care, the team shall develop a crisis plan that includes the following components:

(1) Anticipated crisis or crises that the participant may experience based upon historical information.

(2) Potential triggers that may lead to a crisis situation involving the participant.

(3) Interventions that have either worked or not worked in deescalating a crisis situation in the past.

(4) The plan of action for the participant, the participant's family, and members of the child and family team in the event of a crisis.

(5) Identified resources available to assist the participant and the participant's family in the event of a crisis.

(e) The plan of care and the crisis plan must be submitted to the DMHA for review and approval prior to the delivery of CMHW services.

(Office of the Secretary of Family and Social Services; 405 IAC 5-21.7-6)

405 IAC 5-21.7-7 Participant freedom of choice

Authority: IC 12-8-6.5-5; IC 12-15

Affected: IC 12-13-7-3; IC 12-29; IC 25-23.6-10.5; IC 25-27.5-5

Sec. 7. The participant and the participant's family have freedom of choice regarding the following aspects of CMHW service delivery:

(1) Determining who will participate in the team.

(2) Identifying the plan of care goals and the method for achieving those goals.

(3) Selecting the CMHW services, as supported by the participant's assessment and level of need that will be included in the plan of care.

(4) Choosing the DMHA-certified CMHW service provider or providers who will provide, oversee, and monitor implementation of the plan of care.

(5) Changing the CMHW service provider or providers at any time during the participant's enrollment in the CMHW services program.

(Office of the Secretary of Family and Social Services; 405 IAC 5-21.7-7)

405 IAC 5-21.7-8 Eligibility period

Authority: IC 12-8-6.5-5; IC 12-15

Affected: IC 12-13-7-3; IC 12-29; IC 25-23.6-10.5; IC 25-27.5-5

Sec. 8. (a) Ongoing eligibility for CMHW services is dependent upon the participant continuing to meet eligibility and needs-based criteria for the CMHW services program.

(b) A participant shall be eligible to receive CMHW services, as documented in the plan of care, for up to a twelve (12) month period, as long as eligibility and needs-based criteria continue to be met.

(c) Administration of the DMHA-approved behavioral assessment tool must occur every six (6) months from the date of last administration of the tool to evaluate a participant's level of need and response to CMHW services.

(d) The DMHA-approved wraparound facilitator must complete a face-to-face reevaluation of the participant at least every twelve (12) months with input and participation from the child and family team, including the participant and the participant's family.

(e) The face-to-face evaluation of the participant shall include, but is not limited to, the following:

(1) Administration of the DMHA-approved behavioral assessment tool to determine whether the participant continues to meet the level of need and the needs-based criteria for CMHW services.

(2) Evaluation of the participant's response to CMHW services and progress towards meeting treatment goals on the plan of care.

(3) Evaluation of the participant's strengths, needs, and functional impairments.

(4) Documentation that the participant continues to meet the following eligibility criteria as defined in 405 IAC 5-21.7-5:

(A) Financial criteria.

(B) Target group eligibility.

(C) Needs-based criteria.

(5) The proposed updated plan of care and the crisis plan for DMHA review and approval.

(f) The DMHA reviews the evaluation findings to assess and determine a participant's continued eligibility for CMHW services.

(g) The DMHA shall notify the wraparound facilitator regarding the results of the review determination and the participant's continued eligibility for services, which may include the following:

(1) Approval of the participant for continued enrollment in CMHW services, if the participant continues to meet CMHW services' eligibility and needs-based criteria.

(2) Denial of the participant's enrollment in CMHW services if the eligibility criteria or the needs-based criteria are not met.

(3) Approval of the plan of care for continued CMHW services.

(h) The wraparound facilitator shall notify the participant and the participant's family regarding the DMHA's determination of CMHW services eligibility as follows:

(1) By providing an eligibility determination form that documents the DMHA's eligibility determination of approval or denial of the child for CMHW services.

(2) By providing the family with information regarding the fair hearings and appeals process.

(i) If the participant no longer meets the level of need, or is otherwise deemed ineligible for CMHW services, the wraparound facilitator and team shall work together with the participant and the participant's family to develop and implement a transition plan. The transition plan shall assist the participant in moving from CMHW services to community-based services appropriate for the participant's current level of need.

(Office of the Secretary of Family and Social Services; 405 IAC 5-21.7-8)

405 IAC 5-21.7-9 Coverage requirements and limits

Authority: IC 12-8-6.5-5; IC 12-15

Affected: IC 12-13-7-3; IC 12-29; IC 25-23.6-10.5; IC 25-27.5-5

Sec. 9. (a) In order for a service provider to be reimbursed for providing a CMHW service to an eligible participant, the service must be provided in the manner established by this section.

(b) In order to be eligible for reimbursement, a covered CMHW service shall meet the following criteria:

(1) Be documented on the participant's DMHA-approved plan of care.

(2) Be supported by the participant's level of need, as documented in the most recent assessment of the participant.

(3) Be provided by a DMHA-certified CMHW service provider meeting all required service-specific qualifications and standards.

(4) Be provided within the scope and limitations for the service as approved by the DMHA and the OMPP.

(c) A CMHW service shall be deemed noncovered and shall not be eligible for reimbursement if the service meets any of the following criteria:

(1) The service is provided to the participant at the same time as another service that is the same in nature and scope, regardless of funding source, including federal, state, local, and private entities.

(2) The service is provided as a diversionary, leisurely, or recreational activity that is not a component of respite care service.

(3) The service is provided in a manner that is not within the scope or limitations of the CMHW service.

(4) The service is not documented as a covered or authorized service on the participant's DMHA-approved plan of care.

(5) Provision of the service is not supported by the DMHA-approved documentation standards in the participant's clinical record.

(6) The service is provided by a service provider other than the service provider documented on the participant's plan of care.

(7) The service provided exceeds the limits approved by DMHA, including the quantity, limit, duration, or frequency of the service.

(8) The service is listed in this rule as a noncovered service or is otherwise excluded from coverage.

(Office of the Secretary of Family and Social Services; 405 IAC 5-21.7-9)

405 IAC 5-21.7-10 Provider certification and application process

Authority: IC 12-8-6.5-5; IC 12-15

Affected: IC 12-13-7-3; IC 12-29; IC 25-23.6-10.5; IC 25-27.5-5

Sec. 10. (a) Only a DMHA-certified individual or agency enrolled as a Medicaid provider of CMHW services may be reimbursed for providing a CMHW service to an eligible participant.

(b) A CMHW service provider must be authorized by the DMHA according to the specific qualifications for and standards of the service that the provider or agency is eligible to provide, as further defined in section 11 of this rule.

(c) A DMHA-authorized service provider must be classified as one (1) of the following types of CMHW service provider:

(1) An accredited agency provider, which is defined as a provider employed by an accredited agency meeting the following requirements:

(A) The provider is authorized by the DMHA as a community mental health center (CMHC) or has been accredited by one (1) of the following nationally recognized accrediting bodies:

(i) The Accreditation Association for Ambulatory Health Care (AAAHC).

(ii) The American Council for Accredited Certification (ACAC).

(iii) The Commission on Accreditation of Rehabilitation Facilities (CARF).

(iv) The Council on Accreditation (COA).

(v) The Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

(vi) The National Committee for Quality Assurance (NCQA).

(vii) The Utilization Review Accreditation Commission (URAC).

(B) The agency participates in a local system of care, which includes both a governing coalition and a service delivery system that endorses the values and principles of wraparound services, or, if that area of the state does not have an organized system of care, the provider is a part of a DMHA-authorized access site for services.

(C) The agency has employed a provider or providers that qualify to provide one (1) or more CMHW service, as set out in section 11 of this rule.

(2) A nonaccredited agency provider is defined as a provider employed by an agency without accreditation from a nationally-recognized accrediting body that meets the following requirements:

(A) The agency is able to submit documentation proving that the agency has articles of incorporation.

(B) The agency has employed a provider or providers that qualify to provide one (1) or more CMHW services, as defined in section 11 of this rule.

(3) An individual service provider is defined as a licensed or unlicensed service provider that meets the following requirements:

(A) The individual provider is not employed by an accredited or nonaccredited agency as defined in this section.

(B) The individual provider qualifies to deliver one (1) or more CMHW services, as defined in section 11 of this rule.

(d) An agency or individual provider that requests enrollment as a CMHW service provider must complete the following application requirements:

(1) Complete and submit the CMHW service provider application to the DMHA for review and consideration.

(2) Submit documentation demonstrating that the individual or agency meets all qualifications outlined in this subsection.

(3) Submit documentation demonstrating that an individual provider or a provider hired by an accredited or nonaccredited agency meets the qualifications for the CMHW service certification that is being applied for, as defined in section 11 of this rule.

(4) Submit documentation demonstrating completion of the following screenings required of all providers:

(A) Fingerprinting based on national and state criminal history background screenings.

(B) Local law enforcement screening.

(C) State and local department of child services abuse registry screening.

(D) A five-panel drug screening or, in the alternative, the provider meets the requirements specified under the Federal Drug Free Workplace Act of 1988 (P.L.100-690, Title V, subtitle D).

(e) The DMHA shall review the provider application and documentation to determine whether the agency or the individual meets the criteria for a DMHA-authorized CMHW service provider.

(f) An individual or an agency meeting the criteria as a CMHW service provider and receiving a DMHA certification approval letter must also apply to the OMPP for a Medicaid Indiana Health Coverage Programs (IHCP) provider number prior to providing and billing for CMHW services.

(g) If the OMPP denies the request of an individual or an agency for an IHCP provider number, then the individual or the agency will not be authorized to:

(1) provide;

(2) bill for; or

(3) be reimbursed for;

any CMHW service.

(Office of the Secretary of Family and Social Services; 405 IAC 5-21.7-10)

405 IAC 5-21.7-11 Provider authorization and service provider qualifications

Authority: IC 12-8-6.5-5; IC 12-15

Affected: IC 12-13-7-3; IC 12-17-12; IC 12-17.2-4; IC 12-17.2-5; IC 12-29; IC 25-23.6; IC 25-27.5-5; IC 25-33-1; IC 31-27-3; IC 31-27-4

Sec. 11. (a) In addition to meeting CMHW service standards required for the provider authorization process, as defined in section 10 of this rule, the service provider must also meet service-specific qualifications, based upon the specific CMHW service for which the provider is seeking DMHA authorization to deliver.

(b) A wraparound facilitation service provider must meet the following qualifications and standards:

(1) The provider must be employed by a DMHA-authorized accredited agency.

(2) The provider must qualify as an other behavioral health professional (OBHP), as defined in 405 IAC 5-21.5-1, who has one (1) of the following:

(A) A bachelor's degree with two (2) or more years of clinical experience.

(B) A master's degree in social work, psychology, counseling, nursing, or other mental health-related field, with two (2) or more years of clinical experience.

(3) The provider must complete the following DMHA-required service provider training and certifications:

(A) CMHW services orientation.

(B) Child and adolescent needs and strengths assessment tool certification.

(C) Wraparound practitioner certification, provided, however, that the facilitator shall have eighteen (18) months after the starting date to complete the certification.

(D) Cardiopulmonary resuscitation (CPR) certification.

(c) A habilitation service provider must meet the following qualifications and standards:

(1) Be at least twenty-one (21) years of age.

(2) Possess a high school diploma or the equivalent.

(3) Demonstrate a minimum of three (3) years of qualifying SED work experience.

(4) Provide documentation of a safe driving record, as well as the following:

(A) A current driver's license.

(B) Proof of motor vehicle insurance coverage.

(C) Proof of current vehicle registration.

(5) For every thirty (30) hours of habilitation services provided, the provider must obtain one (1) hour of face-to-face supervision with an approved mental health service provider that meets one (1) of the following licensure requirements:

(A) Licensure in psychology (HSPP) as defined in IC 25-33-1.

(B) Licensed marriage and family therapist (LMFT) under IC 25-23.6-8.

(C) Licensed clinical social worker (LCSW) under IC 25-23.6-5.

(D) Licensed mental health counselor (LMHC) under IC 25-23.6-8.5.

(6) Complete the following DMHA-required service provider training:

(A) CMHW services orientation.

(B) CPR certification.

(d) A CMHW respite care service provider must meet the following requirements and standards as applicable:

(1) All individuals providing respite care services must meet the following qualifications and standards:

(A) Be at least twenty-one (21) years of age.

(B) Possess a high school diploma or the equivalent.

(C) Demonstrate three (3) years of qualifying SED work experience.

(D) Provide documentation of a safe driving record, as well as:

(i) a current driver's license;

(ii) proof of motor vehicle insurance coverage; and

(iii) proof of current vehicle registration.

(E) Complete the following DMHA-required service provider training:

(i) CMHW services orientation.

(ii) CPR certification.

(2) A participant's relative, related by blood, marriage, or adoption, who is not the participant's legal guardian or primary caregiver and who does not live in the participant's home, may also provide respite care services, under the following conditions:

(A) The individual is selected by the participant or the participant's family to provide the service.

(B) The team has determined that provision of the service by a relative is in the best interests of the participant.

(C) The individual providing the service must do the following:

(i) Apply for and be certified as a CMHW respite care service provider.

(ii) Meet all of the qualifications and standards required for an individual respite care service provider.

(3) DMHA-authorized respite care service providers may include the following agencies or facilities licensed by the Indiana family and social services administration, division of family resources, or the Indiana department of child services, and shall meet CMHW services accredited agency certification standards defined in section 10 of this rule:

(A) Emergency shelters licensed under 465 IAC 2-10.

(B) Foster homes licensed under IC 31-27-4, including special needs and therapeutic foster homes only when the licensed child placing agency (LCPA) is a DMHA-certified agency provider. The DMHA is authorized to request a copy of the study of the home of the foster parent providing respite care services.

(C) Other child caring institutions licensed under IC 31-27-3.

(D) Child care centers licensed under IC 12-17.2-4.

(E) Child care homes licensed under IC 12-17.2-5.

(F) School age child care project licensed under IC 12-17-12.

(e) A CMHW services training and support for unpaid caregiver service provider must meet the following qualifications and standards:

(1) Be at least twenty-one (21) years of age.

(2) Possess a high school diploma or the equivalent.

(3) Demonstrate two (2) years of qualifying SED work experience with SED children.

(4) With regard to an individual service provider, live within a one-county area from the county of the participant's residence.

(5) Complete the following DMHA-required service provider training:

(A) CMHW service orientation.

(B) CPR certification.

(Office of the Secretary of Family and Social Services; 405 IAC 5-21.7-11)

405 IAC 5-21.7-12 Provider training

Authority: IC 12-8-6.5-5; IC 12-15

Affected: IC 12-13-7-3; IC 12-29; IC 25-23.6-10.5; IC 25-27.5-5

Sec. 12. (a) Each year a DMHA authorized CMHW service provider must complete ten (10) hours of ongoing training and continuing education in either child mental health or SED child-related topics.

(b) The provider must keep current all service-related trainings and certifications required for a CMHW service provider.

(c) The provider must submit verification of compliance with training and service-related certification requirements to the DMHA at the time of provider reauthorization.

(d) A service provider's failure to comply with CMHW training and service-related certification requirements may result in the revocation of the provider's CMHW service provider authorization.

(Office of the Secretary of Family and Social Services; 405 IAC 5-21.7-12)

405 IAC 5-21.7-13 Provider reauthorization

Authority: IC 12-8-6.5-5; IC 12-15

Affected: IC 12-13-7-3; IC 12-29; IC 25-23.6-10.5; IC 25-27.5-5

Sec. 13. (a) To ensure continued compliance with provider qualifications and standards for providing CMHW services, a DMHA-certified CMHW service provider must reapply for certification according to the following recertification schedule:

(1) An accredited agency provider must apply for recertification:

(A) at least every three (3) years following the initial DMHA certification; or

(B) at the time of the agency reaccreditation;

whichever date is earlier.

(2) A nonaccredited agency provider must apply for reauthorization at least every two (2) years following the initial DMHA authorization.

(3) An individual service provider must apply for reauthorization at least every two (2) years following the initial DMHA certification.

(b) A provider must submit the application for reauthorization in writing to the DMHA at least sixty (60) days prior to the due date for reauthorization.

(c) An agency or individual provider applying for reauthorization as a CMHW service provider must complete the following application requirements:

(1) Complete and submit the CMHW services provider recertification application to the DMHA for review and consideration.

(2) Submit documentation demonstrating that the individual provider or agency provider continues to meet all qualifications contained in section 10 of this rule.

(3) Submit documentation demonstrating that the individual provider or agency provider continues to meet the qualifications for the CMHW service authorization being applied for, as defined in section 11 of this rule.

(4) Submit documentation demonstrating compliance with the following:

(A) Yearly provider continuing education training.

(B) Updated certification requirements.

(d) The DMHA shall review the provider application and documentation to determine whether the agency or individual provider continues to meet the criteria for authorization as a CMHW service provider.

(e) Failure to comply with authorization requirements in a timely manner will result in the following corrective action:

(1) The agency or individual provider will be placed on suspended status as a CMHW services provider, pending the completion of the DMHA reauthorization process.

(2) The agency or individual provider must continue to provide services to those participants whom the provider is currently serving, but will be prohibited from accepting any new participants.

(3) Upon the DMHA's receipt and approval of the provider reauthorization paperwork, the status of the agency or individual provider will be updated to active status, thereby allowing the provider to accept new CMHW services participants.

(4) A provider's continued failure to comply with reauthorization requirements will result in the DMHA's revoking authorization for that provider to deliver CMHW services.

(Office of the Secretary of Family and Social Services; 405 IAC 5-21.7-13)

405 IAC 5-21.7-14 Provider sanctions

Authority: IC 12-8-6.5-5; IC 12-15

Affected: IC 12-13-7-3; IC 12-29; IC 25-23.6-10.5; IC 25-27.5-5

Sec. 14. (a) Under 405 IAC 1-1-6, if a provider has violated any provision established under IC 12-15, the OMPP may impose one (1) or more of the following sanctions:

(1) Deny payment.

(2) Revoke authorization as a CMHW services provider.

(3) Assess a fine.

(4) Assess an interest charge.

(5) Require corrective action against an agency or a provider.

(b) The loss of DMHA authorization for a provider to deliver CMHW services may occur due to, but not limited to, the following:

(1) The provider's failure to adhere to and follow CMHW services policies and procedures for behavior, documentation, billing, or service delivery.

(2) The provider's failure to respond to or resolve a corrective action imposed upon the provider by the DMHA or the OMPP for noncompliance with CMHW services' policies and procedures.

(3) The provider's failure to maintain CMHW services provider qualifications, DMHA-required training, or standards contained in this rule for the CMHW service or services the provider is authorized to provide.

(4) The provider's failure to timely reapply for CMHW services provider authorization.

(Office of the Secretary of Family and Social Services; 405 IAC 5-21.7-14)

405 IAC 5-21.7-15 Services: general provisions

Authority: IC 12-8-6.5-5; IC 12-15

Affected: IC 12-13-7-3; IC 12-29; IC 25-23.6-10.5; IC 25-27.5-5

Sec. 15. (a) All CMHW services provided to a participant must meet the following requirements:

(1) Be supported by the participant's level of need.

(2) Be documented in the participant's plan of care.

(b) A provider shall maintain documentation for services provided to a CMHW services participant in accordance with the requirements under 405 IAC 1-5-1.

(c) Provider reimbursement for CMHW services is subject to, but not limited to, the following:

(1) The participant's eligibility for services.

(2) The provider's qualifications and certification.

(3) Prior authorization by the DMHA.

(4) The scope, limitations, and exclusions of the services.

(Office of the Secretary of Family and Social Services; 405 IAC 5-21.7-15)

405 IAC 5-21.7-16 Wraparound facilitation services

Authority: IC 12-8-6.5-5; IC 12-15

Affected: IC 12-13-7-3; IC 12-29; IC 25-23.6-10.5; IC 25-27.5-5

Sec. 16. (a) Wraparound facilitation services are as follows:

(1) Comprehensive services comprised of a variety of specific tasks and activities designed to carry out the wraparound process.

(2) A required component of the CMHW services program.

(b) Wraparound facilitation is:

(1) a planning process that follows a series of steps; and

(2) provided through a child and family wraparound team.

(c) The team is responsible for assuring that a participant's needs, and the entities responsible for addressing those needs, are identified in a written plan of care.

(d) The wraparound facilitator manages and supervises the wraparound process through the following activities:

(1) Completing a comprehensive evaluation of the participant, including administration of the DMHA-approved behavioral assessment tool.

(2) Guiding the family engagement process by exploring and assessing strengths and needs.

(3) Facilitating, coordinating, and attending team meetings.

(4) Working in full partnership with the participant, family, and team members to ensure that the plan of care is developed, written, and approved by the DMHA.

(5) Assisting the participant and the participant's family in gaining access to the full array of services, that is, medical, social, educational, or other needed services.

(6) Guiding the planning process for the plan of care by:

(A) informing the team of the family's vision; and

(B) ensuring that the family's vision is central to the planning and delivery of services.

(7) Ensuring the development, implementation, and monitoring of a crisis plan.

(8) Assuring that all work to be done to assist the participant and the participant's family in achieving goals on the plan of care is identified and assigned to a team member.

(9) Overseeing and monitoring all services authorized for a participant's plan of care.

(10) Reevaluating and updating the plan of care as dictated by the participant's needs and securing DMHA approval of the plan of care.

(11) Assuring that care is delivered in a manner consistent with strength-based, family-driven, and culturally competent values.

(12) Offering consultation and education to all CMHW service providers regarding the values and principles of the wraparound services model.

(13) Monitoring a participant's progress toward meeting treatment goals.

(14) Ensuring that necessary data for evaluation is gathered, recorded, and preserved.

(15) Ensuring that the CMHW services assessment and service-related documentation are gathered and reported to the DMHA as required by the DMHA.

(16) Completing an annual CMHW services level of need reevaluation, with active involvement of the participant, the participant's family, and the team.

(17) Guiding the transition of the participant and the participant's family from CMHW services to state plan services or other community-based services when indicated.

(Office of the Secretary of Family and Social Services; 405 IAC 5-21.7-16)

405 IAC 5-21.7-17 Habilitation services

Authority: IC 12-8-6.5-5; IC 12-15

Affected: IC 12-13-7-3; IC 12-29; IC 25-23.6-10.5; IC 25-27.5-5

Sec. 17. (a) Habilitation services are provided with the following goals:

(1) Enhancing the participant's level of functioning, quality of life, and use of social skills.

(2) Building the strengths, resilience, and positive outcomes of the participant and the participant's family.

(b) Habilitation services are provided face-to-face in either the participant's home or other community-based setting, based upon the preferences of the participant and the participant's family.

(c) Habilitation services are provided to assist the participant with the following:

(1) Identifying feelings.

(2) Managing anger and emotions.

(3) Giving and receiving feedback, criticism, or praise.

(4) Problem solving and decision making.

(5) Learning to resist negative peer pressure and develop pro-social peer interactions.

(6) Improving communication skills.

(7) Building and promoting positive coping skills.

(8) Learning how to have positive interactions with peers and adults.

(d) Service exclusions are the following:

(1) Services provided to a person other than the participant, such as when an activity occurs in a group setting.

(2) Services provided to a family member or members.

(3) Services provided in order to give the family respite.

(4) Services that are strictly vocational or educational in nature, such as tutoring or any other activity available to the participant through the local educational agency under the:

(A) Individuals with Disabilities Education Improvement Act of 2004; or

(B) Rehabilitation Act of 1973.

(5) Activities provided in the service provider's residence.

(6) Leisure activities that provide a diversion rather than a therapeutic objective.

(e) The provision of habilitation services is limited to the following:

(1) Up to three (3) hours of services daily.

(2) Up to thirty (30) hours of services per month.

(Office of the Secretary of Family and Social Services; 405 IAC 5-21.7-17)

405 IAC 5-21.7-18 Respite care services

Authority: IC 12-8-6.5-5; IC 12-15

Affected: IC 12-13-7-3; IC 12-29; IC 25-23.6-10.5; IC 25-27.5-5

Sec. 18. (a) Respite care services are:

(1) provided to a participant unable to care for himself or herself; and

(2) furnished on a short-term basis because of the absence, or need for relief, of a person or persons who normally provide care for the participant.

(b) Respite care services may be provided in the following manner for planned or routine time frames when a caregiver is aware of needing relief or assistance through respite care:

(1) On an hourly basis, but billed for less than seven (7) hours in the same day.

(2) On a daily basis and billed for a service provided from seven (7) to twenty-four (24) hours in the same day.

(3) As a daily service not to exceed a period of fourteen (14) consecutive days at one (1) time.

(c) Crisis respite care services may be provided on an unplanned basis when the caregiver requires assistance in caring for a participant as follows:

(1) In a crisis situation in which a child's health and welfare would be seriously impacted or harmed in the absence of crisis respite care.

(2) On a daily basis, and billed from eight (8) to twenty-four (24) hours in the same day.

(3) Not to exceed fourteen (14) consecutive days at one (1) time.

(d) Respite care services must be provided in the least restrictive environment available to ensure the health and welfare of the participant.

(e) Respite care service may be provided in the following locations:

(1) The participant's home or private place of residence in the community.

(2) Any DMHA-certified state licensed facility.

(f) A participant who needs consistent twenty-four (24) hour supervision, with regular monitoring of medications or behavioral symptoms, must be placed in a facility under the supervision of any of the following:

(1) A psychologist.

(2) A psychiatrist, physician, or nurse who meets licensing or certification requirements of his or her profession in the state of Indiana.

(g) Allowed respite care service activities include the following:

(1) Assistance with daily living skills, including assistance with accessing community activities and transporting the participant to or from community activities.

(2) Assistance with grooming and personal hygiene.

(3) Meal preparation, serving, and cleanup.

(4) The administration of medications.

(5) Supervision.

(h) Respite care service exclusions are the following:

(1) Respite care provided by the following:

(A) A parent or parents for a participant who is a minor child.

(B) Any relative who is the primary caregiver of a participant.

(C) Any individual living in a participant's residence.

(2) Respite care services provided as a substitute for regular child care to allow the parent to attend school or to engage in employment or employment search-related activities.

(3) Respite care provided in the residence of a CMHW respite care service provider, unless the service is provided by a DMHA- authorized relative of the participant.

(4) Respite care used to provide services to the participant while the participant is attending school.

(5) Crisis respite care service scheduled to relieve the family when a participant is in crisis.

(Office of the Secretary of Family and Social Services; 405 IAC 5-21.7-18)

405 IAC 5-21.7-19 Training and support for unpaid caregiver services

Authority: IC 12-8-6.5-5; IC 12-15

Affected: IC 12-13-7-3; IC 12-29; IC 25-23.6-10.5; IC 25-27.5-5

Sec. 19. (a) Training and support for unpaid caregivers is a service for an individual who is providing unpaid support, training, companionship, or supervision for a participant.

(b) The intent of this service is to provide education and supports to assist the caregiver in preserving the participant's family unit.

(c) Training and support activities must be:

(1) based on the unique needs of the family and caregiver; and

(2) identified in the plan of care.

(d) The providers of training and support activities must be identified in the plan of care.

(e) Allowed training and support activities for a caregiver may include, but are not limited to, the following:

(1) Practical living and decision making skills.

(2) Child development and parenting skills.

(3) Home management skills.

(4) Use of community resources and development of informal supports.

(5) Conflict resolution skills.

(6) Coping skills.

(7) Assistance in increasing understanding of a participant's mental health needs.

(8) Teaching communication and crisis deescalation skills geared for working with participant's mental health and behavioral needs.

(f) Nonhourly training and support service must be provided according to the following requirements:

(1) The service provides reimbursement to cover the costs for a training event or training resources, such as registration or conference fees, books, or supplies associated with the identified training and support need.

(2) A training support need must be as follows:

(A) Identified by the team as a participant's need.

(B) Documented on the participant's plan of care.

(3) An approved event identified by the team must be provided by one (1) of the following types of DMHA-approved resources:

(A) A nonprofit, civic, faith-based, professional, commercial, or government agency or organization.

(B) A community college, vocational school, or university.

(C) A lecture series, workshop, conference, or seminar.

(D) An online training program.

(E) A community mental health center.

(F) Other qualified community service agency.

(4) The maximum annual limitation for a nonhourly service is five hundred dollars ($500).

(g) The hourly training and support service is provided in the following manner:

(1) The service is provided for the caregiver identified on the plan of care.

(2) The service is provided face-to-face in the home or a community-based setting.

(3) An hourly service is limited to a maximum of two (2) hours per day.

(4) There is no annual limit for the hourly service subject, however, to the limitation in subdivision (3).

(Office of the Secretary of Family and Social Services; 405 IAC 5-21.7-19)

405 IAC 5-21.7-20 Fair hearings and appeals

Authority: IC 12-8-6.5-5; IC 12-15

Affected: IC 12-13-7-3; IC 12-29; IC 25-23.6-10.5; IC 25-27.5-5

Sec. 20. (a) CMHW services applicants, participants, and their families shall have an opportunity to request a fair hearing to appeal a decision of the DMHA regarding CMHW services eligibility or a request for services as described in this section.

(b) Information concerning a participant's right to a fair hearing and appeal and how to request such an appeal's hearing shall be provided to an applicant, participant, or the family of an applicant or participant at the following times:

(1) Provided to the applicant and the applicant's family by the local access site following the DMHA's determination of the applicant's eligibility for CMHW services.

(2) Provided to the participant and family by the wraparound facilitator following the DMHA review of a proposed CMHW services plan of care, or updated plan of care, to document the DMHA authorization or denial of the requested CMHW services.

(3) Provided to the participant and family by the wraparound facilitator following the participant's reevaluation for CMHW services eligibility.

(c) Notices of adverse action and the opportunity for a fair hearing shall be maintained in the participant's record by the local wraparound facilitation agency and by the DMHA.

(Office of the Secretary of Family and Social Services; 405 IAC 5-21.7-20)

405 IAC 5-21.7-21 Complaints and grievances

Authority: IC 12-8-6.5-5; IC 12-15

Affected: IC 12-13-7-3; IC 12-29; IC 25-23.6-10.5; IC 25-27.5-5

Sec. 21. (a) An applicant, a participant, and the family of an applicant or a participant shall have the right to file a complaint or grievance in writing with the state regarding CMHW service providers or CMHW services. All complaints and grievances are accepted by the following means:

(1) Delivery to the family-consumer section on the DMHA website.

(2) Delivery in-person to a DMHA staff member.

(3) Delivery via written complaint or e-mail that is submitted to the DMHA.

(b) The receipt of a complaint or grievance shall be recorded in the DMHA's data system with a copy attached to the provider's file. An investigation shall begin within seventy-two (72) hours of receipt of the complaint or grievance.

(c) When an investigation is complete, the following shall occur:

(1) The individual filing the complaint or grievance shall be informed of the DMHA's investigative findings through a letter from a DMHA staff member.

(2) The individual who filed a grievance or complaint must be informed that filing a grievance or complaint is neither a prerequisite nor a substitute for a fair hearing.

(d) If indicated by the results of an investigation, a letter of findings shall be sent to the CMHW service provider who is the subject of the complaint or grievance. The CMHW service provider shall correct any identified deficiency within the timeline established by the DMHA.

(e) If the CMHW service provider fails to correct the deficiency within the established timeline, the DMHA may pursue sanctions up to, and including, revoking authorization for the provider to deliver CMHW services.

(Office of the Secretary of Family and Social Services; 405 IAC 5-21.7-21)

Posted: 09/04/2013 by Legislative Services Agency

DIN: 20130904-IR-405130211PRA

Composed: Nov 01,2016 1:40:05AM EDT

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