Understanding the Behavioral Health Care System

Common Definitions Used in the Behavioral Health Field

1) Brief Intervention Treatment: 

Solution focused and outcomes oriented cognitive and behavioral interventions intended to ameliorate symptoms, resolve situational disturbances which are not amenable to resolution in a crisis service model of care and which do not require long term-treatment, to return the individual to previous higher levels of general functioning.  Individuals must be able to select and identify a focus for care that is consistent with time-limited, solution-focused or cognitive behavioral model of treatment.  Functional problems and/or needs identified in the Medicaid enrollee's Individual Service Plan must include a specific time frame for completion of each identified goal.  This service does not include ongoing care, maintenance/monitoring of the enrollee’s current level of functioning and assistance with self/care or life skills training.  Enrollees may move from Brief Intervention Treatment to longer term Individual Services at any time during the course of care.  This service is provided by or under the supervision of a Mental Health Professional.

2) Crisis Services: 

Evaluation and treatment of mental health crisis to all Medicaid enrolled individuals experiencing a crisis.  A mental health crisis is defined as a turning point in the course of anything decisive or critical, a time, a stage, or an event or a time of great danger or trouble, whose outcome decides whether possible bad consequences will follow.  Crisis services shall be available on a 24-hour basis.  Crisis Services are intended to stabilize the person in crisis, prevent further deterioration and provide immediate treatment and intervention in a location best suited to meet the needs of the individual and in the least restrictive environment available.  Crisis services may be provided prior to completion of an intake evaluation.  Services are provided by or under the supervision of a mental health professional.

3) Day Support: 

An intensive rehabilitative program which provides a range of  integrated and varied life skills training (e.g., health, hygiene, nutritional issues,  money management, maintaining living arrangement, symptom management) for Medicaid enrollees to promote improved functioning or a restoration to a previous higher level of functioning.  The program is designed to assist the individual in the acquisition of skills, retention of current functioning or improvement in the current level of functioning, appropriate socialization and adaptive coping skills.  Eligible individuals must demonstrate restricted functioning as evidenced by an inability to provide for their instrumental activities of daily living.  This modality may be provided as an adjunctive treatment or as a primary intervention.  The staff to consumer ratio is no more than 1:20 and is provided by or under the supervision of a mental health professional in a location easily accessible to the Peer (e.g., community mental health agencies, clubhouses, community centers).  This service is available 5 hours per day, 5 days per week.

4) Family Treatment: 

Psychological counseling provided for the direct benefit of a Medicaid enrolled individual. Service is provided with family members and/or other relevant persons in attendance as active participants.  Treatment shall be appropriate to the culture of the Peer and their family and should reinforce the family structure, improve communication and awareness, enforce and reintegrate the family structure within the community, and reduce the family crisis/upheaval.  The treatment will provide family-centered interventions to identify and address family dynamics and build competencies to strengthen family functioning in relationship to the consumer.  Family treatment may take place without the consumer present in the room but service must be for the benefit of attaining the goals identified for the individual in their individual service plan.  This service is provided by or under the supervision of a mental health professional. 

5) Freestanding Evaluation and Treatment: 

Services provided in freestanding inpatient residential (non-hospital/non-IMD) facilities licensed by the Department of Health and certified by the Mental Health Division to provide medically necessary evaluation and treatment to the Medicaid enrolled individual who would otherwise meet hospital admission criteria.  These are not-for-profit organizations. At a minimum, services include evaluation, stabilization and treatment provided by or under the direction of licensed psychiatrists, nurses and other mental health professionals, and discharge planning involving the individual, family, significant others so as to ensure continuity of mental health care. Nursing care includes but is not limited to; performing routine blood draws, monitoring vital signs, providing injections, administering medications, observing behaviors and presentation of symptoms of mental health challenges.  Treatment modalities may include individual and family therapy, milieu therapy, psycho-educational groups and pharmacology.  The individual is discharged as soon as a less-restrictive plan for treatment can be safely implemented. This service is provided for individuals who pose an actual or imminent danger to self, others, or property due to a mental health challenges, or who have experienced a marked decline in their ability to care for themselves due to the onset or exacerbation of a psychiatric disorder. The severity of symptoms, intensity of treatment needs or lack of necessary supports for the individual does not allow them to be managed at a lesser level of care.  This service does not include cost for room and board.  The Mental Health Division must authorize exceptions for involuntary length of stay beyond a fourteen-day commitment.

6) Group Treatment Services

Services provided to Medicaid enrolled individuals designed to assist in the attainment of goals described in the Individual Service Plan. Goals of Group Treatment may include developing self-care and/or life skills, enhancing interpersonal skills, mitigating the symptoms of mental health challenges, and  lessening the results of traumatic experiences, learning from the perspective and experiences of others and counseling/psychotherapy to establish and /or maintain stability in living, work or educational environment. Individuals eligible for Group Treatment must demonstrate an ability to benefit from experiences shared by others, demonstrate the ability to participate in a group dynamic process in a manner that is respectful of other's right to confidential treatment and must be able to integrate feedback from other group members. This service is provided by or under the supervision of a mental health professional to two or more Medicaid enrolled individuals at the same time. Staff to consumer ratio is no more than 1:12.  Maximum group size is 24.

7) High Intensity Treatment

Intensive levels of service otherwise furnished under this state plan amendment that is provided to Medicaid enrolled individuals who require a multi-disciplinary treatment team in the community that is available upon demand based on the individual’s need.  Twenty-four hours per day, seven days per week, access is required if necessary.  Goals for High Intensity Treatment include the reinforcement of safety, the promotion of stability and independence of the individual in the community, and the restoration to a higher level of functioning.  These services are designed to rehabilitate individuals who are experiencing severe symptoms in the community and thereby avoid more restrictive levels of care such as psychiatric inpatient hospitalization or residential placement.

8) Individual Treatment Services

A set of treatment services designed to help a Medicaid enrolled individual attain goals as prescribed in their individual treatment plan.  These services shall be congruent with the age, strengths, and cultural framework of the individual and shall be conducted with the individual, his or her family, or others at the individual’s behest who play a direct role in assisting the individual to establish and/or maintain stability in his/her daily life.  These services may include, developing the individual's self-care/life skills; monitoring the individual's functioning; counseling and psychotherapy. Services shall be offered at the location preferred by the Medicaid enrolled individual.  This service is provided by or under the supervision of a mental health professional.

9) Intake Evaluation

An evaluation that is culturally and age relevant initiated prior to the provision of any other mental health services, except crisis services, services, stabilization services and free-standing evaluation and treatment. The intake evaluation must be initiated within ten (10) working days of the request for services, establish the medical necessity for treatment and be completed within thirty (30) working days.  Routine services may begin before the completion of the intake once medical necessity is established. This service is provided by a mental health professional.

10) Medication Management

The prescribing and/or administering and reviewing of medications and their side effects.  This service shall be rendered face-to-face by a person licensed to perform such services.  This service may be provided in consultation with collateral, primary therapists, and/or case managers, but includes only minimal psychotherapy.

11) Medication Monitoring

Face-to-face one-on-one cueing, observing, and encouraging a Medicaid enrolled individual to take medications as prescribed.  Also includes reporting back to persons licensed to perform medication management services for the direct benefit of the Medicaid enrolled individual.  This activity may take place at any location and for as long as it is clinically necessary. This service is designed to facilitate medication compliance and positive outcomes.  Enrollees with low medication compliance history or persons newly on medication are most likely to receive this service. This service is provided by or under the supervision of a mental health professional. Time spent with the enrollee is the only direct service billable component of this modality.

12) Mental Health Services provided in Residential Settings

A specialized form of rehabilitation service (non-hospital/non IMD) that offers a sub-acute psychiatric management environment.  Medicaid enrolled individuals receiving this service present with severe impairment in psychosocial functioning or has apparent mental health challenges symptoms with an unclear etiology due to their mental health challenges and treatment cannot be safely provided in a less restrictive environment and do not meet hospital admission criteria.  Individuals in this service require a different level of service than High Intensity Treatment.  The Mental Health Care Provider is sited at the residential location (e.g., boarding homes, supported housing, cluster housing, SRO apartments) for extended hours to provide direct mental health care to a Medicaid enrollee. Therapeutic interventions both in individual and group format may include medication management and monitoring, stabilization, and cognitive and behavioral interventions designed with the intent to stabilize the individual and return him/her to more independent and less restrictive treatment.  The treatment is not for the purpose of providing custodial care or respite for the family, nor is it for the sole purpose of increasing social activity or used as a substitute for other community-based resources.  This service is billable on a daily rate. In order to bill the daily rate for associated costs for these services, a minimum of 8 hours of service must be provided. This service does not include the costs for room and board, custodial care, and medical services, and differs for other services in the terms of location and duration.

13) Peer Support

Services provided by Peer counselors to Medicaid enrolled individuals under the consultation, facilitation or supervision of a mental health professional who understands rehabilitation and recovery.  This service provides scheduled activities that promote socialization, recovery, self-advocacy, development of natural supports, and maintenance of community living skills.  Consumers actively participate in decision-making and the operation of the programmatic supports.  Self-help support groups, telephone support lines, drop-in centers, and sharing the Peer counselor’s own life experiences related to mental health challenges will build alliances that enhance the consumer’s ability to function in the community. These services may occur at locations where consumers are known to gather (e.g., churches, parks, community centers, etc.).  Drop-in centers are required to maintain a log documenting identification of the consumer including Medicaid eligibility. Services provided by Peer counselors to the consumer are noted in the consumers’ Individualized Service Plan which delineates specific goals that are flexible tailored to the consumer and attempt to utilize community and natural supports.  Monthly progress notes document consumer progress relative to goals identified in the Individualized Service Plan, and indicates where treatment goals have not yet been achieved. Peer counselors are responsible for the implementation of Peer support services.  Peer counselors may serve on High Intensity Treatment Teams. Peer support is available daily no more than four hours per day.  The ratio for this service is no more than 1:20.

14) Psychological Assessment

All psychometric services provided for evaluating, diagnostic, or therapeutic purposes by or under the supervision of a licensed psychologist.  Psychological assessments shall: be culturally relevant; provide information relevant to a consumer’s continuation in appropriate treatment; and assist in treatment planning within a licensed mental health agency.

15) Rehabilitation Case Management

A range of activities by the outpatient community mental health agency’s liaison conducted in or with a facility for the direct benefit of a Medicaid-enrolled individual in the public mental health system. To be eligible, the individual must be in need of case management in order to ensure timely and appropriate treatment and care coordination. Activities include assessment for discharge or admission community to mental health care, integrated mental health treatment planning, resource identification and linkage, to mental health rehabilitative services, and collaborative development of individualized services that promote continuity of mental health care. These specialized mental health coordination activities are intended to promote discharge, to maximize the benefits of the placement, and to minimize the risk of unplanned read mission and to increase the community tenure for the individual. Services are provided by or under the supervision of a mental health professional.

16) Special Population Evaluation: 

Evaluation by a child, geriatric, disabled, or ethnic minority specialist that considers age and cultural variables specific to the individual being evaluated and other culturally and age competent evaluation methods.  This evaluation shall provide information relevant to a consumer's continuation in appropriate treatment and assist in treatment planning. This evaluation occurs after intake.  Consultation from a non-staff specialist (employed by another CMHA or contracted the CMHA) may also be obtained, if needed, subsequent to this evaluation and shall be considered an integral, billable component of this service.

17) Stabilization Services

Services provided to Medicaid enrolled individuals who are experiencing a mental health crisis.  These services are to be provided in the person's own home, or another home-like setting, or a setting which provides safety for the individual and the mental health professional.