Therapeutic Behavioral OnSite Services Policy by L76qxdLo

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									          FLORIDA
          Therapy Services, Inc.



SUBJECT: Therapeutic Behavioral On-Site Services (TBOS) for Children and Adolescents

PURPOSE: To establish the scope, goal, need, and target population of TBOS. Florida Therapy
Services, Inc. (FTS) will adhere to the Agency for Health Care Administration (AHCA) Medicaid
Standards as described in the Medicaid Community Behavioral Health Services Coverage and
Limitations Handbook, October 2004, edition when providing TBOS to CMHC recipients.

POLICY:
Therapeutic behavioral on-site services are designed to assist children and their families who have
complex needs in an effort to prevent the need for a more intensive, restrictive behavioral health
placement. The process must be driven by assessment of the individual needs and strengths of each
child and family, and be developed and directed by a treatment team.

The treatment team must include the child and family, other persons who provide natural, informal
support to the family system and the professionals involved in providing services. The child-specific
plan for therapeutic behavioral on-site services must be based on a thorough assessment, with input from
the child and family, regarding needs, strengths and desired outcomes of services. When indicated by
the assessment, and agreed to by the family, the plan must identify referrals and coordination with other
agencies and resources.

It is recognized that involvement of the family in the treatment of the child or adolescent is necessary
and appropriate. Provision of therapeutic behavioral on-site services with the family must clearly be
directed toward meeting the identified treatment needs of the child or adolescent. Services provided to
family members independent of meeting the identified needs of the child or adolescent are not
reimbursable by Medicaid.

If the assessment indicates a need for intensive, clinical therapeutic behavioral on-site services, and the
family agrees to these services, the following services are reimbursable under Medicaid:

      Therapeutic behavioral on-site – therapy services
      Therapeutic behavioral on-site – behavior management services
      Therapeutic behavioral on-site – therapeutic support services

The services are intended to maintain the child or adolescent in the home (biological or foster). Services
are limited to recipients under age 21 meeting the specific eligibility criteria described below.

Additional Documentation Requirements for Therapeutic Behavioral On-Site Services
The assessments and treatment plan for therapeutic behavioral on-site services, in addition to meeting
the requirements in Chapter 2, Section 1 of the Community Behavioral Health Services Coverage and
Limitations Handbook, must address the need for individual and family therapy, behavior management
and therapeutic support services. All treatment plans and treatment plan reviews that include TBOS
as a service must be signed off by that provider’s Program Supervisor. For any services authorized,
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          FLORIDA
          Therapy Services, Inc.

the plan must include the frequency and duration of these services as well as the person or agency
responsible for delivering these services.

If any component of therapeutic behavioral on-site service is provided by a different agency, the
agency’s name must be indicated on the plan. The plan and progress notes must reflect ongoing
coordination with the other agency for the provision of services to the same child.

The treatment plan must include a specific schedule for review of the plan with the child and the family,
others on the child’s treatment team and other agencies that are providing a component of the services.

Place of Service
Services must be provided where the child is living, working, or participating in education activities.

These services may not be provided in a psychiatric hospital, a psychiatric unit of a general hospital, a
crisis stabilization unit, or any other setting where the same services are already being paid for by
another source.

Eligibility Criteria
In order to receive therapeutic behavioral on-site services, documentation must be provided in the
child’s clinical record, indicating that the child meets all of the following criteria:

   1. Has an ICD-9-CM diagnosis in the following range: 294.8, 294.9, 300 through 305.9, 307.1,
      307.23, 307.5 through 307.7, 308.0 through 312.4, 312.81 through 314.9; and
          Is enrolled in a special education program for the seriously emotionally disturbed (SED)
             or the emotionally handicapped; or
          Has scored a 60 or below on the Axis V Children’s Global Assessment of Functioning
             Scale within the last 6 months;

       OR

   2. Has an ICD-9-CM diagnosis of 295 through 298.9 (schizophrenia or other psychotic disorders,
      major depression or bipolar disorder) or 303.0 through 305.9 (substance abuse); and, prior to
      receipt of services, a licensed practitioner of the healing arts experienced in the diagnosis of
      behavioral health disorders must document that:
           The child or adolescent meets the criteria defined above;
           There is adequate evidence to indicate that the child or adolescent is at risk for a more
              intensive, restrictive and costly behavioral health placement; and
           There is adequate evidence to indicate that the child’s or adolescent’s condition and
              functional level cannot be improved with a less intensive service such as individual or
              family therapy or group therapy.




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           FLORIDA
           Therapy Services, Inc.

Continued Eligibility for Services
Within six months of the original determination of eligibility for services and every six months
thereafter, the members of the child’s treatment team must document that the child continues to meet the
eligibility criteria stated above. Services may be authorized for less than six months.

Discharge Criteria
Within 45 days of admission to therapeutic behavioral on-site services, a plan must be developed with
each child or adolescent and family, which contains specific discharge criteria. The discharge plan must
be placed in the child’s clinical record.

If at any time during the course of treatment the recipient is found to no longer meet eligibility criteria,
Medicaid will no longer reimburse for these services.

Therapeutic Behavioral On-Site Services-Therapy
   Therapeutic behavioral on-site therapy services include the following:

           Strength-based, clinical assessment of the mental health, substance abuse, or behavioral
            disorders in order to evaluate, define, and delineate treatment needs;
           Individual and family therapy as agreed to by the child and family;
           Assessment and engagement of the child or adolescent and family’s natural support system to
            assist in implementation of the treatment plan; and
           Development, implementation, and monitoring of behavior programming for the child or
            adolescent.

       Who Must Provide
       Therapeutic behavioral on-site therapy services must be provided by a master’s level practitioner
       supervised by a licensed practitioner of the healing arts.

       Reimbursement Limitations
       Medicaid reimburses therapeutic behavioral on-site therapy services a maximum combined limit
       of a total of 36, 15-minute units per month by a master’s level or certified behavioral analyst. A
       minimum of 8 units per month must be provided by a master’s level practitioner.

       Services Provided to a Group
       Therapeutic behavioral on-site therapy services may not be billed for services provided to a
       group of recipients.

       Combinations of Services that Cannot be Reimbursed
       The following services may not be reimbursed for the same recipient on the same day in
       conjunction with therapeutic behavioral on-site therapy services:

           Therapy services
           Group medical therapy
           Behavioral health day services
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         Psychosocial rehabilitation
         Therapeutic foster care unless therapeutic behavioral on-site services are provided as part of
          a public school program or summer activities program (i.e., outside the home)
         Therapeutic group care
         Behavioral health overlay – Child Welfare and Department of Juvenile Justice
Therapeutic Behavioral On-Site Services-Behavior Management Services
  Therapeutic behavioral on-site behavior management services include the following:

         Assessment of behavior problems, and the functions of these problems and related skill
          deficits and assets, including identifying primary and other important caregiver skill deficits
          and assets related to the client’s behaviors and the interactions that motivate, maintain or
          improve behavior;
         Develop an individual behavior plan with measurable goals and objectives;
         Training caregivers and other involved persons in the implementation of the behavior plan;
         Monitoring the child and caregiver progress and revise as needed; and
         Coordinate services on the treatment plan with the treatment team.

     Who Must Provide
     Therapeutic behavioral on-site behavior management services must be provided by a certified
     behavior analyst or certified associate behavioral analyst, as defined in Chapter 1 of the
     Community Behavioral Health Services Coverage and Limitations Handbook, working as a
     member of the child’s treatment team. Bachelor’s level practitioners providing this service as of
     January 31, 2005 may continue to provide services for up to 18 months while completing
     requirements to become certified behavior analysts. These practitioners must earn certification
     by April 2006 in order to continue to be reimbursed for this service.

     Non-certified associate behavioral analysts hired after January 1, 2005 must have completed
     course work required for certification and be supervised in order to be reimbursed for these
     services.

     Reimbursement Limitations
     Medicaid reimburses therapeutic behavioral on-site behavior management and therapeutic
     behavioral on-site therapy services for a maximum combined total of 36, 15-minute units per
     month by a master’s level practitioner, certified behavioral analyst, or certified associate
     behavioral analyst. A minimum of 8 units per month must be provided by a master’s level
     practitioner.

     Services Provided to a Group
     Therapeutic behavioral on-site behavior management services may not be billed for services
     provided to a group of recipients.

     Combinations of Services that Cannot be Reimbursed
     The following services may not be reimbursed for the same recipient on the same day in
     conjunction with therapeutic behavioral on-site behavior management services:
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         FLORIDA
         Therapy Services, Inc.

         Therapy services
         Group medical therapy
         Behavioral health day services
         Psychosocial rehabilitation
         Therapeutic foster care unless therapeutic behavioral on-site services are provided as part of
          a public school program or summer activities program (i.e. outside the home)
         Therapeutic group care
         Behavioral health overlay services – Child Welfare and Department of Juvenile Justice

Therapeutic Behavioral On-site Therapeutic Support Services
     Therapeutic behavioral on-site therapeutic support services must be related to the child’s or
     adolescent’s treatment plan goals and objective and must include one or more of the following
     services:

             One-to-one supervision and intervention with the child or adolescent during therapeutic
              activities in accordance with the child’s treatment plan;
             Skill training of the child or adolescent for restoration of those basic living and social
              skills necessary to function in the child or adolescent’s own environment; or
             Assistance to the child or adolescent and family in implementing the behavioral goals
              identified through family counseling and development of the treatment plan.

     Agency Requirements
     The provider responsible for delivering the services must be able to recruit qualified
     practitioners, have adequate administrative ability to assure availability of services, and must
     assure adequate staff pre-service and in-service training and appropriate supervision.

     The provider employing or contracting with the person rendering service must maintain
     documentation that the practitioner:

         Has appropriate clinical supervision;
         Is experienced in treating children or adolescents with serious emotional disturbances or
          substance abuse disorders;
         Is capable of implementing services which address the needs identified in the child’s or
          adolescent’s treatment plan; and
         Demonstrates skills and abilities to deliver rehabilitative services to children or adolescents
          with serious emotional disturbances and their families.

     Service practitioners may not be relatives of the recipient.

     Who Must Provide
     Therapeutic behavioral on-site therapeutic support services must be provided, at a minimum, by
     a behavioral health technician supervised by a master’s level practitioner.

     Reimbursement Limitations
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Medicaid reimburses therapeutic behavioral on-site therapeutic support services a maximum of
128 quarter-hour units per month, per recipient.


Special Documentation Requirements
Documentation of therapeutic behavioral on-site support services must provide a description of
the intervention(s), how it addressed the progress in achieving treatment plan goals and
objectives, and how the child or adolescent responded to the intervention.

One-to-One Versus Group
Therapeutic behavioral on-site therapeutic support services are considered primarily one-to-one
interactions. When provided in a group it must be in response to a specific recommendation and
justification by the treating physician or treating licensed practitioner of the healing arts in the
child’s treatment plan.

Under no circumstances may the staff to group ratio exceed 4 group members to one staff
person.

As of October 2006, AHCA contracted with Magellan Health Services to
manage Medicaid funding. As a result, Medicaid recipients that are assigned
to the Magellan Prepaid Mental Health Program (PMHP) will require
preauthorization by Magellan in order to receive TBOS services.

Refer to the Magellan Behavioral Health of Florida 2007 Medical Necessity
Criteria Handbook for additional requirements.




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