Section 17b-262-855 - Coverage limitations(a) Coverage of services shall be subject to the following limitations: (1) Services that do not meet medical necessity requirements or any applicable authorization or certification requirements are not eligible for Medicaid payment.(2) Services shall be based on the rehabilitation plan developed pursuant to section 17b-262-851(7) of the Regulations of Connecticut State Agencies and the requirements of sections 17b-262-849 to 17b-262-861, inclusive, of the Regulations of Connecticut State Agencies, and shall be performed by or under the supervision of a licensed clinician employed by or under contract with the provider.(3) Home and community-based services and EMPS may be provided in a facility, home, hospital or other setting, except as follows:(A) When an individual resides in a facility or institution, the services may not duplicate services included in the facility's or institution's rate; or(B) if the provider operates a clinic or practice for the provision of outpatient services, no more than 10 visits may be provided at the site of the outpatient clinic or practice per individual per episode of care, other than the initial assessment, which may occur off-site. The services rendered under this exception are considered reimbursable services only if the services rendered are part of a rehabilitation plan.(4) EDT programs shall meet the following requirements:(A) Provide time-limited, active services within a clinic or off-site community setting;(B) employ an integrated, comprehensive and complementary schedule of treatment approaches;(C) serve individuals with significant functional impairments resulting from a behavioral health condition in order to avert hospitalization or increase the client's level of independent functioning;(D) provide an adult escort to support the transportation of individuals under 16 years of age, transported by a Medicaid non-emergency medical transportation provider, unless the parent or guardian of the individual between the ages of 12 to 15 years consents, in writing, to transportation of the individual to the EDT program without an escort; and(E) provide a minimum of three hours of scheduled, documented programming of which at least two and one half hours are services.(5) Services may be provided indirectly through counseling of parents, other family members or other persons responsible for the care of the individual, regardless of the Medicaid eligibility of these persons, only to the extent that the provision of such indirect treatment service is necessary and is intended to primarily benefit the individual.(6) The department shall not pay for the following:(A) Programs, services or components of services that are of an unproven, experimental, cosmetic or research nature;(B) programs, services or components of services that do not relate to the individual's diagnosis, symptoms, functional limitations or medical history;(C) programs, services or components of services that are not included in the fee established by the department;(D) programs, services or components of services that are intended solely to prepare individuals for paid or unpaid employment or for vocational equipment and uniforms;(E) programs, services or components of services provided solely for social or recreational purposes not in compliance with section 17b-262-854(e)(5) or 17b-262-854(e)(10) of the Regulations of Connecticut State Agencies;(F) time spent by the provider solely for the purpose of transporting clients;(G) services that are solely educational or vocational;(H) costs associated with room and board for individuals; and(I) services that are provided out-of-state unless the services are not available within Connecticut.(b) Notwithstanding subparagraph (a)(3)(B) of this section, services that are provided at the primary or satellite site of a DCF-licensed clinic, as indicated on the clinic's license, do not qualify as rehabilitation services and may be reimbursed by the Medicaid program only to the extent that such services otherwise qualify for Medicaid reimbursement, for example, as covered clinic services.Conn. Agencies Regs. § 17b-262-855
Effective February 2, 2012