N.H. Admin. Code § He-M 426.12

Current through Register No. 50, December 12, 2024

Section He-M 426.12 - Individualized Resiliency and Recovery Oriented Services (IROS)

(a) IROS shall be a covered service and consist of:

(1) Evidence-based practices delivered in accordance with the Illness Management and Recovery Evidence Based Practice Kit (2010), available as listed in Appendix A, which describes the following services:

a. Illness management and recovery (IMR), group;

b. Illness management and recovery, individual; and

c. Evidence-based supported employment (EBSE); and

(2) Functional support services including the following:

a. Crisis intervention;

b. Group therapeutic behavioral services;

c. Individual therapeutic behavioral services;

d. Family support; and

e. Medication support.

(b) IROS shall be provided in the individual's current living, employment or educational situation. or other community setting taking into account the individual's preferences.

(c) IROS provided in any office setting shall not exceed 1 hour per month, or 12 hours per state fiscal year with the exception of computer-based EBSE, IMR, crisis intervention, and medication support.

(d) IROS shall not be eligible for reimbursement if provided in an office setting with the exception of (c) above, with the exception of computer-based EBSE, IMR, crisis intervention and medication support.

(e) Only individuals eligible to receive long-term services pursuant to He-M 426.19 shall be eligible to receive IROS.

(f) Quality assurance reviews shall be as follows:

(1) A sample of clinical records for recipients of IROS services shall be reviewed as part of a quality assurance review;

(2) The purpose of this review shall be to determine whether documentation in the clinical record conforms with all requirements outlined in He-M 408 and He-M 426.12; and

(3) Fidelity review process utilizing the Illness Management and Recovery Evidence Based Practice Kit (2010), available as listed in Appendix A.

(g) IROS shall be face-to-face individual and group interventions that include the elements and objectives in (h) -(j) below. IROS shall be billed as a group intervention when 2 or more unrelated recipients are in attendance, not to exceed 10 participants.

(h) Illness management and recovery (IMR), delivered on an individual and group basis, shall:

(1) Be based on the Illness Management and Recovery Evidence Based Practice Kit (2010), available as listed in Appendix A, and ensure fidelity to that model;

(2) Have as its objective teaching individuals with a mental illness, strategies for:

a. Collaborating actively in their treatment with professionals;

b. Reducing their risk of relapses and rehospitalizations;

c. Reducing the severity and distress related to symptoms; and

d. Improving their social support;

(3) Include the following specific components, at a minimum:

a. Psychoeducation about the nature of mental illness and its treatment;

b. Behavioral tailoring to help individuals incorporate the taking of medications into their daily routines;

c. Relapse prevention planning;

d. Teaching coping strategies to manage distressing, persistent symptoms;

e. Cognitive behavior therapy strategies for psychosis, depression, and bipolar disorder; and

f. Social skills training;

(4) Incorporate the following:

a. An assessment, identification, and documentation of the target symptom(s) or problem(s) ;

b. The specification of the goals or desired outcomes; and

c. The specific interventions that will be used to achieve the desired outcomes;

(5) Be of a duration that allows the time necessary to complete the IMR curriculum; and

(6) Be individual or group interventions that support recipients' optimal functioning and enhance resiliency, recovery, and integration in the community.

(i) Evidence-based supported employment (EBSE) shall:

(1) Be based on the Supported Employment Evidence Based Practice Kit (2010) as, available as listed in Appendix A, and fidelity to that model;

(2) Have as its objective the participation in competitive employment for individuals eligible under He-M 401;

(3) Utilize a team approach inclusive of an employment specialist for treatment;

(4) Include medicaid and non-medicaid funded services, funded in part by New Hampshire Vocational Rehabilitation;

(5) Include the following specific components and criteria:

a. Support of an individual's entry into or return to competitive employment on a permanent status, where potential applicants include persons in the general population;

b. Full integration of SE staff with other CMHP staff;

c. Eligibility based primarily on consumer choice, where eligibility criteria such as the following shall be irrelevant:

1. Job readiness;

2. Lack of substance abuse;

3. No history of violent behavior;

4. Minimal intellectual functioning; and

5. Mild symptoms;

d. Supports for individuals that are:

1. Provided on an ongoing basis;

2. Not time limited; and

3. Based on the individual's continued need for services, as documented in the ISP;

e. Vocational assessment which shall gather information about psychiatric history, symptoms, functional limitations, coping skills and strengths and how these affect the consumer's employment history and daily functioning as it is relates to employment, and excludes competency testing, screening for exclusionary criterion, work readiness evaluations, vocational testing, interest inventories, situational assessments, and transitional employment;

f. Job search support which shall assist an individual in managing symptoms so that they may develop a plan for approaching employers, identify personal preferences, identify and develop supports around work preparation, have individual outreach to employers, obtain support related to interviews, and include other interventions around meeting with other providers regarding benefits, work incentives, and other vocational supports; and

g. Follow-along supports which shall include interventions, strategies, and prompts to assist individuals in managing their psychiatric symptoms as they affect employment and address the following:

1. Managing social conflicts or challenges in the workplace;

2. Managing symptoms that impact getting to and from employment;

3. Managing work related income;

4. Coordinating benefits and entitlement as impacted by work; and

5. Improving ability to communicate on and off the job;

(6) Be direct, active, face-to-face clinical interventions necessary for the individual to achieve the goals and objectives identified on the ISP;

(7) Be individual interventions; and

(8) Be delivered as a clinical service if they are directly related to an individual's symptoms due to a mental illness which inhibits the individual from participating in or obtaining competitive employment.

(j) The individual's treatment planning team shall include an EBSE specialist to assure services effectively address symptoms and challenges that prevent the individual from successfully achieving their employment goals.

(k) The EBSE components in (j) (5) e.-g. above shall not be a medicaid billable service when they, either:

(1) Do not include the individual; or

(2) Do not address symptoms related to an individual's mental illness.

(l) Documentation of interventions for EBSE shall comply with He-M 408.09.

(m) Functional support services (FSS) shall be medically necessary individual or group interventions that shall:

(1) Be direct, active, face-to-face clinical interventions necessary for the individual to achieve the goals and objectives identified on the ISP;

(2) Actively engage the individual in planned and unplanned, therapeutic activities;

(3) Be billed as an individual service when provided on a one-to-one basis;

(4) Be billed as a group service when provided with 2 or more recipients present;

(5) Exclude activities that are social and recreational in nature without active clinical intervention;

(6) Enhance resiliency, recovery, and integration in the community;

(7) Support the restoration of an individual to the best possible functional level; and

(8) Include interventions consisting of:

a. Crisis intervention services, delivered on an individual basis, that:

1. Are designed for individuals who are experiencing acute exacerbation of symptoms that increase the likelihood that the individual will harm himself, herself or others, or that imminently jeopardize the individual's ability to remain in the community;

2. Include continuous assessment and monitoring of safety and symptoms;

3. Include family, friends, or significant others when appropriate; and

4. Are delivered based on a direct benefit to the service recipient with each crisis intervention service specifically documented in the clinical record;

b. Therapeutic behavioral services, delivered on an individual and group basis, that are specific and individualized interventions whose primary objective is to develop, reinforce and apply skills and strategies to ameliorate or reduce symptoms and behaviors that impede an individual's ability to function in an age and developmentally appropriate manner and return the individual to an optimal level of functioning;

c. Family support, delivered on an individual basis, that:

1. Consists of face-to-face, specific interventions provided to family members, caregivers, or significant others;

2. Supports and maintains the management of the eligible recipient's mental illness or serious emotional disturbance, and maintains the individual's tenure in the community;

3. Has as its primary objective the enhancement and promotion of the recipient's resiliency and recovery;

4. Includes assistance to the family member or caregiver, in delivering specific interventions to the individual to promote the goals and objectives identified in the individual service plan as required by He-M 401; and

5. Is provided in accordance with the following:

(i) The ISP shall specify who shall be present during the delivery of this service; and

(ii) Family support services shall be delivered based on a direct benefit to the service recipient, and documented as such; and

d. Medication support, delivered on an individual basis, that:

1. Is a specific and individualized intervention that is designed to support the individual in maintaining his or her medication regimen, as prescribed in the clinical record, as a strategy to promote effective management of his or her mental illness;

2. Is modeled on the concept of "behavioral tailoring" which includes developing strategies for incorporating medication into the individual's daily routine, as outlined in the Illness Management and Recovery Evidence Based Practice Kit (2010), available as listed in Appendix A;;

3. Is not billed when these interventions are delivered during the course of a routine or comprehensive medication check as outlined in He-M 426.07; and

4. Includes the following as described in the Illness Management and Recovery Evidence Based Practice Kit (2010):

(i) Providing accurate information about medications for mental illness, including both their advantages and disadvantages;

(ii) Providing an opportunity for recipients to talk openly about their beliefs about medication and their experience with taking various medications;

(iii) Helping recipients weigh the advantages and disadvantages of taking medications; and

(iv) Helping recipients who have decided to take medications to develop strategies for taking medication regularly, including behavioral tailoring and simplifying the medication regimen.

(n) The following IROS services shall be billed separately from one another, with one claim submitted per day for each category below:

(1) Illness management and recovery, group;

(2) Illness management and recovery, individual;

(3) Evidence-based supported employment;

(4) Crisis intervention;

(5) Group therapeutic behavioral services; and

(6) Individual therapeutic behavioral services, family support services, and medication support services.

(o) The CMHP shall separately aggregate the minutes for each category listed in (n) above that are provided in a single day into a single claim before determining the number of billable 15 minute units for each category.

(p) Billing for functional support services provided to each individual, except for crisis intervention services, those who are served on an ACT team, and all functional support services provided to individuals eligible to receive children's program services under He-M 401, shall be limited as follows:

(1) Individual therapeutic behavioral services, family support services, and medication support services shall be limited to a combined total of 10 units per day; and

(2) Group therapeutic behavioral services shall be limited to 10 units per day.

(q) A CMHP or community mental health provider may request a waiver of the 10 unit daily limit by submitting the request in writing to the department in accordance with He-M426.24.

(r) In addition to the requirements in He-M 426.24, the waiver request shall include the following:

(1) Supporting documentation that the provision of functional support services beyond the 2.5 hours per day is necessary to allow the individual to achieve the desired outcome;

(2) A statement by the clinician most familiar with the needs of the individual that there are no other treatment modalities available, such as peer support, community support, or other natural supports, that will enable the individual to achieve the desired outcome;

(3) A copy of the current and previous ISP, signed by the psychiatrist, which specifies the frequency, duration and purpose of the requested functional support services in excess of 10 units per day;

(4) A copy of the current eligibility determination form; and

(5) The date range for the waiver, which shall not exceed the date range specified on the ISP.

(s) A waiver request shall be granted by the commissioner, or designee, in accordance with He-M 426.24 and the following:

(1) The commissioner, or designee, determines that there are extenuating circumstances unique to the individual that would make a denial of the waiver request clinically contraindicated; or

(2) The commissioner, or designee, determines that approval of the waiver can reasonably be expected to prevent the need for more costly services within the following 12 months, including prevention of hospitalization or institutionalization.

(t) A recipient whose waiver request to exceed 10 units per day is not granted by the commissioner or his or her designee may appeal pursuant to He-C 200.

(u) IROS shall be reimbursed at a per diem rate if services are provided in:

(1) A non-hospital receiving facility designated pursuant to He-M 405 or He-M 1005; or

(2) A facility licensed by the department or certified as a community residence by the department, if such facilities meet the following criteria:

a. A psychiatrist shall be available 24 hours per day for consultation or treatment, as appropriate, to address medical, medication, and other issues under the domain of a psychiatrist;

b. Supervision shall be provided by program staff who meet the criteria of (a) above;

c. Supervision shall be sufficient to ensure the individual's safety and implementation of ISPs;

d. Supervision of individuals shall be provided whenever individuals are present in the facility unless an individual's ISP requires that that individual be left alone;

e. All service components shall be available within the program and may be provided on site or off; and

f. There shall be regular communication between residential staff and each resident's case manager to ensure that services are provided in accordance with an ISP and that there is no duplication of service.

(v) Reimbursement for IROS pursuant to (u) above shall preclude the possibility of billing for IROS in 15-minute units within the community residence with the exception of IMR provided by non-residential staff. For any day on which an individual receives per diem services, residential staff of the same program shall not also bill for IROS in 15-minute units for that individual.

(w) Reimbursement for services provided on a per diem basis in an acute psychiatric residential treatment program designated pursuant to He-M 1005.04 shall preclude the possibility of billing for any other service described in He-M 426.07 through He-M 426.12 except case management services, emergency services, psychological testing, and intake psychiatric diagnostic interview.

(x) Documentation for IROS services shall include:

(1) The start and duration of each event; or

(2) The start and stop time for each event.

N.H. Admin. Code § He-M 426.12

(See Revision Note at part heading for He-M 426) #5433, eff 7-2-92, EXPIRED: 7-2-98

New. #7088, eff 8-31-99; ss by #8867, eff 4-13-07; ss by #9285, eff 9-30-08; ss by #9581, eff 10-24-09

Amended by Volume XXXVII Number 15, Filed April 13, 2017, Proposed by #12154, Effective 3/28/2017, Expires 3/28/2027.